TEST BANK for Maternal & Child Nursing Care 6th Edition. Marcia London; Patricia Ladewig; Michele Da by ACADEMIAMILL

Maternal & Child Nursing Care, 6e (London et al.) Chapter 1 Contemporary Maternal, Newborn, and Child Health Nursing 1) The nurse is examining different nursing roles. Which statement best illustrates an advanced practice nursing role? 1. A registered nurse who is the manager of a large obstetric unit 2. A clinical nurse specialist working as a staff nurse on a mother-baby unit 3. A registered nurse who is the circulating nurse at surgical deliveries (cesarean sections) 4. A clinical nurse specialist with whom other nurses consult for this nurse's expertise in caring for high-risk infants Answer: 4 Explanation: 1. A RN who is a nurse manager is not required to be an advanced practice nurse. RNs may have a high level of education but are not considered an advanced practice nurse by the American Nurses Association definition. They are not managing the primary care of a patient. 2. The clinical nurse specialist is an advanced practice nurse but is not working in that role when in the clinical nurse role at the bedside. 3. The registered nurse working as a circulating nurse is not required to have an advanced degree. The role of the circulating nurse is a specialized role but does not require a higher level of education like the advanced practice nurse. 4. A clinical nurse specialist with whom other nurses consult for expertise in caring for high-risk infants would illustrate an advanced practice nursing role. This nurse has specialized knowledge and competence in a specific clinical area, and is master's-prepared. Page Ref: 3 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 6.2 Perform effectively in different team roles, using principles and values of team dynamics. | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1 Identify the nursing roles available to maternal-newborn and pediatric nurses.

2) The nurse is investigating opportunities as a nurse practitioner. Which should the nurse identify as the major focus of the nurse practitioner (NP)? 1. Leadership 2. Tertiary prevention 3. Provide ambulatory care services 4. Independent care of the high-risk, pregnant client Answer: 3 Explanation: 1. The role of a nurse practitioner is usually directed toward patient care and not focused on leadership. The Nurse Practitioner can be in a leadership role, but it is not usually the degree that would lead to that type of position in healthcare. 2. The role of providing tertiary prevention is not usually something the NP will provide. Tertiary prevention is usually community-based outreach. This is something an NP can do but does not require an advanced degree and can include other disciplines such as social workers, community activists, public health workers, and mental health workers. 3. A nurse practitioner (NP) often provides ambulatory care services to pregnant women, newborns, children, adolescents, and families. NPs do not necessarily have leadership positions or provide tertiary prevention. Certified nurse-midwives independently manage the care of women at low risk for complications during pregnancy, birth, and the postpartum period. 4. The NP may be part of a team caring for a high-risk mother but would not be independently caring for her. A high risk patient will need to be followed by a physician along with an NP but not independently, NP's must stay within their scope of practice and high risk patients may need care beyond that an NP can provide. Certified nurse-midwives independently manage the care of women at low risk for complications during pregnancy, birth, and the postpartum period. Page Ref: 2-3 Cognitive Level: Remembering Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 6.2 Perform effectively in different team roles, using principles and values of team dynamics. | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1 Identify the nursing roles available to maternal-newborn and pediatric nurses.

3) The nurse wants to become a certified nurse-midwife. What is the role of the certified nursemidwife (CNM)? Select all that apply. 1. Give primary care for healthy newborns. 2. Be educated in two disciplines of nursing. 3. Give primary care for high-risk clients who are in hospital settings. 4. Obtain a physician consultation for all technical procedures at delivery. 5. Be prepared to manage independently the care of women at low risk for complications during pregnancy and birth. Answer: 1, 2, 5 Explanation: 1. The CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns. 2. The CNM is educated in the disciplines of nursing and midwifery. 3. The midwife is not allowed to provide high-risk care per the certification provided by the American College of Nurse-Midwives. The certification states care of the low risk for complications for women or newborn. 4. The CNM is an independent practitioner and is working within the scope and standards of practice. They do not need an order from a practitioner for technical procedures at delivery. They are allowed to do what they need to do without supervision. 5. The CNM is prepared to manage independently the care of women at low risk for complications during pregnancy and birth and the care of healthy newborns. Page Ref: 3 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 6.2 Perform effectively in different team roles, using principles and values of team dynamics. | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1 Identify the nursing roles available to maternal-newborn and pediatric nurses.

4) During the hospital admission process, a child's parent asks for information about familycentered care. Which information should the nurse provide to this parent? 1. Mother is the principal caregiver in each family. 2. Father is the leader in each home; thus, all communications should include him. 3. Family serves as the constant influence and continuing support in the child's life. 4. Child's physician is the key person in ensuring the health of a child. Answer: 3 Explanation: 1. The mother is not always the principal caregiver in each family and it is important for the healthcare provided to not make assumptions in the delivery of family-centered care 2. The mother is not present in all family units. It is important when providing information on family-centered care that it allows for all types of family units in the explanation of forming a family-centered approach to the child. 3. The foundation for the development of trusting relationships and partnerships with families is the recognition that the family is the principal caregiver, knows the unique nature of each individual child best, plays the vital role of meeting the child's needs, and is responsible for ensuring each child's health. 4. Family-centered care is all about the family working with the healthcare professional to care for the patient; the physician is not the key person in this equation. The key is the family as a whole. Page Ref: 3 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 3.2 Engage in effective partnerships. | NLN Competencies: Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.2 Describe the use of community-based nursing care in meeting the needs of childbearing and childrearing families.

5) A child is not enrolled in the Children's Health Insurance Program (CHIP). Which action should the nurse take to encourage the family to consider enrolling the child in this program? 1. Assessment of the details of the family's income and expenditures 2. Case management to limit costly, unnecessary duplication of services 3. Advocacy for the child by encouraging the family to investigate its CHIP eligibility 4. Education of the family about the need for keeping regular well-child visit appointments Answer: 3 Explanation: 1. Every family in today's world is different. We have stay-at-home dads, samesex couples, and untraditional family units. So the mom may not be the primary caregiver in each family, and it is important to not assume when caring for a child. It is not the role of the nurse to assess the family's income or expenditure; the nurse can only inform the family of the Program. 2. All families are made up of different dynamics and may not include a father figure. The nurse must assess the family dynamics when providing family-centered care. Case management should be consulted in the care of this child; however, it is not how the nurse should encourage the family to enroll in the program. 3. In the role of an advocate, a nurse will advance the interests of another by suggesting the family investigate its CHIP eligibility. 4. The child's family is actually the most influential in the health of a child. The physician spends a snapshot of time with the child and family, providing information and resources that the family must take into consideration. The family is the one who is involved in the everyday health decisions for the child, providing food, medication, and shelter to the child. Educating the family about care the child will need such as regular well-child visit appointments is the role of the nurse; however, this will be needed no matter if the child is enrolled in the program or not. Page Ref: 4 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 3.5 Demonstrate advocacy strategies. | NLN Competencies: RelationshipCentered Care; Practice; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.3 Summarize the current status of factors related to health insurance and access to healthcare.

6) The nurse is evaluating telephone calls made by the mothers of newborns in a community clinic. Which calls should the nurse make a priority? Select all that apply. 1. Mother who is 16 years old 2. Mother who is breastfeeding 3. Mother who is a single parent 4. Mother who gave birth to twins two weeks ago 5. Infant mortality rates are higher among infants born prematurely. Answer: 3, 4, 5 Explanation: 1. The mother's age does not necessarily make her a priority. She may be well supported at home. The mortality rates for a teen mother are not as high as the other choices, so the focus needs to be on the higher risk newborns. 2. Breastfeeding mothers do need support, but it does not increase infant mortality and the focus of this question is prioritization of who to call first. 3. Infant mortality rates are higher among unmarried mothers. 4. Infant mortality rates are higher among infants born in multiple births. 5. Infant mortality rates are higher among infants born prematurely. Page Ref: 6 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.5 Relate the availability of statistical data to the formulation of further research questions.

7) The nurse is coordinating a clinical research trial with pediatric clients. From which clients should the nurse seek assent to participate in the research? Select all that apply. 1. A 9-year-old client who qualifies to test a medication for muscular dystrophy 2. A precocious 4-year-old starting as a participant in a cystic fibrosis research study 3. A 10-year-old starting in an investigative study for clients with precocious puberty 4. A 7-year-old client with leukemia who has elected to receive a newly developed trial medication 5. A 13-year-old client beginning participation in a research program for attention deficit/hyperactivity disorder (ADHD) treatments Answer: 1, 3, 4, 5 Explanation: 1. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments, and give assent. 2. The patient is under 7 years of age and per the federal requirements it is not required that the nurse seek assent to participate in the research. The child is too young to understand the research at the age of 4. 3. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments, and give assent. 4. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments, and give assent. 5. Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments, and give assent. Page Ref: 9 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 5.2 Contribute to a culture of patient safety. | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.6 Delineate significant legal and ethical issues that influence the practice of maternal-child nursing.

8) A 12-year-old pediatric client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure? 1. The nurse 2. The physician 3. The social worker 4. The unit secretary Answer: 2 Explanation: 1. The nurse is not legally responsible for obtaining the consent. They are not performing the procedure the physician is. They are allowed to answer questions and reach out to the physician if the patient or guardian has further questions or concerns regarding the procedure. 2. Informed consent is legal preauthorization for an invasive procedure. It is the physician's legal responsibility to obtain this because it consists of an explanation about the medical condition, a detailed description of treatment plans, the expected benefits and risks related to the proposed treatment plan, alternative treatment options, the client's questions, and the client's or guardian's right to refuse treatment. The nurse, social worker, or unit secretary is not responsible for obtaining informed consent. 3. The social worker has no involvement in the medical procedure, and it is not allowed legally for them to obtain consent. 4. The unit secretary has no involvement in the medical procedure, and it is not allowed legally for them to obtain consent. Page Ref: 8 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 5.2 Contribute to a culture of patient safety. | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.8 Contrast the policies for obtaining informed consent for minors with policies for adults.

9) The nurse tells family members the sex of a newborn baby without first consulting the parents. Which act did this nurse commit? 1. Negligence 2. Malpractice 3. A breach of ethics 4. Breach of privacy Answer: 4 Explanation: 1. Negligence is defined as failure to take action when needed. Sharing information without consent is not covered by that definition. 2. Malpractice is doing something wrong and causing harm to the patient by negligence or by omission. Sharing information does not fall under that definition. (https://www.abpla.org/whatis-malpractice) 3. A breach of ethics is doing something that is not right and can harm a patient. Sharing information without consent is not meant to be harmful so does not fall under that definition. 4. A breach of privacy would have been committed in this situation, because it violates the right to privacy of this family. The right to privacy is the right of a person to keep the person and property free from public scrutiny (of even other family members). Sharing this information is not negligence, malpractice, or a breach of ethics. Page Ref: 9 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 5.2 Contribute to a culture of patient safety. | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.6 Delineate significant legal and ethical issues that influence the practice of maternal-child nursing.

10) The nurse is reviewing the 1973 Supreme Court decision in Roe v. Wade for a patient asking about an abortion. Which information should the nurse explain about the induction of a legal abortion? 1. It must be performed at a federally funded clinic. 2. It must be performed before the period of viability. 3. It must be performed at a military hospital overseas. 4. It must be performed to provide tissue for therapeutic research. Answer: 2 Explanation: 1. An abortion does not need to be performed in a federally-funded clinic 2. Abortion can be performed legally until the period of viability; after viability, the rights of the fetus take precedence. There is no information about the abortion to be performed at a federally funded client, at a military hospital overseas, or performed to provide tissue for research. 3. That is not a requirement of Roe v. Wade. Abortions can be performed on American soil 4. That is not a requirement of Roe v. Wade Page Ref: 10 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 5.2 Contribute to a culture of patient safety. | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.6 Delineate significant legal and ethical issues that influence the practice of maternal-child nursing.

11) A nurse is providing guidance to a group of parents of children in the infant-to-preschool age group. After reviewing statistics on the most common cause of death in this age group, which information should the nurse include about prevention? 1. Reduce the use of pesticides in the home to prevent cancer. 2. Review swimming pool and traffic accidents to prevent accidental injury. 3. Incorporate heart-healthy foods into the child's diet to prevent heart disease. 4. Provide a diet high in vitamin C from fruits and vegetables to prevent pneumonia. Answer: 2 Explanation: 1. Malignant Neoplasm is the 3rd most common cause of death from 1-4 years of age and is not the most common, so it is not the best answer to the question. Pesticides would contribute to the development of neoplasms; however, this is not the most common cause of death in this age group. 2. The most common mechanisms of unintentional injury leading to fatality in children and adolescents (1 to 19 years) include motor vehicle crashes, drowning, drug poisoning, fire/flame, and suffocation. 3. Heart disease is the 5th most common cause of mortality in this age group and is not the most common so not the best answer to the question. 4. Pneumonia is not listed as a common cause of mortality in this age group. Page Ref: 7 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice | AACN 2021 Domains and Competencies: 3.1 Manage population health. | NLN Competencies: Knowledge and Science; Practice; evaluate the strength of evidence for application of research findings to clinical practice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Report the most common public health data for maternal mortality and births and causes of child morbidity and mortality.

12) The nurse manager is reviewing information about the use of evidence-based practice in client care. Which practices characterize the basic competencies related to evidence-based practice? Select all that apply. 1. Clinical practice supported by data 2. Use data to evaluate outcomes of care 3. Appraise and integrate scientific bases into practice 4. Clinical practice supported by intuitive evidence 5. Appraise evidence according to cost-effectiveness Answer: 1, 2, 3 Explanation: 1. Nurses need to meet three basic competencies related to evidence-based practice. The first is recognizing clinical practices that are supported by data or evidence. The second is to use data to evaluate outcomes of care. The third competency is appraising and integrating scientific bases into practice. 2. Nurses need to meet three basic competencies related to evidence-based practice. The first is recognizing clinical practices that are supported by data or evidence. The second is to use data to evaluate outcomes of care. The third competency is appraising and integrating scientific bases into practice. 3. Nurses need to meet three basic competencies related to evidence-based practice. The first is recognizing clinical practices that are supported by data or evidence. The second is to use data to evaluate outcomes of care. The third competency is appraising and integrating scientific bases into practice. 4. Intuitive evidence is not one of the three basic competencies related to evidence-based practice. 5. Cost effectiveness is not one of the three basic competencies related to evidence-based practice. Also evidence-based practice is not always cost effective in the short term but based on providing quality outcomes to our patients that will save money in the long run. Page Ref: 12 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining the best clinical practice | AACN 2021 Domains and Competencies: 5.1 Apply quality improvement principles in care delivery. | NLN Competencies: Knowledge and Science; Practice; evaluate the strength of evidence for application of research findings to clinical practice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.9 Analyze the role of evidence-based practice in improving the quality of nursing care for childbearing and childrearing families.

13) The maternal-child nurse is caring for a teenager who is 16 weeks pregnant. Which actions should the nurse perform when advocating for this client? Select all that apply. 1. Understand what the client needs. 2. Know the needs of the client's family. 3. Compile a list of community resources. 4. Coordinate services to meet quality measures. 5. Examine policies to ensure meeting the client's needs. Answer: 1, 2, 3, 5 Explanation: 1. be an effective advocate, the nurse must be aware of the individual's needs. 2. be an effective advocate, the nurse must be aware of the family's needs. 3. To be an effective advocate, the nurse must be aware of the healthcare services available in the hospital and the community. The nurse can then assist the family to make informed choices about these services and to act in their best interests. 4. Meeting quality measures is not part of advocating for patients and families. This is also part of the nurses role but not at this moment of the patient's care. 5. To be an effective advocate, nurses must also ensure that the policies and resources of healthcare agencies meet the psychosocial needs of childbearing women and of children and their families. Page Ref: 2 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 6.2 Perform effectively in different team roles, using principles and values of team dynamics. | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.1 Identify the nursing roles available to maternal-newborn and pediatric nurses.

14) The nurse is establishing criteria for a medical or healthcare home for children. Which information should the nurse include when planning this approach to care? Select all that apply. 1. Providers partner with the family. 2. Children are known by the provider. 3. Home visits are made when necessary. 4. Specialty care can be accessed, if necessary. 5. Communication with family occurs routinely. Answer: 1, 2, 4, 5 Explanation: 1. Criteria for a medical or healthcare home for children include partnering with the family in the child's care. 2. Criteria for a medical or healthcare home for children include being well known by a physician or nurse who provides the usual source of sick care. 3. In this case the setting will be providing medical care already, so home visits will not be necessary in this setting. 4. Criteria for a medical or healthcare home for children include having access to specialty care. 5. Criteria for a medical or healthcare home for children include spending adequate time communicating clearly with the family. Page Ref: 4 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 3.2 Engage in effective partnerships. | NLN Competencies: Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.2 Describe the use of community-based nursing care in meeting the needs of childbearing and childrearing families.

15) The nurse is assisting with the design of a study to analyze changes in maternal mortality. Which information should the nurse keep in mind when planning the design? Select all that apply. 1. The marital status of maternity clients 2. The use of hospitals by maternity clients 3. The prevention of infection with antibiotics 4. The availability of blood products for transfusions 5. The establishment of care centers for high-risk mothers Answer: 2, 3, 4, 5 Explanation: 1. Marital status is not a factor that could affect the medical care and the maternal mortality rate of the patients. It is demographic data that could be correlated to maternal mortality but should not be considered in the study design. 2. .Factors influencing maternal mortality include the increased use of hospitals by maternity clients. 3. Factors influencing maternal mortality include the prevention of infection with antibiotics. 4. Factors influencing maternal mortality include the availability of blood products for transfusions. 5. Factors influencing maternal mortality include the establishment of care centers for high-risk mothers. Page Ref: 8 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities | AACN 2021 Domains and Competencies: 1.2 Apply theory and research‐based knowledge from nursing, the arts, humanities, and other sciences. | NLN Competencies: Knowledge and Science; Knowledge; Defining the relationships between research and science building, and between research and EBP | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.5 Relate the availability of statistical data to the formulation of further research questions.

16) The nurse manager is considering adopting clinical practice guidelines to care for clients experiencing abruptio placentae. Which advantage of these guidelines should the manager discuss with the nursing staff? Select all that apply. 1. Limit the cost of care. 2. Help evaluate the effectiveness of care. 3. Reduce the number of nurses needed to provide care. 4. Reduce variations when caring for clients with the same health problem. 5. Provide sequence and timing of interventions to help achieve expected client outcomes. Answer: 1, 2, 5 Explanation: 1. Clinical practice guidelines are adopted within a healthcare setting to limit costs of care. 2. Clinical practice guidelines are adopted within a healthcare setting to evaluate the effectiveness of care. 3. Clinical practice guidelines are used to provide the best care for clinical conditions, not to make staffing decisions. 4. Clinical practice guidelines are used to provide the best care for clinical conditions. They are not used to streamline care of conditions. 5. Clinical practice guidelines are not used to identify the number of nurses needed to provide care. Page Ref: 12 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 5.1 Apply quality improvement principles in care delivery. | NLN Competencies: Legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.6 Delineate significant legal and ethical issues that influence the practice of maternal-child nursing.

17) A female client is considering ovulation-inducing medications to achieve pregnancy. Which information should the nurse explain as potential adverse effects of this type of assisted reproductive technology (ART)? Select all that apply. 1. Miscarriage 2. Preterm birth 3. Neonatal morbidity 4. Multifetal pregnancy 5. Pelvic inflammatory disease Answer: 1, 2, 3, 4 Explanation: 1. Multifetal pregnancy, which can occur through the use of ovulation-inducing medications, increases the risk of miscarriage. 2. Multifetal pregnancy, which can occur through the use of ovulation-inducing medications, increases the risk of preterm birth. 3. Multifetal pregnancy, which can occur through the use of ovulation-inducing medications, increases the risk of neonatal morbidity. 4. Multifetal pregnancy can occur through the use of ovulation-inducing medications. 5. Pelvic Inflammatory disease is not a side effect of ART Page Ref: 10 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science; Practice; evaluate the strength of evidence for application of research findings to clinical practice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.7 Explore the value of the QSEN project in promoting patient safety and high-quality care.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 2 Culture and the Family 1) A 7-year-old client says, "Grandpa, mommy, daddy, and my brother live at my house." In which type of family should the nurse identify that this child lives? 1. Extended 2. Binuclear 3. Traditional 4. Gay or lesbian Answer: 1 Explanation: 1. An extended family contains a parent or a couple who share the house with their children and another adult relative. 2. A binuclear family is a family that has two households, most commonly a post-divorce family. Both parents have an equal say in the child's life and usually have co-parenting responsibilities. 3. Traditional families are families that have the core members living together. They have biological parents and no other members of the extended family living in the home. 4. Gay or lesbian families are same-sex families with a couple made up of the same sex. They may or may not have children. Page Ref: 16 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship Centered; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Compare the characteristics of different types of families.

2) The nurse is performing a family assessment. Which type of family should the nurse identify when both parents work? 1. An extended family 2. An extended kin family 3. A nuclear family 4. A dual-career/dual-earner family Answer: 4 Explanation: 1. An extended family is more likely to have someone who is not working in the mix. The likelihood of a grandparent being home while others in the family work is high for this type of family unit. 2. The extended-kin family is two different families that are nuclear in nature that are living together. You may or may not have both parents working in this family unit. 3. In a nuclear family no other relatives live in the house; one parent is home while the other parent is working. This family unit is the base of the dual career family unit. 4. A dual-career/dual-earner family is characterized by both parents working, by either choice or necessity. An extended family contains a parent or a couple who share the house with their children and another adult relative. An extended kin network family is a specific form of an extended family in which two nuclear families of primary or unmarried kin live in proximity to each other. In the nuclear family, children live in a household with both biologic parents and no other relatives or persons. Page Ref: 16 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship Centered; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Compare the characteristics of different types of families.

3) The nurse is comparing several different families' developmental stages. Which criterion serves as a marker for a family's developmental stage according to Duvall? 1. The father's age 2. The mother's age 3. The oldest child's age 4. The youngest child's age Answer: 3 Explanation: 1. The father's age is not a criterion in the family developmental stage according to Duvall's Theory. 2. The mother's age is not a criterion in the family developmental stage according to Duvall's Theory. 3. The oldest child's age serves as a marker for the family's developmental stage, except in the last two stages, when children are no longer present. The father, mother, or youngest child's age are not markers for the developmental stage, according to Duvall. 4. The youngest child's age is not a criterion in the family developmental stage according to Duvall's Theory. It goes by the age of the oldest child to mark when the family enters that stage. Page Ref: 17 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship Centered; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.2 Identify the stages of a family life cycle.

4) A client of Asian descent who immigrated to the United States 5 years ago asks for the regular hospital menu because she likes American food. To which cultural concept should the nurse attribute this client's request? 1. Stereotyping 2. Acculturation 3. Enculturation 4. Ethnocentrism Answer: 2 Explanation: 1. Stereotyping is thinking that all people who share characteristics will have the same likes and dislikes. Assuming the patient wants Asian food because she is Asian is stereotyping. 2. Acculturation (assimilation) is the correct assessment because the client adapted to a new cultural norm in terms of food choices. Stereotyping is assuming that all members of a group have the same characteristics. Enculturation is the gradual acquisition of the characteristics and norms of a culture or group by a person, another culture. Ethnocentrism is the conviction that the values and beliefs of one's own cultural group are the best or only acceptable ones. 3. Enculturation is learning a new culture and slowly starting to do things that are seen as normal in a culture that is new to the individual. So the patient is already enculturated after 5 years because she is requesting American food. 4. The concept of ethnocentrism is thinking your way is the best way, which this client is not demonstrating. (Wikipedia and Oxford languages) Page Ref: 18 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship Centered; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Assessment; Culture and Spirituality Learning Outcome: 2.3 Identify prevalent cultural norms related to childbearing and childrearing.

5) During an assessment, the nurse notices that an African American baby has a darker, slightly bluish patch about 5 by 7 cm on the buttocks and lower back. Which action should the nurse take? 1. Record the location of the patch. 2. Ask the mother about the cause of the patch. 3. Confer with the physician about the possibility of a bleeding tendency. 4. Call the Department of Social Services (DSS) to report this sign of abuse. Answer: 1 Explanation: 1. The nurse will record the presence and location of the patch. The mother does not need to be asked about the patch. The patch does not indicate a bleeding tendency. This patch is not a sign of abuse. 2. This is not something that the mother needs to explain to a healthcare provider. It is most likely a congenital melanocytosis that is common in dark-skinned infants. 3. A congenital melanocytosis is not an indication of a bleeding disorder. 4. The mark is not a sign of abuse and does not need to be reported to DSS. It is most likely a melanocytosis. Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation; Culture and Spirituality Learning Outcome: 2.4 Summarize the importance of cultural competency in providing nursing care.

6) A client of Asian descent has just given birth and the spouse provides hot broth that was brought from home. Which action should the nurse take? 1. Explain that cold beverages are approved. 2. Provide the broth only after warming it in the microwave. 3. Explain that food is not allowed to be brought from home. 4. Encourage the spouse to provide sips of their broth and offer to bring warm water to drink. Answer: 4 Explanation: 1. It is a cultural preference to like cold drinks; many cultures prefer warm liquids. 2. If the broth was warm, there is no need to rewarm the broth. 3. There is no reason the patient cannot drink the food or broth brought in from home. 4. Encouraging the spouse to provide sips of their broth and offer to bring warm water to drink are approaches that show cultural sensitivity. Not all cultures drink cold beverages after birth. There is no reason to warm the beverage in the microwave. There is no reason for food to not be brought from home. Page Ref: 23 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation; Culture and Spirituality Learning Outcome: 2.4 Summarize the importance of cultural competency in providing nursing care.

7) The nurse wants to teach an adolescent newly enrolled in an English as a Second Language class about the importance of handwashing before meals and not eating food dropped on the floor. In which way should the nurse help the client understand the importance of hygienic nutrition? 1. Schedule a medical interpreter to accompany the client to the next visit. 2. Have the child repeat the information that was taught. 3. Provide written materials in English about hygiene and diet for the client to take home. 4. Have the nurse model proper handwashing before examining the child and throw out the dropped cookie. Answer: 2 Explanation: 1. The client is in an English as a Second Language class, so a medical interpreter is not needed. 2. Asking the client to repeat the information provided reveals how concepts were understood. A medical interpreter is not needed. The written instructions would be helpful; however, the client needs to repeat the information to determine if learning has occurred. Modeling handwashing is appropriate but does not evaluate if learning has occurred. 3. Handing out printed teaching material in English is a good technique to aid in learning, but how do you know if they understand what is being taught without a conversation? 4. This is a good answer, but not the best answer as you do not have the client return to demonstrate the proper hand hygiene so that you know they understand the handwashing concept. Page Ref: 22 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation; Culture and Spirituality Learning Outcome: 2.5 Discuss the use of a cultural assessment tool as a means of providing culturally sensitive care.

8) The charge nurse is reviewing the healthcare plans written by the unit's staff nurses. Which problem is most likely to be construed as culturally biased and possibly offensive? 1. Fear related to separation from support system during hospitalization 2. Spiritual distress related to discrepancy between beliefs and prescribed treatment 3. Interrupted family processes related to a shift in family roles secondary to demands of illness 4. Impaired verbal communication related to recent immigration from non-English-speaking area Answer: 4 Explanation: 1. This is an appropriate care plan that does not bring any cultural bias into play. 2. This is an appropriate care plan that takes into account that medical care is not always in line with cultural beliefs without bringing any bias into the situation. 3. This is an appropriate care plan that does not bring any cultural bias into play. 4. The phrase "impaired verbal communication" might be offensive because speaking a different language is not equivalent to being impaired. Fear, spiritual distress, and interrupted family processes are not culturally biased problems. Page Ref: 24 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Diagnosis; Culture and Spirituality Learning Outcome: 2.5 Discuss the use of a cultural assessment tool as a means of providing culturally sensitive care.

9) The nurse is working in a clinic where children from several cultures are seen. Which action should the nurse take as a first step toward the goal of personal cultural competence? 1. Enhance cultural skills 2. Gain cultural awareness 3. Seek cultural encounters 4. Acquire cultural knowledge Answer: 2 Explanation: 1. This is not the best answer, as the starting point will be gaining cultural awareness; and then you can move on to the other skills including enhancing cultural skills. 2. Without cultural awareness, healthcare providers tend to project their own cultural responses onto foreign-born clients; clients from different socioeconomic, religious, or educational groups; or clients from different regions of the country. 3. Gaining cultural encounters will come in time as you work in the clinic but is not the starting point toward gaining personal cultural competency. 4. This is not the best answer, as the starting point will be gaining cultural awareness; and then you can move on to the other skills including acquiring cultural knowledge. Page Ref: 21 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 3.5 Demonstrate advocacy strategies. | NLN Competencies: Context and Environment; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning; Culture and Spirituality Learning Outcome: 2.5 Discuss the use of a cultural assessment tool as a means of providing culturally sensitive care.

10) The nurse is working with a child whose religious beliefs differ from those of the general population. Which action should the nurse take to meet the specific spiritual needs of this child and family? 1. Ask, "What do you think caused the child's illness?" 2. Show respect while allowing time and privacy for religious rituals. 3. Identify healthcare practices forbidden by religious or spiritual beliefs. 4. Ask, "How do the child's and family's religious/spiritual beliefs impact their practices for health and illness?" Answer: 2 Explanation: 1. Questioning the patient and/or family regarding religious reasoning around illness is not necessary to meet the needs of the patient and family. 2. Whenever possible, the nurse should accommodate religious rituals and practices requested by the family. Asking questions about the illness or religious/spiritual beliefs will not necessarily support the spiritual needs of the child and family. Identifying healthcare practices that are forbidden by the religious beliefs will not support the spiritual needs of the child and family. 3. Asking about forbidden practices may or may not support the spiritual needs of the patient, and so is not the best answer to this question. 4. This is a good question to analyze, as the practitioner is caring for the patient but is not necessarily needed for support of the patient and family's spirituality. Page Ref: 20 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation; Culture and Spirituality Learning Outcome: 2.6 Identify key considerations in providing spiritually sensitive care.

11) The nurse notes a general increase in clients' use of complementary and alternative therapies. Which reason should the nurse identify for the increase in these therapies? Select all that apply. 1. Increased media attention 2. The advent of the Internet 3. Increased international travel 4. The use of traditional Western medicine for treatment 5. Increased consumer awareness of the limitations of conventional medicine Answer: 1, 2, 3, 5 Explanation: 1. Increased media attention has spotlighted complementary and alternative therapies. 2. The advent of the Internet has made obtaining complementary and alternative therapies easier. 3. Increased international travel has increased the awareness of complementary and alternative therapies. 4. Traditional Western medicine typically does not have a place for complementary and alternative therapies. 5. Increased consumer awareness of the limitations of current conventional medicine has increased the awareness of complementary and alternative therapies Page Ref: 25 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.7 Differentiate between complementary and alternative therapies.

12) The nurse is reviewing a client's use of complementary and alternative therapies. Which situations should the nurse identify as being risky for the client? Select all that apply. 1. Trying out a homeopathic medicine obtained from a friend to reduce swelling in the legs 2. Joining a group that practices tai chi weekly to help with physical fitness and movement 3. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain 4. Getting a massage from a licensed massage therapist for back pain, when such treatment has been prescribed by the primary healthcare provider 5. Getting a chiropractic treatment for lower back pain due to discomforts of pregnancy without telling the primary healthcare provider Answer: 1, 3, 5 Explanation: 1. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky. Trying a homeopathic medicine obtained from a friend to reduce swelling in the legs would be risky for any client. 2. Tai chi has many benefits for the individual using it, including flexibility and low-impact physical exercise. 3. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky. Taking an herbal preparation suggested by a health food store worker for treatment of leg pain would be risky for the client. 4. This is not a concern, as it was prescribed by a practitioner. 5. Lack of standardization, lack of regulation and research to substantiate their safety and effectiveness, and inadequate training and certification of some healers make some therapies risky. Getting a chiropractic treatment for lower back pain due to discomforts of pregnancy without telling the primary healthcare provider would be risky for the pregnant client. Page Ref: 25 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.8 Determine the benefits and risks of complementary and alternative therapies.

13) A pregnant client is interested in using herbs during her pregnancy. In which way should the nurse counsel this client? Select all that apply. 1. Do not take any herbs with other medication. 2. Refer to the list to learn which herbs to avoid during pregnancy. 3. Most herbs are harmless and can be safely taken while pregnant. 4. Refer to the list to learn which herbs to avoid during breastfeeding. 5. Consult with your healthcare provider before taking any herbs, even as teas. Answer: 1, 2, 4, 5 Explanation: 1. Certain herbs may interact with some prescribed medications, and should not be used. 2. Lists identifying common herbs that women are advised to avoid or use with caution during pregnancy are available. 3. Many herbal remedies have multiple contraindications, so it is important to discuss all of them with a healthcare provider. 4. Lists identifying common herbs that women are advised to avoid or use with caution during lactation are available. 5. Pregnant and lactating women interested in using herbs are best advised to consult with their healthcare provider before taking any herbs, even as teas. Page Ref: 26 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.9 Summarize complementary therapies appropriate for the nurse to use with childbearing and childrearing families.

14) A client says that she is taking a preparation that enhances the symptoms of her illness. Which type of complementary and alternative therapy is this client using? 1. Naturopathy 2. Homeopathy 3. Herbal therapy 4. Chinese medicine Answer: 2 Explanation: 1. Naturopathy is focused on healing, not on bringing the illness in or enhancing it. 2. Homeopathy is a healing approach in which a sick person is treated with small doses of medicines that would cause illness when given to someone who is healthy. Naturopathy focuses on the healing forces of nature. Herbal therapy uses herbs to treat symptoms and illnesses. Chinese medicine focuses on the balance of energy. 3. Herbal therapy is used to reduce symptoms with herbs. 4. Chinese medicine is used to bring balance to the body like the yin and yang. Page Ref: 25 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.9 Summarize complementary therapies appropriate for the nurse to use with childbearing and childrearing families.

15) The nurse is preparing to assess a client who is from a non-English-speaking culture. Which aspects of the client's culture should the nurse review before beginning the assessment? Select all that apply. 1. Touch 2. Employment 3. Personal space 4. Physical differences 5. Use of nonverbal communication Answer: 1, 3, 4, 5 Explanation: 1. . The appropriateness of touch varies according to culture. 2. Employment has no bearings on the cultural influence during an assessment of a patient. 3. An individual's sense of personal space may be culturally based. 4. Genetic and physical differences occur among cultural groups and can lead to disparity in needs and care. 5. Gestures and body language can be culturally based; this can lead to misunderstanding or misinterpretation. Page Ref: 21-23 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment; Culture and Spirituality Learning Outcome: 2.5 Discuss the use of a cultural assessment tool as a means of providing culturally sensitive care.

16) The nurse is preparing a teaching session for staff nurses on cultural influences of childbearing practices. Which topics should the nurse include? Select all that apply. 1. Gender of children 2. Number of children 3. Use of contraception 4. Achievement of developmental milestones 5. Pregnancy as an illness or expected condition Answer: 1, 2, 3, 5 Explanation: 1. In some cultures, a woman who gives birth achieves a higher status, especially if the child is male. 2. In many cultures throughout the world, it is common to have as many children as possible. 3. Culture may also influence attitudes and beliefs about contraception. In some cultures, contraception is appropriate but sterilization is not. 4. Cultural influences have no bearing on the achievement of developmental milestones. These are standard for most children and are not influenced by childbearing practices. 5. Certain behaviors can be expected if a culture views pregnancy as a sickness, whereas other behaviors can be expected if the culture views pregnancy as a natural occurrence. Page Ref: 20 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship Centered; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Planning; Culture and Spirituality; Teaching/Learning Learning Outcome: 2.3 Identify prevalent cultural norms related to childbearing and childrearing.

17) A pregnant client wants natural childbirth and asks what approaches can be used to keep the mind and body relaxed during labor. Which mind-based therapies should the nurse review with this client? Select all that apply. 1. Qigong 2. Massage 3. Hypnosis 4. Visualization 5. Guided imagery Answer: 3, 4, 5 Explanation: 1. Qigong is a type of martial arts and is not a mind-based therapy. 2. Massage is a therapeutic touch not a mind-based therapy. 3. Hypnosis is a state of great mental and physical relaxation during which a person is very open to suggestions. Pregnant women who receive hypnosis before childbirth have reported shorter, less painful labors and births. 4. Visualization is a complementary therapy in which a person goes into a relaxed state and focuses on, or "visualizes," soothing or positive scenes such as a beach or a mountain glade. Visualization helps reduce stress and encourage relaxation. 5. Guided imagery is a state of intense, focused concentration used to create compelling mental images. It is sometimes considered a form of hypnosis. Page Ref: 25 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship Centered; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Nursing Process: Planning; Teaching/Learning Learning Outcome: 2.7 Differentiate between complementary and alternative therapies.

18) The maternity nurse is planning to incorporate complementary and alternative therapies when providing care to clients in labor. Which action should the nurse take before implementing these therapies? Select all that apply. 1. Find evidence-based research for the use of the therapies. 2. Identify the therapies that are within the scope of nursing practice. 3. Document the use of therapies within the context of nursing practice. 4. List the therapies that are permitted according to the nurse practice act. 5. Determine which therapies are appropriate for a client's health problem. Answer: 1, 2, 3, 4 Explanation: 1. The use of complementary and alternative therapies should also be supported by evidence-based research. 2. Nurses should use complementary modalities that are in the scope of their nursing practice. 3. Nurses who use complementary modalities should document their use within the context of nursing practice. This is most effective when the modality is identified as an intervention to address a specific nursing diagnosis or an identified client need. 4. Nurses should use complementary modalities that are in the nursing practice act in their state. 5. Nurses cannot diagnose patients, so they cannot determine what therapy will meet the needs of the health issues of the patients. Page Ref: 27 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.9 Summarize complementary therapies appropriate for the nurse to use with childbearing and childrearing families.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 3 Genetic and Genomic Influences in Maternal, Newborn, and Child Health 1) The nurse is reviewing the process of mitosis with a group of young adults attending a family planning seminar. Which information should the nurse include when explaining the role of mitosis? Select all that apply. 1. Replaces lost skin cells. 2. Ensures rapid cell growth in early life. 3. Results in the formation of sperm and ova. 4. Maintains cells for respiratory functioning. 5. Ensures continuity of cells in the gastrointestinal tract. Answer: 1, 2, 4, 5 Explanation: 1. Mitosis replaces cells lost daily from skin surfaces. 2. Mitosis is responsible for rapid human growth in early life. 3. Mitosis is responsible for replacing cells lost daily from the lining of the respiratory tract. 4. Mitosis replaces cells lost daily from the lining of the gastrointestinal tract. 5. Mitosis is not involved in the formation of sperm and ova. Page Ref: 31 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.1 Understand foundational concepts of genetics and genomics, including how DNA influences health and illness.

2) After genetic testing, a patient is suspected of having mitochondrial gene alteration. When reviewing the test result with the patient, which body systems are noted as being affected by this alteration? Select all that apply. 1. Brain 2. Renal 3. Cardiac 4. Genitourinary 5. Musculoskeletal Answer: 1, 3, 5 Explanation: 1. Clinical manifestations occurring as a result of mitochondrial gene alterations primarily affect high-energy tissues such as the brain. 2. Mitochondrial gene alteration does not affect kidneys or genitourinary tissue. 3. Clinical manifestations occurring as a result of mitochondrial gene alterations primarily affect high-energy tissues such as cardiac muscle. 4. Mitochondrial gene alteration does not affect kidneys or genitourinary tissue. 5. Clinical manifestations occurring as a result of mitochondrial gene alterations primarily affect high-energy tissues, such as skeletal muscle. Page Ref: 34 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.1 Understand foundational concepts of genetics and genomics, including how DNA influences health and illness.

3) Through genetic testing, a patient is found to have a germline variant of a specific gene. What information about this finding should be reviewed with the patient? 1. No children will have the variant. 2. All future children will have the variant. 3. Only male children will have the variant. 4. Only female children will have the variant. Answer: 2 Explanation: 1. Hereditary variants are passed to offspring from one or both parents and are also known as germline variants because the variant exists in the reproductive cells or gametes. The DNA in every cell of that offspring will have the variant, which can then be transmitted to following generations. 2. Hereditary variants are passed to offspring from one or both parents and are also known as germline variants because the variant exists in the reproductive cells or gametes. The DNA in every cell of that offspring will have the variant, which can then be transmitted to following generations. 3. Hereditary variants are passed to offspring from one or both parents and are also known as germline variants because the variant exists in the reproductive cells or gametes. The DNA in every cell of that offspring will have the variant, which can then be transmitted to following generations. 4. Hereditary variants are passed to offspring from one or both parents and are also known as germline variants because the variant exists in the reproductive cells or gametes. The DNA in every cell of that offspring will have the variant, which can then be transmitted to following generations. Page Ref: 34 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.2 Explain mechanisms by which alterations in DNA cause disease.

4) A patient learns that Huntington disease has occurred in some family members. Which type of genetic anomaly should the nurse explain as causing this disorder? 1. Somatic variant 2. Germline variant 3. Single gene variant 4. Trinucleotide repeat expansion Answer: 1 Explanation: 1. Somatic mutations are DNA alterations that occur in an individual at any time throughout a lifetime after fertilization. They result from errors during cell division (mitosis) or from environmental influences such as radiation, toxins, or viral infections and are not passed from one generation to another. 2. Somatic mutations are DNA alterations that occur in an individual at any time throughout a lifetime after fertilization. They result from errors during cell division (mitosis) or from environmental influences such as radiation, toxins, or viral infections and are not passed from one generation to another. 3. Somatic mutations are DNA alterations that occur in an individual at any time throughout a lifetime after fertilization. They result from errors during cell division (mitosis) or from environmental influences such as radiation, toxins, or viral infections and are not passed from one generation to another. 4. Somatic mutations are DNA alterations that occur in an individual at any time throughout a lifetime after fertilization. They result from errors during cell division (mitosis) or from environmental influences such as radiation, toxins, or viral infections and are not passed from one generation to another. Page Ref: 34 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.2 Explain mechanisms by which alterations in DNA cause disease.

5) A pregnant patient is scheduled for fetal genetic testing to determine the presence of multifactorial disorders. Which health problem can occur in the fetus from this type of genetic anomaly? Select all that apply. 1. Autism 2. Asthma 3. Cleft lip 4. Scoliosis 5. Cleft palate Answer: 1, 2, 3, 5 Explanation: 1. The term multifactorial implies genetic effect of the environment on genetic expression. Most diseases and health conditions are polygenic, and the expression of those altered genes is often modified by environmental influences. Such conditions are said to be multifactorial and include the pediatric condition autism. 2. The term multifactorial implies genetic effect of the environment on genetic expression. Most diseases and health conditions are polygenic, and the expression of those altered genes is often modified by environmental influences. Such conditions are said to be multifactorial and include the pediatric condition asthma. 3. The term multifactorial implies genetic effect of the environment on genetic expression. Most diseases and health conditions are polygenic, and the expression of those altered genes is often modified by environmental influences. Such conditions are said to be multifactorial and include cleft lip. 4. Scoliosis is not identified as a multifactorial disorder. 5. The term multifactorial implies genetic effect of the environment on genetic expression. Most diseases and health conditions are polygenic, and the expression of those altered genes is often modified by environmental influences. Such conditions are said to be multifactorial and include cleft palate. Page Ref: 34 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3 Distinguish between single-gene (Mendelian) and multifactorial diseases and health conditions.

6) The nurse notes that a patient is admitted for treatment of a disease caused by a singlenucleotide genetic disorder. For which health problem should the nurse plan care for this patient? 1. Cancer 2. Heart disease 3. Sickle cell anemia 4. Huntington disease Answer: 3 Explanation: 1. Alterations, as small as a single-nucleotide change, are known to cause disease. Sickle cell disease is such a disorder. Cancer, heart disease, and Huntington disease are not caused by a single-nucleotide change. 2. Alterations, as small as a single-nucleotide change, are known to cause disease. Sickle cell disease is such a disorder. Cancer, heart disease, and Huntington disease are not caused by a single-nucleotide change. 3. Alterations, as small as a single-nucleotide change, are known to cause disease. Sickle cell disease is such a disorder. Cancer, heart disease, and Huntington disease are not caused by a single-nucleotide change. 4. Alterations, as small as a single-nucleotide change, are known to cause disease. Sickle cell disease is such a disorder. Cancer, heart disease, and Huntington disease are not caused by a single-nucleotide change. Page Ref: 34 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.3 Distinguish between single-gene (Mendelian) and multifactorial diseases and health conditions.

7) Through genetic testing, a homosexual male learns of having two copies of a gene deleted in gene CCR5. Which information should the nurse prepare to discuss with this patient? Select all that apply. 1. Safe sexual practices 2. Reduced risk of contracting HIV 3. Increased risk of contracting HIV 4. Expectation to develop AIDS quickly 5. Delayed conversion of HIV to AIDS Answer: 1, 2 Explanation: 1. Even though persons who have two copies of the altered CCR5 gene are almost completely resistant to infection with HIV type 1, the patient should still be reminded of safe sexual practices. 2. Persons who have two copies of the altered CCR5 gene are almost completely resistant to infection with HIV type 1. 3. The patient is not at increased risk for contracting HIV. AIDS will not develop quickly nor will there be a delayed conversion of HIV to AIDS. 4. The patient is not at increased risk for contracting HIV. AIDS will not develop quickly nor will there be a delayed conversion of HIV to AIDS. 5. The patient is not at increased risk for contracting HIV. AIDS will not develop quickly nor will there be a delayed conversion of HIV to AIDS. Page Ref: 35 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.3 Distinguish between single-gene (Mendelian) and multifactorial diseases and health conditions.

8) The nurse notes that a patient has the following genetic pedigree:

Which information would be important for the nurse to discuss with the patient about this pedigree? Select all that apply. 1. The condition may skip a generation. 2. Both males and females are affected. 3. There is no male-to-male inheritance. 4. More males will be affected than females. 5. An affected male will have all carrier daughters.

Answer: 3, 4, 5 Explanation: 1. This condition will not skip a generation and both males and females will not be affected. 2. This condition will not skip a generation and both males and females will not be affected. 3. This is a diagram of X-linked inheritance. There is no male-to-male inheritance with this pattern. 4. This is a diagram of X-linked inheritance. More males will be affected than females with this pattern. 5. This is a diagram of X-linked inheritance. An affected male will have all carrier daughters with this pattern. Page Ref: 37 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.4 Identify characteristics of common inheritance patterns of single-gene (Mendelian) conditions.

9) From genetic testing, a patient learns of having a Y-linked genetic disorder. Which health problem would be explained by this finding? 1. Infertility 2. Hemophilia A 3. Beta-thalassemia 4. Tay-Sachs disease Answer: 1 Explanation: 1. Because the Y chromosome has very few genes, alterations on the Y chromosome are not often associated with health problems. The Y chromosome does contain genes associated with spermatogenesis, and alterations in those genes can cause male infertility. 2. Because the Y chromosome has very few genes, alterations on the Y chromosome are not often associated with health problems. The Y chromosome does contain genes associated with spermatogenesis, and alterations in those genes can cause male infertility. 3. Because the Y chromosome has very few genes, alterations on the Y chromosome are not often associated with health problems. The Y chromosome does contain genes associated with spermatogenesis, and alterations in those genes can cause male infertility. 4. Because the Y chromosome has very few genes, alterations on the Y chromosome are not often associated with health problems. The Y chromosome does contain genes associated with spermatogenesis, and alterations in those genes can cause male infertility. Page Ref: 37 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4 Identify characteristics of common inheritance patterns of single-gene (Mendelian) conditions.

10) Two family members are diagnosed with the same genetic disorder but have distinctly different manifestations. Which reason should the nurse consider for this occurrence? 1. Imprinting 2. Penetrance 3. New mutation 4. Variable expression Answer: 1 Explanation: 1. The expression of a few genetic conditions varies depending on whether the altered gene is inherited from the mother or the father. This differential gene expression is due to genomic imprinting. Imprinting takes place before gametes are formed, when certain genes are chemically marked as having maternal or paternal origin. After conception, the imprint controls gene expression so that only one allele, either maternal or paternal, is expressed. If the unsilenced (active) allele carries a mutation, disease may result and the diseases may be different. The occurrence is not caused by penetrance, a new mutation, or variable expression. 2. The expression of a few genetic conditions varies depending on whether the altered gene is inherited from the mother or the father. This differential gene expression is due to genomic imprinting. Imprinting takes place before gametes are formed, when certain genes are chemically marked as having maternal or paternal origin. After conception, the imprint controls gene expression so that only one allele, either maternal or paternal, is expressed. If the unsilenced (active) allele carries a mutation, disease may result and the diseases may be different. The occurrence is not caused by penetrance, a new mutation, or variable expression. 3. The expression of a few genetic conditions varies depending on whether the altered gene is inherited from the mother or the father. This differential gene expression is due to genomic imprinting. Imprinting takes place before gametes are formed, when certain genes are chemically marked as having maternal or paternal origin. After conception, the imprint controls gene expression so that only one allele, either maternal or paternal, is expressed. If the unsilenced (active) allele carries a mutation, disease may result and the diseases may be different. The occurrence is not caused by penetrance, a new mutation, or variable expression. 4. The expression of a few genetic conditions varies depending on whether the altered gene is inherited from the mother or the father. This differential gene expression is due to genomic imprinting. Imprinting takes place before gametes are formed, when certain genes are chemically marked as having maternal or paternal origin. After conception, the imprint controls gene expression so that only one allele, either maternal or paternal, is expressed. If the unsilenced (active) allele carries a mutation, disease may result and the diseases may be different. The occurrence is not caused by penetrance, a new mutation, or variable expression. Page Ref: 38 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4 Identify characteristics of common inheritance patterns of single-gene (Mendelian) conditions.

11) The nurse suspects that a pregnant patient will be scheduled for chorionic villi sampling (CVS). Which assessment data did the nurse use to make this clinical determination? Select all that apply. 1. Patient age 39 years 2. Patient carrying twins 3. Fetus at 10 weeks' gestation 4. Patient has an X-linked disorder 5. Patient has a history of smoking Answer: 1, 3, 4 Explanation: 1. Invasive diagnostic testing is frequently targeted to women who are over the age of 35. Chorionic villi sampling can be performed after 9 weeks' gestation. Invasive diagnostic testing is frequently targeted to women who have an X-linked disorder. 2. Invasive diagnostic testing is frequently targeted to women who are over the age of 35. Chorionic villi sampling can be performed after 9 weeks' gestation. Invasive diagnostic testing is frequently targeted to women who have an X-linked disorder. 3. Invasive diagnostic testing is frequently targeted to women who are over the age of 35. Chorionic villi sampling can be performed after 9 weeks' gestation. Invasive diagnostic testing is frequently targeted to women who have an X-linked disorder. 4. Invasive diagnostic testing is frequently targeted to women who are over the age of 35. Chorionic villi sampling can be performed after 9 weeks' gestation. Invasive diagnostic testing is frequently targeted to women who have an X-linked disorder. 5. Invasive diagnostic testing is frequently targeted to women who are over the age of 35. Chorionic villi sampling can be performed after 9 weeks' gestation. Invasive diagnostic testing is frequently targeted to women who have an X-linked disorder. Page Ref: 41-42 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.5 Describe the uses, implications, and limitations of various prenatal and postnatal types of genetic tests that are offered to childbearing families and children, distinguishing between screening and diagnostic tests.

12) A genetic screening test completed on a newborn is found to be positive. Which action should the nurse expect for this infant? 1. Scheduling for diagnostic testing 2. Discussing the need for major intervention 3. Nothing, since further action is not necessary 4. Instructing the parents on expression of the genetic disorder Answer: 1 Explanation: 1. Each positive screening test must be followed by a diagnostic test. Major interventions are not discussed until testing is complete. Further action is needed. Instruction will be provided after the disorder is identified. 2. Each positive screening test must be followed by a diagnostic test. Major interventions are not discussed until testing is complete. Further action is needed. Instruction will be provided after the disorder is identified. 3. Each positive screening test must be followed by a diagnostic test. Major interventions are not discussed until testing is complete. Further action is needed. Instruction will be provided after the disorder is identified. 4. Each positive screening test must be followed by a diagnostic test. Major interventions are not discussed until testing is complete. Further action is needed. Instruction will be provided after the disorder is identified. Page Ref: 47 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.5 Describe the uses, implications, and limitations of various prenatal and postnatal types of genetic tests that are offered to childbearing families and children, distinguishing between screening and diagnostic tests.

13) Healthcare providers strongly suggest that a patient undergo genetic testing before becoming pregnant. Which action should the nurse take to ensure this patient's informed consent and confidentiality? Select all that apply. 1. Explain potential societal impact. 2. Discuss risks and benefits of the test. 3. Explain that all genetic testing is voluntary. 4. Review potential physical or psychologic harm. 5. Expect that results are to be shared with family. Answer: 1, 2, 3, 4 Explanation: 1. It is the nurse's responsibility to ensure that the consent process includes discussion of the potential societal injury due to stigmatization or discrimination. 2. It is the nurse's responsibility to ensure that the consent process includes discussion of the risks and benefits of the test. 3. All genetic testing should be voluntary. 4. It is the nurse's responsibility to ensure that the consent process includes discussion of any physical or psychologic harm. 5. It is up to the patient to share the findings with the family. Page Ref: 48 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6 Explain ways that nurses can advocate for and support patients and families undergoing genetic testing.

14) The staff development trainer is preparing content on the psychologic implications of genetic testing for a group of neonatal intensive care nurses. Which information should the trainer include in this instruction? Select all that apply. 1. Survivor guilt of other nonaffected children 2. Feelings of unworthiness and altered self-image 3. Carrier status interfering with relationships 4. Formation of higher expectations for the child 5. Stress of uncertainty while waiting for test results Answer: 1, 2, 3, 5 Explanation: 1. Survivor guilt may affect children with negative results if their siblings are positive. 2. A positive test result may lead to feelings of unworthiness and may disturb self-image. 3. Concerns about carrier status may interfere with development of intimacy and interpersonal relationships. 4. Uncertainty and stress associated with making a decision to undertake genetic testing may extend into weeks or even months before results are available. 5. Formation of expectations for the child is not a part of the training. Page Ref: 49 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 3.6 Explain ways that nurses can advocate for and support patients and families undergoing genetic testing.

15) A patient asks why a genetic pedigree is being prepared. Which response would be appropriate? Select all that apply. 1. Illustrates patterns of inheritance. 2. Reduces the cost for genetic diagnostic testing. 3. Provides guidance for reproductive risk teaching. 4. Identifies appropriate diagnostic tests for the patient. 5. Identifies family members who would benefit from genetic counseling. Answer: 1, 3, 5 Explanation: 1. A pedigree can illustrate patterns of inheritance. 2. On the basis of the pedigree, reproductive risk teaching for the individual and family can occur. 3. A pedigree identifies family members who might benefit from a genetic consultation. 4. A pedigree does not reduce the cost for genetic testing. 5. A pedigree does not identify diagnostic tests for the patient. Page Ref: 43 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.7 Describe the role of the nurses in assessing and communicating genetic risk, including eliciting a family history, creating a genetic pedigree, and incorporating understanding of genetics into physical assessment.

16) The nurse determines that a newborn has a minor genetic anomaly. Which finding did the nurse most likely assess in this infant? Select all that apply. 1. Broad face 2. Wide-set eyes 3. Single palmar crease 4. Low anterior hairline 5. Upward-slanting eyes Answer: 1, 2, 3, 4 Explanation: 1. Minor anomalies include a broad face. 2. Minor anomalies include wide-set eyes. 3. Minor anomalies include single palmar crease. 4. Minor anomalies include low anterior hairline. 5. Some ethnic groups have upward-slanting eyes as a facial expectation. Page Ref: 44 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.7 Describe the role of the nurses in assessing and communicating genetic risk, including eliciting a family history, creating a genetic pedigree, and incorporating understanding of genetics into physical assessment.

17) The nurse is reviewing a list of families scheduled for clinic visits. Which family would benefit from genetic counseling? 1. Family who has a child with cystic fibrosis 2. Family whose youngest child is overweight 3. Family whose oldest child wears eyeglasses 4. Family who has a neighbor with Down syndrome Answer: 1 Explanation: 1. Any couple who has had a child with a chromosomal abnormality may be at increased risk of having another child similarly affected. Genetic counseling would not be recommended for a weight or an eye problem. It would also not be recommended for a family with a person with Down syndrome. 2. Any couple who has had a child with a chromosomal abnormality may be at increased risk of having another child similarly affected. Genetic counseling would not be recommended for a weight or an eye problem. It would also not be recommended for a family with a person with Down syndrome. 3. Any couple who has had a child with a chromosomal abnormality may be at increased risk of having another child similarly affected. Genetic counseling would not be recommended for a weight or an eye problem. It would also not be recommended for a family with a person with Down syndrome. 4. Any couple who has had a child with a chromosomal abnormality may be at increased risk of having another child similarly affected. Genetic counseling would not be recommended for a weight or an eye problem. It would also not be recommended for a family with a person with Down syndrome. Page Ref: 43 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.8 Identify children or families who might benefit from genetic information and services or referral to a genetic professional, and explain the nurse's role in supporting the family undergoing genetic counseling.

18) A family is scheduled for a genetic consultation. Which information should the nurse explain to the family about this appointment? Select all that apply. 1. A diagnosis will be made. 2. Photographs may be taken. 3. An interview will be conducted. 4. A geneticist will examine the child. 5. The appointment can last several hours. Answer: 2, 3, 4, 5 Explanation: 1. Photos may be taken. 2. An interview will be done with the parents and the child. 3. A geneticist will examine the child and possibly the parents. 4. The initial visit can last several hours. 5. A diagnosis will not be made during a consultation. Page Ref: 49-50 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.8 Identify children or families who might benefit from genetic information and services or referral to a genetic professional, and explain the nurse's role in supporting the family undergoing genetic counseling.

19) A patient scheduled for genetic testing is concerned that an employer will learn about the testing and terminate the patient's employment. In which way should the nurse respond to this patient? 1. "There really is not anything that can be done." 2. "The insurance company has to report the testing to the employer." 3. "Your employer will have this information from the healthcare claim." 4. "There is a federal law prohibiting employers from using genetic information for employment purposes." Answer: 4 Explanation: 1. Federal legislation to prohibit discrimination based on genetic information in health insurance and employment (the Genetic Information Nondiscrimination Act [GINA]) was implemented in November 2009. As a federal law, GINA offers protection to Americans in all states. The insurance company does not report the testing to the employer nor will the employer have the information from the healthcare claim. 2. Federal legislation to prohibit discrimination based on genetic information in health insurance and employment (the Genetic Information Nondiscrimination Act [GINA]) was implemented in November 2009. As a federal law, GINA offers protection to Americans in all states. The insurance company does not report the testing to the employer nor will the employer have the information from the healthcare claim. 3. Federal legislation to prohibit discrimination based on genetic information in health insurance and employment (the Genetic Information Nondiscrimination Act [GINA]) was implemented in November 2009. As a federal law, GINA offers protection to Americans in all states. The insurance company does not report the testing to the employer nor will the employer have the information from the healthcare claim. 4. Federal legislation to prohibit discrimination based on genetic information in health insurance and employment (the Genetic Information Nondiscrimination Act [GINA]) was implemented in November 2009. As a federal law, GINA offers protection to Americans in all states. The insurance company does not report the testing to the employer nor will the employer have the information from the healthcare claim. Page Ref: 48 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.9 Discuss ethical, legal, and social implications of genomic healthcare.

20) The nurse learns that a patient from a different country and culture was married to her first cousin before moving to the United States. The couple is expecting their first child in 4 months. Which information should the nurse consider when counseling this patient? 1. Birth control 2. Carrier testing 3. Pregnancy termination 4. Legal issues in the United States Answer: 2 Explanation: 1. In many other cultures, marriage of first cousins and others who are related by blood is customary or even preferred. Genetic counseling involves identifying consanguinity and offering risk information, carrier testing, and nondirective counseling. It would be inappropriate to discuss birth control, pregnancy termination, or legal issues in the United States. 2. In many other cultures, marriage of first cousins and others who are related by blood is customary or even preferred. Genetic counseling involves identifying consanguinity and offering risk information, carrier testing, and nondirective counseling. It would be inappropriate to discuss birth control, pregnancy termination, or legal issues in the United States. 3. In many other cultures, marriage of first cousins and others who are related by blood is customary or even preferred. Genetic counseling involves identifying consanguinity and offering risk information, carrier testing, and nondirective counseling. It would be inappropriate to discuss birth control, pregnancy termination, or legal issues in the United States. 4. In many other cultures, marriage of first cousins and others who are related by blood is customary or even preferred. Genetic counseling involves identifying consanguinity and offering risk information, carrier testing, and nondirective counseling. It would be inappropriate to discuss birth control, pregnancy termination, or legal issues in the United States. Page Ref: 36 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.9 Discuss ethical, legal, and social implications of genomic healthcare.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 4 Health Promotion for Women 1) Which client should the nurse document as exhibiting signs and symptoms of primary dysmenorrhea? 1. 17-year-old, has never had a menstrual cycle 2. 19-year-old, regular menses for 5 years that have suddenly become painful 3. 14-year-old, irregular menses for 1 year, experiences cramping every cycle 4. 16-year-old, had regular menses for 4 years, but has had no menses in 4 months Answer: 3 Explanation: 1. This is primary amenorrhea, or the lack of menses. 2. Secondary dysmenorrhea is the sudden onset of pain and discomfort with menses. 3. Primary dysmenorrhea is when menstruation has been painful from the first menstrual cycle and consistently continues to be painful each month. 4. Secondary amenorrhea is the term used when a client has had regular cycles that cease. Page Ref: 58 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome.

2) A client asks, "Is it okay for me to use a vaginal douche each day when I'm on my period?" In which way should the nurse respond? 1. "Douching should be avoided when you're on your period." 2. "Regular douching is necessary in order to promote good hygiene." 3. "Using a douche each day will help prevent vaginal infections from occurring." 4. "During your period, douching will help promote the flow of menstrual secretions." Answer: 1 Explanation: 1. Women should avoid douching during menstruation because the cervix is dilated to permit the downward flow of menstrual fluids from the uterine lining. 2. Douching as a hygiene practice is unnecessary because the vagina cleanses itself. 3. Douching washes away the natural mucus and upsets the vaginal flora, which can make the vagina more susceptible to infection. 4. During menstruation, douching may interfere with downward flow of menstrual fluids from the uterine lining. Page Ref: 67 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.

3) Which recommendation should the gynecology clinic nurse make to the client experiencing premenstrual syndrome (PMS)? 1. "Increase your consumption of red meat when you feel symptoms, and eat three large meals per day." 2. "Engage in aerobic activity often throughout the month, and continue exercising when your symptoms begin." 3. "Decrease your dietary intake of dairy and soy slightly during the month, and especially during your days of bleeding." 4. "Eat more chocolate and drink more caffeine beginning a week prior to when your menstrual cycle bleeding should begin." Answer: 2 Explanation: 1. Decreased red meat consumption can be beneficial to reduce PMS symptoms, as will eating several small meals per day rather than three large meals. 2. Regular aerobic activity helps to decrease PMS symptoms. 3. 1200 mg of calcium per day can help decrease PMS symptoms. The calcium can either come from supplements or be obtained through dietary intake of dairy and soy products. 4. Chocolate and caffeine contain methylxanthines; therefore, intake of chocolate, coffee, and colas should be limited throughout the month. Page Ref: 59 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.2 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome.

4) A client comes to the clinic complaining of severe menstrual cramps. She has never been pregnant, has been diagnosed with ovarian cysts, and has had an intrauterine device (IUD) for 2 years. Which condition should the nurse suspect the client is experiencing? 1. Menorrhagia 2. Hypermenorrhea 3. Primary dysmenorrhea 4. Secondary dysmenorrhea Answer: 4 Explanation: 1. Menorrhagia is excessive, profuse flow. 2. Hypermenorrhea is an abnormally long menstrual flow. 3. Primary dysmenorrhea is defined as cramps without underlying disease. 4. Secondary dysmenorrhea is associated with pathology of the reproductive tract and usually appears after menstruation has been established. Conditions that most frequently cause secondary dysmenorrhea include ovarian cysts and the presence of an intrauterine device. Page Ref: 58 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2 Contrast the signs, symptoms, and nursing management of women with dysmenorrhea and those with premenstrual syndrome.

5) Which issues should the nurse consider when counseling a client on contraceptive methods? Select all that apply. 1. Age at menarche 2. Efficacy of the method 3. Future childbearing plans 4. Whether the client is a vegetarian 5. Cultural perspectives on menstruation and pregnancy Answer: 2, 3, 5 Explanation: 1. Age at menarche has no impact on contraceptive method use. 2. Efficacy of contraceptive methods varies and must be considered when discussing contraception with clients. When pregnancy is medically contraindicated, high-efficacy methods (such as an IUD, hormonal methods, or sterilization) should be discussed with the client. When the client would like to avoid pregnancy at this time, but pregnancy is not medically contraindicated, lower-efficacy methods (such as diaphragm, cervical cap, or Today sponge) could be discussed. 3. If a client desires children in the future, sterilization methods would be inappropriate to discuss. 4. Vegetarianism has no impact on contraceptive method use. 5. Cultural and religious beliefs, practices, and sanctions must be considered when discussing contraception with clients in order to avoid insulting a client for whom a particular type of contraceptive method is prohibited by her background. Page Ref: 60 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

6) A client has decided to use the NuvaRing vaginal contraceptive ring as her method of contraception. Which statement suggests the client needs further instruction? 1. "When I store my replacement rings, I should keep them in my refrigerator." 2. "The contraceptive ring provides a sustained release of low-dose contraceptive." 3. "Every 3 months, I will need to remove the contraceptive ring and replace it with a new one." 4. "I do not need to be examined in order to determine the contraceptive ring size that is correct for me." Answer: 3 Explanation: 1. Replacement rings should be kept in the refrigerator to maintain integrity. 2. The contraceptive ring provides a low-dose, sustained-release hormonal contraceptive. 3. The ring is left in place for 3 weeks and then removed for 1 week to allow for withdrawal bleeding. 4. One size of the NuvaRing fits virtually all women. Page Ref: 66 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 4.3 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today. 7) Which client should be counseling to avoid Depo-Provera (DMPA)? 1. One with a vaginal prolapse 2. One who weighs 200 pounds 3. One who wishes to breastfeed 4. One who wishes to get pregnant within 3 months Answer: 4 Explanation: 1. There is no correlation between a vaginal prolapse and use of Depo-Provera. 2. There is no correlation between one's weight and use of Depo-Provera. 3. Studies have proven there is no harm to a breastfed baby when a woman uses Depo-Provera. 4. Return of fertility after the use of Depo-Provera takes an average of 10 months. Page Ref: 67 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3 Compare the advantages, disadvantages, and effectiveness of the various methods of contraception available today.

8) A 16-year-old girl asks, "Do I need to have a Pap smear just because I'm sexually active?" Which response should the nurse make? 1. "No, you do not need to be screened for cervical cancer until you are 21 years old." 2. "Yes, all sexually active females should be screened for both cervical cancer and human papilloma virus (HPV)." 3. "Yes, all women under the age of 29 should be screened for both cervical cancer and human papilloma virus (HPV)." 4. "No, but you will need to begin your screenings for both cervical cancer and human papilloma virus (HPV) when you are 18 years old." Answer: 1 Explanation: 1. 2018 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend initiating cervical cancer screening at age 21. 2. Engaging in sexual activity is not an indication for routine cervical cancer or for HPV screening. 3. 2018 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend cervical cancer screening without HPV cotesting in women ages 21 to 29. 4. 2018 guidelines issued by the U.S. Preventive Services Task Force (USPSTF) recommend initiating cervical cancer screening at age 21. Page Ref: 71 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Identify basic gynecologic screening procedures indicated for well women.

9) A nurse provides a client with instructions regarding breast self-examination (BSE). Which client statements indicate an understanding of detecting lumps in the breast? Select all that apply. 1. "I should inspect my breasts to notice any changes." 2. "Knowing the texture and feel of my breasts is important." 3. "I should perform BSE 1 week prior to the start of my period." 4. "When I reach menopause, I will perform BSE every 2 months." 5. "I should inspect my breasts while in a supine position, with my arms at my sides." Answer: 1, 2 Explanation: 1. Inspecting the breasts to detect changes is recommended by the American College of Obstetricians and Gynecologists. 2. A woman who knows the texture and feel of her own breasts is far more likely to detect changes that develop. 3. BSE should be performed 1 week after the start of each menstrual period because hormonal levels are lowest and allow closer examination of softer breast tissue. 4. BSE should be performed monthly, on the same day each month, during menopause. 5. The breasts should be inspected while standing with arms at sides. Page Ref: 70 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 4.5 Identify basic gynecologic screening procedures indicated for well women. 10) Which finding indicates to the nurse that a client is experiencing menopause? 1. Hot flashes and night sweats 2. No menses for 8 consecutive months 3. High serum follicle-stimulating hormone (FSH) with low serum estrogen 4. Diagnosis of osteoporosis 4 months ago Answer: 3 Explanation: 1. Although hot flashes and night sweats are common in menopause, laboratory values or 12 months of amenorrhea are better indicators. 2. Menopause is defined as 12 months of amenorrhea. 3. Examining serum levels of the hormones FSH and estrogen is a very accurate indication of menopause. 4. Menopause is not the only cause of osteoporosis; therefore, the diagnosis of osteoporosis 4 months ago is not an indicator of menopause. Page Ref: 72 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.6 Delineate the physical and psychologic aspects of menopause. 8 Copyright © 2022 Pearson Education, Inc.

11) A 63-year-old female client requests information about complementary and alternative therapies that promote wellness during menopause. Which therapy should the nurse recommend? 1. Soy for reducing insomnia symptoms 2. Non-weight-bearing exercise, such as swimming 3. Calcium intake of 600 mg per day to help prevent osteoporosis 4. Increased consumption of phytoestrogens for women with a history of endometriosis or fibroids Answer: 1 Explanation: 1. Research suggests that isoflavones, which are found in soy, are effective in reducing symptoms of insomnia in postmenopausal women. 2. Weight-bearing exercises such as walking, jogging, tennis, and low-impact aerobics are encouraged in order to increase bone mass and decrease the risk of osteoporosis. 3. Perimenopausal and postmenopausal women are advised to have a calcium intake of at least 1200 mg per day. Most women require supplements to achieve this level. 4. Women who have endometriosis or fibroids should be cautioned about the use of phytoestrogens. Page Ref: 73 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.6 Delineate the physical and psychologic aspects of menopause.

12) The nurse is presenting a session on intimate partner violence. Which statement indicates a need for further education? 1. "The 'honeymoon period' follows an episode of violence." 2. "Everyone experiences anger and hitting in a relationship." 3. "Abusers can be either husbands or boyfriends or wives or girlfriends." 4. "My daughter is not to blame for the violence in her marriage." Answer: 2 Explanation: 1. An acute episode of battering is followed by the tranquil phase, or honeymoon period, when the abuser is often repentant and promising never to abuse the victim again. In some cases, the honeymoon period is the only time there is a lack of building tension. 2. Violence is not a normal part of intimate relationships. This statement indicates that the client has likely been a victim of domestic violence. 3. Abusers can be spouses or boyfriends or girlfriends. Intimate partner violence can be experienced in any intimate relationship, regardless of whether the couple is straight, gay, or lesbian, and both within marriage and outside of marriage. 4. The victims of violence are not the cause of the violence. Abusers are responsible for their violent behavior. Avoiding blaming and shaming of victims of domestic violence is important to establish a therapeutic relationship. Page Ref: 74 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 4.8 Describe the phases of the cycle of violence.

13) When a woman who has been raped is admitted to the emergency department, which nursing intervention has priority? 1. Contact family members. 2. Create a safe, secure atmosphere for the woman. 3. Assure the woman that everything will be all right. 4. Explain exactly what will need to be done to preserve legal evidence. Answer: 2 Explanation: 1. Contacting family members is not the top priority and can wait until a safe environment is established. 2. The first priority in caring for a survivor of a sexual assault is to create a safe, secure atmosphere that will allow the woman to process what has happened. 3. Assuring the woman that everything will be all right is not the top priority and is giving false promise. 4. Explaining exactly what will need to be done to preserve legal evidence is not the top priority. Page Ref: 78 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 5.2 Contribute to a culture of patient safety. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.10 Discuss the nurse's role in screening and caring for women who have experienced domestic violence or rape.

14) A middle school student comes to the nurse's office concerned about her menstrual flow. Which information should the nurse include when discussing menstruation with this student? Select all that apply. 1. A tub bath is helpful to promote blood flow and reduce cramping. 2. Show a variety of pads and tampons available for the student to use. 3. A fishy odor experienced during menstruation is expected and normal. 4. Demonstrate that the volume of blood lost during menstruation is about 1 to 2 ounces. 5. Wash the hands before and after using any feminine hygiene products for menstruation. Answer: 1, 2, 4, 5 Explanation: 1. A long, leisurely soak in a warm tub promotes menstrual blood flow and relieves cramps by relaxing the muscles. 2. If working with teens and preteens, keeping a variety of pads and tampons on hand helps these young girls become familiar with the options available for dealing with menstruation. 3. Conditions such as vaginitis produce a foul-smelling discharge that women often describe as having a "fishy" odor. This is not expected or normal. 4. The average flow is approximately 25 to 60 mL per period. 5. Because of the potential for developing an infection, a woman should wash her hands before inserting a fresh tampon and should avoid touching the tip of the tampon when unwrapping it or before insertion. Hand washing should also occur after using the commode. Page Ref: 57 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 4.1 Summarize information that women may need in order to implement appropriate self-care measures for dealing with menstruation.

15) During a health interview, the nurse determines that a client contemplating pregnancy would benefit from teaching on preconception health measures. Which information did the nurse use to make this clinical determination? Select all that apply. 1. Smokes one half of a pack per day of cigarettes. 2. Works in an industrial plant. 3. Drinks decaffeinated coffee. 4. Drinks 4 ounces red wine every evening. 5. Takes over-the-counter antacids as needed. Answer: 1, 2, 4, 5 Explanation: 1. One preconception health measure is smoking cessation. 2. One preconception health measure is identifying environmental hazards. 3. Avoiding caffeine several months before conception is a preconception health measure. 4. One preconception health measure is alcohol intake. 5. One preconception health measure is the use of over-the-counter medications. Page Ref: 69 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 4.4 Summarize major health measures to address in providing preconception counseling.

16) During a wellness visit, a young adult client asks for information regarding weight management and exercise prior to pregnancy. Which information should the nurse explain to this client? Select all that apply. 1. Reduce the intake of complex carbohydrates. 2. Achieve normal weight for height before conceiving. 3. Begin an exercise program a month before conceiving. 4. Select an exercise program to be followed throughout the pregnancy. 5. Reduce weight to below normal for height to compensate for pregnancy weight gain. Answer: 3, 4 Explanation: 1. No particular food group should be avoided for adequate nutritional status. 2. Before conception, it is advisable for the woman to be at an average weight for her body build and height. 3. A woman is advised to establish a regular exercise plan beginning at least 3 months before she plans to attempt to become pregnant. 4. The exercise should be one she enjoys and will continue. 5. Weight should not be reduced to an unhealthy level before conceiving. Page Ref: 70 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 4.4 Summarize major health measures to address in providing preconception counseling.

17) The nurse suspects that a home care client is experiencing the tension-building phase within the cycle of violence. Which observation caused the nurse to make this clinical determination? Select all that apply. 1. Spouse ignoring the client. 2. Spouse yelling at the client. 3. Client asking the nurse to leave. 4. Client apologizing to the spouse. 5. Spouse throwing items at the client. Answer: 2, 3, 4 Explanation: 1. During the tension-building phase of the cycle of violence, the batterer demonstrates power and control. Ignoring the client could occur during the tranquil loving phase. 2. During the tension-building phase of the cycle of violence, the batterer demonstrates power and control, which is characterized by anger and arguing. 3. During the tension-building phase of the cycle of violence, the batterer demonstrates power and control; however, the woman may believe the escalation of anger can be controlled by her own actions. Asking the nurse to leave would be a controllable action. 4. During the tension-building phase of the cycle of violence, the batterer demonstrates power and control; however, the woman may blame herself and apologize for her actions. 5. Throwing things at the client would occur during the acute battering incident. Page Ref: 75 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety; Practice; Encourage clients and families to communicate their observations and concerns regarding safety | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.8 Describe the phases of the cycle of violence. 18) The nurse is preparing a community education session on the stages of the rape trauma syndrome. In which order should the nurse explain the phases of this syndrome? 1. Buys a weapon. 2. Advocates for others. 3. Desires revenge and feels guilty. 4. Changes email address and phone number. Answer: 3, 1, 4, 2 Explanation: 1. Buying a weapon occurs during the outward adjustment phase. Page Ref: 77 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 4.9 Identify the phases of the rape trauma syndrome.

19) During a group session of rape trauma survivors, the nurse notes that one participant is in the reorganization phase of recovery. Which behavior did this participant demonstrate to cause the nurse to make this decision? Select all that apply. 1. Blames the assailant for the rape. 2. Asks what she did to deserve the attack. 3. Explains about constantly reliving the rape. 4. Asks when the nightmares are going to stop. 5. Talks about having one-night stands after bar hopping. Answer: 3, 4, 5 Explanation: 1. Blaming the assailant is a behavior consistent with the integration and recovery phase. 2. Asking what she did to deserve the attack is a characteristic of the acute phase. 3. Constantly reliving the rape or having flashbacks is a characteristic of the reorganization phase. 4. Experiencing nightmares is a characteristic of the reorganization phase. 5. Risky sexual behavior is a characteristic of the reorganization phase. Page Ref: 77 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.9 Identify the phases of the rape trauma syndrome. 20) The emergency room nurse is caring for a victim of sexual assault. Which pharmacologic intervention should the nurse prepare to discuss with the victim? Select all that apply. 1. Prophylactic analgesics 2. Postcoital contraceptive therapy 3. Prophylactic immunizations for tetanus 4. Postexposure prophylaxis with HIV antiviral medications 5. Prophylactic treatment for sexually transmitted infections (STIs) Answer: 2, 4, 5 Explanation: 1. Pain medications are not routinely required for this situation. 2. Postcoital contraceptive therapy should be offered to the victim. 3. Prophylactic tetanus immunization is not routinely required for this situation. 4. Postexposure prophylaxis with HIV antiviral medications should be offered to the victim. 5. Prophylactic treatment for STIs should be offered to the victim. Page Ref: 78 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.10 Discuss the nurse's role in screening and caring for women who have experienced domestic violence or rape. 16 Copyright © 2022 Pearson Education, Inc.

21) A client experiencing menopause asks what type of activities can be done to help alleviate the symptoms. Which activity should the nurse recommend to the client? Select all that apply. 1. Yoga 2. Cycling 3. Meditation 4. Acupuncture 5. Hydrotherapy Answer: 1, 3, 4, 5 Explanation: 1. Mind and body practices such as yoga have been found to ease or relieve some symptoms of menopause. 2. Cycling is not a mind and body practice used to ease or relieve symptoms of menopause. 3. Mind and body practices such as meditation have been found to ease or relieve some symptoms of menopause. 4. Mind and body practices such as acupuncture have been found to ease or relieve some symptoms of menopause. 5. Mind and body practices such as hydrotherapy have been found to ease or relieve some symptoms of menopause. Page Ref: 73 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 4.7 Identify medical and complementary therapies to alleviate the discomforts of menopause.

22) A client asks what can be done to prevent the development of osteoporosis once menopause begins. Which activity should the nurse suggest to this client? Select all that apply. 1. Tennis 2. Jogging 3. Cycling 4. Walking 5. Swimming Answer: 1, 2, 4 Explanation: 1. Weight-bearing exercises such as tennis help increase bone mass and decrease the risk of osteoporosis. 2. Weight-bearing exercises such as jogging help increase bone mass and decrease the risk of osteoporosis. 3. Cycling is not a weight-bearing exercise to help increase bone mass and decrease the risk of osteoporosis. 4. Weight bearing exercises such as walking help increase bone mass and decrease the risk of osteoporosis. 5. Swimming is not a weight-bearing exercise to help increase bone mass and decrease the risk of osteoporosis. Page Ref: 73 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 4.7 Identify medical and complementary therapies to alleviate the discomforts of menopause.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 5 Common Gynecologic Problems 1) The nurse is teaching a class to women who were recently diagnosed with benign breast disease (BBD), commonly known as fibrocystic breast disease. One of the participants reports increased swelling, pain, and pressure in her breasts just before menstruation. Which response should the nurse make? 1. "It's best to make an appointment with an oncologist." 2. "The pain may be caused by thinning of the normal breast tissue." 3. "Consider asking your healthcare provider about adding a mild analgesic to your regimen." 4. "Breast swelling and pressure are expected symptoms, but pain is abnormal and should be evaluated by your physician." Answer: 3 Explanation: 1. Cyclic breast pain, swelling, and tenderness are common symptoms associated with BBD. Generally, fibrocystic changes are not a risk factor for breast cancer. 2. The pathology of BBD involves fibrosis, which is a thickening of the normal breast tissue. 3. Treatment of BBD may include taking a mild analgesic to relieve the pain and pressure. 4. Common symptoms associated with BBD include cyclic breast pain, tenderness, and swelling. Page Ref: 92 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1 Contrast the contributing factors, signs and symptoms, treatment options, and nursing care management of women with common benign breast disorders.

2) The nurse is caring for a client diagnosed with endometriosis. Which statement by the client requires immediate follow-up? 1. "I've noticed my voice is lower since I started taking danazol." 2. "I am having many hot flashes since I had the Lupron injection." 3. "The pain I experience with intercourse is becoming more severe." 4. "My leg has become painful and swollen since I started taking birth control pills." Answer: 4 Explanation: 1. Danocrine (danazol) is a testosterone derivative that suppresses gonadotrophinreleasing hormone (GnRH) and has high-androgen and low-estrogen effects. A lowered voice is one side effect of danazol. This client is not experiencing a complication. 2. Leuprolide acetate (Lupron) is a GnRH agonist and causes symptoms of a hypoestrogenic state (hot flashes, vaginal dryness, decreased libido, and bone density loss). Hot flashes are expected and not a complication. 3. Dyspareunia is a common symptom of endometriosis and therefore is not a complication. 4. Combination oral contraceptive pills contain estrogen. A painful, swollen lower extremity can be a sign of deep vein thrombosis, which can cause thromboembolus, which is potentially life threatening. This is a complication and must be addressed immediately. Page Ref: 83 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.2 Explain the signs and symptoms, medical therapy, and implications for fertility of endometriosis. 3) The nurse is creating a care plan for a client who is unable to conceive as a consequence of endometriosis. Which problem should the nurse add to the client's plan of care? 1. Pain 2. Anxiety 3. Fluid imbalance 4. Problems with coping Answer: 1 Explanation: 1. Pelvic pain is a frequent symptom of endometriosis. 2. Anxiety is not identified as a problem in endometriosis. 3. Fluid imbalance is not identified as a problem in endometriosis 4. Problems with coping are not identified as an issue in endometriosis. Page Ref: 84 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.2 Explain the signs and symptoms, medical therapy, and implications for fertility of endometriosis. 2 Copyright © 2022 Pearson Education, Inc.

4) A client diagnosed with polycystic ovarian syndrome (PCOS) asks why spironolactone (Aldactone) has been prescribed. In which way should the nurse respond? 1. "Spironolactone is often used to reduce complications associated with PCOS, including rectocele." 2. "Menstrual irregularities related to polycystic ovarian disease are treated using spironolactone." 3. "Condylomata acuminata, which are sometimes caused by polycystic ovarian disease, are treated with spironolactone." 4. "Spironolactone may be used to decrease symptoms associated with PCOS, such as excessive hair growth and acne." Answer: 4 Explanation: 1. A rectocele, which may develop when the posterior vaginal wall is weakened, is associated with pelvic relaxation. 2. Combined oral contraceptive (COC) or cyclic progesterone is used to treat menstrual irregularities associated with PCOS. 3. Condylomata acuminata, also called genital or venereal warts, is a sexually transmitted condition unrelated to PCOS. 4. Spironolactone may be used to treat symptoms of hyperandrogenism that are secondary to PCOS, including excessive hair growth and acne. Page Ref: 84 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Discuss the signs and symptoms, treatment options, and health implications of polycystic ovarian syndrome (PCOS).

5) The nurse is planning a group session for parents who are beginning infertility evaluation. Which statements should be included in this session? Select all that apply. 1. "Infertility can be stressful for a marriage." 2. "Taking a vacation usually results in pregnancy." 3. "Your insurance will pay for the infertility treatments." 4. "The doctor will be able to tell why you have not conceived." 5. "Keep communicating with one another through this process." Answer: 1, 5 Explanation: 1. Infertility is often stressful on a marriage, as a result of the need to schedule intercourse and pay for treatments and the societal expectation to have children. 2. A common myth is that taking a vacation or just relaxing will result in conception. 3. Insurance often does not pay for infertility treatment. 4. Some infertility cannot be explained, despite extensive treatments. 5. Communication is important to help cope with stress. The nurse should always encourage clients to ask questions. Page Ref: 105 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.13 Relate the physiologic and psychologic effects of infertility on a couple to the nursing care management indicated for them.

6) Which statement indicates that client teaching about vaginal infections has been effective? 1. "The fishy vaginal odor I have is caused by a bacterial infection." 2. "I can use this antiyeast medication weekly to prevent another infection." 3. "My diabetes is unrelated to the frequency of my vaginal yeast infections." 4. "I should douche weekly to prevent a recurrence of my bacterial vaginosis." Answer: 1 Explanation: 1. Bacterial vaginosis is characterized by a fishy vaginal odor and greenish discharge with a vaginal pH over 4.5. 2. Medication for vaginal yeast infections should be used as treatment, not prophylaxis. Using medication as prescribed is important client education. Medication should not be saved for future use. 3. Yeast vaginitis is more common in diabetic and prediabetic women. Four episodes or more per year of yeast vaginitis are an indication to screen a woman for diabetes. 4. Douching disrupts normal flora by washing out desirable bacteria; douching is not recommended. Page Ref: 85 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 5.4 Compare the causes, signs and symptoms, treatment options, and nursing care for women with vulvovaginal candidiasis versus bacterial vaginosis.

7) Which client is at greatest risk for developing Chlamydia trachomatis infection? 1. 35-year-old woman on oral contraceptives 2. 22-year-old mother of two, developed dyspareunia 3. 16-year-old, sexually active, using no contraceptive 4. 48-year-old woman with hot flashes and night sweats Answer: 3 Explanation: 1. There is no correlation between oral contraceptive use and an increased rate of chlamydial infection. Additionally, chlamydial infection is more commonly seen in young women. 2. Dyspareunia sometimes develops with chlamydial infection, but dyspareunia is not a symptom specific to chlamydial infection. 3. Adolescents have the highest incidence of sexually transmitted infections, especially chlamydial infection. A client not using contraceptives is not using condoms, which decrease the risk of contracting a sexually transmitted infection (STI). 4. This client is experiencing signs of menopause, not chlamydial infection. Page Ref: 88 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5 Compare the common sexually transmitted infections with regard to their etiology, treatment options, nursing care, and methods of prevention. 8) A client with trichomoniasis is prescribed metronidazole (Flagyl). Which information should the nurse include when teaching about this medication? 1. "It will turn your urine orange." 2. "This medication could produce drowsiness." 3. "Both partners must be treated with the medication." 4. "Alcohol does not need to be avoided while taking this medication." Answer: 3 Explanation: 1. Metronidazole does not turn the urine orange. 2. Metronidazole does not cause drowsiness. 3. Both partners should be treated with the medication. 4. Alcohol should be avoided. Page Ref: 88 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 5.5 Compare the common sexually transmitted infections with regard to their etiology, treatment options, nursing care, and methods of prevention. 6 Copyright © 2022 Pearson Education, Inc.

9) The nurse reviews the consequences of not treating a chlamydial infection with a young couple. Which statements indicate that teaching has been effective? Select all that apply. 1. "She could become pregnant." 2. "It could cause us to develop rashes." 3. "She could have severe vaginal itching." 4. "She could develop a worse infection of the uterus and tubes." 5. "He could get an infection in the tube that carries the urine out." Answer: 4, 5 Explanation: 1. Chlamydial infection does not cause a woman to become pregnant. 2. Chlamydial infection does not cause a rash. 3. Chlamydial infection does not cause vaginal itching. 4. Chlamydial cervicitis can ascend and become pelvic inflammatory disease, or infection of the uterus, fallopian tubes, and sometimes ovaries. 5. Chlamydia trachomatis is a major cause of nongonococcal urethritis (NGU) in men. Page Ref: 88 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 5.5 Compare the common sexually transmitted infections with regard to their etiology, treatment options, nursing care, and methods of prevention. 10) Which client should be treated with ceftriaxone (Rocephin) IM and doxycycline (Vibramycin) by mouth? 1. A pregnant client with syphilis 2. A nonpregnant client with gonorrhea and chlamydial infection 3. A pregnant client with gonorrhea and a yeast infection 4. A nonpregnant client with chlamydial infection and trichomoniasis Answer: 2 Explanation: 1. Syphilis is treated with penicillin. 2. This combined treatment provides dual treatment for gonorrhea and chlamydial infection because the two infections frequently occur together. 3. Doxycycline is contraindicated during pregnancy. 4. Trichomoniasis is treated with metronidazole. Page Ref: 93 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.5 Compare the common sexually transmitted infections with regard to their etiology, treatment options, nursing care, and methods of prevention.

11) The nurse is preparing a brochure that compares and contrasts cystitis and pyelonephritis. Which information should be included in the brochure? 1. Urine culture is included in the evaluation of both cystitis and pyelonephritis. 2. Dysuria, especially at the end of urination, is often the initial symptom of both conditions. 3. Both conditions usually present with sudden onset of chills, high temperature, and flank pain. 4. Both conditions are associated with pregnancy complications including increased risk of preterm birth and of intrauterine growth restriction. Answer: 1 Explanation: 1. Diagnosis of cystitis is made with a urine culture. Women with acute pyelonephritis should have a urine culture and sensitivity done to determine the appropriate antibiotic. 2. The initial symptom of cystitis is often dysuria, specifically at the end of urination. 3. Acute pyelonephritis has a sudden onset, with chills, high temperature, and flank pain (either unilateral or bilateral). 4. Pyelonephritis during pregnancy is associated with an increased risk of preterm birth and intrauterine growth restriction. Page Ref: 95 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.8 Contrast the causes, signs and symptoms, treatment options, and nursing care for women with cystitis versus pyelonephritis.

12) The nurse is discharging a client after hospitalization for pelvic inflammatory disease (PID). Which statements indicate that teaching was effective? Select all that apply. 1. "Tubal pregnancy could occur after PID." 2. "My PID was caused by a yeast infection." 3. "It is important for me to finish my antibiotics." 4. "I might have infertility because of this infection." 5. "I am going to have an intrauterine device (IUD) placed for contraception." Answer: 3, 4 Explanation: 1. There is no evidence to support that PID increases the risk of tubal pregnancies. 2. PID is caused by bacteria, most commonly Chlamydia trachomatis or Neisseria gonorrhoeae. Yeast infections do not ascend and become upper reproductive tract infections. 3. Antibiotic therapy should always be completed when a client is diagnosed with any infection. 4. Women sometimes become infertile because of scarring in the fallopian tubes as a result of the inflammation of PID. 5. An IUD in place increases the risk of developing PID; a client who has a history of PID is not a good candidate for an IUD. Page Ref: 93 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 5.6 Summarize the pathology, signs and symptoms, treatment, nursing care, and implications for future fertility of pelvic inflammatory disease (PID). 13) Which diagnostic test should the nurse question if prescribed for a client with pelvic inflammatory disease (PID)? 1. RPR (rapid plasma reagin) 2. Throat culture for streptococcus A 3. Vaginal culture for Neisseria gonorrhoeae 4. CBC (complete blood count) with differential Answer: 2 Explanation: 1. RPR is a test for syphilis, another cause of PID. 2. Streptococcal infection of the throat is not associated with PID. 3. Gonorrhea is a common cause of PID, and the client should be tested for this. 4. CBC with differential will give an indication of the severity of the infection. Page Ref: 93 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.6 Summarize the pathology, signs and symptoms, treatment, nursing care, and implications for future fertility of pelvic inflammatory disease (PID). 9 Copyright © 2022 Pearson Education, Inc.

14) The nurse is explaining a client's abnormal Pap smear results. Which statement should the nurse include? 1. "Your cervix needs to be treated with cryotherapy." 2. "The Pap smear is used to diagnose cervical cancer." 3. "Colposcopy to further examine your cervix is the next step." 4. "A loop electrosurgical excision procedure (LEEP) is needed." Answer: 3 Explanation: 1. Cryotherapy, or freezing of the cervix, is one treatment option for precancerous cervical lesions. However, this client does not yet have a diagnosis; she has only had an abnormal screening test. 2. The Pap smear is a screening tool for cervical abnormalities; it is not diagnostic. 3. Colposcopy is an examination of the cervix through a magnifying device. Solutions are often painted onto the cervix and surrounding tissue and observed for changes secondary to the application of the solution. Biopsy samples are taken of suspected abnormal tissue and sent for pathologic examination and diagnosis. Endocervical canal biopsy is often undertaken with colposcopy. 4. Although LEEP (the removal of the surface tissue of the cervix) might be performed to treat cervical dysplasia or carcinoma in situ, this client has not had a diagnostic examination yet. Page Ref: 93 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.7 Identify the implications of an abnormal finding during a pelvic examination in the provision of nursing care.

15) The nurse is preparing an education session for women on prevention of urinary tract infections (UTIs). Which statement should be included? 1. Lower urinary tract infections rarely occur in women. 2. Back pain often develops with a lower urinary tract infection. 3. The most common causative organism of cystitis is Escherichia coli. 4. Wiping from back to front after a bowel movement will help prevent a UTI. Answer: 3 Explanation: 1. About 60% of women will experience an episode of cystitis during their lifetime. 2. Low back or flank pain is a sign of pyelonephritis, which is an upper urinary tract infection. Signs of a lower UTI include dysuria, urinary frequency, and urinary urgency. 3. Because E. coli is a common bacterium in the bowel and the female urethra is short and close to the anus, cross-contamination of bowel bacteria into the female urinary tract is common. 4. Wiping from back to front increases the risk of UTIs because the E. coli of the bowel is being drawn toward the urethra. Women should be instructed always to wipe from front to back. Page Ref: 95 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 5.8 Contrast the causes, signs and symptoms, treatment options, and nursing care for women with cystitis versus pyelonephritis.

16) A client who has been unable to conceive asks the nurse if it is her fault or her husband's fault that they have not been able to become pregnant. Which response should the nurse make? 1. "The male infertility factors are more common than female." 2. "Female infertility issues are more common than male issues." 3. "The testing the doctor will order will determine who is at fault." 4. "We will know more about what is causing your infertility after some tests are done." Answer: 4 Explanation: 1. This statement is not true. Because of the complexity of ovulation and maintaining a pregnancy, it is more likely that a female issue is causing the infertility. Regardless, using the term "at fault" is blaming and should be avoided. 2. Although this statement is true because of the complexity of ovulation and maintaining a pregnancy, using the term "at fault" is blaming and should be avoided. 3. Testing will determine what the infertility issue is, but using the term "at fault" is blaming and should be avoided. 4. This is a factual answer that avoids using the term "at fault." This statement is therapeutically worded and therefore is the best answer. Page Ref: 98 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.13 Relate the physiologic and psychologic effects of infertility on a couple to the nursing care management indicated for them.

17) A 31-year-old woman with normal ovaries, a normal prolactin level, and an intact pituitary gland is undergoing initial pharmacologic treatment of anovulation. Which medication should the nurse anticipate being prescribed for this client? 1. Bromocriptine (Parlodel) 2. Metformin (Glucophage) 3. Clomiphene citrate (Clomid or Serophene) 4. Human menopausal gonadotropins (hMGs) Answer: 3 Explanation: 1. Bromocriptine (Parlodel) is used to treat hyperprolactinemia accompanied by anovulation. 2. Oral hypoglycemic agents such as metformin (Glucophage) are used for inducing ovulation in women with polycystic ovary syndrome (PCOS). 3. Clomiphene citrate (Clomid or Serophene) is a common first-line therapy for inducing ovulation in women with normal ovaries, normal prolactin level, and intact pituitary gland. 4. Human menopausal gonadotropins (hMGs) represent a second line of therapy in women who fail to ovulate or conceive with clomiphene citrate therapy. Page Ref: 101 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.12 Summarize the indications for the tests and associated treatments, including assisted reproductive technologies, that are performed in an infertility workup.

18) A client has questions about a semen analysis. Which information should the nurse provide? 1. Use a lubricant while obtaining the semen specimen. 2. Remain abstinent for 3 days prior to collecting the specimen. 3. Immediately refrigerate the specimen for a maximum of 8 hours. 4. Deliver the specimen to the laboratory within 1 hour of collection. Answer: 2 Explanation: 1. Most lubricants also are spermicidal and should not be used unless approved by the andrology laboratory. 2. To obtain accurate results of a semen analysis, the specimen is collected after 3 days of abstinence. 3. If the specimen is obtained at home, it needs to be kept at body temperature and delivered to the laboratory within 1 hour so as not to impair motility. 4. If the specimen is obtained at home, it needs to be delivered to the laboratory within 1 hour so as not to impair motility. Page Ref: 101 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.12 Summarize the indications for the tests and associated treatments, including assisted reproductive technologies, that are performed in an infertility workup.

19) A client undergoing infertility treatment states that her partner is angry all of the time since beginning treatment and is very negative in comments made about the likelihood of their achieving pregnancy. The client states, "I was angry and depressed, but now I am dedicated to following through with treatment and hoping we get pregnant." Which statements best describe the partner's behavior? Select all that apply. 1. Showing that he will not be a good parent 2. Experiencing a different stage of grief than the client 3. Feeling guilty about not being able to father a child 4. Having difficulty accepting the reality of their infertility 5. Exhibiting signs of the anger stage of grieving the loss of their dreams of having children Answer: 2, 5 Explanation: 1. Being in the anger stage of grief is expected and normal and has no bearing on parenting ability. 2. The client is in the acceptance stage of grief, while the partner is in the anger stage. It is common and normal for families to be in different stages of the grieving process. 3. Guilt would manifest as feelings that it is his fault that pregnancy has not yet occurred. The client is describing anger. 4. The partner is in the anger stage of grief. Lack of acceptance would manifest as not believing that the diagnosis is correct. 5. The client's description of her partner correlates with the anger stage of grief. Couples often experience the stages of grief when infertility is diagnosed because childbearing is an expected outcome in marriage; the inability to become pregnant is the loss of the dream of parenthood. Page Ref: 106 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.13 Relate the physiologic and psychologic effects of infertility on a couple to the nursing care management indicated for them.

20) The nurse manager is interviewing nurses for a position in an infertility clinic. Which statement best indicates that the interviewee understands the role of the nurse when working with infertile clients? 1. "This position is an assistant to the physician during diagnostic testing for infertility." 2. "My job will be teaching clients how to take their medications and scheduling tests." 3. "I will both teach and support families struggling with emotions as they attempt to become pregnant." 4. "Many of my duties will involve forming therapeutic relationships with clients struggling with infertility." Answer: 3 Explanation: 1. Some assisting might be a part of this position; the role of the registered nurse (RN) in an infertility clinic involves much teaching and providing emotional support to infertile clients. 2. Although teaching and facilitating scheduling are important, the emotions that families deal with during treatment for infertility must also be addressed. 3. This answer addresses the two main aspects of the RN working with infertile clients: emotional support and education. 4. Although this response addresses the emotional aspects of infertility, it does not mention providing support or teaching, which are also major components of the job. Page Ref: 106 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.13 Relate the physiologic and psychologic effects of infertility on a couple to the nursing care management indicated for them.

21) A female client with infertility is suspected as having a problem with patent fallopian tubes and ovum motility. For which health problems should the nurse expect that this client will be evaluated? Select all that apply. 1. Endometriosis 2. Cervical stenosis 3. Ectopic pregnancy 4. Peritubal adhesions 5. Pelvic inflammatory disease Answer: 1, 3, 4, 5 Explanation: 1. Fallopian tube function and motility can be affected by endometriosis. 2. Cervical stenosis affects cervical mucus. 3. Fallopian tube function and motility can be affected by an ectopic pregnancy. 4. Fallopian tube function and motility can be affected by peritubal adhesions. 5. Fallopian tube function and motility can be affected by pelvic inflammatory disease. Page Ref: 101 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.11 Compare the essential components of fertility with the possible causes of infertility. 22) During an assessment, the nurse suspects that a client is at risk for developing a cystocele. What findings did the nurse use to come to this conclusion? Select all that apply. 1. Age 68 2. Body mass index (BMI) 32 3. Pregnant seven times 4. History of diabetes 5. Takes hormone replacement therapy Answer: 1, 2, 3 Explanation: 1. Advanced age is a risk factor for the development of a cystocele. 2. Obesity is a risk factor for the development of a cystocele. 3. Childbearing is a risk factor for the development of a cystocele. 4. History of diabetes is not a risk factor for the development of a cystocele. 5. Hormone replacement therapy is not a risk factor for the development of a cystocele. Page Ref: 96 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.9 Compare the signs and symptoms and treatment options of the three forms of pelvic relaxation–cystocele, rectocele, and uterine relaxation. 17 Copyright © 2022 Pearson Education, Inc.

23) A client is diagnosed with a uterine prolapse. Which treatments should the nurse prepare to discuss with this client? Select all that apply. 1. Hysterectomy 2. Kegel exercises 3. Vaginal pessary 4. Topical estrogen 5. Systemic estrogen Answer: 1, 3, 4, 5 Explanation: 1. Surgery for uterine prolapse often involves hysterectomy and repair of the prolapsed vaginal walls. 2. Kegel exercises are indicated in the treatment of a cystocele. 3. Conservative treatment for a uterine prolapse includes a vaginal pessary. 4. Conservative treatment for a uterine prolapse includes topical estrogen. 5. Conservative treatment for a uterine prolapse includes systemic estrogen. Page Ref: 96 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.9 Compare the signs and symptoms and treatment options of the three forms of pelvic relaxation–cystocele, rectocele, and uterine relaxation.

24) A client asks about the difference between an abdominal hysterectomy and a laparoscopicassisted vaginal hysterectomy (LAVH). Which information should the nurse explain to this client? Select all that apply. 1. Recovery will be quicker with an abdominal hysterectomy. 2. The results are nearly the same between the two surgical approaches. 3. An abdominal hysterectomy is indicated for uterine bleeding and small fibroids. 4. Hospitalization will be longer with a laparoscopic-assisted vaginal hysterectomy. 5. A laparoscopic-assisted vaginal hysterectomy does not have an abdominal incision. Answer: 2, 5 Explanation: 1. Recovery is quicker with a LAVH. 2. A benefit is that the surgeon can achieve results similar to those of a total abdominal hysterectomy when using LAVH, but without a large abdominal incision. 3. A vaginal hysterectomy is indicated for uterine bleeding and small fibroids. 4. Hospitalization will be longer with an abdominal hysterectomy. 5. A benefit is that a LAVH does not have a large abdominal incision. Page Ref: 96 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.10 Contrast laparoscope-assisted vaginal hysterectomy and abdominal hysterectomy with regard to indications for use and the advantages and disadvantages of each procedure.

25) The nurse learns that a client is being considered for a total abdominal hysterectomy. Which health problem should the nurse suspect this client is experiencing? Select all that apply. 1. Small fibroids 2. Ovarian cancer 3. Cervical cancer 4. Pelvic relaxation 5. Abnormal uterine bleeding Answer: 2, 3 Explanation: 1. Vaginal hysterectomy is generally done for small fibroids. 2. Abdominal hysterectomy is the usual treatment for cancer of the ovary. 3. Abdominal hysterectomy is the usual treatment for cancer of the cervix. 4. Vaginal hysterectomy is generally done for pelvic relaxation. 5. Vaginal hysterectomy is generally done for abnormal uterine bleeding. Page Ref: 96 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.10 Contrast laparoscope-assisted vaginal hysterectomy and abdominal hysterectomy with regard to indications for use and the advantages and disadvantages of each procedure.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 6 Reproductive Physiology, Conception, and Fetal Development 1) The nurse is teaching a classroom of teenage girls about the female reproductive system. After teaching, the nurse asks the students to describe the release of an ovum during ovulation. Which response indicates that teaching has been effective? 1. "Ovulation is when the uterus releases an unfertilized egg or ovum." 2. "During ovulation, an egg is released from the ovary and enters the fallopian tube." 3. "The endometrium is where the eggs are formed and released into the fallopian tube." 4. "Around the middle of the menstrual cycle, one of the fallopian tubes releases an egg." Answer: 2 Explanation: 1. The egg is formed in the ovary and travels by way of the fallopian tube to the uterus. 2. The egg is formed in the ovary and once released, it enters the fallopian tube. 3. The uterine endometrium is the site of implantation of a fertilized egg. 4. The egg is formed in the ovary and then released near the fimbria of the fallopian tube. Page Ref: 118 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.3 Identify the two phases of the ovarian cycle and the changes that occur in each phase.

2) A prenatal client states, "The doctor said he might have to cut my cervix so the baby can get out during delivery." Based upon this statement, which structure should the nurse define when teaching about an episiotomy? 1. Mons pubis 2. Labia majora 3. Perineal body 4. Vaginal vestibule Answer: 3 Explanation: 1. The mons pubis is a softly rounded mound of subcutaneous fatty tissue that covers the front portion of the symphysis pubis. 2. The labia majora are longitudinal, raised folds of pigmented skin located on either side of the vulvar cleft. 3. The perineal body, which is located between the lower part of the vagina and the anus, is often the site of an episiotomy or lacerations during childbirth. 4. The vaginal vestibule contains the vaginal opening, which is the border between the external and internal genitals. Page Ref: 110 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth.

3) A pregnant adolescent asks about fundal height. Which location should the nurse identify about the uterine fundus? 1. It is the lower third area of the uterus. 2. It is at the uppermost (dome-shaped top) portion of the uterus. 3. It is the elongated portion of the uterus where the fallopian tubes enter. 4. It is the portion of the uterus that lies between the internal cervical os and the endometrial cavity. Answer: 2 Explanation: 1. The lower third of the uterus is called the cervix or neck. 2. The rounded, uppermost (dome-shaped top) portion of the uterus that extends above the points of attachment of the fallopian tubes is called the fundus. 3. The elongated portion where the fallopian tubes enter the uterus is called the cornua. 4. The portion of the uterus between the internal cervical os and the endometrial cavity is called the isthmus. Page Ref: 111 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. 4) The nurse is teaching a client who recently learned that she is pregnant. Which hormone should the nurse instruct as being secreted by the fertilized egg? 1. Estrogen 2. Progesterone 3. Luteinizing hormone 4. Human chorionic gonadotropin (hCG) Answer: 4 Explanation: 1. Estrogen is an ovarian hormone. 2. Progesterone is an ovarian hormone. 3. Luteinizing hormone is excreted by the anterior pituitary. 4. When the ovum is fertilized and implants in the endometrium, the fertilized egg begins to secrete hCG hormone to maintain the corpus luteum. Page Ref: 117 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.2 Summarize the actions of the hormones that affect reproductive functioning. 3 Copyright © 2022 Pearson Education, Inc.

5) The school nurse is teaching a health class to middle school children. Which structure should the nurse explain as secreting follicle-stimulating hormone (FSH) and luteinizing hormone (LH)? 1. Hypothalamus 2. Anterior pituitary 3. Posterior pituitary 4. Ovaries and testes Answer: 2 Explanation: 1. The hypothalamus secretes gonadotropin-releasing hormone to the pituitary gland in response to signals from the central nervous system. 2. The anterior pituitary secretes FSH and LH, which are primarily responsible for maturation of the ovarian follicle. 3. The posterior pituitary gland secretes oxytocin and antidiuretic hormone. 4. The ovaries secrete the female hormones estrogen and progesterone, and the testes secrete testosterone. Page Ref: 116 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.2 Summarize the actions of the hormones that affect reproductive functioning.

6) The nurse is presenting a community education session on female hormones. Which participant statement indicates the need for further information? 1. "Estrogen is what causes females to look female." 2. "Prostaglandin is responsible for achieving conception." 3. "Progesterone is present at the end of the menstrual cycle." 4. "The presence of some hormones causes others to be secreted." Answer: 2 Explanation: 1. Estrogen causes secondary sex characteristics, such as enlarged breasts and widened hips. 2. Prostaglandin is not related to conception. Prostaglandin is called the hormone of pregnancy because it maintains pregnancy. 3. Progesterone is present in large quantities during the secretory phase of the menstrual cycle. 4. An example is that the production of gonadotropin-releasing hormone (GnRH) causes the secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Page Ref: 116 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.2 Summarize the actions of the hormones that affect reproductive functioning. 7) A woman has been unable to complete a full-term pregnancy because the fertilized ovum failed to implant in the uterus. Which hormone is most likely causing this client's issues with pregnancy? 1. Estrogen 2. Progesterone 3. LH (luteinizing hormone) 4. FSH (follicle-stimulating hormone) Answer: 2 Explanation: 1. Estrogen primarily assists in maturation of the ovarian follicles and causes endometrial mucosa to proliferate. 2. Progesterone is the likely cause because it decreases uterine motility and contractibility caused by estrogens, thereby preparing the uterus for implantation. 3. LH is a hormone secreted by the pituitary gland. 4. FSH is a hormone secreted by the pituitary gland. Page Ref: 116 Cognitive Level: Remembering Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Summarize the actions of the hormones that affect reproductive functioning. 5 Copyright © 2022 Pearson Education, Inc.

8) The nurse is explaining the menstrual cycle to a group of women. In which phase should the nurse instruct that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and the blood supply to the endometrium is reduced? 1. Ischemic phase 2. Secretory phase 3. Menstrual phase 4. Proliferative phase Answer: 1 Explanation: 1. The ischemic phase is characterized by ischemia of the endometrium. 2. The secretory phase involves glycogen secretion by the endometrium after ovulation. 3. The menstrual phase is the menses. 4. The proliferative phase is characterized by proliferation of the endometrium. Page Ref: 12 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase. 9) Which statement best indicates that the client understands the differences in the follicular and luteal phases of the ovarian cycle? 1. "My period will be every 28 days." 2. "The follicular phase is when the egg is fertilized." 3. "The follicular phase is the second half of my cycle." 4. "The first part of my period might vary in length, but not the second." Answer: 4 Explanation: 1. The follicular phase can vary, resulting in cycle length other than 28 days. 2. The follicular phase comprises days 1 to 14 of the menstrual cycle, not when the egg is fertilized. 3. The luteal phase is the second half of the cycle. 4. For a female with a 28-day cycle, the follicular phase comprises days 1 to 14 of the menstrual cycle, and the luteal phase comprises days 15 to 28. The luteal phase does not vary. Page Ref: 115 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.3 Identify the two phases of the ovarian cycle and the changes that occur in each phase.

10) The nurse is preparing a handout on the ovarian cycle for a group of middle school girls. Which information should the nurse include? 1. There are two phases of the ovarian cycle: luteal and follicular. 2. The hormone human chorionic gonadotropin (hCG) stimulates ovulation. 3. The ovum travels from the ovary to the tube during the luteal phase. 4. Irregular menstrual cycles have varying lengths of the follicular phase. Answer: 1 Explanation: 1. The two phases of the ovarian cycle are follicular (days 1 to 14 of the menstrual cycle) and luteal (days 15 to 28 of the menstrual cycle). 2. hCG is secreted by a fertilized ovum and does not stimulate ovulation. 3. The ovum is released from the graafian follicle of the ovary and travels to the fallopian tube during the follicular phase of the ovarian cycle. 4. Menstrual cycles that are irregular in length have a consistent follicular phase but a varying luteal phase. Page Ref: 116 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.3 Identify the two phases of the ovarian cycle and the changes that occur in each phase.

11) The nurse is preparing a presentation on the menstrual cycle for a group of high school students. Which statement should the nurse include in this presentation? 1. "One hormone controls the phases of the menstrual cycle." 2. "The secretory phase occurs when a woman is most fertile." 3. "Menstrual cycle phases vary in order from one woman to another." 4. "The menstrual cycle has five distinct phases that occur during the month." Answer: 2 Explanation: 1. Four hormones control ovulation and therefore the menstrual cycle: progesterone, estrogen, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). 2. During the secretory phase, the endometrium is thickest, and glycogen is produced to nourish a fertilized ovum. 3. Although the length of the menstrual cycle might vary, the phases of the menstrual cycle always occur in the same order. 4. There are four phases of the menstrual cycle: menstrual, proliferative, secretory, and ischemic phases. Page Ref: 116 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase.

12) A woman is experiencing mittelschmerz and increased vaginal discharge. Her temperature has increased by 0.6°C (1.0°F) for the past 36 hours. In which way should the nurse interpret these findings? 1. Ovulation has occurred. 2. Ovulation will occur soon. 3. Menstruation is about to begin. 4. She is pregnant and will not menstruate. Answer: 1 Explanation: 1. Signs that ovulation has occurred include: pain associated with rupture of the ovum (mittelschmerz), increased vaginal discharge, and a temperature increase of 0.6°C (1.0°F) over the past 36 hours. 2. A temperature increase does not occur before ovulation has occurred. 3. A temperature increase does not occur when menstruation is about to begin. 4. Pregnancy can be detected only through testing the urine or serum for the presence of human chorionic gonadotropin hormone. Page Ref: 117 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4 Describe the phases of the uterine (menstrual) cycle, their dominant hormones, and the changes that occur in each phase.

13) A pregnant client is scheduled for a lower-segment cesarean birth. Place an X on the area of the uterine structure where the nurse should instruct that this incision for the procedure will be placed.

Answer:

Explanation: The isthmus is that portion of the uterus between the internal cervical os and the endometrial cavity. The isthmus is about 6 mm above the uterine opening of the cervix and takes on importance in pregnancy because it becomes the lower uterine segment. At birth, this thin lower segment, situated behind the bladder, is the site for lower-segment cesarean births. Page Ref: 111 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth.

14) After delivery, the nurse notes that a client is having considerable vaginal bleeding. On the diagram provided, identify the area of the myometrium that is responsible for stopping bleeding after birth.

Answer:

Explanation: The thick middle layer of the myometrium is made up of interlacing muscle fibers in figure-eight patterns that surround large blood vessels. Their contraction produces a tourniquet-like action on blood vessels to stop bleeding after birth. Page Ref: 112 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth. 12 Copyright © 2022 Pearson Education, Inc.

15) The nurse is reviewing the anatomy and physiology of the reproductive organs during a prenatal class. On the diagram, select the area that the nurse should identify as being the round ligament.

Answer:

Explanation: The round ligaments arise from the sides of the uterus near the fallopian tube insertions. They extend outward between the folds of the broad ligament, passing through the inguinal ring and canals and eventually fusing with the connective tissue of the labia majora. The round ligaments are made up of longitudinal muscle and undergo hypertrophy and increase in both length and diameter during pregnancy. Page Ref: 113 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.1 Discuss the significance of specific female reproductive structures during pregnancy and childbirth.

16) The nurse is reviewing the male reproductive system with a group of high school students. Using the diagram, select the structure that the nurse should identify as a storage area for spermatozoa.

Answer:

Explanation: The epididymis provides a reservoir for maturing spermatozoa. Page Ref: 118 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.5 Identify the structures and functions of the male reproductive system.

17) The nurse is preparing materials to counsel a couple after a consultation visit at an infertility clinic. On the diagram, select the area on the sperm that the nurse should identify as fertilizing the ovum.

Answer:

Explanation: The head's main components are the acrosome and nucleus. The head carries the male's haploid number of chromosomes (23), and it is the part that enters the ovum at fertilization. Page Ref: 119 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 6.5 Identify the structures and functions of the male reproductive system.

18) The nurse has completed a presentation on reproduction. Which participant's statement indicates that teaching has been successful? 1. "Ova separate into two unequally sized cells." 2. "A male is born with all the sperm he will ever produce." 3. "Females create new ova throughout their reproductive life." 4. "Each primary spermatocyte divides into four haploid cells." Answer: 1 Explanation: 1. Each ovum undergoes meiotic division just prior to being released from the graafian follicle. Each cell created by this meiosis has the same number of chromosomes, but the cytoplasm does not split equally. This causes a polar body to be produced along with a secondary oocyte. 2. A female is born with all sperm that she will ever produce. 3. Males create new sperm throughout their reproductive life. 4. Each primary spermatocyte divides into two haploid cells. Page Ref: 120 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 6.6 Compare the processes by which ova and sperm are produced. 19) After teaching a class about the female reproductive system, the nurse asks the attendees to describe the process of meiosis. Which student response suggests successful comprehension of the material? 1. "At the time of ovulation, the first meiotic division begins." 2. "At the time of puberty, the second meiotic division begins." 3. "Completion of the first meiotic division produces three polar bodies and one primary oocyte." 4. "Completion of the second meiotic division results in formation of three polar bodies and one ovum." Answer: 4 Explanation: 1. At the time of ovulation, one ova is released. 2. The second meiotic division occurs at the time of fertilization. 3. In the second division, cell division occurs, resulting in the formation of four cells, each containing 23 single chromosomes, 4. Completion of the second meiotic division produces three polar bodies and one ovum. Page Ref: 119 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 6.6 Compare the processes by which ova and sperm are produced.

20) The nurse instructs a patient about conception and fetal development. Which patient statement indicates understanding about transportation time of the zygote through the fallopian tube and into the cavity of the uterus? 1. "It will take 8 days for the egg to reach the uterus." 2. "It will take at least 3 days for the egg to reach the uterus." 3. "It will take 18 hours for the fertilized egg to implant in the uterus." 4. "It will only take 12 hours for the egg to go through the fallopian tube." Answer: 2 Explanation: 1. It does not take 8 days for the egg to reach the uterus. 2. It takes at least 3 days for the egg to reach the uterus. 3. The fertilized egg is not implanted into the uterus in 18 hours. 4. It takes longer than 12 hours for the fertilized egg to travel through the fallopian tube. Page Ref: 122 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 6.7 Analyze the components of the process of fertilization as to how each may affect conception. 21) If only a small volume of sperm is discharged into the vagina, an insufficient amount of enzymes might be released when sperm encounters the ovum. In which way will this affect pregnancy? 1. The block to polyspermy (cortical reaction) would not occur. 2. The fertilized ovum would be unable to implant in the uterus. 3. Sperm would be unable to penetrate the zona pellucida of the ovum. 4. Peristalsis of the fallopian tube would decrease, making it difficult for the ovum to enter the uterus. Answer: 3 Explanation: 1. The cortical reaction occurs after fertilization. 2. An insufficient amount of enzymes does not affect implanatation in the uterus. 3. Sperm would be unable to penetrate the zona pellucida of the ovum because it takes hundreds of acrosomes (the result of the acrosomal reaction) to rupture and release enough hyaluronic acid to clear the way for a single sperm to penetrate the ovum's zona pellucida successfully. 4. The amount of enzymes does not effect fallopian tube peristalsis. Page Ref: 120 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Assessment Learning Outcome: 6.7 Analyze the components of the process of fertilization as to how each may affect conception. 20 Copyright © 2022 Pearson Education, Inc.

22) The nurse is caring for a patient who is pregnant with twins. Which statement indicates the patient needs additional information? 1. "It is rare for twins to both be within the same amniotic sac." 2. "Because both of my twins are boys, I know that they are identical." 3. "If I have one boy and one girl, I will know they came from two eggs." 4. "If my twins came from one fertilized egg that split, they are identical." Answer: 2 Explanation: 1. Twins will have two amnions and two chorions. 2. Not all same-sex twins are identical or monozygotic, because fraternal, or dizygotic, twins can be the same sex or different sexes. 3. Fraternal twins are fertilized by two separate spermatozoa. 4. Identical twins develop from a single fertilized ovum. Page Ref: 126 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 6.9 Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed. 23) A pregnant patient asks about the differences between monozygotic and dizygotic twins. Which should the nurse include during this teaching? 1. Dizygotic twins share one placenta and one chorion. 2. Monozygotic twins are also referred to as "fraternal" twins. 3. Dizygotic twinning occurs less frequently than does monozygotic twinning. 4. Monozygotic twins originate from division of the fertilized ovum at different stages. Answer: 4 Explanation: 1. Dizygotic twins have separate placentas and chorions. 2. Monozygotic twins are referred to as identical. 3. There is no evidence that dizygotic twinning occurs less frequently than monozygotic twinning. 4. Monozygotic twins originate from division of the fertilized ovum at different stages of early development. Page Ref: 126 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 6.9 Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed.

24) Which statement by a patient pregnant with twins would indicate that teaching was effective? 1. "Identical twins can be the same or different sex." 2. "Identical twins occur more frequently than fraternal twins." 3. "Congenital abnormalities are more prevalent in identical twins." 4. "Because of their birth relationship, fraternal twins are more similar to each other than if they had been born singly." Answer: 3 Explanation: 1. Identical twins are of the same sex. 2. There is no evidence that identical twins occur more frequently than fraternal twins. 3. Due to variations in the timing of the splitting of the embryo, congenital abnormalities are more common in monozygotic twins. 4. There is no evidence that fraternal twins are more similar to each other than if they had been born singly. Page Ref: 127 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 6.9 Compare the factors and processes by which fraternal (dizygotic) and identical (monozygotic) twins are formed. 25) The nurse is creating a teaching poster for pregnant mothers. Which description of fetal development should the nurse include? 1. Most organs are formed by 8 weeks after fertilization. 2. The embryonic stage is from fertilization until 5 months. 3. Four layers of cells form after the embryo is at the ball stage. 4. After fertilization, the cells only become larger for several weeks. Answer: 1 Explanation: 1. Most organs are formed during the embryonic stage, which lasts from fertilization until the end of the 8th week after fertilization. This is also a critical period because major organs are being developed and teratogens introduced during this time can increase the risk of congenital abnormalities. 2. The embryonic stage lasts from the fertilization until the end of the 8th week after fertilization. 3. There are three layers of germ cells to include ectoderm, mesoderm, and endoderm. 4. After fertilization the cells divide and multiple and not become larger. Page Ref: 131 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 6.8 Summarize the processes that occur during the cellular multiplication and differentiation stages of intrauterine development and their effects on the structures that form. 22 Copyright © 2022 Pearson Education, Inc.

26) The nurse is conducting an early pregnancy class for a group of pregnant women. Which statement indicates a need for further education about the placenta? 1. "It develops and grows larger until about 20 weeks' gestation." 2. "It floats in the amniotic sac and filters waste products from the fetus." 3. "It creates hormones and enzymes that are necessary during pregnancy." 4. "It ages and becomes less permeable during the last month of pregnancy." Answer: 2 Explanation: 1. The placenta develops at the site where the developing embryo attaches to the uterine wall. Expansion of the placenta continues until about 20 weeks, when it covers about half the inside of the uterus. 2. The placenta is attached to the uterine wall, and does not float in the amniotic sac. One function of the placenta is to filter metabolic waste products from the baby's blood so that they can be excreted by the mother. 3. The syncytium is in direct contact with the maternal blood in the intervillous spaces. It is the functional layer of the placenta and secretes the placental hormones of pregnancy. 4. The placental permeability increases until about the last month of pregnancy, when permeability begins to decrease as the placenta ages. Page Ref: 124 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 6.10 Describe the development, structure, and functions of the placenta and umbilical cord during intrauterine life (embryonic and fetal development). 27) A client who has experienced a fetal death in utero at 20 weeks asks what her baby will look like when it is delivered. In which way should the nurse respond to this patient? 1. "The genitals of the baby will be ambiguous." 2. "Your baby will be covered in fine hair called lanugo." 3. "Your child will have arm and leg buds, but not fully formed limbs." 4. "A white, cheesy substance called vernix caseosa will be on the skin." Answer: 2 Explanation: 1. External genitalia appear similar until the end of the 9th week. 2. Downy fine hair called lanugo covers a 20-week fetus. 3. Limb buds appear by week 4. 4. Vernix caseosa will not appear until the 24th week. Page Ref: 132 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Implementation Learning Outcome: 6.11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. 23 Copyright © 2022 Pearson Education, Inc.

28) At her first prenatal visit, the client states, "I'm 5 weeks' pregnant now, and I would like to hear my baby's heartbeat today." In which way should the nurse respond? 1. Anticipate that the patient will be scheduled for Doppler ultrasound. 2. Prepare to assist with auscultation of the fetal heartbeat using a fetoscope. 3. Explain to the patient that the fetal heartbeat is not yet detectable at 5 weeks' gestation. 4. Explain to the patient that the fetal heart does not begin to beat until approximately 7 weeks' gestation. Answer: 3 Explanation: 1. A Doppler ultrasound will not be scheduled. 2. The heart tones will not be audible at the 5th week. 3. While the tubular heart begins to form during the 3rd week, fetal heart tones generally are not detectable until at least 7 weeks' gestation. 4. The heart begins tubular beats at 28 days gestation. Page Ref: 132 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Implementation Learning Outcome: 6.11 Summarize the significant changes in growth and development of the fetus at 4, 6, 12, 16, 20, 24, 28, 32, 36, and 40 weeks' gestation. 29) A client at 18 weeks' gestation thinks she might have been exposed to a toxin at work that could affect fetal development and asks what organs might be affected at this point in the pregnancy. In which way should the nurse respond to this patient? 1. "The brain is developing now and could be affected." 2. "Because you are in the second trimester, there is no danger." 3. "It's best to not worry about possible problems with your baby." 4. "The internal organs like the heart and lungs could be impacted." Answer: 1 Explanation: 1. Maximum brain growth and myelination are occurring at this point in fetal development. 2. The brain is still developing and could be affected. 3. The nurse should not tell the client to not worry because the exposure to the toxin could cause a problem. 4. Heart development is complete by week 8 and lung buds are present at week 6. Page Ref: 132 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Implementation Learning Outcome: 6.12 Identify the factors that influence congenital malformations of the organ systems and the resulting congenital malformations. 24 Copyright © 2022 Pearson Education, Inc.

30) The nurse is preparing a presentation about causes of fetal organ malformation in the first trimester. Which prenatal influences on the intrauterine environment should be included in this teaching? Select all that apply. 1. The use of drugs 2. Maternal nutrition 3. The use of saunas or hot tubs 4. Age of the mother at conception 5. The quality of the sperm or ovum are not identified as influencing the intrauterine environment. Answer: 1, 2, 3 Explanation: 1. Many drugs can have teratogenic effects. 2. Maternal nutrition, if deficient, can cause damage to the fetus. Vitamins and folic acid taken prior to and during the pregnancy can have beneficial effects. 3. The use of saunas or hot tubs is associated with maternal hyperthermia and neural tube defects. 4. Maternal age is not considered a prenatal influence on the intrauterine environment. Page Ref: 137 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 6.12 Identify the factors that influence congenital malformations of the organ systems and the resulting congenital malformations.

31) The nurse is reviewing the embryonic primary germ layers with a group of students. Which structures should the nurse identify as being formed from the mesoderm? Select all that apply. 1. Nails 2. Liver 3. Spleen 4. Muscles 5. Skeleton Answer: 3, 4, 5 Explanation: 1. The nails are formed from the ectoderm. 2. The liver is formed the endoderm. 3. The spleen originates from the mesoderm. 4. The muscles originate from the mesoderm. 5. The skeleton originates from the mesoderm. Page Ref: 124 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 6.8 Summarize the processes that occur during the cellular multiplication and differentiation stages of intrauterine development and their effects on the structures that form.

32) The nurse is discussing an embryonic structure that forms red blood cells until the liver takes over the process in the developing fetus. Place an X on the diagram to identify the structure that the nurse is discussing.

Answer:

Explanation: The yolk sac is small and functions early in embryonic life. It forms primitive red blood cells during the first 6 weeks of development, until the embryo's liver takes over the process. Page Ref: 125 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 6.8 Summarize the processes that occur during the cellular multiplication and differentiation stages of intrauterine development and their effects on the structures that form.

33) The nurse is reviewing the structures of the developing fetus with a group of pregnant clients. Which information about the placenta should the nurse emphasize? Select all that apply. 1. It produces hormones. 2. It produces glycogen, cholesterol, and fatty acids. 3. It maintains fetal respiration, nutrition, and excretion. 4. It provides a circulatory pathway from the chorionic villi to the embryo. 5. It contains a specialized mucoid connective tissue known as Wharton jelly. Answer: 1, 2, 3 Explanation: 1. The placenta produces human chorionic gonadotropin (hCG); human placental lactogen (hPL), also referred to as human chorionic somatomammotropin (hCS); relaxin; inhibin; and estrogen and progesterone. 2. The placenta produces glycogen, cholesterol, and fatty acids continuously for fetal use and hormone production. 3. The placental functions include fetal respiration, nutrition, and excretion. To carry out these functions, the placenta is involved in metabolic and transfer activities. 4. The body stalk fuses with the embryonic portion of the placenta to provide a circulatory pathway from the chorionic villi to the embryo. 5. Wharton jelly surrounds blood vessels in the umbilical cord. Page Ref: 128 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 6.10 Describe the development, structure, and functions of the placenta and umbilical cord during intrauterine life (embryonic and fetal development).

34) A pregnant client who restricted the intake of fat, protein, and sugar to prevent a large weight gain delivers a small-for-gestational-age fetus. Which long-term health problems is this child at risk for developing as an adult? Select all that apply. 1. Arthritis 2. Diabetes 3. Hypertension 4. Cystic fibrosis 5. Coronary heart disease Answer: 2, 3, 5 Explanation: 1. Arthritis is not identified as an illness that results from poor maternal nutritional intake. 2. Poor maternal nutrition may also predispose babies who were small or disproportionate at birth to the development of adult diabetes. 3. Poor maternal nutrition may also predispose babies who were small or disproportionate at birth to the development of adult hypertension. 4. Cystic fibrosis is a genetic anomaly and not caused by poor maternal nutrition. 5. Poor maternal nutrition may also predispose babies who were small or disproportionate at birth to the development of adult coronary heart disease. Page Ref: 138 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Planning Learning Outcome: 6.12 Identify the factors that influence congenital malformations of the organ systems and the resulting congenital malformations.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 7 Physical and Psychologic Changes of Pregnancy 1) While auscultating fetal heart tones, a client who is at 37 weeks' gestation and is in the supine position is experiencing dizziness, lightheadedness, and clammy skin. Which nursing action is the most appropriate? 1. Administer supplemental oxygen. 2. Help the patient turn onto her right side. 3. Place a wedge beneath the patient's right hip. 4. Prepare for administration of packed red blood cells (PRBCs). Answer: 3 Explanation: 1. The patient does not have a vital sign that would indicate a need for oxygen administration. 2. The patient should lie on the left side to increase the blood flow to the right atrium and increase the patient's blood pressure. 3. The patient is verbalizing symptoms consistent with supine hypotension syndrome, in which compression of the vena cava by the uterus reduces right atrial blood flow. Signs and symptoms include decreased blood pressure, dizziness, pallor, and clamminess. Appropriate interventions include having the woman lie on her left side, or placing a pillow or wedge under her right hip as she lies in a supine position. 4. None of the patient's listed symptoms indicate the need for a blood transfusion. Hypotension is an indicator of many conditions including low blood volume though you were not given any lab results or any indications of blood loss to have this be a correct answer. Page Ref: 142 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.1 Describe the anatomic and physiologic changes that occur during pregnancy.

2) A patient with a normal prepregnancy weight asks why she has been told to gain 25 to 35 pounds during her pregnancy, but her underweight friend was told to gain 28 to 40 pounds. What should the nurse explain as being the recommended weight gain during pregnancy? 1. More than 25 to 35 pounds for an overweight patient 2. More than 25 to 35 pounds for an underweight woman 3. 25 to 35 pounds, regardless of a patient's prepregnancy weight 4. The same for a normal-weight woman as for an overweight woman Answer: 2 Explanation: 1. Overweight women are encouraged to gain 15-25 lbs (Pg. 145) 2. Underweight women are encouraged to gain 28 to 40 pounds during pregnancy. For women who are overweight before pregnancy, the recommended weight gain is 15 to 25 lbs. 3. There are different amounts for overweight, underweight, and normal weight. (Pg. 145) 4. There are different amounts for overweight and normal weight. (Pg. 145) Page Ref: 143 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.1 Describe the anatomic and physiologic changes that occur during pregnancy.

3) The nurse is reviewing the assessment findings of a patient who is at 35 weeks' gestation. Which data suggest the need for further investigation? 1. Glycosuria 2. Funic souffle 3. Pseudoanemia 4. Melasma gravidarum Answer: 1 Explanation: 1. Glycosuria (glucose in the urine) during pregnancy may be normal or may indicate gestational diabetes, so it always warrants further testing. 2. This is an expected finding in a pregnant woman. It is the sound of the increased uterine blood flow pulsing through the placenta. (Pg. 147) 3. Pseudoanemia is a side effect of pregnancy due to the increased blood volume and the increased amount of plasma in the woman's body the hematocrit decreases slightly due to the volume of plasma. 4. Melasma gravidarum is a common occurrence in pregnancy thought to be caused by the increase in estrogen causing the pregnancy mask. Page Ref: 142 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7.1 Describe the anatomic and physiologic changes that occur during pregnancy.

4) A client in the prenatal clinic believes she is pregnant because she has not menstruated for 3 months, and her breasts are getting bigger. Which response by the nurse is the best? 1. "Lack of menses and breast enlargement are presumptive signs of pregnancy." 2. "The changes you are describing are definitely indicators that you are pregnant." 3. "Lack of menses can be caused by many things. We need to do a pregnancy test." 4. "Breast and menstrual changes are positive signs of pregnancy. Congratulations." Answer: 3 Explanation: 1. This is not the best answer as the patient may not understand the wording of presumptive and may think you are telling her that she is pregnant. 2. They may be indicators of pregnancy but may be indicators of other conditions, so this is not the best answer. 3. This is a true statement and addresses that these changes could be caused by things other than pregnancy. 4. This is not the best answer as you cannot say someone is pregnant based on symptoms alone without a positive pregnancy test. Page Ref: 145 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.3 Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy.

5) The nurse has completed a presentation for newly pregnant women about the changes of pregnancy. Which participant's statement reflects accurate comprehension of the information? 1. "Uterine souffle is a positive change of pregnancy." 2. "A positive Goodell sign is a probable change of pregnancy." 3. "Changes in the pelvic organs are presumptive signs of pregnancy." 4. "Three positive pregnancy tests in a 1-week period are considered to be a positive change of pregnancy." Answer: 2 Explanation: 1. It is a change that can be associated with pregnancy but can also be confused with funic souffle. 2. A positive Goodell sign can be objectively identified but may also be caused by conditions other than pregnancy; therefore, it is considered to be a probable change of pregnancy. 3. Changes in the pelvic organs are the only physical changes detectable during the first three months of pregnancy and are caused by increased vascular congestion. These changes are noted on pelvic examination which the pregnant woman cannot perform on herself. 4. This is not a change of pregnancy but a positive test result. Page Ref: 146 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 7.3 Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy.

6) A client who is experiencing her first pregnancy has just completed the initial prenatal examination with a certified nurse-midwife. Which statement indicates that the client has a correct understanding of her condition? 1. "The increased size of my uterus means that I am finally pregnant." 2. "Because we heard the baby's heartbeat, I am undoubtedly pregnant." 3. "Since I haven't felt the baby move yet, we don't know if I'm pregnant." 4. "My last period was 2 months ago, which means I'm 2 months along." Answer: 2 Explanation: 1. Increasing size of a uterus can be caused by other factors including uterine tumor. (pg.146) 2. Hearing the fetal heart rate is a positive, or diagnostic, change of pregnancy. 3. Movement is usually not felt until around the 18-20 week mark so is not a true indicator of early pregnancy. 4. Amenorrhea is a subjective change of pregnancy and is not a true date of conception as that is based on ovulation and insemination. Page Ref: 147 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation Learning Outcome: 7.3 Compare subjective (presumptive), objective (probable), and diagnostic (positive) changes of pregnancy.

7) An adolescent client reports that her period is late but that her home pregnancy test is negative. Which response is most appropriate? 1. "This means you are not pregnant." 2. "We do not trust home tests. Come to the clinic for a blood test." 3. "Most people do not use the tests correctly. Did you read the instructions?" 4. "You might be pregnant, but it might be too early for your home test to be accurate." Answer: 4 Explanation: 1. The home tests are pretty accurate but do have some risk for false negatives, especially early in pregnancy. 2. The home tests are pretty accurate but do have some risk for false negatives, especially early in pregnancy. 3. The test is pretty easy, and it is not the best answer to assume the client didn't perform the test correctly. 4. This is an accurate and appropriate response. Most home pregnancy tests have low falsepositive rates, but the false-negative rate is slightly higher. Repeating the test in 1 week is recommended. Page Ref: 147 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.4 Contrast the various types of pregnancy tests.

8) A 28-year-old client who is pregnant with a first child reports increased dental caries (cavities) since becoming pregnant. In which way should the nurse explain the likely cause for this change? 1. "Each woman experiences changes that affect her teeth while she's pregnant." 2. "When a woman is pregnant, her teeth lose calcium, and she is more susceptible to getting cavities." 3. "During pregnancy, tooth enamel softens and the woman is more susceptible to getting cavities." 4. "It may be necessary to pay extra attention to dental care while you're pregnant, especially if you're vomiting frequently." Answer: 4 Explanation: 1. This is not the best answer but is not completely wrong. Many factors can affect patient's teeth while pregnant including increased saliva, bleeding gums, and nausea/vomiting. 2. This is not the reason for the increase in dental caries as it is not proven to be true in pregnant women. 3. This is not the reason for the increase in dental caries as it is not proven to be true in pregnant women. The enamel is affected by oral hygiene and dental care. 4. The dental cavities that sometimes accompany pregnancy are caused by inadequate oral hygiene and dental care, especially if the woman has problems with bleeding gums or nausea and vomiting. Page Ref: 143 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.1 Describe the anatomic and physiologic changes that occur during pregnancy.

9) A client at 30 weeks' gestation is tearful at the time of her follow-up visit. She tells the prenatal clinic nurse that she is excited to finally become a mother and that she has been thinking about what kind of parent she will be. However, she is upset because her mother has told her that she does not want to be a grandmother because she does not feel old enough. Meanwhile, the client's husband has said that the pregnancy does not feel real to him yet, and that he will become excited when the baby is actually here. In which way should the nurse interpret what is happening within this family? 1. Family members are adjusting to the role change at their own pace. 2. Her mother is rejecting the role of grandparent and will not help out. 3. Her husband will not attach with this child and will not be a good father. 4. The client is not progressing through the developmental tasks of pregnancy. Answer: 1 Explanation: 1. This is a true statement. When the other family members are at different stages of adjustment to the pregnancy, conflict can ensue. 2. Her mother is still coming to terms with the changes in the family dynamics; this does not mean that she will not be a grandparent or help out. 3. This is a common stage of fathers as they are not experiencing the pregnancy like the mother is and they may feel disconnected. 4. The client is progressing through the different stages adjusting to the pregnancy. Page Ref: 150 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7.5 Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy.

10) The partner of a pregnant client at 16 weeks' gestation accompanies her to the clinic. The partner tells you that the baby just does not seem real to him, and he is having a hard time relating to his partner's fatigue and food aversions. Which statement would be best for the nurse to make? 1. "Many men feel this way. Feeling the baby move will help make it real." 2. "My husband had no problem with this. What was your childhood like?" 3. "You might need professional psychologic counseling. Ask your physician." 4. "If you would concentrate harder, you would be aware of the reality of this pregnancy." Answer: 1 Explanation: 1. Kicking and ultrasound visualization are concrete evidence of the baby's existence and often are turning points in acceptance for partners. 2. This is not an appropriate answer to a client; you should not make personal assumptions about a client. 3. The client's partner is at the correct reactionary stage to his partner's pregnancy 4. The client's partner is being appropriate, and this is not the right way to address him. Page Ref: 150 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.5 Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy.

11) A 20-year-old client who is at 10 weeks' gestation confides that the pregnancy was unplanned and is unsure about continuing it or sharing news about it with her partner. In which way should the nurse respond to this client? 1. "You should go to a pregnancy support group to be a good mother." 2. "It's common to feel ambiguous about pregnancy in the first trimester." 3. "These thoughts are because your mother died when you were 4 years old." 4. "It's really unusual for a pregnant woman to feel this way early in the pregnancy." Answer: 2 Explanation: 1. This is not an appropriate answer to a mother considering her options; it is her right and as a health care provider it is important to support her in her feelings. 2. Ambivalence toward the pregnancy is very common in the first trimester. 3. The healthcare provider is not a psychologist and is not qualified to make those assumptions. 4. This is a very normal reaction to an unplanned pregnancy, and the client should be provided support. Page Ref: 149 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.5 Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy.

12) During an interview, the nurse asks the partner of a woman in the second trimester of pregnancy what changes they have noticed during the pregnancy. Which answer would indicate a typical response to pregnancy? 1. "She daydreams about what kind of parent she is going to be." 2. "I have not noticed anything. I just found out she is pregnant." 3. "She has been having dreams at night about misplacing the baby." 4. "She has been more tense and anxious than usual, and she is not sleeping well." Answer: 1 Explanation: 1. The second trimester usually brings increased introspection and consideration of how she will parent. 2. This would not be a typical response of a partner attending a prenatal visit. 3. This is a typical reaction in the third trimester of pregnancy not of the second trimester. (pg. 148) 4. Insomnia is more common in the third trimester of pregnancy, so this is not the typical response.(pg.148) Page Ref: 149 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7.5 Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy.

13) The mother of a client who is 14 weeks pregnant is uncertain about how to be a good grandmother to this baby due to working full time and being so busy. In which way should the nurse respond in this situation? 1. "How do you envision your role as grandmother?" 2. "Don't worry. You'll be a wonderful grandmother. It will all work out fine." 3. "As long as there is another grandmother available, you do not have to worry." 4. "Grandmothers are supposed to be available. You should retire from your job." Answer: 1 Explanation: 1. Supportive, nonjudgmental exploration of the client's concerns is one component of therapeutic communication and is appropriate. 2. Answers should not ignore the client's concerns; they should be supportive and listen to the client's concerns regarding the situation. 3. Answers should not ignore the client's concerns; they should be supportive and listen to the client's concerns regarding the situation. 4. Answers should not be judgmental of the client or support system. They should be supportive of the client's feelings. Page Ref: 148 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.5 Examine the emotional and psychologic changes that commonly occur in a woman, her partner, and her family during pregnancy.

14) A client in labor is a Lebanese immigrant, and she explains that in the Islamic faith, the baby's name is selected after the baby is born. Which nursing response is appropriate? 1. "Are you afraid your baby will not live?" 2. "We have a very low rate of complications at this facility." 3. "In the United States, you can feel free to choose your baby's name prior to the delivery." 4. "Thank you for explaining that to me. By sharing your cultural beliefs with me, you are helping me to provide you with the best possible care." Answer: 4 Explanation: 1. This is not therapeutic communication and not supportive of the culture of the clients. 2. This is not therapeutic communication and not supportive of the culture of the clients. 3. This is not therapeutic communication and not supportive of the culture of the clients. 4. The identification of cultural values is useful in planning and providing culturally sensitive care. Page Ref: 151 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation/Culture and Spirituality Learning Outcome: 7.6 Summarize cultural factors that may influence a family's response to pregnancy.

15) The nurse is presenting an in-service to nursing staff regarding the provision of culturally competent client care. Which statement should the nurse include in the presentation? 1. "Developed countries are becoming increasingly more ethnically diverse." 2. "The rituals and customs of a group reflect the values of the dominant culture." 3. "Identification of cultural values is a task that is unrelated to providing culturally sensitive care." 4. "Many immigrants to a new country will adopt the beliefs and practices of the dominant culture." Answer: 1 Explanation: 1. In many developed countries, such as the United States, Canada, England, and Germany, populations are becoming more and more ethnically diverse as the number of immigrants continues to grow. 2. It reflects the group's values not those of the dominant culture. 3. The task of identifying cultural values is the basis of providing culturally sensitive care. 4. The process of adopting beliefs and practices of the dominant culture is something that will occur over time and is not expected of new immigrants. Page Ref: 151 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Implementation/Culture and Spirituality/Teaching/Learning Learning Outcome: 7.6 Summarize cultural factors that may influence a family's response to pregnancy.

16) The nurse notes that a client who is 10 weeks pregnant is experiencing changes to the upper respiratory system. In which way should the nurse explain the reason for these changes? Select all that apply. 1. Estrogen-induced edema 2. Hypersecretion of mucus 3. Decreased white blood cell production 4. Vascular congestion of the nasal mucosa 5. Amniotic fluid reducing total fluid volume Answer: 1, 2, 4 Explanation: 1. Upper respiratory changes in the form of nasal stuffiness and epistaxis may occur because of estrogen-induced edema. 2. Upper respiratory changes in the form of nasal stuffiness and epistaxis may occur because of hypersecretion of mucus. 3. This is false; the white blood cell production actually increases due to the stress on the woman's body. (pg. 142) 4. Upper respiratory changes in the form of nasal stuffiness and epistaxis may occur because of vascular congestion of the nasal mucosa. 5. The total fluid volume actually increases in pregnancy and is not decreased due to the amniotic fluid. Page Ref: 141 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 7.2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman.

17) The nurse suspects that a pregnant client is experiencing effects to the gastrointestinal system because of elevated progesterone levels. Which information did the nurse assess to make this clinical determination? Select all that apply. 1. Nausea 2. Bloating 3. Diarrhea 4. Vomiting 5. Constipation Answer: 2, 5 Explanation: 1. Nausea is related to high levels of hCG not progesterone. 2. Elevated progesterone levels cause smooth muscle relaxation, resulting in delayed gastric emptying and decreased peristalsis. As a result, the pregnant woman may complain of bloating. 3. Diarrhea can be caused from pregnancy hormones or food sensitivities brought on by pregnancy. 4. Vomiting is related to high levels of hCG not progesterone. 5. Elevated progesterone levels cause smooth muscle relaxation, resulting in delayed gastric emptying and decreased peristalsis. As a result, the pregnant woman may complain of constipation. Page Ref: 142 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 7.2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman.

18) The nurse is reviewing with a pregnant client the skin changes that she might experience during gestation. Which information should the nurse include in this discussion? Select all that apply. 1. Linea nigra 2. Spider nevi 3. Psoriatic lesions 4. Striae gravidarum 5. Melasma gravidarum Answer: 1, 2, 4, 5 Explanation: 1. Changes in skin pigmentation occurring during pregnancy are thought to be stimulated by increased estrogen, progesterone, and α-melanocytic-stimulating hormone levels. The skin in the middle of the abdomen may develop a pigmented line, the linea nigra, which usually extends from the pubic area to the umbilicus or higher. 2. Vascular spider nevi, small, bright-red elevations of the skin radiating from a central body, may develop on the chest, neck, face, arms, and legs. They may be caused by increased subcutaneous blood flow in response to elevated estrogen levels. 3. Psoriasis is not a condition brought on by pregnancy. 4. Striae gravidarum, or stretch marks, may appear on the abdomen, thighs, buttocks, and breasts. They result from reduced connective tissue strength because of elevated adrenal steroid levels. 5. Changes in skin pigmentation occurring during pregnancy are thought to be stimulated by increased estrogen, progesterone, and α-melanocytic-stimulating hormone levels. Melasma gravidarum, also known as the "mask of pregnancy," a darkening of the skin over the forehead and around the eyes, may develop. Melasma is more prominent in dark-haired women and is aggravated by exposure to the sun. Page Ref: 142-143 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 7.2 Relate the physiologic and anatomic changes that occur in the body systems during pregnancy to the signs and symptoms that develop in the woman.

19) The nurse is preparing an educational program on the different types of pregnancy tests. Which information should the nurse include about the serum pregnancy tests? Select all that apply. 1. It causes a color change. 2. It takes 2 to 3 hours to perform. 3. It is able to detect trophoblastic disease. 4. It is able to detect an ectopic pregnancy. 5. It is the same as an over-the-counter test. Answer: 3, 4 Explanation: 1. The serum test is performed by a lab using a blood sample; it is not the same as a home test with two different colored lines using urine. 2. The serum test is performed by a lab using a blood sample, and time frames vary from lab to lab. 3. Serum pregnancy tests may not only detect pregnancy but also detect trophoblastic disease. 4. Serum pregnancy tests may not only detect pregnancy but also detect an ectopic pregnancy. 5. The serum test is performed by a lab using a blood sample. Page Ref: 147 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 7.4 Contrast the various types of pregnancy tests.

20) The manager notes that a neonatal intensive care unit (NICU) nurse is practicing culturally competent care. Which observation caused the manager to make this decision? Select all that apply. 1. Respects the rituals of the ethnic group of a new mother. 2. Explains the processes that are followed in an American hospital. 3. Speaks a few phrases in the language of a non-English speaking client. 4. Discusses the odd practices that a client from Europe wants to have done. 5. Contacts an interpreter to facilitate communication with a Spanish-speaking client. Answer: 1, 3, 5 Explanation: 1. Evidence of cultural competence includes respecting the rituals of the client's ethnic group. 2. Providing culturally competent care does not mean pushing American practices toward a new mother. 3. Evidence of cultural competence includes learning the language, or at least several key phrases, of at least one of the cultural groups with whom the nurse interacts. 4. Providing culturally competent care is providing care in a non-judgmental setting and being respectful of a patient's beliefs and practices. 5. Evidence of cultural competence includes providing for the services of an interpreter if a language barrier exists. Page Ref: 151-152 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Evaluation/Culture and Spirituality Learning Outcome: 7.6 Summarize cultural factors that may influence a family's response to pregnancy.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 8 Antepartum Nursing Assessment 1) The pregnant client has completed the prenatal questionnaire and asks the nurse why this form had to be filled out. Which response is the most appropriate? 1. "We occasionally identify a health problem that puts the current pregnancy at higher risk." 2. "This form is designed to predict who will develop problems with their pregnancy or delivery." 3. "The doctor wants all of the pregnant clients to fill out the form so that our records are complete." 4. "Some people have things that have happened in the past that could impact their current pregnancy." Answer: 1 Explanation: 1. This is the reason for risk assessment during pregnancy, whether it is a patientcompleted questionnaire or a nurse assessment form. 2. The form can help point out a higher risk patient through medical histories on the form. The form does not predict who will have issues in pregnancy. 3. Complete records are important, but that is not the reason for the history form. 4. This answer is not completely wrong just not the best answer to the question that occasionally we identify a health problem that puts the current pregnancy at higher risk. Page Ref: 157 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 8.1 Summarize the essential components of a prenatal history.

2) The pregnant client's prenatal record indicates that she is a gravida 4 para 2022. In which way should the nurse interpret this data about the client? 1. Is proabortion. 2. Has four living children. 3. Delivered two term infants. 4. Delivered two infants preterm. Answer: 3 Explanation: 1. The A number stands for either spontaneous or therapeutic abortions so it doesn't mean the client had an abortion. 2. the T stands for the number of births at any stage beyond 37 0/7 weeks. 3. In the four-digit number, the first digit indicates the number of term infants born, which is 2. 4. The P stands for preterm births, and this spot has a 0 in it. Page Ref: 155 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 8.2 Define common obstetric terminology found in the history of maternity clients. 3) A multigravida gave birth to an 18-week fetus last week. During her follow-up, she sees that it is documented in her medical record that she had one abortion and becomes upset over the use of this word. In which way can the nurse best explain this terminology to the client? 1. "Abortion is what we call all babies who are stillborn." 2. "Abortion is the word we use when someone has miscarried." 3. "Abortion is how we label pregnancies that end in the second trimester." 4. "Abortion is the medical term for all pregnancies that end before 28 weeks." Answer: 4 Explanation: 1. Stillborn is a term provided to babies born dead after 20 weeks. 2. Miscarriage is a medical term for any pregnancy loss that occurs before 20 weeks gestation. 3. Any pregnancy loss that occurs up to 20 weeks is considered an abortion. 4. Abortions are fetal losses prior to the onset of the third trimester and include elective induced (medical or surgical) abortions, ectopic pregnancies, and spontaneous abortions or miscarriages. Page Ref: 155 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 8.2 Define common obstetric terminology found in the history of maternity clients.

4) Which client should the nurse identify as being a multipara? 1. A client at 28 weeks' gestation with no previous pregnancies 2. A client at 32 weeks' gestation who previously delivered one term infant 3. A client at 13 weeks' gestation who previously delivered two term infants 4. A client at 34 weeks' gestation who previously had one spontaneous abortion Answer: 3 Explanation: 1. This patient has no previous births. 2. This patient has only had one birth not multiple per the definition of multipara. 3. A woman who has had two or more births at more than 20 weeks' gestation is considered a multipara. 4. This patient has no previous births. Page Ref: 155 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.2 Define common obstetric terminology found in the history of maternity clients. 5) The client has delivered her first child at 39 weeks. In which way should the nurse document this type of delivery? 1. Preterm 2. Postterm 3. Full term 4. Near term Answer: 3 Explanation: 1. Preterm is defined as a birth that occurs from 20 weeks to pre 37 weeks of gestation. 2. This is birth past 42 0/7 weeks of gestation. 3. Full-term births occur between 39 weeks 0 days and 40 weeks 6 days. 4. Near term means that the patient is between the 37 0/7 weeks of gestation and 38 6/7 gestation. Page Ref: 155 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 8.2 Define common obstetric terminology found in the history of maternity clients.

6) The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is the most important to include on this form? 1. What is the name of the baby's father? 2. Where was the father of the baby born? 3. Are you married to the father of the baby? 4. Do genetic diseases run in the family of the baby's father? Answer: 4 Explanation: 1. The father's name is important in the social history of the patient if they are involved but not a priority for the intake form. 2. Where the father was born is not a priority piece of information in the intake of a pregnant client. 3. This is a social question that can lead to understanding the support your pregnant client has but is not a priority in the intake of a client. 4. This question has the highest priority because it determines physiologic issues of inheritable genetic diseases that might directly impact the baby. Page Ref: 156 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning/Communication and Documentation Learning Outcome: 8.1 Summarize the essential components of a prenatal history.

7) The nurse learns that a pregnant client's religion is Judaism. For which reason is this information important? 1. Religious and cultural background can impact what a client eats during pregnancy. 2. Knowing the client's beliefs and behaviors regarding pregnancy is important. 3. Clients sometimes encounter problems in their pregnancies based on what religion they practice. 4. It provides a baseline from which to ask questions about the client's religious and cultural background. Answer: 4 Explanation: 1. This may or may not affect how the client eats; it depends on how deep the beliefs of the client are. 2. Understanding a client's beliefs are a factor in caring for them but asking a baseline question first is the best answer. 3. Understanding the patient's risk factors related to religious beliefs is important, but we should not assume that they are at risk because a certain religion is listed. 4. This is the best explanation because not all people interpret or live out their religious or cultural backgrounds the same way. It is imperative to avoid stereotyping clients. Thus, the nurse should use the information on the client's background as a starting point on which to base further questions about how this specific client enacts her religious or cultural background. Page Ref: 167 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Planning Learning Outcome: 8.1 Summarize the essential components of a prenatal history.

8) The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. Which action should the nurse take based on these findings? 1. Have the healthcare provider see the client today. 2. Instruct the client to avoid direct sunlight. 3. Document the findings on the prenatal chart. 4. Analyze previous thyroid hormone laboratory results. Answer: 1 Explanation: 1. Mottling of the skin is indicative of poor oxygenation and a circulation problem. Skin and nail bed pallor can indicate either hypoxia or anemia. These abnormalities must be reported to the healthcare provider immediately. 2. The patient is presenting cardiac concerns so instructing them to avoid direct sunlight is not an appropriate response for this patient. 3. Documentation is not the priority action for this patient; yes you need to document but having the client seen by the provider is the best answer. 4. Looking at the labs is not the priority action for this patient as they are presenting with cardiac symptoms and need to be seen immediately by the provider. Page Ref: 162 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

9) The nurse is assessing a 25-year-old primigravida who is 20 weeks pregnant. Which vital sign finding should the nurse report immediately to the physician? 1. Pulse 88/min 2. Respirations 30/min 3. Blood pressure 134/82 4. Temperature 37.4°C (98.3°F) Answer: 2 Explanation: 1. This is a normal pulse rate in pregnancy.(pg. 160) 2. Tachypnea is not a normal finding and requires medical care. 3. This is a normal blood pressure finding that is considered pre hypertensive but does not require immediate attention, just more monitoring. (pg. 160) 4. This is a normal temperature. Page Ref: 161 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman. 10) The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings? 1. Primipara at 26 weeks with fundal height of 30 cm 2. Multipara at 12 weeks who reports bright red vaginal bleeding 3. Multipara at 22 weeks who reports no fetal movement felt yet 4. Primipara at 12 weeks with fetal heart tones heard by Doppler fetoscope Answer: 4 Explanation: 1. Fundal height should match with the weeks of gestation, so this is an abnormal finding.(pg. 169) 2. Bright red blood is a sign of a complication in this stage of pregnancy. 3. Fetal movement should be felt starting at 16 weeks but should definitely be felt by 22 weeks. 4. This is an expected finding because fetal heart tones should be heard by 12 weeks using an ultrasonic Doppler fetoscope. Page Ref: 164 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.3 Predict the normal physiologic changes one would expect to find when performing a physical assessment on a pregnant woman.

11) The nurse receives a phone call from a client who thinks she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. In which way should the nurse calculate the client's estimated date of birth (EDB)? 1. January 10 2. January 17 3. December 3 4. November 13 Answer: 2 Explanation: 1. Nagele's rule is calculated by taking the first day of the LMP, subtracting 3 months, and adding 7 days. This answer doesn't follow that formula. 2. Nagele's rule is to add 7 days to the last menstrual period (LMP) and subtract 3 months. The LMP is April 10; therefore, January 17 is the EDB. 3. Nagele's rule is calculated by taking the first day of the LMP, subtracting 3 months, and adding 7 days. This answer doesn't follow that formula. 4. Nagele's rule is calculated by taking the first day of the LMP, subtracting 3 months, and adding 7 days. This answer doesn't follow that formula. Page Ref: 169 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.4 Calculate the estimated date of birth using the common methods.

12) The nurse explains to a pregnant woman that her antepartum assessment will include assessment of clinical pelvimetry. Which client response reflects understanding of the reason for this test? 1. "It will help me understand how big a baby I can have." 2. "It will be used to screen for gestational diabetes." 3. "It will be used to find out whether my baby has a chromosomal abnormality." 4. "It will help tell whether my pelvis is big enough to deliver my baby vaginally." Answer: 4 Explanation: 1. The patient is close but it will decide how big of a baby you can safely deliver vaginally, so it is not the best answer. 2. Screening for gestational diabetes is done through an oral glucose tolerance test.(g. 172) 3. Clinical pelvimetry is a physical exam and not a lab test to check the baby for abnormalities. 4. Clinical pelvimetry is performed to estimate the ease or difficulty associated with vaginal delivery of an infant. Page Ref: 170 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 8.5 Describe the essential measurements that can be determined by clinical pelvimetry. 13) During a prenatal examination, the healthcare provider is going to estimate the adequacy of the client's pelvis for birth. Which measurement will the physician perform vaginally? 1. True conjugate 2. Diagonal conjugate 3. Obstetric conjugate 4. Transverse outlet diameter Answer: 2 Explanation: 1. The true conjugate is one part of the measurement but not the full measurement. 2. The diagonal conjugate is measured from the lower edge of the symphysis to the sacral promontory. 3. The obstetric conjugate is one part of the measurement but not the full measurement. 4. The transverse diameter is one part of the measurement but not the full measurement. Page Ref: 171 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 8.5 Describe the essential measurements that can be determined by clinical pelvimetry.

14) The nurse is working with a prenatal client. Which statement indicates that additional teaching about prenatal screening tests is necessary? 1. "My blood will be checked for hemoglobin level." 2. "Because I am married, I won't have the STI screening." 3. "My vagina will be cultured at 36 weeks for group B strep." 4. "I will have Rh testing, even though this is my first pregnancy." Answer: 2 Explanation: 1. This answer indicates that the patient understands that testing hemoglobin is a standard prenatal screening test. 2. All women should be screened for syphilis, gonorrhea, and hepatitis B despite their relationship status. 3. This answer indicates that the patient understands that testing for group B strep is a standard prenatal screening test. 4. This answer indicates that the patient understands that testing for Rh is a standard prenatal screening test. Page Ref: 172 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 8.6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the prenatal patient. 15) Which phone call should the prenatal clinic nurse return first? 1. Primipara at 32 weeks, reports headache and blurred vision. 2. Primipara at 16 weeks, reports increased urinary frequency. 3. Multipara at 18 weeks, reports no fetal movement this pregnancy. 4. Multipara at 40 weeks, reports sudden gush of fluid and contractions. Answer: 1 Explanation: 1. Headache and blurred vision are signs of preeclampsia, which is potentially life threatening for both mother and fetus. This client has top priority. 2. This is a common complaint at 16 weeks so should not be prioritized over other complaints. 3. This is not an emergency; some patients do not feel fetal movement until approximately 20 weeks. 4. This is not an emergency; this patient is experiencing normal labor complaints and is full term. Page Ref: 173 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.7 Relate the danger signs of pregnancy to their possible causes.

16) The nurse is completing an assessment for a prenatal visit. Which client statement indicates that further teaching is necessary? 1. "Now that I've felt fetal movement, I should feel movement regularly." 2. "Because I'm in my third trimester, I should return to the clinic in a month." 3. "Alcohol is possibly harmful to my baby, even at the end of my pregnancy." 4. "Before I take any over-the-counter medications, I should contact my doctor." Answer: 2 Explanation: 1. The patient understands the importance of monitoring fetal movement during this stage of pregnancy. 2. This statement is incorrect because prenatal visits during the third trimester are every 2 weeks from 26 to 36 weeks, and every week from 36 weeks to delivery. 3. The patient understands the importance of abstaining from alcohol during pregnancy. 4. The patient understands that certain medications can affect the baby and it is important to check with your provider before taking anything over the counter. Page Ref: 176 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 8.8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal patient.

17) A pregnant client is having pelvimetry measurements made. Which diagram should the nurse use to demonstrate the technique for determining the anteroposterior diameter? 1.

Answer: 4 Explanation: 1. This picture shows the McDonald method measuring fundal height.(pg. 169) 2. This picture shows the closed fist measuring the transverse diameter of the outlet. 3. This picture shows the estimation of the diagonal conjugate. 4. This diagram demonstrates how the anteroposterior diameter of the outlet is estimated, which extends from the lower border of the symphysis pubis to the tip of the sacrum. Page Ref: 171 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 8.5 Describe the essential measurements that can be determined by clinical pelvimetry.

18) A pregnant client's quadruple screen shows a risk for the fetus to have Down syndrome. Which test results within the screen were used to make this determination? Select all that apply. 1. Inhibin-A 2. Alpha-fetoprotein (AFP) 3. Unconjugated estriol (UE) 4. Hemoglobin electrophoresis 5. Human chorionic gonadotropin (hCG) Answer: 1, 2, 3, 5 Explanation: 1. Higher than normal levels of inhibin-A may indicate that a woman is at increased risk of having a baby with Down syndrome. 2. Lower than normal AFP could indicate that the woman's child is at risk for Down syndrome or trisomy 18. 3. Lower than normal UE may indicate that a woman is at increased risk of having a baby with Down syndrome. 4. Hemoglobin electrophoresis is used to evaluate for sickle cell disease and thalassemia. 5. Higher than normal levels of hCG may indicate that a woman is at increased risk of having a baby with Down syndrome. Page Ref: 172 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.6 Summarize the results of the major screening tests used during the prenatal period in the assessment of the prenatal patient.

19) During a phone call to the clinic, the nurse suspects that a pregnant client is experiencing preeclampsia. Which manifestations did this client report that caused the nurse to make this clinical determination? Select all that apply. 1. Double vision 2. Epigastric pain 3. Facial swelling 4. Painful urination 5. Severe headache Answer: 1, 2, 3, 5 Explanation: 1. Double vision is a manifestation of preeclampsia. 2. Epigastric pain is a manifestation of preeclampsia. 3. Facial edema is a manifestation of preeclampsia. 4. Painful urination is not a symptom of preeclampsia; it is an indicator of a urinary tract infection. 5. Severe headache is a manifestation of preeclampsia. Page Ref: 173 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 8.7 Relate the danger signs of pregnancy to their possible causes. 20) During a prenatal visit, the nurse notes that a client entering the third trimester has gained a total of 8 lb. Which action should the nurse take at this time? Select all that apply. 1. Assess for nausea. 2. Refer to a dietitian. 3. Suggest amniocentesis. 4. Assess nutritional intake. 5. Discuss importance of adequate weight gain. Answer: 1, 2, 4, 5 Explanation: 1. The nurse should assess for reasons that may restrict the client's intake, such as nausea. 2. The nurse should refer the client to a dietitian for nutritional teaching. 3. The patient's lack of weight gain is not an indicator for an amniocentesis in a pregnancy. 4. The nurse should discuss the importance of adequate nutritional intake. 5. The nurse should discuss the importance of adequate weight gain to support the developing fetus. Page Ref: 174 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 8.8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal patient. 15 Copyright © 2022 Pearson Education, Inc.

21) The nurse provides teaching on the signs of impending labor with a client at week 37 of gestation. Which client statements indicate that additional teaching would be beneficial? Select all that apply. 1. "A bloody show means labor will begin within 2 days." 2. "Having uterine contractions that increase over time is a sign of labor." 3. "Uterine contractions that do not radiate to the back are a sign of labor." 4. "Having a spontaneous flow of water from my vagina is a sign of labor." 5. "Expulsion of a plug of mucus means the baby has dropped into the pelvis." Answer: 1, 3, 5 Explanation: 1. Bloody show is a sign of impending labor, which will begin before 2 days. 2. This statement indicates that the client has understood the teaching. 3. Uterine contractions that do not radiate to the back describe false labor. 4. This statement indicates that the client has understood the teaching. 5. Expulsion of a mucous plug is a sign of impending labor and not an indication that the fetus has dropped into the pelvis. Page Ref: 176 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 8.8 Relate the components of the subsequent prenatal history and assessment to the progress of pregnancy and the nursing care of the prenatal patient.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 9 The Expectant Family: Needs and Care 1) The nurse is preparing a class for expectant fathers. Which information should the nurse include? 1. Siblings adjust readily to the new baby. 2. Sexual activity is safe for normal pregnancy. 3. The expectant mother decides the feeding method. 4. Fathers are expected to be involved in labor and birth. Answer: 2 Explanation: 1. Siblings often have difficulty adapting to the arrival of a new baby. Regression is often seen in siblings' behaviors. 2. During a normal pregnancy, sexual activity is safe for both mother and baby. 3. Often, the father wants input into the feeding method. 4. In some cultures, labor and birth are only for women, and it is inappropriate for fathers to be involved with the labor and birth. Page Ref: 195 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 9.9 Identify some of the concerns that an expectant couple may have about sexual activity.

2) The spouse accompanies a pregnant client to a prenatal visit. Which question should the nurse use to determine the amount of anticipatory guidance the spouse will need? 1. "What kind of work do you do?" 2. "How moody has your wife been lately?" 3. "What furniture have you gotten for the baby?" 4. "How are you feeling about becoming a father?" Answer: 4 Explanation: 1. Asking about vocation does not help determine the amount of anticipatory guidance the spouse will need. 2. Asking about the client's mood does not help determine the amount of anticipatory guidance the spouse will need. 3. Buying furniture does not help determine the amount of anticipatory guidance the spouse will need. 4. Anticipatory guidance of the expectant father is a necessary part of any plan of care. He may need information on a variety of topics about the pregnancy, and the best question to learn the spouse's needs is to ask about his feelings about becoming a father. Page Ref: 179 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 9.2 Describe actions the nurse can take to help maintain the well-being of the expectant father and siblings during a family's pregnancy.

3) The nurse is teaching an early pregnancy class for clients in the first trimester of pregnancy. Which statement requires immediate intervention by the nurse? 1. "When my nausea is bad, I will drink some ginger tea." 2. "It is normal for my vaginal discharge to get green colored." 3. "I will urinate less often during the middle of my pregnancy." 4. "The fatigue I am experiencing will improve in the second trimester." Answer: 2 Explanation: 1. Ginger helps nausea and is safe for use during pregnancy. 2. Leukorrhea is an increase in white vaginal discharge and is an expected finding during pregnancy. Green discharge is not a normal finding and could indicate an infection. Further assessment is required for a client with green vaginal discharge. 3. As the uterus rises in the pelvis during the second trimester, urinary frequency decreases. Urinary frequency increases again during the end of the third trimester as the fetal head descends into the pelvis. 4. First-trimester fatigue is common; fatigue usually improves during the second trimester. Page Ref: 187 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 9.6 Identify the common discomforts of pregnancy and their causes.

4) A client who is at 10 weeks' gestation is concerned about the amount of saliva that is in her mouth since she seems to be spitting when she talks. In which way should the nurse respond? 1. "You should avoid astringent mouthwashes and chewing gum." 2. "That's called ptyalism, and it's usually caused by increased salt intake during the second trimester." 3. "Excess salivation commonly occurs during the first trimester, although the cause is unknown." 4. "Let's schedule you for a doctor's appointment because excessive salivation can signal a complication of pregnancy." Answer: 3 Explanation: 1. Astringent mouthwashes, chewing gum, and sucking hard candy may help relieve the bitter taste that often accompanies ptyalism. 2. Ptyalism, which is excess production of saliva, usually occurs during the first trimester, and the cause is unknown. 3. Ptyalism, which is excess production of saliva, commonly occurs during the first trimester, and the cause is unknown. 4. Excess salivation, also called ptyalism, is a normal occurrence in women during the first trimester. Page Ref: 187 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.6 Identify the common discomforts of pregnancy and their causes.

5) Upon arriving at the prenatal clinic in the morning, the nurse receives messages from four clients. Which client complaint should be addressed first? 1. Primipara at 24 weeks' gestation with ankle edema 2. Multipara at 35 weeks' gestation with new onset of hemorrhoids 3. Primipara at 9 weeks' gestation with increased fatigue and nocturia 4. Multipara at 30 weeks' gestation with vaginal bleeding after performing yoga Answer: 4 Explanation: 1. Particularly during the second and third trimesters, ankle edema is a common pregnancy-related discomfort. 2. Hemorrhoids are a common pregnancy-related discomfort, especially during the second and third trimesters. 3. Fatigue and increased urination at night is a common pregnancy-related discomfort during the first trimester. 4. Vaginal bleeding after yoga is a warning sign that should be immediately reported to the healthcare provider; this client is the highest priority for care. Page Ref: 192 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 9.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy.

6) A 32-year-old primipara who is at 8 weeks' gestation asks if she should expect any breathing changes as the pregnancy progresses. In which way should the nurse respond? 1. "By the third trimester, you will no longer feel as though you're short of breath." 2. "You may experience shortness of breath due to stretching of the round ligament." 3. "If you develop shortness of breath, it should improve in the last few weeks of your pregnancy, as lightening occur." 4. "Shortness of breath is an abnormal finding during any stage of pregnancy, and it is considered a serious complication." Answer: 3 Explanation: 1. Shortness of breath occurs as the uterus rises into the abdomen and causes pressure on the diaphragm. This problem worsens in the last trimester. 2. Round ligament stretching causes a "grabbing" sensation in the lower abdomen and inguinal area. 3. The primigravida experiences considerable relief from shortness of breath in the last few weeks of pregnancy, when lightening occurs, and the fetus and uterus move down in the pelvis. 4. Because of decreased vital capacity from pressure of the enlarging uterus on the diaphragm, shortness of breath is a common problem of pregnancy. Page Ref: 189 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy.

7) A client in the first trimester of pregnancy is experiencing nausea. Which suggestion should the nurse make to relieve the nausea? 1. Eat spicy foods. 2. Eat small, frequent meals. 3. Avoid carbonated beverages. 4. Wait to eat for 2 hours in the morning. Answer: 2 Explanation: 1. The nausea of pregnancy can be exacerbated by ketosis, fatigue, and certain foods, such as those containing caffeine or spices. 2. Avoiding severe hunger by eating small, frequent meals throughout the day can help to prevent or decrease the severity of the nausea. 3. Carbonated beverages might be helpful in decreasing nausea. 4. Eating dry carbohydrates prior to rising each day can help to prevent or decrease the severity of the nausea. Page Ref: 186 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. 8) A client in the third trimester of pregnancy reports frequent leg cramps. Which strategy would be the most appropriate for the nurse to suggest? 1. Limit activity for several days. 2. Flex the foot to stretch the calf. 3. Point the toes of the affected leg. 4. Increase intake of protein-rich foods. Answer: 2 Explanation: 1. Limiting activity is not appropriate. 2. Leg cramps are a common problem in pregnancy, resulting from an imbalance in the calcium—phosphorus ratio; pressure on nerves or decreased circulation in the legs from the enlarged uterus; or fatigue. Dorsiflexing the foot will stretch the calf muscles and will help relieve the cramps. 3. Pointing the toes will exacerbate leg cramps. 4. Protein intake does not affect leg cramps. Page Ref: 188 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy. 7 Copyright © 2022 Pearson Education, Inc.

9) A client in the third trimester of pregnancy reports working 8 hours a day as a cashier and stands when at work. What response by the nurse is the most appropriate? 1. "No problem. Your baby will be fine." 2. "Do you get regular breaks for eating?" 3. "Your pregnancy may be at risk." 4. "Standing might increase ankle swelling." Answer: 3 Explanation: 1. Standing more than 5 hours a day increases the risk of preterm labor. To be therapeutic in communication, avoid false reassurance. 2. Although breaks for eating, drinking, and toileting are important for pregnant employees, it is more important to tell the client about the increased risk of preterm labor. 3. Pregnant women who are employed in jobs that require prolonged standing may be at increased risk of poor pregnancy outcomes. 4. Although this is true, it is less important than teaching the client about the risks of preterm labor when standing more than 3 hours a day. Page Ref: 192 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy. 10) A pregnant client asks what kinds of medications cause birth defects. Which statement would best answer this question? 1. "Almost all medications will cause birth defects in the first trimester." 2. "To be safe, do not take any medication without talking to your doctor." 3. "Too much vitamin C is one of the most common issues but is avoidable." 4. "Birth defects are very rare. Do not worry; your healthcare provider will watch for problems." Answer: 2 Explanation: 1. Not all medications are teratogenic. 2. Pregnant women need to avoid all medications–prescribed, homeopathic, or over-the-counter– if possible. 3. Vitamin C can cause rebound scurvy but is not teratogenic. 4. The nurse should avoid a "do not worry" answer to ensure therapeutic communication, but it is appropriate to instruct the client to talk to the doctor about medications. Page Ref: 197 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy. 8 Copyright © 2022 Pearson Education, Inc.

11) A pregnant client who swims 3 to 5 times per week asks the nurse if she should stop this activity. Which response should the nurse make? 1. "You should discontinue your exercise program immediately." 2. "You should increase the number of times you swim per week." 3. "You should decrease the number of times you swim per week." 4. "You should continue your exercise program because it would be beneficial." Answer: 4 Explanation: 1. 150 minutes of moderate-intensity exercise per week is recommended for pregnant women, but even mild exercise is helpful. There is no reason for the exercise to be discontinued. 2. 150 minutes of moderate-intensity exercise per week is recommended for pregnant women. There is no reason for the exercise to be increased. 3. 150 minutes of moderate-intensity exercise per week is recommended for pregnant women. There is no reason for the exercise to be decreased. 4. 150 minutes of moderate-intensity exercise per week is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, selfimage, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary. Page Ref: 193 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.

12) A pregnant client in the 21st week of pregnancy is planning a vacation with family and asks which method of travel she should use. In which way should the nurse respond? 1. "Travel by bus." 2. "Fly on an airplane." 3. "Take an automobile." 4. "Do not travel this late in the pregnancy." Answer: 2 Explanation: 1. Traveling by bus is similar to traveling by automobile, which does not allow for frequent enough ambulation. 2. As pregnancy progresses, long-distance trips are best taken by plane. 3. Automobile travel does not allow for frequent enough ambulation. 4. It is not necessary to cease travel altogether. Page Ref: 192 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.

13) The nurse is explaining the importance of fetal activity assessment to a pregnant client. Which action should the nurse take to best reinforce the significance of fetal kick monitoring? 1. Perform daily phone calls to the client at work or home. 2. Ask the client to remember to count the fetal movements. 3. Explain the reason for counting fetal movement to the client. 4. Review the client's written record of fetal movement at each visit. Answer: 3 Explanation: 1. Daily phone calls would take emphasis away from the importance of the client's counting of fetal movement. 2. Writing down the count is more accurate than the client's simply remembering. When the nurse examines the written record the client has kept, it reinforces the importance of the record and improves the likelihood of continued record keeping. 3. Many healthcare providers encourage pregnant women to monitor their unborn child's wellbeing by regularly assessing fetal activity beginning at 28 weeks' gestation. Vigorous activity generally provides reassurance of fetal well-being, but a marked decrease in activity or cessation of movement may indicate a problem that needs immediate evaluation. 4. Knowing the reasons for the counting will increase understanding of the process but will not reinforce the significance of the task. Page Ref: 189 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.

14) A 23-year-old client who is at 10 weeks' gestation with a first pregnancy expresses worry over feeling no sexual desire for her spouse and asks if this is normal. In which way should the nurse respond? 1. "That's unusual. Throughout a healthy pregnancy, sexual desire usually increases with each trimester." 2. "That's unusual. Usually, there are minimal changes in sexual desire throughout a healthy pregnancy." 3. "That sounds normal. In many cases, sexual desire decreases in the first trimester, but it increases again during the second trimester." 4. "That sounds normal. During the first trimester, sexual desire often decreases; however, by the third trimester, sexual desire is usually greater than before pregnancy." Answer: 3 Explanation: 1. While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester. 2. While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester. 3. During the first trimester, factors such as fatigue, nausea, vomiting, and breast tenderness may decrease desire for sexual activity. During the second trimester, as these discomforts lessen and pelvic vascular congestion increases, the woman may experience greater sexual satisfaction than before pregnancy. 4. While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester. Page Ref: 196 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.9 Identify some of the concerns that an expectant couple may have about sexual activity.

15) The nurse is assisting an expectant couple in developing a birth plan. Which instructions should the nurse include when teaching about this plan? 1. It is a communication tool between the client and the healthcare provider. 2. It is a legally binding contract between the client and the healthcare provider. 3. It allows the client to make choices about the birth process; however, these choices cannot be altered. 4. It includes only client choices and does not take into account standard choices of the healthcare provider. Answer: 1 Explanation: 1. The birth plan is used as a tool for communication among the expectant parents, the healthcare provider, and the healthcare professionals at the birth setting. 2. It is not a legal document. 3. The written plan identifies options that are available; thus, it can be altered. 4. The birth plan is used as a tool for communication among the expectant parents, the healthcare provider, and the healthcare professionals at the birth setting. Page Ref: 182 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 9.4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth.

16) A pregnant couple would like their 5-year-old to attend the birth. Which should the nurse say in response to this couple's plan? 1. "Bring some toys to keep your child occupied." 2. "Children under 12 are not allowed to be present at the birth." 3. "You should let your child stay home because you will be focusing on the birth." 4. "You should bring someone who will only tend to any specific needs of your child." Answer: 4 Explanation: 1. Preparing the child on what to expect is beneficial. Toys will not sustain a 5year-old's attention for an extended time period. 2. Children are allowed to be present at births. 3. A sibling should have his own support person whose primary responsibility is to take care of the child's needs so that the child will have support if anxiety develops over the birth process, and the mother can concentrate on the labor and birth. 4. A sibling should have his own support person whose primary responsibility is to take care of the child's needs so that the child will have support if anxiety develops over the birth process, and the mother can concentrate on the labor and birth. Page Ref: 184 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.5 Explain the basic goals of childbirth education in providing care to expectant couples and their families.

17) The nurse is preparing materials for couples beginning prenatal care. Which information is most important for the nurse to include? 1. The birthing unit was remodeled and redecorated last year. 2. Some of the healthcare providers recommend circumcision for baby boys. 3. There are various types of healthcare providers to support the client through the process. 4. There are different types of rooms for giving birth, each with different equipment. Answer: 3 Explanation: 1. This information does not help clients understand their options or make decisions. 2. Because not all clients will be having boys, this statement is only helpful to those clients who give birth to males and see a healthcare provider who recommends circumcision. This statement is too narrowly focused to be helpful to all clients. 3. This statement is the most important. The nurse should inform clients what their options are, including the types of healthcare providers available. 4. This statement is too vague to facilitate decision-making by the couple. Page Ref: 184 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 9.4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth. 18) An expectant couple is determining their compatibility with a healthcare provider. Which question should the nurse encourage the couple to ask first? 1. "Can my children attend the birth?" 2. "What is your philosophy of birth?" 3. "If I have a cesarean birth, can my husband attend?" 4. "What percentage of your clients have episiotomies?" Answer: 2 Explanation: 1. Children's attendance is a complement to the healthcare provider's philosophy. 2. A thorough understanding of the healthcare provider's philosophy is essential to determining compatibility. 3. A husband's presence at a cesarean birth is a complement to the healthcare provider's philosophy. 4. Episiotomy percentages are a complement to the healthcare provider's philosophy. Page Ref: 182 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth. 15 Copyright © 2022 Pearson Education, Inc.

19) The nurse is teaching a couple pregnant for the first time. Which statement made by the couple about prenatal classes indicates that additional information is necessary? 1. "Facilitate better communication between both partners." 2. "Eliminate the risk of needing a vacuum extraction or cesarean birth." 3. "Help parents cope with the discomforts and unknowns of childbirth." 4. "Encourage participants to write a list of their requests for labor and birth." Answer: 2 Explanation: 1. A secondary goal of prenatal classes is to facilitate communication between the pregnant woman and her partner. The primary goals are to inform participants of the birth process and teach them skills to cope with labor and birth. 2. This is false reassurance. There is no guarantee that an operative birth can be avoided, even if a couple attends prenatal classes. 3. This is one of the main goals of prenatal classes: learning skills to help get through the discomforts of childbirth. Participants also learn how the birthing process progresses. Participants will learn new skills that will facilitate the birthing process. 4. One of the strategies used in prenatal classes is to have participants write a birth plan that lists their requests for how they want their birthing experience to be. But putting their desires down in writing is less important than learning about the birth process and learning skills to cope with labor and delivery. Page Ref: 183 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 9.5 Explain the basic goals of childbirth education in providing care to expectant couples and their families.

20) The community nurse is providing prenatal care to a client in the home who has been unable to receive traditional prenatal care. Which barriers should the nurse consider when caring for this client? Select all that apply. 1. Location of healthcare facilities 2. View that prenatal care is insignificant 3. Lack of transportation to healthcare facilities 4. Appointment schedule conflicting with work hours 5. Lack of support to care for other children while attending prenatal appointments Answer: 1, 3, 4, 5 Explanation: 1. Home care is especially effective in removing barriers for women who have difficulty accessing healthcare. A lack of locally available healthcare facilities is a barrier. 2. Viewing that prenatal care is insignificant is not identified as a barrier to a woman having difficulty accessing healthcare. 3. Home care is especially effective in removing barriers for women who have difficulty accessing healthcare. Lack of transportation to healthcare facilities is a barrier. 4. Home care is especially effective in removing barriers for women who have difficulty accessing healthcare. Appointment schedule that conflicts with work hours is a barrier. 5. Home care is especially effective in removing barriers for women who have difficulty accessing healthcare. Lack of support to care for other children while attending prenatal appointments is a barrier. Page Ref: 179 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 9.1 Describe the significance of using the nursing process to promote health in the woman and her family during pregnancy.

21) The nurse is evaluating the effectiveness of prenatal education provided to the spouse of a pregnant client. Which observations indicate that this education was effective? Select all that apply. 1. Client is relaxed. 2. Client and spouse are arguing. 3. Spouse is looking forward to the birth. 4. Spouse expresses fear of being a father. 5. Client is following prenatal recommendations. Answer: 1, 3, 5 Explanation: 1. Research indicates that increased focus on the father's needs during prenatal care improves the mother's stress levels. 2. Arguing could indicate that the spouse is not transitioning to fatherhood and will affect the client's stress levels. 3. Research indicates that increased focus on the father's needs during prenatal care aids his transition to fatherhood. 4. Fear of being a father indicates that prenatal education was not effective in helping the spouse transition to fatherhood. 5. Research indicates that increased focus on the father's needs during prenatal care improves the mother's prenatal health behavior. Page Ref: 179-180 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 9.2 Describe actions the nurse can take to help maintain the well-being of the expectant father and siblings during a family's pregnancy.

22) The nurse is preparing to perform an initial prenatal assessment of a pregnant client who recently immigrated to the United States. Which cultural aspects should the nurse include during the assessment of this client? Select all that apply. 1. Birth rituals 2. Nutritional practices 3. Use of home remedies 4. Expectations to return to work 5. Beliefs about exercise and activity Answer: 1, 2, 3, 5 Explanation: 1. Birth rituals may vary according to cultural group and should be assessed. 2. Nutritional practices may vary according to cultural group and should be assessed. 3. Use of home remedies may vary according to cultural group and should be assessed. 4. Expectations to return to work are part of anticipatory guidance, from which every pregnant client and family would benefit. 5. Beliefs about exercise and activity may vary according to cultural group and should be assessed. Page Ref: 180-182 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development│ Nursing/Integrated Concepts: Assessment/Culture and Spirituality Learning Outcome: 9.3 Discuss the significance of respecting cultural practices in managing nursing care during pregnancy.

23) A client in the second trimester of pregnancy is experiencing severe heartburn. Which information should the nurse explain about this health problem? Select all that apply. 1. Decreased gastrointestinal motility 2. Changes in carbohydrate metabolism 3. Increased production of progesterone 4. Relaxation of the esophageal sphincter 5. Displacement of the stomach by the enlarging uterus Answer: 1, 3, 4, 5 Explanation: 1. Decreased gastrointestinal motility contributes to heartburn. 2. Changes in carbohydrate metabolism contribute to the development of nausea and vomiting. 3. The increased production of progesterone in pregnancy contributes to heartburn. 4. Relaxation of the esophageal sphincter contributes to heartburn. 5. Heartburn during pregnancy appears to be primarily a result of the displacement of the stomach by the enlarging uterus. Page Ref: 187 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 9.6 Identify the common discomforts of pregnancy and their causes.

24) The nurse is preparing teaching for a pregnant client with a history of preterm labor. Which information should the nurse specifically provide regarding sexual activity? Select all that apply. 1. Avoid intercourse. 2. Avoid nipple stimulation. 3. Avoid intercourse if vaginal bleeding occurs. 4. Avoid intercourse after the membranes rupture. 5. There are no restrictions to intercourse during pregnancy. Answer: 1, 2 Explanation: 1. Women with a history of preterm labor may be advised to avoid intercourse because the oxytocin that is released with orgasm stimulates uterine contractions and may trigger preterm labor. 2. Because oxytocin is also released with nipple stimulation, fondling the breasts may also be contraindicated in women with a history of preterm labor. 3. All pregnant women should be instructed to avoid intercourse if vaginal bleeding occurs. 4. All pregnant women should be instructed to avoid intercourse after the membranes rupture. 5. Women with a history of preterm labor may be advised to avoid intercourse because the oxytocin that is released with orgasm stimulates uterine contractions and may trigger preterm labor. Page Ref: 196 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 9.9 Identify some of the concerns that an expectant couple may have about sexual activity.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 10 Material Nutrition 1) A 15-year-old primipara at 8 weeks' gestation who is 64 inches tall and weighs 115 pounds asks why she is supposed to gain so much weight. Which response should the nurse make? 1. "Inadequate weight gain delays lactation after delivery." 2. "It's what your certified nurse-midwife recommended for you." 3. "Weight gain is important to assure that you get enough vitamins." 4. "Gaining 25 to 35 pounds is recommended for healthy fetal growth." Answer: 4 Explanation: 1. Inadequate weight gain is not necessarily associated to delayed lactation. 2. That is not an answer to the question; you should validate the patient's question with a valid answer. 3. Weight gain is not a true indicator of adequate vitamin levels. Weight gain is caused by calories; you can eat empty calories and not be absorbing adequate nutrition. 4. Adolescents who become pregnant less than 4 years after menarche are at risk because of their physiologic and anatomic immaturity. They are more likely than older adolescents to still be growing, which can affect the fetus's development. Page Ref: 202 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 10.6 Compare recommendations for weight gain and nutrient intakes in the pregnant adolescent with those for the mature pregnant adult.

2) The nurse is preparing an antenatal nutrition class for pregnant women. Which material should be included in the teaching? 1. During pregnancy, consumption of oily fish should be avoided. 2. Dietary protein can only be obtained through consuming dairy, meat, and eggs. 3. Nutritional iodine requirements generally can be met through intake of iodized salt. 4. Iron absorption is generally higher for vegetable products than for animal products. Answer: 3 Explanation: 1. Oily fish contain DHA and EPA that are essential fatty acids and important in the developing CNS system of the fetus. 2. Meat alternatives can also provide adequate protein requirements such as legumes, nuts, nut butter, and seeds. (pg. 203) 3. Intake of iodized salt generally provides the recommended intake of iodine. 4. Iron absorption is actually higher in animal products vs vegetables. Page Ref: 205 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 10.2 Explain the significance of specific nutrients in the diet of the pregnant woman. 3) The nurse instructs on the importance of niacin during a preconception counseling class. Which food item selected by a participant indicates that teaching about the sources of niacin has been effective? 1. Fish 2. Milk 3. Apples 4. Broccoli Answer: 1 Explanation: 1. Dietary sources of niacin include meats, fish, and enriched grains. 2. Milk is not a source of Niacin. 3. Apples are not a source of Niacin. 4. Broccoli is not a source of Niacin. Page Ref: 207 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 10.2 Explain the significance of specific nutrients in the diet of the pregnant woman.

4) It has been identified that a pregnant client's diet is low in zinc. Which food should the nurse suggest to increase intake of this mineral? 1. Yogurt 2. Bananas 3. Cabbage 4. Shellfish Answer: 4 Explanation: 1. Yogurt is not a food source that is high in zinc. 2. Bananas are not a food source that is high in zinc. 3. Cabbage is not a food source that is high in zinc. 4. Zinc is found in greatest concentration in meats and meat by-products. Enriched grains also tend to be high in zinc. Page Ref: 205 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 10.2 Explain the significance of specific nutrients in the diet of the pregnant woman. 5) The nurse is providing nutritional counseling for a postpartum client with a hemoglobin of 8. Which statement indicates that additional teaching is necessary? 1. "I need to increase food sources that contain iron." 2. "If I drink lots of milk, I will increase my iron level faster." 3. "My iron is low, but it will increase as I take iron supplements." 4. "I might feel less energetic and tire more easily while my iron is low." Answer: 2 Explanation: 1. The client should focus on increasing her intake of iron rich foods, so this is an appropriate answer. 2. Milk does not contain iron; it contains calcium. Increased calcium intake will not increase hemoglobin levels. Further, iron should not be taken with milk, as the iron will not be absorbed. 3. This is an appropriate answer from the client that she will need to take and iron supplement to help her raise her hemoglobin. 4. That is an appropriate answer to teaching that a low hemoglobin may make you feel less energetic. Page Ref: 205 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 10.3 Compare nutritional needs during pregnancy, the postpartum period, and lactation with nonpregnant requirements. 3 Copyright © 2022 Pearson Education, Inc.

6) The nurse reviews nutritional requirements with a breastfeeding mother who is concerned that her milk production has decreased. Which statement indicates that further teaching is required? 1. "I have started cutting back on my protein intake." 2. "At least 3 times a day, I drink a glass of milk." 3. "I am drinking a minimum of 8 to 10 glasses of liquid a day." 4. "I try to take a nap in the morning and afternoon when the baby is sleeping." Answer: 1 Explanation: 1. It is especially important for the breastfeeding mother to consume sufficient calories because inadequate caloric intake can reduce milk volume. The decreased intake of protein represents a decrease in calories, which will decrease milk production. 2. Calcium is an integral part of breast milk so taking in enough is important for a breastfeeding mother. 3. Adequate fluid intake is important for the breastfeeding mother, so this is an appropriate answer. 4. Adequate rest will allow for better stress management as stress and lack of rest can affect milk production. Page Ref: 212 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 10.8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers.

7) The nurse is conducting a postpartum visit to a client who is formula-feeding her infant. Which client statement indicates that teaching about weight maintenance has been effective? 1. "I have increased my caloric intake by 600 calories per day." 2. "My dietician has set my weight loss goal at 1 to 2 pounds per week." 3. "Instead of making another doctor's appointment, I started a diet that my best friend recommended." 4. "My daily regimen includes taking extra vitamin A, vitamin C, and thiamine in order to meet my body's increased need for nutrients after pregnancy." Answer: 2 Explanation: 1. he patient is not breastfeeding, so she doesn't have a need to increase her dietary requirements. 2. Weight loss goals of 1 to 2 pounds (0.45 to 0.9 kg)/week are usually suggested for mothers who formula-feed. 3. Any patient starting a weight loss program should consult their physician. 4. If the patient is not breastfeeding, she doesn't have an increased nutritional need so there is no need to be taking extra vitamins. Page Ref: 212 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 10.8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers.

8) The nurse is planning an educational session for pregnant clients who are vegans. Which information should the nurse include? 1. Vegan diets are high in iron. 2. Rice contains a high level of vitamin B12. 3. Soy is not a good source of protein for vegans. 4. Eating beans and rice provides complete protein needs. Answer: 4 Explanation: 1. Many vegetables are high sources of iron, but the best form of iron can be found in animal meat. 2. Rice doesn't contain high levels of vitamin B12, most vegans need to take supplemental B12. 3. Soy is a good alternative source of protein for vegans. 4. Complete proteins can be obtained by eating different types of plant-based proteins such as beans and rice. Page Ref: 207-208 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 10.4 Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy.

9) A pregnant client who is a lacto-ovo vegetarian asks for help planning a diet that includes adequate protein intake. Which instruction should the nurse give? 1. "To improve protein absorption, avoid simultaneous intake of animal protein and plant protein." 2. "Following a lacto-ovo vegetarian diet will require you to take a daily supplement of vitamin B12." 3. "Because you don't eat meat, eggs, or dairy products, it's important to eat adequate plant-based proteins." 4. "In addition to eggs and dairy products, beans, peanut butter, and soy milk can be effective sources of plant-based proteins." Answer: 4 Explanation: 1. This diet does not include animal protein.(pg. 208) 2. This diet does contain dairy from animals so should provide an adequate source of vitamin B12. 3. The client is consuming eggs and dairy, so this is not an appropriate topic to include in the education. (pg. 208) 4. A diet that includes plant proteins, such as beans and rice, peanut butter on whole-grain bread, and whole-grain cereal with soy milk, helps ensure the expectant mother obtains all the essential amino acids. Page Ref: 207 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 10.4 Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy.

10) Which client statement on cultural or religious influences on nutrition requires intervention? 1. "I avoid milk and meat at meals because I am Jewish." 2. "My grandmother makes sure I eat clay every day." 3. "Because I am Muslim, I do not ever eat any pork products." 4. "My grandmother makes sure I eat a serving of greens each day." Answer: 2 Explanation: 1. This is an appropriate answer and is safe for the pregnant client; she can gain calcium from alternative sources. 2. Eating clay may indicate a nutritional deficiency. This client requires nutritional assessment and counseling. Although considered a form of pica, eating clay during pregnancy may be influenced by cultural or family practices. 3. No intervention is needed from leaving out one animal product. 4. This is a good dietary practice and requires no intervention. Page Ref: 210 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship-Centered Care; Knowledge; 1. The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Assessment/Culture and Spirituality Learning Outcome: 10.5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing management of pregnant women. 11) A pregnant 14-year-old client confides having problems with bulimia nervosa. Which nursing observation best supports the client's statement? 1. The client reports dietary cravings for soil and clay. 2. In terms of food variety and quantity, the client's diet is extremely restrictive. 3. Despite being extremely underweight, the client describes herself as being fat. 4. The client is of normal weight for her height and reports binge eating followed by purging. Answer: 4 Explanation: 1. This is a sign of pica and not that of bulimia nervosa. 2. This is a sign of Anorexia nervosa not bulimia nervosa. 3. This is a sign of Anorexia nervosa not bulimia nervosa. 4. Bulimia is characterized by binge eating and purging, and individuals with bulimia nervosa often maintain normal or near-normal weight for their height. Page Ref: 210 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 10.5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing management of pregnant women.

12) When preparing nutritional instructions, which pregnant client should the nurse consider the highest priority? 1. 40-year-old gravida 2 2. 35-year-old gravida 4 3. 15-year-old nulligravida 4. 22-year-old primigravida Answer: 3 Explanation: 1. The client has been pregnant multiple times and most likely has an understanding of the nutritional requirements of pregnancy so is not a priority. 2. The client has been pregnant multiple times and most likely has an understanding of the nutritional requirements of pregnancy so is not a priority. 3. Adolescent clients typically are still in their own growth cycle. Suddenly, they have to supply nutrition for themselves and the fetus. This places them at greatest risk for malnutrition. 4. Though the client has not been through pregnancy before, she is not the highest priority as the 15-year-old is still growing herself. Page Ref: 211 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 10.6 Compare recommendations for weight gain and nutrient intakes in the pregnant adolescent with those for the mature pregnant adult.

13) Which statement is the best to include when teaching a pregnant adolescent about nutritional needs? 1. "You just need to pay attention to what you eat now." 2. "Folic acid intake is the key to having a healthy baby." 3. "It is important eat iron-rich foods like meat every day." 4. "Calcium and milk aren't needed until the third trimester." Answer: 3 Explanation: 1. This statement can cause undue pressure to an adolescent who is going through a lot of body changes and places too much stress on what they are eating. 2. Although folic acid is important to the development of the fetus, it is not the best answer to the question. 3. Adolescents often have an iron intake that is inadequate for pregnancy. Giving specific examples is the most helpful when providing nutritional information. 4. Calcium and milk are very important in all trimesters for the fetus and if the client will be breastfeeding. Page Ref: 211 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 10.7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. 14) Being aware that several pregnant students have been diagnosed with iron-deficiency anemia, the school nurse plans a class about nutrition for pregnant teens. Which item should the nurse encourage the teens to consume to increase iron absorption? 1. Milk 2. Green tea 3. Gatorade 4. Orange juice Answer: 4 Explanation: 1. Milk is not high in iron. 2. Green tea does not help in iron absorption. 3. As much as Gatorade is high in electrolytes, it is not helpful in absorption of iron. 4. Vitamin C is found in citrus fruits and juices and is known to enhance the absorption of iron from meat and nonmeat sources. Page Ref: 206 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 10.7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent. 10 Copyright © 2022 Pearson Education, Inc.

15) The nurse is caring for a pregnant teen. Which action should the nurse take to accurately assess the teen's nutritional intake? 1. Assess laboratory values. 2. Ask about cooking facilities. 3. Observe for clinical signs of malnutrition. 4. Ask to complete a dietary recall to identify eating patterns. Answer: 4 Explanation: 1. The lab values may not give a clear picture of the teen's nutritional intake as they may be eating a well-balanced diet but still be low on certain nutrients. 2. They may not be cooking the meals or have access to a kitchen but may be eating food from other places. This question will not give you a clear picture of the intake of the individual. 3. Observing for signs of malnutrition is one way to observe the patient, but asking for a recall is the best way to assess the intake of the nutritional consumption of the client. 4. In assessing the diet of the pregnant adolescent, it is important to consider the eating pattern over time, not simply a single day's intake. Once the pattern is identified, counseling can be directed toward correcting deficiencies. Page Ref: 211 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 10.7 Describe basic factors a nurse should consider when offering nutritional counseling to a pregnant adolescent.

16) The nurse is leading a session on nutrition for postpartum clients. Which statement indicates that teaching has been effective? 1. "Breastfeeding requires that I eat lots of protein daily." 2. "Because I am breastfeeding, I need a low calcium intake." 3. "Since I am bottle-feeding, I don't have to eat vegetables." 4. "Bottle-feeding moms like me require a high sodium intake." Answer: 1 Explanation: 1. Breastfeeding clients should consume 65 g of protein daily during the first 6 months of breastfeeding and 62 g daily during the second 6 months. Protein is a major ingredient in breast milk. 2. This answer is the opposite of the take away the client should have that they should have a high calcium intake while breastfeeding. 3. Everyone should eat vegetables even if they are not breastfeeding, 4. Bottle-feeding has no effect on how much sodium the client needs to ingest. Page Ref: 212 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 10.8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers. 17) The nurse is preparing a prenatal class about infant feeding methods to include maternal nutritional requirements for breastfeeding and formula-feeding. Which statement should the nurse include? 1. "Formula-feeding mothers need a high protein intake to avoid fatigue." 2. "Producing breast milk requires calories, but any source of food is fine." 3. "Breastfeeding requires a continued high intake of protein and calcium." 4. "Formula-feeding mothers should protect their health with a lot of calcium." Answer: 3 Explanation: 1. Formula-feeding mothers have no increased nutritional needs. 2. Breastfeeding mothers have specific nutritional needs that should be met. 3. Lactation requires calories, along with increased protein and calcium intake. 4. Formula-feeding mothers have no increased nutritional needs. Page Ref: 212-213 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 10.8 Compare nutritional counseling issues for breastfeeding and formulafeeding mothers.

18) A newly pregnant client weighs 75.0 kg and has a body mass index of 28.5. What is the maximum amount of weight in pounds that this client should weigh during the pregnancy? Answer: 190 lb Explanation: For a client with a BMI between 25.0 and 29.9, the weight gain for the total pregnancy should be between 15 and 25 lb. This client's weight is 75 kg. To determine the maximum amount of weight to gain, first determine the client's weight in pounds by multiplying the weight in kilograms by 2.2, or 75.0 × 2.2 = 165 lb. Then, add the maximum amount of weight of 25 lb to this total, or 165 + 25 = 190 lb. Page Ref: 202 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 10.1 Describe the recommended levels of weight gain during pregnancy. 19) A client who became pregnant at a weight of 60 kg and a BMI of 16 has gained 4 kg at the end of the 5th gestational month. How many more pounds of weight should the nurse counsel this client to gain to achieve the least amount of weight that an underweight person should gain while pregnant? Answer: 19.2 lb Explanation: For a client with a BMI less than 18.5, the weight gain for the total pregnancy should be between 28 and 40 lb. The client has gained 4 kg, or 8.8 lb. To achieve the minimal amount of weight that the client should gain during the entire pregnancy, subtract the amount of weight gained from the minimal amount, or 28 lb - 8.8 lb = 19.2 lb. Page Ref: 202 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 10.1 Describe the recommended levels of weight gain during pregnancy.

20) The nurse is preparing a teaching guide to be used for prenatal, pregnancy, and postpartum nutritional classes. Which nutrients should the nurse emphasize that remain consistent throughout these gestational periods? Select all that apply. 1. Fat 2. Iron 3. Protein 4. Vitamin K 5. The pregnant mother has a slightly higher nutritional requirement for this vitamin Answer: 1, 4 Explanation: 1. Fat requirements are unchanged during pregnancy and should account for about 20% to 35% of daily caloric intake, of which 10% or less should be saturated fat. 2. Iron needs are higher during pregnancy and decrease postpartum as iron is not transferred well through breastmilk. 3. Prenatal protein requirements are less than that of a pregnant or nursing mother. 4. The recommended daily allowance (RDA) for vitamin K, 90 mcg per day, does not increase during pregnancy. Page Ref: 205-206 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 10.3 Compare nutritional needs during pregnancy, the postpartum period, and lactation with nonpregnant requirements.

21) The nurse is instructing a newly pregnant client who follows a vegan eating plan about folic acid. Which information should the nurse include when teaching the client about this nutrient? Select all that apply. 1. The best sources are fresh green leafy vegetables. 2. Overcooking foods high in folic acid is preferred. 3. Foods high in folic acid should be protected from light. 4. Cook foods high in folic acid with small amounts of water. 5. Peanuts and whole-grain breads and cereals are good sources. Answer: 1, 3, 4, 5 Explanation: 1. Sources for folic acid include fresh green leafy vegetables. 2. Overcooking foods with folic acid can actually cause the folic acid content to become inactive. 3. To prevent unnecessary loss, foods with folic acid should be stored covered to protect them from light. 4. To prevent unnecessary loss, foods with folic acid should be cooked with only a small amount of water. 5. Sources of folic acid include peanuts and whole-grain breads and cereals, which are all appropriate for the vegan eating plan. Page Ref: 207 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 10.4 Plan adequate prenatal vegetarian diets based on the nutritional requirements of pregnancy.

22) A pregnant client is reviewing the tentative buffet menu for her upcoming baby shower. Which items should the nurse suggest be substituted to ensure the health of the client and developing fetus? Select all that apply. 1. Baked brie with crackers 2. Greek salad with feta cheese 3. Caesar salad with sourdough croutons 4. Salmon pate with toasted bread rounds 5. Grilled orange roughy with summer vegetables Answer: 1, 2, 3, 4 Explanation: 1. Soft cheese such as brie should be avoided because of the potential for harboring Listeria. 2. Soft cheese such as feta should be avoided because of the potential for harboring Listeria. 3. Salad dressings such as caesar are made with raw eggs, which should be avoided because of the potential for a Salmonella infection. 4. Pates should be avoided because of the potential for harboring Listeria. 5. Orange Roughy is one of the categories that is allowed once a week in pregnant woman, so it is ok to have in the buffet. Page Ref: 209 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 10.5 Explain the ways in which various physical, psychosocial, and cultural factors can affect nutritional intake and status in the nursing management of pregnant women.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 11 Pregnancy in Selected Populations 1) The nurse is preparing an in-service presentation about the role of culture in adolescent pregnancy. Which information should the nurse include in this presentation? Select all that apply. 1. "Teens with future goals tend to use birth control more consistently." 2. "Most pregnant teens do not have any relatives who had their first child as teens." 3. "Young teens who have a child are more likely to have another while still a teen." 4. "Although the rate has dropped, African American and Hispanic teens are more likely to become pregnant." 5. "Eighty-five percent of teen mothers are middle class, and give birth to gain adult status." Answer: 1, 3, 4 Explanation: 1. Teens with future goals such as college or a job tend to use birth control more consistently compared with other teens; if they become pregnant, they are also more likely to have abortions. 2. Teens with a family history of teen pregnancy is a risk factor for teen pregnancy. 3. When the first birth occurs in the early teen years, the next birth also is likely to occur prior to adulthood. 4. In the United States, the adolescent birth rate is higher among African American teens and Hispanic teens than among Caucasian teens. 5. Teen pregnancy has its highest percentage in teens living in poverty. Page Ref: 218 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 11.1 Describe the scope of the problem and the impact of adolescent pregnancy.

2) The nurse who is counseling a group of middle school girls about how to prevent pregnancy should include which statement? 1. "Although condom use is growing, the rate of STIs among teens is rising." 2. "It has become far less acceptable to give birth during your teenage years than it used to be." 3. "You have learned enough from your friends and families to understand how pregnancy occurs." 4. "Although sexuality is common in the media, peer pressure to have sex is not an important factor." Answer: 1 Explanation: 1. Condom use is increasing, but the rate of sexually transmitted infections (STIs), including HIV, is also rising. Research indicates that young people 15 to 24 years of age make up 25% of the sexually experienced population in the United States. However, they account for nearly half of the new cases of STIs. 2. This is not a proper way to counsel pregnancy prevention by shaming girls into not becoming pregnant. 3. Some families may not discuss the topic of sex in the home setting, so it is not helpful to assume that they know about it. 4. Peer pressure is a real feeling for adolescents and must be acknowledged when providing counseling. Page Ref: 218 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 11.1 Describe the scope of the problem and the impact of adolescent pregnancy.

3) The school sexual health clinic nurse has female adolescent students waiting to be seen. Which student should be seen first? 1. 17-year-old adolescent with a history of child abuse 2. 14-year-old adolescent whose 17-year-old sister is pregnant 3. 15-year-old adolescent who reports using condoms regularly 4. 16-year-old adolescent who had a chlamydial infection treated 2 weeks ago Answer: 4 Explanation: 1. This client is not the top priority as they are not reporting a current problem but a past problem. 2. This client is reporting a problem that per that report is not directly related to her health. 3. The client is reporting a safe practice on intake so is not a priority. 4. This client is the top priority. Having had a chlamydial infection, a sexually transmitted infection, indicates that the client is sexually active and not using a barrier method of birth control. This client is at risk for pregnancy and another STI. Page Ref: 218 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces.

4) While developing a conference for adolescents, the nurse prepares a handout describing socioeconomic and cultural factors that contribute to adolescent pregnancy. Which information should the nurse include in the handout? 1. Poverty is a major risk factor for teen pregnancy. 2. All cultures share an aversion to early pregnancy. 3. A child born to a teenage mother is at a lower risk for teen pregnancy. 4. The younger the teen when she first gets pregnant, the less likely she is to have another pregnancy in her teens. Answer: 1 Explanation: 1. Poverty is a major risk factor for teen pregnancy. Adolescents who do not have access to middle-class opportunities tend to maintain their pregnancies because they see pregnancy as their only option for adult status. Teens who are on a low economic trajectory are more likely to become pregnant because of the lack of economic opportunity and the social marginalization that comes with poverty. 2. Some cultures celebrate early pregnancy in married young women, especially ones that encourage multiple children in families. 3. If you are born to a teenage mother, you are at risk for a teen pregnancy yourself. 4. Having one child while a teenager puts you at a higher likelihood of having additional teen pregnancies. Page Ref: 218 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 11.1 Describe the scope of the problem and the impact of adolescent pregnancy.

5) The nurse is working with a group of pregnant teens. Which statement indicates that teaching has been successful? 1. "My baby could come late because I am a teenager." 2. "Because I am young, I have a low risk for preeclampsia." 3. "I am more likely to use birth control after I have this baby." 4. "Pregnant teens are more likely to quit school prior to graduation." Answer: 4 Explanation: 1. Teen mothers are less likely to get the correct prenatal care, putting them at risk for preterm delivery.(pg. 218) 2. Teen mothers are less likely to get the correct prenatal care, putting them at risk for preeclampsia. (pg. 218) 3. Teen parents are at higher risk for having an additional teenage pregnancy (pg. 218) 4. Clients who give birth the first time as adolescents are more likely to have lower educational levels, including a higher rate of dropping out of high school and not attending college or vocational training. Page Ref: 219 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces.

6) An adolescent at 20 weeks' gestation states that it is important not to have a baby that weighs too much. She has been limiting her calories so that her current weight has dropped from 110 pounds to 106 pounds. In which way should the nurse respond? 1. "You are causing harm to your baby." 2. "You shouldn't be worrying about your figure." 3. "Your baby needs adequate nutrition to develop." 4. "It's okay to want a small baby when you're a teen." Answer: 3 Explanation: 1. This is not a therapeutic way to communicate with your patient. 2. This is not a therapeutic way to communicate with your patient. 3. Teens might not understand the physiology behind the profound body changes of pregnancy and how their nutritional choices impact the health of the baby. 4. This is not a good thing to encourage, as the expectant mother needs to eat properly to provide nutrition to herself and the baby, not worry about the size of the baby. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. 7) Which statement, if made by a pregnant adolescent, indicates that she understands her increased risk of physiologic complications during pregnancy? 1. "Smoking and using crack cocaine won't harm my baby." 2. "My anemia and eating mostly fast food are not important." 3. "It's no big deal that I started prenatal care in my seventh month." 4. "I need to take good care of myself so my baby doesn't come early." Answer: 4 Explanation: 1. Smoking and using cocaine are proven to cause harm to the fetus. 2. Fast food is not providing adequate iron to you or your baby, and the anemia can cause harm to the mother and the fetus. 3. Prenatal care should be started as soon as possible to monitor for any issues the mother may be having throughout the pregnancy. 4. Early and regular prenatal care is the best intervention to prevent complications or to detect them early, to minimize the harm to both the teen and her fetus. Page Ref: 223 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Evaluation Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces. 6 Copyright © 2022 Pearson Education, Inc.

8) The nurse is working with male teens whose partners are pregnant. Which situation with a father-to-be requires nursing intervention? 1. The pregnancy does not seem real to him, and he is not sure what he should do to plan for the future. 2. Because his father was not involved in his life, he wants to be actively involved in the life of his child. 3. He is not convinced that he is the father of the baby and does not want his name on the birth certificate. 4. He is the only other person who will be present, although his girlfriend wants her mother-to-be with her during the birth. Answer: 4 Explanation: 1. This is a common feeling for fathers-to-be and does not warrant immediate intervention. 2. This is a positive response and does not warrant any intervention at this time. 3. This does not require nursing intervention. 4. It is common for pregnant adolescents to want their mothers to accompany them for the labor and birth. Overriding his girlfriend's expressed desire could be an indication that their relationship is abusive. Page Ref: 223 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.3 Delineate the characteristics of the fathers of children of adolescent mothers.

9) The nurse seeks to involve the adolescent father in the prenatal care of his partner. For which reason is the nurse using this strategy? 1. Improves the long-term outcome of the relationship 2. Increases the self-care behaviors of the pregnant teen 3. Avoids legal action by the adolescent father's family 4. Avoids conflict between the adolescent father and pregnant teen Answer: 2 Explanation: 1. The nurse has no involvement in the future relationship of the expectant couples. 2. Involving the partner of a pregnant adolescent helps the mother-to-be feel more confident in her decision making and improves her self-confidence and self-esteem, which in turn will improve positive self-care behaviors. 3. This is not a reason to involve the father in prenatal care especially if the mother doesn't want him involved. 4. This is not a reason to involve the father in prenatal care especially if the mother doesn't want him involved. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 11.3 Delineate the characteristics of the fathers of children of adolescent mothers. 10) Which statement by a parent of a pregnant, unmarried 15-year-old is expected? 1. "I'm not going to get involved. She understands how her health insurance works." 2. "An abortion is the best choice for her. She can deal with our Catholic priest later." 3. "We're very happy for her. It will be easier to focus on education with a new baby." 4. "Her father told her to stop dating that boy. Now look at the trouble she's gotten into." Answer: 4 Explanation: 1. This is not an expected reaction because it is usually the mother that manages health care for a teen expectant mother. 2. This is not expected as it goes against the mother's religious beliefs. 3. Families are usually very concerned about the ability of the teen to complete school. 4. This statement indicates anger and dismay, which are expected when a parent finds out about a teen daughter's pregnancy. Page Ref: 221 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.4 Discuss the possible reactions of the adolescent's family and social network to her pregnancy. 8 Copyright © 2022 Pearson Education, Inc.

11) Which statement from the mother of a pregnant 13-year-old would be an expected response? 1. "We had such high hopes for you." 2. "I told you that boy was up to no good." 3. "But she was always an easygoing child." 4. "This is just one of those things that happen." Answer: 1 Explanation: 1. When an adolescent pregnancy is first revealed to the teen's mother, the result is often anger, shame, or disappointment. The degree of negative response will be determined by the age of the teen, the family expectations for the teen, and the presence or absence of other teen pregnancies in the family or support network. In early adolescence, the teen's mother frequently accompanies her daughter to prenatal examinations. The role of the nurse is to facilitate communication between mother and daughter and provide education for both. 2. Blame is not usually the first reaction; it is usually anger, shame, or disappointment. 3. Avoidance is not usually the first reaction; it is usually anger, shame, or disappointment. 4. Denial or ignoring the importance of the news is not usually the first reaction; it is usually anger, shame, or disappointment. Page Ref: 221 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.4 Discuss the possible reactions of the adolescent's family and social network to her pregnancy.

12) Which approach to planning educational activities is best suited for a group of pregnant adolescents? 1. Primarily using visual-based presentations during teaching 2. Combining teaching for adolescent mothers of all ages as one group 3. Respecting confidentiality and building trust by avoiding the topics of drug and alcohol abuse 4. Avoiding the inclusion of handouts with bulleted items and white space as part of the teaching Answer: 1 Explanation: 1. Many teens prefer teaching aids that are visual and that they can handle, such as realistic fetal models. 2. Teaching adolescents in groups that are focused on their age groups is best to promote a good learning environment. 3. Avoiding the topics that are affecting the adolescents is not the way to build trust. Being open and honest is the best way to develop that relationship. 4. Adolescents may have low reading levels, so handouts with lots of visuals and bulleted simple language are the best tools to use with this group. Page Ref: 222 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces.

13) The nurse is working in a teen pregnancy clinic. In order to give the pregnant adolescent a role in her prenatal care, which activity should the nurse encourage the adolescent to do? 1. Choose the schedule of her prenatal visits. 2. Decide if she wants her labor to be induced. 3. Measure and record her weight at each visit. 4. Choose the type of prenatal vitamin she takes. Answer: 3 Explanation: 1. Pregnant teens need to follow the recommended prenatal schedule to promote a healthy pregnancy. 2. The decision to induce labor is decided based on many factors and can including input from the patient when needed however is not the only factor. 3. Having the patient weigh herself and record her weight provides her with information that indicates she is growing a healthy fetus. 4. Choosing a type of vitamin will not provide the teen a role in her prenatal care. Page Ref: 223 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces.

14) A 16-year-old is making her first prenatal visit to the clinic in her fourth month of pregnancy. Which action should the nurse focus on first? 1. Contact the social worker. 2. Develop a trusting relationship. 3. Teach the patient about proper nutrition. 4. Schedule the patient for prenatal classes. Answer: 2 Explanation: 1. There is no need to consult a social worker because this is the teen's first visit. Acceptance of a teen pregnancy may take some time and this is not a social issue. 2. The most important goal for the nurse caring for a pregnant adolescent is to be open minded and nonjudgmental in order to foster trust between the adolescent and the nurse. Through a trusting relationship, the nurse can provide counseling and education to the mother-to-be, both about her body and the fetus. Developing a trusting relationship with the pregnant adolescent is essential. Honesty, respect, and a caring attitude promote self-esteem. 3. Nutrition will need to be reviewed with the patient but is not the most important for the initial visit; building a relationship with the client is the most important. 4. This is the patient's first visit and developing a relationship is most important. You can schedule her for prenatal classes during future visits. Page Ref: 222 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice | Nursing/Integrated Concepts: Planning Learning Outcome: 11.2 Identify the physical, psychologic, and sociologic risks a pregnant adolescent faces.

15) The nurse has been asked by a community organization to give a presentation on prevention of teen pregnancy. Which statement indicates appropriate steps toward reduction of the local teen pregnancy rate? 1. Classes on how to parent will be mandatory in high school. 2. Plans are made to create a low-cost reproductive health clinic. 3. Parents will be encouraged to avoid discussing sexual activity. 4. Abstinence-only education will be offered in the school and clinics. Answer: 2 Explanation: 1. This is not a preventative measure; it will help teen parents by preventing child abuse but not prevent teen pregnancy. 2. Confidential, low-cost contraceptive education and services are most likely to increase contraceptive use by teens who are sexually active and therefore decrease teen pregnancy rates. 3. Having an open line of communication discussing sexual activity is shown to reduce teen pregnancy and reduce the peer pressure that teens feel to have sex. (pg. 218) 4. Providing sex education classes has proven to reduce the teen sexual activity and teen pregnancy. (pg. 218) Page Ref: 225 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Assessment/Teaching/Learning Learning Outcome: 11.5 Describe successful community approaches to prevention of adolescent pregnancy.

16) The nurse is planning a community adolescent pregnancy prevention program aimed toward parents. Which recommendation should be included in the program in order to be effective? 1. Parents should encourage steady dating. 2. Parents should not allow their son to develop an intense relationship with a girl who is much younger. 3. Rather than embarrassing an adolescent by addressing specific topics related to sex, parents should speak in broad, general terms. 4. Instead of bringing up the topic of sex, parents should allow their children to reach a point where the children initiate the discussion. Answer: 2 Explanation: 1. Encouraging steady dating is a risk factor for a teen pregnancy. 2. Parents should take a strong stand against allowing a daughter to date a much older boy; nor should they allow a son to develop an intense relationship with a much younger girl. 3. Bringing up specific topics is more useful in preventing teen pregnancy, being straight and to the point instead of general conversation. 4. Being open with children regarding sex and talking about it is shown to reduce teen pregnancy. Page Ref: 225 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 11.5 Describe successful community approaches to prevention of adolescent pregnancy.

17) The nurse notes that the majority of clients who signed up to attend prenatal classes are over the age of 35. For which reason should the nurse expect the clients to be of this age? Select all that apply. 1. Age of marriage was later. 2. More effective birth control methods. 3. Waited until financially secure before having a family. 4. Needed to care for aging parents before having a family. 5. Wanted to become established in a career before having a family. Answer: 1, 2, 3, 5 Explanation: 1. Reasons for women choosing to have their first baby after age 35 include marrying later in life. 2. Reasons for women choosing to have their first baby after age 35 include more effective birth control methods. 3. Reasons for women choosing to have their first baby after age 35 include waiting until financially secure before having a family. 4. Women over 35 are usually not at the age that they require caring for yet. 5. Reasons for women choosing to have their first baby after age 35 include wanting to become established in a career before having a family. Page Ref: 226 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.6 Describe factors that have contributed to the increased incidence of pregnancy in women over 35 years of age.

18) A 38-year-old client is thrilled to learn of being pregnant with her first child. For which reason would the client have advantages for having a child at this age? Select all that apply. 1. Most likely well educated. 2. Ready to make a life change. 3. Decision was made deliberately. 4. Child care will be easier at this age. 5. Able to take on the responsibilities of a child. Answer: 1, 2, 3, 5 Explanation: 1. ingle women or couples who delay childbearing until they are older tend to be well educated and financially secure. 2. Some women are ready to make a change in their lives, wanting to stay home with a new baby. 3. Usually, the decision to have a baby at an older age was deliberately and thoughtfully made. 4. Childcare may not be easier at this age because most women have established careers and may be working full time requiring full-time childcare. 5. Many of the women have experienced fulfillment in their careers and feel secure enough to take on the added responsibility of a child. Page Ref: 226 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.6 Describe factors that have contributed to the increased incidence of pregnancy in women over 35 years of age.

19) A 40-year-old client, pregnant with her first child, arrives for a prenatal visit. Which perinatal risk factors should the nurse keep in mind when planning this client's care? Select all that apply. 1. Miscarriage 2. Maternal death 3. Perinatal morbidity 4. Potential for multiple births 5. Maternal chronic health conditions Answer: 1, 2, 3, 5 Explanation: 1. The rate of miscarriage is higher in pregnant women over age 35. 2. The risk of maternal death is higher for women over age 35 and even higher for women age 40 and older. 3. The rate of perinatal morbidity is higher in pregnant women over age 35. 4. Potential for multiple births is not considered a risk factor in this age group. 5. Women over the age of 40 and older are more likely to have chronic medical conditions that can complicate a pregnancy. Page Ref: 226 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 11.7 Summarize the nursing care needs of an expectant woman over age 35.

20) The screening results of a quadruple screening completed on a 37-year-old pregnant client were not within the normal range. For which additional testing should the nurse prepare this client? Select all that apply. 1. Ultrasound 2. Serum glucose 3. Amniocentesis 4. Serum ferritin levels 5. Fetal heart monitoring Answer: 1, 3 Explanation: 1. If the screening results are not in the normal range, follow-up testing using ultrasound is often indicated. 2. Serum glucose is not an indicator of Down Syndrome so is not a test that would be needed for follow up on a quadruple screening. 3. If the screening results are not in the normal range, follow-up testing using amniocentesis is often indicated. 4. Serum ferritin is not an indicator of Down Syndrome so is not a test that would be needed for follow up on a quadruple screening. 5. Fetal heart monitoring would not indicate whether the fetus has Down Syndrome or not. Page Ref: 226 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 11.7 Summarize the nursing care needs of an expectant woman over age 35.

21) A 38-year-old pregnant client is reluctant to attend prenatal classes because the other participants will be much younger. Which action should the nurse take to encourage this client's attendance at classes? Select all that apply. 1. Support the client's strengths. 2. Find a class with participants that are older. 3. Encourage the client to read prenatal training material online. 4. Nothing, since the client most likely has already researched the birthing process. 5. Prepare a list of reasons for the late pregnancy to use as responses when others ask. Answer: 1, 2 Explanation: 1. Even though women who are over age 35 and having their first baby tend to be better educated than other healthcare consumers, it should not be assumed that anticipatory guidance and support are not needed. Instead, support the client's strengths and be sensitive to her individual needs. 2. Older expectant parents often feel uncomfortable in classes in which most of the participants are much younger. Because of this, classes for expectant parents over age 35 are now available in many communities. 3. Most women over 35 are well educated and usually enter pregnancy more prepared, but that will not encourage the patient to attend class. 4. Even though the patient may be better prepared at her age, it is still important for her to attend childbirth classes. 5. That will not be helpful to the patient's participation in class. Page Ref: 227 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 11.7 Summarize the nursing care needs of an expectant woman over age 35.

22) The nurse is preparing a presentation on psychosocial issues of older pregnant clients. Which information should the nurse include in this presentation? Select all that apply. 1. Social isolation 2. Financial issues 3. Pending mortality 4. Managing adverse effects 5. Family's and friends' attitudes Answer: 1, 2, 3, 5 Explanation: 1. Older couples facing pregnancy may feel isolated socially. They may feel different because they are often the only couple in their peer group expecting their first baby. 2. The older couple is generally more financially secure, but when their "baby" is ready for college, the older couple may be close to retirement and might not have the means to provide for their child. 3. The older couple may also be forced to face their own mortality. Older expectant parents may confront the issue earlier as they consider what will happen as their child grows. 4. Managing adverse effects of pregnancy is not a psychosocial factor in pregnancy and should not be addressed in this setting. 5. The family's and friends' responses to the pregnancy may be mixed since it will affect relationships and lifestyle. Page Ref: 227 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 11.7 Summarize the nursing care needs of an expectant woman over age 35.

23) A pregnant client with rheumatoid arthritis arrives for a prenatal examination. In which way should the nurse support this client's needs? Select all that apply. 1. Assist with positioning on the examination table. 2. Repeat teaching instructions slowly and succinctly. 3. Assist with changing clothing for the examination. 4. Permit the client privacy while preparing for the examination. 5. Recommend delaying an examination until later in the pregnancy. Answer: 1, 3 Explanation: 1. A client with arthritis might find examination positions uncomfortable. The nurse should assist this client with positioning. 2. The patient has RA not a hearing or mental impairment. 3. A client with arthritis might need assistance changing into an examination gown. 4. This is not specific to a patient with RA. 5. Delaying an examination is not in the best interest of the client or the fetus as the RA is a chronic condition and is not going anywhere. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 11.8 Discuss general healthcare risks that a woman with a significant chronic physical disability might face during pregnancy.

24) The nurse is caring for a pregnant client who has scoliosis that has affected sensation below the level of the umbilicus. Which information should the nurse instruct the client to do, to reduce the risk of adverse effects during pregnancy? Select all that apply. 1. Walk slowly and deliberately. 2. Limit the amount of daily exercise. 3. Eat fewer calories to restrict weight gain. 4. Ingest adequate amounts of fruits, vegetables, and water. 5. Review signs of pending labor other than uterine contractions. Answer: 1, 4, 5 Explanation: 1. Pregnancy may shift the center of gravity. For the client with lumbar scoliosis, this could cause the client to have difficulty maintaining balance with walking. Walking slowly and deliberately will reduce the risk of falling. 2. Limiting physical activity is not necessary and should not be recommended. 3. The client should have the same amount of weight gain as others in her weight class. 4. Ingesting adequate amounts of fruits, vegetables, and water will prevent the development of constipation, which can occur when nervous innervation to the lower abdomen is affected. 5. The client has reduced sensation below the level of the umbilicus and may not recognize or feel uterine contractions associated with pending labor. The nurse needs to review the other signs of pending labor, such as spontaneous rupture of membranes and bloody show. Page Ref: 229 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 11.8 Discuss general healthcare risks that a woman with a significant chronic physical disability might face during pregnancy.

25) A client who is at 28 weeks' gestation arrives for her first prenatal examination in a wheelchair. Which focus the nurse includes when assessing this client? Select all that apply. 1. Signs of physical abuse 2. Evidence of mental abuse 3. Teaching about cesarean birth 4. Reason why prenatal care was delayed 5. Language that would hint toward financial abuse Answer: 1, 2, 4, 5 Explanation: 1. Women with disabilities are at greater risk of being victimized and of sustaining intimate partner violence. Women who rely on their partner for assistance with activities of daily living are at risk for physical abuse. 2. Women with disabilities are at greater risk of being victimized and of sustaining intimate partner violence. Women who rely on their partner for assistance with activities of daily living are at risk for mental abuse. 3. Women with disabilities are at a higher risk of having healthcare workers perceive pregnancy negatively that comment would not encourage therapeutic communication. 4. Women with disabilities are at greater risk of being victimized and of sustaining intimate partner violence. Women who rely on their partner for assistance with activities of daily living are at risk for having care withheld. 5. Women with disabilities are at greater risk of being victimized and of sustaining intimate partner violence. They are also at risk for financial abuse. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 11.8 Discuss general healthcare risks that a woman with a significant chronic physical disability might face during pregnancy.

26) A 25-year-old client with a learning disability arrives for her first prenatal visit at week 24 of gestation. Which care should the nurse emphasize when caring for this client? Select all that apply. 1. Ask if the client has any questions. 2. Avoid rushing through the examination. 3. Provide information in small increments. 4. Ask who is going to financially assist the client. 5. Suggest discussing the pregnancy with social services. Answer: 1, 2, 3 Explanation: 1. The client may have a lower reading and comprehension level. Asking if the client has any questions will help with retention. 2. The client will be anxious, which can be helped by not rushing through the examination. 3. Providing information in small increments will help with comprehension. 4. This answer may show a healthcare provider making assumptions that the client is unable to provide for herself or her baby because she has a disability. 5. Just because the patient has a learning disability doesn't mean she is unable to care for her child. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 11.9 Identify the key needs of a pregnant woman with an intellectual disability.

27) The nurse is preparing prenatal teaching material to support the learning needs of a pregnant client with a learning disability. Which strategy should the nurse keep in mind when preparing these materials? Select all that apply. 1. Provide with videotapes. 2. Provide website addresses. 3. Allow for extra teaching time. 4. Select an easy-to-understand format. 5. Audiotape information from prenatal classes. Answer: 1, 3, 4, 5 Explanation: 1. Good communication aids such as videotapes should be used. 2. The client needs simple, specific, and concise education. Directing them to a website may be overwhelming. 3. Extra teaching time should be provided to ensure all learning needs are met. 4. Easy-to-understand information will facilitate learning. 5. Good communication aids such as audiotapes from prenatal classes should be used. Page Ref: 228 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 11.9 Identify the key needs of a pregnant woman with an intellectual disability.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 12 Assessment of Fetal Well-Being 1) The nurse is responding to phone calls. Which call should the nurse return first? 1. 29 weeks' gestation reports increased fetal movement. 2. 37 weeks' gestation reports no fetal movement for 24 hours. 3. 32 weeks' gestation reports decreased fetal movement for 2 days. 4. 35 weeks' gestation reports decreased fetal movement for 4 hours. Answer: 2 Explanation: 1. Increased fetal movement is not indicative of a problem. 2. A lack of fetal movement in a fetus in the third trimester can indicate fetal hypoxia or fetal death. This client is the highest priority. 3. Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, this client is not the highest priority. 4. Although decreased fetal movement can indicate intrauterine growth restriction or fetal hypoxia, 4 hours is a very short amount of time to assess decreased fetal movement. Page Ref: 233 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 12.1 Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity.

2) A woman at 28 weeks' gestation reports not feeling the baby move for over 30 minutes. In which way should the nurse respond first? 1. "When did you eat last?" 2. "Have you been smoking?" 3. "Your baby might be asleep." 4. "You need to go to the emergency room immediately for further evaluation." Answer: 3 Explanation: 1. After meals, an infant typically is active and moving. 2. Smoking typically will stimulate the infant. 3. Lack of fetal activity for 30 minutes typically is insignificant and means only that the infant is sleeping. The mother should continue to observe for fetal movements over the next 2.5 hours. If a lack of fetal movements continues, she should contact the healthcare provider. 4. The mother would need to come to be examined if there had been no fetal activity for several hours. Page Ref: 234 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 12.1 Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity. 3) The nurse is preparing a client in her second trimester for a four-dimensional ultrasound examination. Which statement indicates that teaching had been effective? 1. "I might be able to see who the baby looks like with the ultrasound." 2. "If the ultrasound is normal, it means my baby has no abnormalities." 3. "The nuchal translucency measurement will diagnose Down syndrome." 4. "Measuring the length of my cervix will determine if I will deliver early." Answer: 1 Explanation: 1. Ultrasounds provide a very clear photo-like image of the fetus, often providing parents the opportunity to identify a familial characteristic such as nose shape. 2. Not all fetal anomalies are detectable by ultrasound. 3. Nuchal translucency measurements are screening, not diagnostic, for trisomies 13, 18, and 21. 4. Transvaginal ultrasound is used to measure the cervical length as a screening for risk of preterm labor. However, a normal-length cervix does not preclude preterm birth. Page Ref: 235 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 12.2 Describe the methods, clinical applications, and results of ultrasound in the nursing management of the pregnant woman. 2 Copyright © 2022 Pearson Education, Inc.

4) A pregnant client's fundal height is 26 cm at 32 weeks' gestation. For which reason would the healthcare provider schedule this client for sonograms every 2 weeks? 1. Evaluate fetal growth. 2. Determine fetal presentation. 3. Assess for congenital anomalies. 4. Rule out a suspected hydatidiform mole. Answer: 1 Explanation: 1. A person who is at 32 weeks' gestation should measure 32 cm of fundal height. When a discrepancy between fundal height and measurement exists, the purpose of serial ultrasounds is to monitor fetal growth. 2. Fetal presentation would require only one ultrasound. 3. Assessment of anomalies would require only one ultrasound. 4. Ruling out a hydatidiform mole would require only one ultrasound. Page Ref: 234 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 12.2 Describe the methods, clinical applications, and results of ultrasound in the nursing management of the pregnant woman. 5) What should the nurse do when assisting a pregnant client who is having an abdominal ultrasound to determine fetal age? 1. Has the woman empty her bladder before the test begins. 2. Assists the woman into a supine position on the examining table. 3. Asks the woman to sign an operative consent form prior to the procedure. 4. Instructs the woman to eat a fat-free meal 2 hours before the scheduled test time. Answer: 2 Explanation: 1. The recommendation is that the client should have a full bladder to help elevate the uterus out of the pelvic cavity for better visualization. 2. Clients are placed in a supine position on the table. 3. Abdominal ultrasounds are not invasive procedures and do not require a consent form. 4. Dietary intake is not relevant to the ultrasound. Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 12.2 Describe the methods, clinical applications, and results of ultrasound in the nursing management of the pregnant woman.

6) A pregnant client is receiving the results of perinatal testing. Which statement indicates that the client understands the test result? 1. "Because my contraction stress test was positive, we know that my baby will tolerate labor well." 2. "The reactive nonstress test means that my baby is not growing because of a lack of oxygen." 3. "My biophysical profile score of 6 points indicates everything being normal and healthy for my baby." 4. "The normal Doppler velocimetry wave result indicates my placenta is getting enough blood to the baby." Answer: 4 Explanation: 1. A contraction stress test creates mild contractions. The presence of decelerations is termed a positive result and indicates a lack of adequate placental functioning. 2. The nonstress test utilizes external fetal monitoring to assess the fetal heart rate in relationship to fetal movement. When accelerations in the fetal heart rate are associated with fetal movement (a reactive result), the fetus is well oxygenated, and the placenta is functioning well. 3. The biophysical profile score should be 8 (with adequate amniotic fluid) or 10. A score of 6 is abnormal and indicates that further assessment is needed. 4. The Doppler velocimetry test looks at blood flow through the umbilical artery. A normal result indicates there is no vasospasm decreasing blood flow to the placenta; therefore, the baby is getting an adequate blood supply. Page Ref: 237 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 12.3 Describe the use, procedure, information obtained, and nursing considerations for the following: first trimester combined screening, cell-free fetal DNA testing, Doppler velocimetry, nonstress test, fetal acoustic and vibroacoustic stimulation tests, biophysical profile, and contraction stress test.

7) At 32 weeks' gestation, a woman is scheduled for a second nonstress test. Which client response indicates an adequate understanding of this procedure? 1. "I'll have an IV started before the test." 2. "I need to have a full bladder for this test." 3. "I cannot get up and walk around during the test." 4. "I must avoid drinks containing caffeine for 24 hours before the test." Answer: 3 Explanation: 1. There is no IV needed to administer medications. 2. Clients usually are asked to have their bladders full only for ultrasounds. 3. The purpose of the nonstress test is to determine the results of movement on fetal heart rate. The client will have to lie still on her side during the procedure. 4. Caffeine might cause the infant to be more active and cause the test to go more quickly. Page Ref: 238 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 12.3 Describe the use, procedure, information obtained, and nursing considerations for the following: first trimester combined screening, cell-free fetal DNA testing, Doppler velocimetry, nonstress test, fetal acoustic and vibroacoustic stimulation tests, biophysical profile, and contraction stress test.

8) During a nonstress test, the nurse notes that the fetal heart rate decelerates about 15 beats during a period of fetal movement. The decelerations occur twice during the test and last 20 seconds each. In which way should the results of this test be evaluated? 1. A reactive test 2. A negative test 3. An equivocal test 4. A nonreactive test Answer: 4 Explanation: 1. A reactive stress test has the expected results of an increase in heart rate of 15 beats per minute for 15 seconds or more. 2. Nonstress tests are scored as either reactive or nonreactive. 3. Nonstress tests are scored as either reactive or nonreactive. 4. In a nonreactive stress test, the reactivity criteria are not met. Since this client experienced a deceleration during the test, this is considered nonreactive. Page Ref: 238 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 12.3 Describe the use, procedure, information obtained, and nursing considerations for the following: first trimester combined screening, cell-free fetal DNA testing, Doppler velocimetry, nonstress test, fetal acoustic and vibroacoustic stimulation tests, biophysical profile, and contraction stress test.

9) A pregnant woman is having a breast-stimulated contraction stress test. Which result indicates hyperstimulation? 1. There are more than five fetal movements in a 10-minute period. 2. There are more than three uterine contractions in a 6-minute period. 3. The fetal heart rate accelerates when contractions last up to 60 seconds. 4. The fetal heart rate decelerates when three contractions occur within a 10-minute period. Answer: 2 Explanation: 1. The fetal movement is considered a negative contraction stress test. 2. An equivocal or suspicious test has nonpersistent late decelerations or decelerations associated with hyperstimulation (contraction frequency of every 2 minutes or duration lasting longer than 90 seconds). When this test result occurs, more information is needed. 3. The acceleration of the heart rate is considered a negative contraction stress test. 4. Decelerations are considered a positive contraction stress test. Page Ref: 241 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 12.3 Describe the use, procedure, information obtained, and nursing considerations for the following: first trimester combined screening, cell-free fetal DNA testing, Doppler velocimetry, nonstress test, fetal acoustic and vibroacoustic stimulation tests, biophysical profile, and contraction stress test.

10) The nurse is reviewing clients who would benefit from a biophysical profile (BPP). Which clients should the nurse identify as a priority? Select all that apply. 1. A gravida who is postterm 2. A gravida with intrauterine growth restriction 3. A gravida with mild hypertension of pregnancy 4. A gravida who is experiencing nausea and vomiting 5. A gravida who complains of decreased fetal movement for 2 days Answer: 1, 2, 3, 5 Explanation: 1. The infant who is postterm might be compromised due to placental insufficiency. 2. The infant who has intrauterine growth problems might be compromised due to placental insufficiency. 3. The BPP is indicated when there is risk of placental insufficiency or fetal compromise because of maternal preeclampsia or eclampsia. 4. Maternal nausea and vomiting is not a criterion for a BPP. 5. The gravida who is experiencing decreased fetal movement for 2 days needs assessment of the placenta and the fetus. Page Ref: 240 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 12.3 Describe the use, procedure, information obtained, and nursing considerations for the following: first trimester combined screening, cell-free fetal DNA testing, Doppler velocimetry, nonstress test, fetal acoustic and vibroacoustic stimulation tests, biophysical profile, and contraction stress test.

11) The nurse is reviewing nursing documentation related to the care of a client who had an amniocentesis. Which nursing note reflects appropriate client care? 1. Prior to discharge, the client demonstrated vaginal spotting. 2. An Rh-positive client received RhoGAM after the amniocentesis. 3. The client was monitored for a short while after completion of the test. 4. The client reported that she takes insulin before each meal and at bedtime. Answer: 3 Explanation: 1. Vaginal spotting after the amniocentesis is not an expected finding. A client experiencing vaginal bleeding of any amount after amniocentesis requires additional assessment and should not be sent home. 2. Only Rh-negative clients receive RhoGAM after amniocentesis. The Rh-positive client should not ever receive RhoGAM. 3. Fetal monitoring after the test is performed to assess for fetal well-being and to rule out injury of the fetus or placenta during the examination. 4. Whether or not a client takes insulin has nothing to do with amniocentesis. This answer does not relate to the question asked. Page Ref: 244 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Knowledge and Science; Practice; document via electronic health records │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 12.4 Explain the use of amniocentesis as a diagnostic tool.

12) A woman who is at 12 weeks' gestation asks the nurse if she can undergo chorionic villus sampling (CVS) testing in order to determine whether her baby has a neural tube defect. Which response is the best? 1. "No, because CVS testing is not performed until after 20 weeks' gestation." 2. "No, because CVS testing alone at any stage cannot detect neural tube defects." 3. "Yes, at 12 weeks' gestation, CVS can be used to diagnose a neural tube defect." 4. "Yes, at 12 weeks' gestation, CVS is combined with amniocentesis to diagnose neural tube defects." Answer: 2 Explanation: 1. While CVS is typically performed between 10 and 13 weeks' gestation, this test cannot detect neural tube defects. 2. Because CVS testing is performed so early in the pregnancy, it cannot detect neural tube defects. 3. CVS is typically performed between 10 and 13 weeks' gestation; however, CVS does not detect neural tube defects. 4. CVS is typically performed between 10 and 13 weeks' gestation; however, amniocentesis is not performed until 15 weeks' gestation. Page Ref: 243 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 12.6 Compare the advantages and disadvantages of chorionic villus sampling (CVS).

13) A woman who is at 15 weeks' gestation received normal chorionic villus sampling (CVS) results and abnormal quadruple screen test results. For detection of congenital anomalies, which test should the nurse expect the woman to be offered next? 1. Ultrasound 2. Amniocentesis 3. Nonstress test (NST) 4. Contraction stress test (CST) Answer: 2 Explanation: 1. While ultrasound has many uses, it is not useful in the diagnosis of congenital anomalies. 2. Women who have a normal CVS and an abnormal quadruple screen test would be offered amniocentesis to screen for congenital anomalies. 3. The nonstress test is used to assess fetal status. 4. The contraction stress test is used to assess fetal status. Page Ref: 243 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 12.6 Compare the advantages and disadvantages of chorionic villus sampling (CVS). 14) In which way should the nurse interpret a pregnant client's lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid? 1. Fetal lungs are mature. 2. Fetal lungs are still immature. 3. The fetus has a congenital anomaly. 4. The fetus is small for gestational age. Answer: 1 Explanation: 1. A 2:1 L/S ratio indicates that the risk of respiratory distress syndrome (RDS) is very low and that the fetus's lungs are mature. 2. Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low if the fetus's lungs are immature, which is not the case in this instance. 3. The L/S ratio is not a measurement for congenital anomalies. 4. The L/S ratio is not a measurement for size of the fetus. Page Ref: 243 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 12.5 Describe the tests that can be performed using amniotic fluid. 11 Copyright © 2022 Pearson Education, Inc.

15) During a home visit, the nurse observes a pregnant client assess fetal activity. Which observations indicate that the client understands the correct process for this count? Select all that apply. 1. Sits in a chair. 2. Assumes a side-lying position. 3. Counts the same time every day. 4. Watches television while counting. 5. Begins counting 1 hour after a meal. Answer: 2, 3, 5 Explanation: 1. The client should be in a side-lying position when assessing fetal activity. 2. A side-lying position is the position for assessing fetal activity. 3. The count should be conducted the same time every day. 4. The environment should be quiet during the count. 5. The count should occur about 1 hour after a meal. Page Ref: 234 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 12.1 Identify pertinent information to be discussed with the woman regarding her own assessment of fetal activity and methods of recording fetal activity.

16) A pregnant client is hesitant to have nuchal translucency testing. Which information should the nurse explain as being the advantages of having this test? Select all that apply. 1. It has a high false-positive rate. 2. It is performed early in the pregnancy. 3. There is no risk of spontaneous abortion. 4. It provides reassurance of the fetus's development. 5. It accurately detects 90% of Down syndrome fetuses. Answer: 2, 3, 4, 5 Explanation: 1. A high false-positive rate would be a disadvantage of this test. 2. Nuchal translucency testing can be performed in the first trimester to determine if a fetus is at risk for chromosomal disorders. 3. Since it is noninvasive, there is no risk of spontaneous abortion. 4. A normal result can provide reassurance to the woman that her baby most likely does not have a chromosomal disorder. 5. Nuchal translucency testing accurately detects 90% of fetuses with Down syndrome. Page Ref: 237 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 12.3 Describe the use, procedure, information obtained, and nursing considerations for the following: first trimester combined screening, cell-free fetal DNA testing, Doppler velocimetry, nonstress test, fetal acoustic and vibroacoustic stimulation tests, biophysical profile, and contraction stress test. 17) The nurse is reviewing amniocentesis with a pregnant client. In which order should the nurse explain the steps that will occur during this procedure? Answer: 1, 4, 3, 6, 5, 2 Explanation: 1. An ultrasound is performed first to identify amniotic fluid pockets. 2. Fetal heart rate is assessed last. 3. A local anesthetic is provided after the skin is cleansed. 4. Skin is cleansed after the ultrasound. 5. Fluid streaming occurs after the 22-gauge needle is removed. 6. A 22-gauge needle is inserted after the local anesthetic. Page Ref: 242 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 12.4 Explain the use of amniocentesis as a diagnostic tool.

18) A client's amniocentesis results indicate that the fetus is at risk for respiratory distress. Which testing values support this clinical decision? Select all that apply. 1. Amniotic glucose level 50 mg/dL 2. Phosphatidylglycerol (PG) negative 3. Lecithin/sphingomyelin (L/S) ratio 1:6 4. Amniotic fluid red blood cell count 5 mg/dL 5. Lamellar body counts (LBCs) 5000/counts/mcL Answer: 2, 3, 5 Explanation: 1. There is no information to support the use of amniotic fluid glucose level to predict respiratory functioning. 2. The absence of phosphatidylglycerol (PG) indicates the fetal lungs are not mature. 3. Lecithin and sphingomyelin are two components of surfactant. Early in pregnancy, the sphingomyelin concentration in amniotic fluid is greater than the concentration of lecithin, and so the L/S ratio is low (lecithin levels are low, and sphingomyelin levels are high). This can result in the development of respiratory distress syndrome (RDS). 4. There is no information to support the use of amniotic fluid red blood cell counts to predict respiratory functioning. 5. When the LBC is 30,000 to 40,000 counts/mcL, probable lung maturity is assumed. Page Ref: 243 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 12.5 Describe the tests that can be performed using amniotic fluid.

19) The nurse is preparing teaching material on chorionic villus sampling (CVS) for a client who is entering the 10th week of gestation. Which risks should the nurse include with this material? Select all that apply. 1. Bleeding 2. Embryonic puncture 3. Intrauterine infection 4. Inability to obtain a tissue sample 5. Inadvertent rupture of the membranes Answer: 1, 3, 4, 5 Explanation: 1. Risks of CVS include bleeding. 2. Embryonic puncture is not a risk associated with CVS. 3. Risks of CVS include intrauterine infection. 4. Risks of CVS include failure to obtain tissue. 5. Risks of CVS include rupture of the membranes. Page Ref: 243 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning Learning Outcome: 12.6 Compare the advantages and disadvantages of chorionic villus sampling (CVS).

20) A client at 20 weeks' gestation is scheduled for a transabdominal ultrasound. Which information should the nurse instruct the client about the examination? Select all that apply. 1. "The entire procedure takes between 20 and 30 minutes." 2. "Arrive 30 minutes before the examination so pain medication will be effective." 3. "Transmission gel will be spread over the abdomen during the examination." 4. "Use an over-the-counter enema to empty the colon before the examination." 5. "Drink 1.5 quarts of water 2 hours before the exam and refrain from voiding." Answer: 1, 3, 5 Explanation: 1. Ultrasound testing takes 20 to 30 minutes. 2. Ultrasound is a painless noninvasive diagnostic test. No anesthesia or pain medication is required prior to the procedure. 3. Transmission gel is generously spread over the client's abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture of the uterine contents. 4. It is not necessary to have an empty colon for an ultrasound. 5. The bladder must be full for an ultrasound. The client should be instructed to drink 1 to 1.5 quarts of water 2 hours before the examination and refrain from voiding to ensure a full bladder. Page Ref: 235 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN Essential Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 12.2 Describe the methods, clinical applications, and results of ultrasound in the nursing management of the pregnant woman.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 13 Pregnancy at Risk: Pregestational Problems 1) A pregnant client who uses cocaine and ecstasy on a regular basis asks why ecstasy should not be used during pregnancy. Which information should the nurse explain about this drug? 1. "It produces intrauterine growth restriction and meconium aspiration." 2. "It leads to deficiencies of thiamine and folic acid, which help the baby develop." 3. "It produces babies with small heads and short bodies with brain function alterations." 4. "It can cause a high fever in you if high doses are taken and therefore cause the baby harm." Answer: 4 Explanation: 1. Heroin causes these fetal effects, not ecstasy. 2. Alcohol, not ecstasy, causes deficiencies of thiamine and folic acid. Folic acid helps prevent neural tube defects. 3. Cocaine causes these fetal effects, not ecstasy. 4. High body temperature is a side effect of MDMA (methylenedioxymethamphetamine: ecstasy). Increased body temperature increases fetal oxygen needs, which can lead to hypoxia and subsequent brain and major organ damage. Page Ref: 257 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to healthtranscultural approaches to healthtranscultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 13.3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

2) The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which client statement indicates that teaching has been effective? 1. "A beer once a week will not damage the fetus." 2. "I can continue to drink alcohol until I am diagnosed as being pregnant." 3. "I can drink alcohol while breastfeeding since it does not pass into breast milk." 4. "I need to stop drinking alcohol completely when I start trying to get pregnant." Answer: 4 Explanation: 1. It is not known how much alcohol will cause fetal damage; therefore, alcohol during pregnancy is contraindicated. 2. Women should discontinue drinking alcohol when they start to attempt pregnancy. 3. Breastfeeding generally is not contraindicated, although alcohol is excreted in breast milk. Excessive alcohol consumption may intoxicate the infant and inhibit the maternal letdown reflex. 4. Because birth defects that are related to fetal alcohol exposure can occur in the first 3 to 8 weeks' gestation, often before the woman even knows she is pregnant, women should discontinue drinking alcohol when they start to attempt pregnancy. Page Ref: 256-257 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 13.3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn.

3) The nurse suspects that a pregnant client is a substance user. Which approach should the nurse take during the health history? 1. Explaining how harmful drugs can be for her baby. 2. Asking the woman directly, "Do you use any street drugs?" 3. Asking the woman if she would like to talk to a counselor. 4. Asking some questions about over-the-counter medications and avoiding the mention of illicit drugs. Answer: 2 Explanation: 1. When talking to clients in a therapeutic manner, it is important not to be threatening or judgmental. Explaining how harmful drugs can be for her baby is an example of being judgmental. 2. The best method of finding out if a client is using substances is to be direct and ask the question in a direct fashion without prejudice, bias, or negative body language. Lack of judgmental attitudes/body language typically results in honest answers. 3. It is the responsibility of the nurse to question the client. 4. It is the responsibility of the nurse not to avoid the issue. Page Ref: 258 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 13.3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. 4) A 20-year-old woman at 28 weeks' gestation has a history of past drug abuse and her urine screening indicates recent heroin use. Which condition should the nurse recognize this client is at risk for developing? 1. Diabetes mellitus 2. Abruptio placentae 3. Erythroblastosis fetalis 4. Preeclampsia Answer: 4 Explanation: 1. Diabetes is an endocrine disorder that is unrelated to drug use/abuse. 2. Abruptio placentae is seen more commonly with cocaine/crack use. 3. Erythroblastosis fetalis is secondary to physiologic blood disorders such as Rh incompatibility. 4. Women who use heroin are at risk for poor nutrition, anemia, and preeclampsia. Page Ref: 258 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 13.3 Summarize the effects of alcohol and illicit drugs on the childbearing woman and her fetus/newborn. 3 Copyright © 2022 Pearson Education, Inc.

5) The client with insulin-dependent type 2 diabetes and an HbA1c of 5% is planning to become pregnant soon. Which anticipatory guidance should the nurse provide this client? 1. Vascular disease that accompanies diabetes slows progression. 2. The risk of ketoacidosis decreases during the length of the pregnancy. 3. The baby is likely to have a congenital abnormality because of the diabetes. 4. Insulin needs decrease in the first trimester and increase during the third trimester. Answer: 4 Explanation: 1. Vascular disease progresses more rapidly during pregnancy, especially if blood sugar control is not good. Problems such as nephropathy and retinopathy can result. 2. The risk of ketoacidosis increases during pregnancy. 3. Infants of diabetic mothers have a 5% to 10% greater risk of having a congenital abnormality. This risk increases to 20% to 25% if the HbA1c is over 10%. 4. In addition, insulin requirements drop suddenly after delivery of the placenta. Page Ref: 247 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 13.1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

6) A client with type 1 diabetes is 20 weeks' pregnant and asks how the diabetes will affect the baby. In which way should the nurse respond? 1. "Your baby may be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3. "Your baby might have high blood sugar for several days." 4. "As long as you control your blood sugar, your baby will not be affected at all." Answer: 2 Explanation: 1. Poorly controlled type 1 diabetics who have developed vascular problems will have infants who are small-for-gestational-age (SGA) due to placental insufficiency. 2. The infant of a diabetic mother produces excessive amounts of insulin in response to the high blood sugar. This hyperinsulinism stimulates growth (or macrosomia) in the infant because the infant utilizes the glucose in the bloodstream. 3. Within minutes of delivery, the baby of an insulin-dependent diabetic can begin to develop low blood sugar. 4. The demands of pregnancy will make it difficult for the best of clients to control blood sugar on a regular basis. Page Ref: 248 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 13.1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

7) A 26-year-old multigravida who is 28 weeks' pregnant and follows a program of regular exercise develops gestational diabetes. Which instruction should be included in a teaching plan for this client? 1. "Carry hard candy (or other simple sugar) when exercising." 2. "If your blood sugar is 120 mg/dL, eat 20 g of carbohydrate." 3. "Exercise either just before meals or wait until 2 hours after a meal." 4. "If your blood sugar is more than 120 mg/dL, drink a glass of whole milk." Answer: 1 Explanation: 1. A client should be encouraged to continue any exercise programs in which she already is involved. She should keep hard candy (simple sugar) with her at all times, just in case the exercise induces hypoglycemia. 2. A finger-stick result of 120 mg/dL is considered to be normal. 3. It is best to exercise just after the meal in order to utilize the glucose. 4. Such clients need no additional carbohydrate or protein intake. Page Ref: 251 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 13.1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

8) A 31-year-old woman who is at high risk for diabetes is at 18 weeks' gestation. During her first antenatal visit, which is the accurate approach to evaluate the client for diabetes? 1. Conduct screening for type 2 diabetes mellitus as soon as possible. 2. Begin serial testing of the client's serum glucose and HA1c at 24 weeks' gestation. 3. If diabetes is diagnosed, consider this condition to be gestational diabetes mellitus (GDM). 4. Recognize HA1c equal to or greater than 4.5% or a fasting plasma glucose level equal to or greater than 90 mg/dL as being diagnostic of diabetes. Answer: 1 Explanation: 1. Women at high risk for type 2 DM should be screened for diabetes as soon as possible. 2. Women at high risk for type 2 DM should be screened for diabetes as soon as possible. 3. Women who are determined to have diabetes at this visit should be diagnosed as having overt diabetes and not GDM. 4. HA1c equal to or greater than 6.5% would be considered diagnostic, as would a fasting plasma glucose level equal to or greater than 126 mg/dL or a 2-hour plasma glucose equal to or greater than 200 mg/dL during an oral glucose tolerance test (OGTT). Page Ref: 248 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 13.1 Discuss the pathology, treatment, and nursing care of pregnant women with diabetes mellitus.

9) A pregnant client at 23 weeks' gestation has a hemoglobin of 9.5 mg/dL. Which diet choice indicates that teaching has been effective? 1. Broiled fish, lettuce salad, grapefruit half, and carrot sticks 2. Pork chop, mashed potatoes and gravy, cauliflower, and tea 3. Roast beef, steamed spinach, tomato soup, and orange juice 4. Tofu with mixed vegetables in curry, milk, and whole-wheat bun Answer: 3 Explanation: 1. This meal is high in fiber, low in fat, and moderately high in protein, but low in iron. This client is anemic and needs iron. 2. This meal has a moderate amount of protein, but no vitamin C. The meal containing beef is better. 3. This client is anemic and needs iron. This meal contains iron in the beef, folic acid in the spinach, and vitamin C in the tomato soup and orange juice. Vitamin C helps absorption of the iron; folic acid is needed for production of red cells. 4. This diet is high in calcium. The client has iron-deficiency anemia and requires a high-iron diet. Page Ref: 255 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 13.2 Distinguish among the major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care.

10) A woman at 30 weeks' gestation and a history of sickle cell anemia is experiencing fever, chills, and diarrhea for 3 days. For which potential complication should the nurse plan care for this client? 1. Severe lethargy 2. Sickle cell crisis 3. Electrolyte imbalance 4. Fetal neural tube defects Answer: 2 Explanation: 1. While the client may develop severe lethargy, her greatest risk concerns development of sickle cell crisis. 2. Dehydration and fever can trigger sickling and crisis; for this reason, maternal infections are treated promptly. 3. While the client may experience electrolyte imbalance, sickle cell crisis is the most serious potential complication of dehydration and fever. 4. Fever, chills, and dehydration in the client with sickle cell anemia are not associated with an increased incidence of neural tube defects. Page Ref: 255 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 13.2 Distinguish among the major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care.

11) A client who is at 18 weeks' gestation has been newly diagnosed with megaloblastic anemia. Which client statement indicates teaching has been effective? 1. "My body makes red blood cells that are smaller than they should be." 2. "Megaloblastic anemia is not known to cause any serious risks to my baby." 3. "Whenever possible, I should boil my vegetables in at least 2 quarts of water." 4. "I should include fresh leafy green vegetables, red meat, fish, poultry, and legumes in my diet." Answer: 4 Explanation: 1. In megaloblastic anemia, red blood cells become enlarged and are fewer in number. 2. Maternal folic acid deficiency has been associated with an increased risk of neural tube defects (NTDs) such as spina bifida, meningomyelocele, and anencephaly in the newborn. 3. Folic acid, which is crucial for inclusion in the diet of clients with megaloblastic anemia, is easily destroyed by overcooking or cooking with large quantities of water. 4. Folic acid, which is used to treat megaloblastic anemia, is readily available in foods such as fresh leafy green vegetables, red meat, fish, poultry, and legumes. Page Ref: 255 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 13.2 Distinguish among the major types of anemia associated with pregnancy with regard to signs, treatment, implications for pregnancy, and nursing care.

12) A client at 9 weeks' gestation learns about being HIV positive. Which client statement indicates teaching about the effects on the baby has been effective? 1. "The pregnancy will increase the progression of my disease and will reduce my CD4 counts." 2. "The HIV will not affect my baby, and I will have a low-risk pregnancy without additional testing." 3. "My baby will probably be born with anti-HIV antibodies, but that does not mean the baby is infected." 4. "I cannot take the medications that control HIV during my pregnancy because they will harm the baby." Answer: 3 Explanation: 1. There is no evidence to indicate that pregnancy increases the progression of HIV/AIDS. 2. Pregnancy affected by HIV/AIDS is considered complicated, and the fetus is monitored closely. Fetal assessments include weekly nonstress tests beginning at 32 weeks. 3. Babies of HIV-positive women or women with AIDS are born with maternal anti-HIV antibodies. HIV infection in infants should be diagnosed using HIV virologic assays as soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is positive. 4. Most of the medications that control HIV progression are safe to take during pregnancy. Antiretroviral medications are recommended during pregnancy to prevent perinatal transmission. Page Ref: 260 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 13.5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care.

13) During the first antepartal visit, a client who is at 10 weeks' gestation learns of being HIV positive. Which client statement indicates an understanding of the plan of care both during the pregnancy and postpartally? 1. "I should not breastfeed my baby." 2. "When my baby is 2 months old, he or she will be tested for HIV." 3. "If I have a cesarean section, there is an increased risk that my HIV will be passed to my baby." 4. "I am supposed to take highly active antiretroviral therapy (HAART), but only during the first trimester." Answer: 1 Explanation: 1. HIV transmission can occur during pregnancy and through breast milk; however, it is believed that the majority of all infections occur during labor and birth. 2. Following birth, HIV infection in infants should be diagnosed using HIV virologic assays as soon as possible, with initiation of infant antiretroviral prophylaxis immediately if the test is positive. 3. Cesarean section reduces the transmission of HIV from mother to infant. 4. Longer duration therapy is preferable to shorter duration approaches, and it is best to start prophylaxis after the first trimester and no later than 28 weeks' gestation in women who do not require immediate therapy for their own health. Page Ref: 260 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 13.5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care.

14) A client who is 32 weeks' pregnant is HIV positive, but asymptomatic. Which action would be important in managing her pregnancy and delivery? 1. An amniocentesis at 30 and 36 weeks 2. Weekly nonstress testing beginning at 32 weeks' gestation 3. Administration of intravenous antibiotics during labor and delivery 4. Application of a fetal scalp electrode as soon as her membranes rupture in labor Answer: 2 Explanation: 1. All invasive procedures that would expose the uninfected infant to the HIV virus are avoided. 2. Clients who are HIV positive are considered high-risk pregnancies. Therefore, beginning at about 32 weeks, these clients have weekly nonstress tests to assess for placental function and an ultrasound every 2 to 3 weeks to assess for intrauterine growth retardation (IUGR). 3. Antibiotics would be ineffective for either the mother or the infant who was HIV positive. 4. All invasive procedures that would expose the uninfected infant to the HIV virus are avoided. Page Ref: 261 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 13.5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. 15) A pregnant woman married to an intravenous drug user had a negative HIV screening test just after missing her first menstrual period. Which finding would indicate that the client needs to be retested for HIV? 1. Elevated blood pressure and ankle edema 2. Shortness of breath and frequent urination 3. Hemoglobin of 11 g/dL and a rapid weight gain 4. Unusual fatigue and recurring Candida vaginitis Answer: 4 Explanation: 1. The client would have a decrease in blood pressure and no ankle edema. 2. Shortness of breath and frequent urination do not indicate a need to retest for HIV. 3. The client would be anemic and anorexic. 4. The client who is HIV-positive would have a suppressed immune system and would experience symptoms of fatigue and opportunistic infections such as Candida vaginitis. Page Ref: 260 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 13.5 Discuss AIDS, including care of the pregnant woman with HIV/AIDS, neonatal implications, ramifications for the childbearing family, and nursing care. 13 Copyright © 2022 Pearson Education, Inc.

16) A client at 24 weeks' gestation has a history of class II heart disease secondary to rheumatic fever. Which information should the nurse expect to see in the medical record? 1. Dyspnea and chest pain with mild exertion 2. Elective cesarean birth scheduled for 37 weeks 3. Discussed need for labor epidural and vacuum extraction 4. Respiratory rate 28, pulse 110, and 3+ pretibial edema bilaterally Answer: 3 Explanation: 1. Dyspnea and angina with mild exertion are not expected with class II heart disease even during pregnancy, but are symptoms seen in class IV heart disease. 2. Cesarean birth is only undertaken in cardiac clients for fetal or maternal intrapartal indications, not for cardiac reasons alone. 3. Lumbar epidural analgesia decreases the stress response during labor, while vacuum extraction or forceps decreases maternal pushing efforts. Both of these decrease stress on the heart during birth. 4. 3+ pretibial edema is never an expected finding during pregnancy. Pulse over 100 and respiratory rate over 24 are indicators of cardiac decompensation. Page Ref: 265 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 13.6 Describe the effects of various heart disorders on pregnancy, including their implications for nursing care.

17) The prenatal clinic nurse has received four phone calls. Which client should be called back first? 1. Multipara at 11 weeks with untreated hyperthyroidism describing the onset of vaginal bleeding 2. Multipara at 6 weeks with a seizure disorder inquiring what foods are good sources of folic acid 3. Primipara at 28 weeks with a history of asthma reporting difficulty breathing and shortness of breath 4. Primipara at 35 weeks with a positive hepatitis B surface antigen (HBsAG) wondering what treatment her baby will receive after birth Answer: 3 Explanation: 1. Pregnant women with untreated hyperthyroidism have an increased risk of fetal loss. Vaginal bleeding at 11 weeks could indicate that spontaneous abortion is taking place. But the majority of spontaneous abortions prior to 12 weeks' gestation are complete and without complications. This client is not experiencing a normal pregnancy, but the health of both mother and fetus are not in immediate danger. 2. Women with seizure disorders should be started on folic acid supplements prior to pregnancy, and should continue throughout pregnancy. This client is not the highest priority. 3. Asthma exacerbations are the most common between 24 and 36 weeks. Asthma attacks can lead to maternal hypoxia, which can lead to fetal hypoxia. This client is the top priority. 4. A client with a positive HBsAG is contagious for hepatitis B. The risk of transmission to the fetus at birth is reduced by bathing the neonate as soon as possible after birth and giving the infant immunoprophylaxis and the first HBsAG vaccine dose. The client seeking information about what will happen after delivery is a low priority when there are pregnant clients currently experiencing physiologic problems. Page Ref: 266 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 13.7 Compare the effects of selected pregestational medical conditions on pregnancy.

18) A client is identified as having hepatitis B surface antigen (HBsAG) early in her pregnancy. Which client statement about the labor and birth process and having hepatitis B infection indicates the need for additional teaching? 1. "Breastfeeding is a good feeding method for my baby." 2. "My baby will get a bath as soon as its temperature is stable." 3. "An internal fetal monitor will be applied as soon as possible during labor." 4. "Two shots will be given to my baby to prevent transmission of hepatitis B." Answer: 3 Explanation: 1. Breastfeeding is not contraindicated in a client with HBsAG. 2. The presence of HBsAG indicates that the client is contagious for and capable of transmitting hepatitis B. Perinatal transmission is most likely to occur at the time of birth; thus, measures are taken to prevent exposing the fetus to the mother's blood and body fluids and to clean the baby's skin thoroughly of fluids as soon as possible after birth. 3. An internal fetal monitor will be avoided. 4. A newborn of a mother with HBsAG will receive an injection of hepatitis B immune globulin and a hepatitis B vaccine injection. Page Ref: 267 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 13.7 Compare the effects of selected pregestational medical conditions on pregnancy. 19) The nurse is concerned that a pregnant client is experiencing depression. Which potential health issues should the nurse include when planning care for this client? Select all that apply. 1. Alcohol use 2. Preterm birth 3. Poor appetite 4. Poor weight gain 5. A pregnant client with schizophrenia is at risk for antenatal hemorrhage. Answer: 2, 3, 4 Explanation: 1. A pregnant client with bipolar disorder is at risk for alcohol use. 2. A pregnant client with depression is at risk for preterm birth. 3. A pregnant client with depression is at risk for poor appetite. 4. A pregnant client with depression is at risk for poor weight gain. Page Ref: 258 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 13.4 Explain the possible implications of maternal psychologic factors and disorders in caring for the childbearing family. 16 Copyright © 2022 Pearson Education, Inc.

20) After completing a physical assessment, the nurse determines that a laboring client is experiencing a panic attack. Which findings did the nurse use to make this clinical determination? Select all that apply. 1. Flat affect 2. Monotone replies 3. Heart rate 120 bpm 4. Respiratory rate 28/minute 5. Disoriented to place and time Answer: 3, 4 Explanation: 1. A flat affect would be associated with depression. 2. Monotone replies are associated with depression. 3. A heart rate of 120 bpm indicates tachycardia, a manifestation of a panic attack. 4. A respiratory rate of 28/minute indicates hyperventilation, a manifestation of a panic attack. 5. Disorientation to place and time would be associated with schizophrenia. Page Ref: 259 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 13.4 Explain the possible implications of maternal psychologic factors and disorders in caring for the childbearing family.

21) A client in labor is demonstrating acute manifestations of schizophrenia. Which action should the nurse identify as a priority for this client? Select all that apply. 1. Ensuring fetal well-being 2. Ensuring maternal well-being 3. Maintaining a safe environment 4. Medicating for pain as necessary 5. Considering pharmacologic intervention Answer: 1, 2, 3, 5 Explanation: 1. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on ensuring fetal well-being. 2. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on ensuring maternal well-being. 3. Some women with severe psychologic disorders may have excessive symptoms during their labor and birth. Care of these women should focus on maintaining a safe environment. 4. Medicating for pain would be provided for all laboring clients, not just those experiencing acute manifestations of schizophrenia. 5. Pharmacologic interventions may be necessary for excessive symptoms. Page Ref: 259 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 13.4 Explain the possible implications of maternal psychologic factors and disorders in caring for the childbearing family.

22) A pregnant client is diagnosed with a cardiac problem. Which teaching should the nurse provide to the client to ensure a safe pregnancy? Select all that apply. 1. Restrict activities 2. Follow a diet high in iron and protein. 3. Restrict the intake of sodium. 4. Obtain 8 to 10 hours of sleep. 5. Obtain pneumococcal vaccination. Answer: 1, 2, 3, 4 Explanation: 1. To help preserve her cardiac reserves, the woman may need to restrict her activities. 2. For the pregnant client with cardiac problems, the client should be instructed in the importance of a diet high in iron and protein. 3. For the pregnant client with cardiac problems, the client should be instructed in the importance of a diet low in sodium. 4. For the pregnant client with cardiac problems, 8 to 10 hours of sleep are essential. 5. Because upper respiratory infections may tax the heart and lead to decompensation, the woman must avoid contact with sources of infection. A pneumococcal vaccination is not indicated. Page Ref: 264 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 13.6 Describe the effects of various heart disorders on pregnancy, including their implications for nursing care.

23) A 32-year-old pregnant client is diagnosed with active tuberculosis (TB). Which fetal health issues is this client at risk for developing? Select all that apply. 1. Cleft palate 2. Preterm labor 3. Microcephaly 4. Spontaneous abortion 5. Suboptimal weight gain Answer: 2, 4, 5 Explanation: 1. Infants of women taking prednisone or prednisolone for rheumatoid arthritis during the first trimester have a slightly increased risk of cleft palate. 2. Women with TB have a higher rate of preterm labor. 3. Women with untreated hyperphenylalaninemia have an increased incidence of microcephaly. 4. Women with TB have a higher rate of spontaneous abortion. 5. Women with TB have a higher rate of suboptimal weight gain. Page Ref: 268 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 13.7 Compare the effects of selected pregestational medical conditions on pregnancy.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 14 Pregnancy at Risk: Gestational Onset 1) The nurse is supervising care in the emergency department. Which situation requires immediate intervention? 1. Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20. 2. Dark red bleeding at 30 weeks' gestation with normal vital signs; client reports the presence of fetal movement. 3. Spotting of pinkish brown discharge at 6 weeks' gestation and abdominal cramping; ultrasound scheduled in 1 hour. 4. Moderate vaginal bleeding at 36 weeks' gestation; client has an IV of lactated Ringer solution running at 125 mL/hour. Answer: 1 Explanation: 1. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid. This client has a low blood pressure with an increased pulse rate, which indicates hypovolemic shock, which can be fatal to the mother and therefore the baby. Both lives are at risk in this situation. Since there is no information given that the client has an IV started, this client is the least stable and, therefore, the highest priority. 2. Occasional spotting can occur. The presence of normal vital signs and usual fetal movements reduces this client's risk of needing immediate intervention. 3. Bleeding in the first trimester can be indicative of the beginning of spontaneous abortion or of an ectopic pregnancy. An ultrasound will diagnose which situation is occurring and will determine care. Because this client is very early in the pregnancy and only experiencing spotting, it is not appropriate to have an IV at this time. 4. Bleeding in the third trimester is usually associated with placenta previa or placental abruption. Blood loss can be heavy and rapid, so having an IV stabilizes the client's vascular volume. Page Ref: 272 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 14.1 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

2) A pregnant client at 14 weeks' gestation is diagnosed with hyperemesis gravidarum. The most recent vital signs are blood pressure 95/48, pulse 114, and respirations 24. Which order should the nurse implement first? 1. Weigh the client. 2. Encourage clear liquids orally. 3. Give 1 L of intravenous fluids. 4. Administer 30 mL Maalox (magnesium hydroxide) orally. Answer: 3 Explanation: 1. Weighing the client provides information on weight gain or loss, but it is not the top priority in a client with excessive vomiting during pregnancy. The vital signs indicate hypovolemia. The client needs IV fluids. 2. The client needs IV fluids because of the vital signs indicating hypovolemia. Oral fluids are not likely to be tolerated well by a client with hyperemesis. Lack of tolerance of oral fluids through excessive vomiting is what has led to the hypovolemia. 3. The vital signs indicate hypovolemia. Giving this client a liter of intravenous fluids will reestablish vascular volume and bring the blood pressure up, and the pulse and respiratory rate down. 4. The vital signs indicate hypovolemia. There is no indication that the client has dyspepsia. The client needs IV fluids. Page Ref: 278 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 14.2 Discuss the medical therapy and nursing care of a woman with hyperemesis gravidarum.

3) A 28-year-old woman at 16 weeks' gestation being screened for ABO incompatibility learns that her blood contains anti-A antibodies. Which information should the nurse explain about this finding? 1. "You may have contracted anti-A antibodies as a result of a viral infection." 2. "It's most likely that you contracted anti-A antibodies through sexual activity." 3. "Anti-A antibodies are inherited; usually, they are genetically passed down from father to daughter." 4. "Anti-A antibodies occur naturally, as a result of exposure to foods and different infections." Answer: 4 Explanation: 1. Women develop anti-A and anti-B antibodies as a result of exposure to the A and B antigens through infection by gram-negative bacteria and not viruses. 2. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gramnegative bacteria. These antibodies are not contracted through sexual activity. 3. Women develop anti-A and anti-B antibodies naturally as a result of exposure to the A and B antigens through the foods they eat and through exposure to infection by gram-negative bacteria. These antibodies are not inherited. 4. Anti-A and anti-B antibodies are naturally occurring; that is, women are naturally exposed to the A and B antigens through the foods they eat and through exposure to infection by gramnegative bacteria. Page Ref: 295 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 14.9 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

4) The nurse is preparing teaching on maternal-fetal ABO incompatibility for antepartum clients. Which statement should the nurse include in the teaching information? 1. In most cases, ABO incompatibility is limited to type A mothers with a type B or O fetus. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. 3. ABO incompatibility occurs as a result of the fetal serum antibodies present and interaction between the antigen sites on the maternal red blood cells (RBCs). 4. Group A infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type. Answer: 2 Explanation: 1. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 2. In most cases, ABO incompatibility is limited to type O mothers with a type A or B fetus. The group B fetus of a group A mother and the group A fetus of a group B mother are only occasionally affected. 3. The incompatibility occurs as a result of the maternal antibodies present in her serum and interaction between the antigen sites on the fetal red blood cells (RBCs). 4. Group O infants, because they have no antigenic sites on the red blood cells (RBCs), are never affected regardless of the mother's blood type. Page Ref: 295 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 14.9 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

5) A client who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing? 1. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM). 2. Obtain an antibody screen (indirect Coombs test) to determine whether the client has developed isoimmunity. 3. Note the potential for ABO incompatibility, and plan to carefully assess the neonate for the development of hyperbilirubinemia. 4. Notify the primary care provider, and document the potential need for treatment of fetal hemolytic anemia in the baby after delivery. Answer: 3 Explanation: 1. RhoGAM is administered to prevent sensitization after exposure to Rh-positive blood. 2. An antibody screen (indirect Coombs test) is done to determine whether an Rh-negative woman is sensitized (has developed isoimmunity) to the Rh antigen. 3. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment; however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert healthcare providers to the need for carefully assessing the newborn for the development of hyperbilirubinemia. 4. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. Page Ref: 295 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 14.9 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

6) A client with preeclampsia is assessed with the following: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. Which new assessment finding indicates the client's condition is getting worse? 1. Reflexes 2+ 2. Platelet count 150,000 3. Blood pressure 158/104 4. Urinary output 20 mL/hour Answer: 4 Explanation: 1. The reflexes are normal at 2+. 2. The platelet count is normal, though it is at the lower end. 3. The blood pressure has not had a significant rise. 4. The decrease in urine output is an indication of decrease in glomerular filtration, which indicates a loss of renal perfusion. The assessment finding most abnormal and life threatening is the urine output change. Page Ref: 280 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 14.3 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

7) The community nurse is caring for a client at 32 weeks' gestation diagnosed with preeclampsia. Which statement indicates that additional information is needed about the health problem? 1. "My urine may become darker and smaller in amount each day." 2. "Lying on my left side as much as possible is good for the baby." 3. "I should call the doctor if I develop a headache or blurred vision." 4. "Pain in the top of my abdomen is a sign my condition is worsening." Answer: 1 Explanation: 1. Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. Oliguria should be reported to the healthcare provider. 2. Left lateral position maximizes uterine and renal blood flow and therefore is the optimal position for a client with preeclampsia. 3. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia and should be reported to the healthcare provider. 4. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the healthcare provider. Page Ref: 284 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 14.3 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

8) A newly admitted client at 32 weeks' gestation is experiencing a sudden onset of intense nausea and a frontal headache for the past 2 days. The client's initial blood pressure is 158/98, and she reports scant urination over the past 24 hours. Which intervention should the nurse anticipate implementing? 1. Ordering a low-protein diet for the client 2. Conducting a urine dipstick test to assess for proteinuria 3. Placing a wedge under the client's left hip so that she is in a right lateral tilt position 4. Administering diuretics and facilitating a dietary regimen of strict sodium restriction Answer: 2 Explanation: 1. This client's signs and symptoms are consistent with preeclampsia. Dietary interventions include moderate to high protein intake (80 to 100 g/day, or 1.5 g/kg/day) to replace protein lost in the urine. 2. This client's signs and symptoms are consistent with preeclampsia. Treatment includes daily urine dipstick testing to assess for proteinuria. 3. This client's signs and symptoms are consistent with preeclampsia. Appropriate interventions include instituting bed rest with the client positioned primarily on her left side, to decrease pressure on the vena cava, thereby increasing venous return, circulatory volume, and placental and renal perfusion. 4. This client's signs and symptoms are consistent with preeclampsia. Treatment includes avoidance of excessively salty foods, but sodium restriction and diuretics are no longer used in treating preeclampsia. Page Ref: 284 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 14.3 Describe the maternal and fetal/neonatal risks, clinical manifestations, and nursing care of a pregnant woman with a hypertensive disorder.

9) The nurse receives the following report on a client who delivered 36 hours ago: para 1, rubella immune, A-negative, antibody screen negative, newborn B-positive, Coombs negative, discharge orders are written for both mother and newborn. Which action should the nurse take? 1. Administer rubella vaccine. 2. Ask if she is breast- or bottle-feeding. 3. Determine if Rh immune globulin has been given. 4. Discuss the discharge education with the client. Answer: 3 Explanation: 1. The client is rubella immune and does not need the rubella vaccine. 2. This is important but is not the top priority. 3. The client is A-negative, and the newborn is B-positive. The client needs Rh immune gobulin prior to discharge. Without it, the client will make antibodies against Rh-positive blood, and future pregnancies would be in jeopardy. 4. Discharge education is always important, but in this case, it is not the most important action. Page Ref: 294 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 14.9 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

10) A postpartum client with blood type A, Rh-negative delivered a newborn with blood type AB, Rh-positive. Which statement indicates that teaching about this blood type inconsistency has been effective? 1. "Because my baby is Rh-positive, I do not need Rh immune globulin." 2. "Before my next pregnancy, I will need to have an Rh immune globulin shot." 3. "If my baby had the same blood type I do, it might cause complications." 4. "I need to get Rh immune globulin so I do not have problems with my next pregnancy." Answer: 4 Explanation: 1. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin to prevent alloimmunization. 2. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin. The injection must be given within 72 hours after delivery to prevent alloimmunization. 3. It is specifically the Rh factor that causes complications; ABO grouping does not cause alloimmunization. 4. Rh-negative mothers who give birth to Rh-positive infants should receive Rh immune globulin to prevent alloimmunization, which could cause fetal anemia and other complications during the next pregnancy. Page Ref: 294 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 14.9 Compare Rh incompatibility to ABO incompatibility with regard to occurrence, clinical treatment, and implications for the fetus or newborn.

11) Which maternal-child client should the nurse see first? 1. Blood type B, Rh-positive 2. Blood type O, Rh-negative 3. Direct Coombs test positive 4. Indirect Coombs test negative Answer: 3 Explanation: 1. This client's blood type creates no problems. 2. This client is Rh-negative, but there is no indication that the alloimmunization has occurred. 3. A direct Coombs test looks for Rh antibodies in the fetal blood circulation. A positive result indicates that that there is an Rh incompatibility between mother and infant, and the baby is making anti-Rh antibodies, which in turn leads to hemolysis. This infant is at risk for anemia and hyperbilirubinemia. 4. An indirect Coombs test looks for Rh antibodies in the maternal serum; a negative result indicates the client has not been alloimmunized. Page Ref: 295 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 14.8 Explain the cause and prevention of hemolytic disease of the newborn secondary to Rh incompatibility.

12) Which situation in the high-risk antepartal unit requires immediate intervention? 1. Fetal monitoring is being performed on a client in her third trimester who is scheduled for a cholecystectomy tomorrow. 2. A third-trimester client pregnant with twins who required an appendectomy yesterday is positioned in a supine position. 3. Oxygen is being administered at 2 L via nasal cannula to a client in her third trimester who underwent a urolithotomy today. 4. The client in her third trimester who returned from bowel resection surgery has a nasogastric tube attached to intermittent suction. Answer: 2 Explanation: 1. Fetal monitoring prior to, during, and after surgery on pregnant clients is important to assess the fetal condition. 2. A client undergoing surgery in the third trimester should be positioned in a left lateral position or with a hip wedge placed under the right hip. Being supine will cause vena cava syndrome and hypotension, which in turn will decrease fetal oxygenation. Twin gestation, with the larger uterus and heavier uterine contents, makes vena cava syndrome more problematic. 3. Oxygen is required during and after surgery during pregnancy to maintain adequate fetal oxygenation. 4. Due to the decreased peristalsis of pregnancy, pregnant clients who undergo abdominal surgery are at risk for vomiting. A nasogastric tube is placed to prevent vomiting. Page Ref: 289 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 14.4 Summarize the risks and implications of surgical procedures performed during pregnancy.

13) The nurse is caring for a client at 35 weeks' gestation who has been critically injured in a shooting. Which statement by the paramedics bringing the woman to the hospital should cause the greatest concern? 1. "Blood pressure 110/68, pulse 90." 2. "Clear fluid is leaking from the vagina." 3. "Client is positioned in a left lateral tilt." 4. "Entrance wound present below the umbilicus." Answer: 4 Explanation: 1. These are normal vital signs, indicating a hemodynamically stable client. 2. Clear fluid from the vagina could be amniotic fluid from spontaneous rupture of the membranes. Although this is not a normal finding at 35 weeks, this fetus is near term and would likely survive birth at this time. 3. Positioning the client in a lateral tilt position prevents vena cava syndrome. 4. Penetrating abdominal trauma has a 59% to 80% fetal injury rate. This fetus is at great risk for injury. Page Ref: 291 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 14.5 Relate the impact of trauma caused by an accident to the nursing care of the pregnant woman or her fetus.

14) The nurse is admitting a client at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is the most critical to ask? 1. "Do you have a safe place where you can go?" 2. "What did you do to make your spouse so angry?" 3. "How many times has this happened in the past?" 4. "Will you be pressing charges against your spouse?" Answer: 1 Explanation: 1. This question is the highest priority because having a safe place to go after leaving the hospital reduces the risk of a repeated attack and further injury to both mother and fetus. 2. This statement is blaming and must be avoided to establish a trusting, therapeutic relationship with an abused client. 3. Although domestic abuse tends to increase in frequency and violence during pregnancy, this is not the highest priority. 4. Legal issues are a low priority at this time. Physiologic issues such as safety in the future have more importance. Page Ref: 292 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 14.6 Discuss the needs and care of the pregnant woman who experiences abuse.

15) The nurse instructs a client on the importance of reducing exposure to infections while pregnant. Which client statement indicates that teaching has been effective? 1. "My genital herpes infection will have no effect on my baby." 2. "Because I have toxoplasmosis, my baby might be born with an abnormally long body." 3. "The rubella infection I experienced in my second trimester may lead me to become deaf." 4. "My baby may develop a serious blood infection because I have group B strep in my vagina." Answer: 4 Explanation: 1. Primary herpes simplex infection poses the greatest risk to both the mother and her infant. Primary infection has been associated with spontaneous abortion, low birth weight, and preterm birth. Transmission to the fetus almost always occurs after the membranes rupture, and the virus ascends or during birth through an infected birth canal. 2. Toxoplasmosis during pregnancy can cause fetal microcephaly, hydrocephalus, coma, convulsions, or retinochoroiditis. 3. Rubella infection during pregnancy can lead to fetal deafness, congenital heart defects, and developmental delays in the fetus. Maternal deafness is not a risk for perinatal rubella. 4. Group B streptococcus can cause neonatal septicemia or pneumonia unless IV antibiotics are given during labor. Page Ref: 288 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 14.7 Contrast the effects of various infections on the pregnant woman and her unborn child.

16) A pregnant client is in a motor vehicle crash and needs surgery to repair a fractured lower leg. Which special precautions will this client need during and after the surgery? Select all that apply. 1. Prepare for intubation. 2. Insert a nasogastric tube. 3. Maintain on strict bed rest. 4. Insert an indwelling urinary catheter. 5. Apply sequential compression devices (SCDs). Answer: 1, 2, 4, 5 Explanation: 1. Pregnancy causes increased secretions of the respiratory tract and engorgement of the nasal mucous membrane, often making breathing through the nose difficult. Consequently, pregnant women often need an endotracheal tube to maintain an airway during surgery. 2. The decreased intestinal motility and delayed gastric emptying that occur in pregnancy increase the risk of vomiting when anesthetics are given and during the postoperative period. A nasogastric tube may be recommended before major surgery. 3. Exercises in bed should be encouraged along with early ambulation after surgery. 4. An indwelling urinary catheter prevents bladder distention, decreases risk of injury to the bladder, and permits monitoring of output. 5. SCDs during and after surgery help prevent venous stasis and the development of thrombophlebitis. Page Ref: 289 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 14.4 Summarize the risks and implications of surgical procedures performed during pregnancy. 17) A pregnant woman is being excavated from the back seat of a motor vehicle after a crash. In which order should this victim receive emergency care? 1. Apply oxygen. 2. Establish an airway. 3. Monitor fetal activity. 4. Position on the left side. 5. Administer intravenous fluids. Answer: 2, 1, 5, 4, 3 Page Ref: 291 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 14.5 Relate the impact of trauma caused by an accident to the nursing care of the pregnant woman or her fetus. 16 Copyright © 2022 Pearson Education, Inc.

18) The nurse is caring for a client recovering from an ectopic pregnancy that occurred in the ampulla of the fallopian tube. When using the diagram, where should the nurse identify for the client the location at which the pregnancy occurred?

Answer:

Explanation: Ectopic pregnancy occurs when the fertilized ovum is prevented or slowed in its passage through the tube and thus implants before it reaches the uterus, usually in the ampulla of the fallopian tube, which is the outer edge, a few centimeters above the ovary. Page Ref: 275 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation Learning Outcome: 14.1 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

19) A client is suspected of having a hydatidiform mole. Which finding should the nurse expect to assess in this client? Select all that apply. 1. Elevated blood pressure 2. Absence of fetal heart tones 3. Frequent urination and thirst 4. Dark brown vaginal drainage 5. Larger than gestational age fundal height Answer: 1, 2, 4, 5 Explanation: 1. Manifestations of preeclampsia are associated with a hydatidiform mole, which would include an elevated blood pressure. 2. Fetal heart sounds are absent with a hydatidiform mole because a fetus is not developing in the uterus. 3. Frequent urination and thirst are not manifestations of hydatidiform mole. 4. Dark brown vaginal discharge, similar to prune juice, occurs because of liquefaction of the uterine clot. 5. Uterine enlargement greater than expected for gestational age is a classic sign of a complete mole, which is present in about half of cases. Enlargement is due to the proliferating trophoblastic tissue and to a large amount of clotted blood. Page Ref: 276-277 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 14.1 Contrast the etiology, medical therapy, and nursing interventions for the various bleeding problems associated with pregnancy.

20) A pregnant client diagnosed with Chlamydia trachomatis infection is refusing treatment. Which effects on the fetus should the nurse explain might occur if treatment is waived? Select all that apply. 1. Fetal death 2. Premature labor 3. Newborn conjunctivitis 4. Chlamydial pneumonia 5. Ophthalmia neonatorum Answer: 1, 2, 3, 4 Explanation: 1. Fetal death is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 2. Premature labor is a potential adverse effect of maternal untreated Chlamydia trachomatis infection. 3. An infant of a woman with untreated chlamydial infection may develop newborn conjunctivitis. 4. An infant of a woman with untreated chlamydial infection may develop chlamydial pneumonia. 5. Ophthalmia neonatorum is associated with gonorrhea. Page Ref: 290 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 14.7 Contrast the effects of various infections on the pregnant woman and her unborn child.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 15 Processes and Stages of Labor and Birth 1) The nurse is caring for laboring clients. Which women are experiencing problems related to a critical factor of labor? Select all that apply. 1. Multipara at 3 cm, fetus in longitudinal lie 2. Primipara at 7 cm, fetus in military attitude 3. Multipara at 6 cm, fetus at −2 station, mild contractions 4. Primipara at 5 cm, fetal presenting part is right shoulder 5. Primipara at 4 cm, fetus with macrocephaly due to hydrocephalus Answer: 2, 3, 4, 5 Explanation: 1. Lie refers to the relationship between the cephalocaudal axis of the mother and the cephalocaudal axis of the fetal body; longitudinal lie is normal. 2. Attitude refers to the relationship of the fetal parts to one another. Military attitude is an unflexed neck; normal fetal attitude is flexion of the neck. Military attitude creates a larger diameter of the head fitting through the pelvis. This client is experiencing a problem between the maternal pelvis and the presenting part. 3. Station refers to how low in the pelvis the baby's presenting part is; −2 station is high in the pelvis. Contractions should be strong to cause fetal descent and cervical dilation. Mild contractions will not move the baby down or open the cervix. This client is experiencing a problem between the maternal pelvis and the presenting part. 4. The presenting part is the fetal part coming through the cervix. The occiput or back of the baby's head is the most common and most effective presenting part. A shoulder presentation cannot deliver vaginally and will require a cesarean birth. This client is experiencing a problem between the maternal pelvis and the presenting part. 5. Hydrocephalus can lead to macrocephaly, or an abnormally large head. Macrocephalic babies might not fit through the bony pelvis and could require birth by cesarean section. This client is experiencing a problem between the maternal pelvis and the presenting part. Page Ref: 303 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 15.2 Describe the five critical factors that influence labor in the assessment of an expectant woman's and fetus's progress in labor and birth.

2) The primiparous client has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. In which way should the nurse respond to this client? 1. "What did you expect? You have only had contractions for a few hours. Labor takes time." 2. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." 3. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix." 4. "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." Answer: 4 Explanation: 1. This reply is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a primipara averages 12 to 24 hours, the nurse must always be therapeutic in all communication. 2. The perineal body thinning primarily occurs during the second stage of labor; it is not expected now. 3. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change. 4. Cervical effacement must be nearly complete before cervical dilation takes place in primips. This is why the labor and birth of a first baby usually take much longer than do subsequent labors and births. Page Ref: 307 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.3 Examine an expectant woman's and fetus's response to labor based on the physiologic processes that occur during labor.

3) The primiparous client at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and leg cramps. Which response by the nurse is the best? 1. "Come in for an appointment today, and we will check everything out." 2. "Unless you have pain with urination, we do not need to worry about it." 3. "This might indicate that the baby is no longer in a head down position." 4. "These symptoms usually mean the baby's head has descended further." Answer: 4 Explanation: 1. There is no need for an additional appointment, as increased pelvic pressure and urinary frequency are premonitory signs of labor. 2. Increased pelvic pressure and urinary frequency are premonitory signs of labor. These are not signs of a urinary tract infection. 3. The client is experiencing premonitory signs of labor; the fetus changing to a breech presentation would be experienced as fetal movement that was formerly felt in the upper abdomen but now is down in the pelvis. 4. This is the best response because it most directly addresses what the client has reported. Increased pelvic pressure and leg cramps are premonitory signs of labor. Page Ref: 330 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.4 Assess for the premonitory signs of labor when caring for the expectant woman.

4) The primiparous client at 39 weeks' gestation calls the clinic and reports slight ankle edema but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? 1. "You should not work so much at this point in pregnancy." 2. "Your body may be telling you it is going into labor soon." 3. "If the bladder pressure continues, come into the clinic tomorrow." 4. "What you are describing is not commonly experienced in the last weeks." Answer: 2 Explanation: 1. There is no indication that the client should decrease her work schedule. 2. One of the premonitory signs of labor includes lightening: The baby drops lower into the pelvis, which creates increased pelvic pressure and venous stasis but less pressure on the diaphragm, which makes breathing easier. 3. Lightening does not indicate pathology, and therefore, there is no need to come to the clinic if the symptoms continue. 4. Lightening is a common and expected finding. Page Ref: 329 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.4 Assess for the premonitory signs of labor when caring for the expectant woman.

5) A 25-year-old woman who is at 38 weeks' gestation with her first pregnancy is embarrassed because of going to the hospital 3 times in the last week for false labor. In which way should the nurse respond? 1. "Do not feel bad. Everyone makes mistakes sometimes." 2. "It is impossible to distinguish between false labor and true labor." 3. "We will discuss the differences between true labor and false labor so this does not happen again." 4. "It is very difficult to tell the difference between true and false labor. Please know we are here to take care of you whenever you need us." Answer: 4 Explanation: 1. Instead of reinforcing the woman's perception of having made an error, the nurse should reassure her that her embarrassment is unwarranted. 2. While it may be difficult to subjectively distinguish between false labor and true labor, vaginal examination can be performed to determine if cervical dilatation is occurring. 3. Rather than reinforcing the woman's incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman's embarrassment. 4. Rather than reinforcing the woman's incorrect interpretation of what she believed to be true labor, the nurse should provide reassurance and ease the woman's embarrassment. Page Ref: 309 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.5 Differentiate between false and true labor.

6) The nurse is teaching a prenatal class. Which characteristics about false labor should the nurse include? Select all that apply. 1. Increased thin vaginal secretions 2. Pain in the abdomen that does not radiate 3. Progressive cervical effacement and dilatation 4. Contractions that do not intensify while walking 5. An increase in the intensity and frequency of contractions Answer: 2, 4 Explanation: 1. True labor results in an increase in vaginal secretions. 2. True labor results in pain beginning low in the abdomen and radiating upward or into the back. 3. True labor results in progressive dilation. 4. True labor contractions intensify while walking. 5. True labor results in increased intensity and frequency of contractions. Page Ref: 309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 15.5 Differentiate between false and true labor.

7) A client whose cervix is dilated 8 cm is restless and frequently changing position in an attempt to get comfortable. Which nursing action is most important? 1. Leave the client alone so she can rest. 2. Ask the family to take a coffee and snack break. 3. Reassure the client that she will not be left alone. 4. Encourage the client to have an epidural for pain. Answer: 3 Explanation: 1. The client is in the transitional phase of the first stage of labor and will not want to be alone. 2. The client is in the transitional phase of the first stage of labor. The family members might want to take a break, but the client will not want to be alone. 3. Because the client is in the transitional phase of the first stage of labor, she will not want to be left alone; staying with the client and reassuring her that she will not be alone are the highest priorities at this time. 4. The client is in the transitional phase of the first stage of labor. There is no indication that the client wants pain relief. Page Ref: 310 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.6 Describe the physiologic and psychologic changes that occur in an expectant woman during each stage of labor in the nursing care management of the expectant woman.

8) During the fourth stage of labor, the client's blood pressure (BP) is 110/60, pulse is 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. Which action should the nurse take? 1. Massage the fundus. 2. Continue to monitor. 3. Turn the client onto her left side. 4. Place the bed in Trendelenburg position. Answer: 2 Explanation: 1. The uterus should be midline and firm; massage is not necessary. 2. The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in BP and a slightly increased pulse. 3. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. 4. Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. Page Ref: 315 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.6 Describe the physiologic and psychologic changes that occur in an expectant woman during each stage of labor in the nursing care management of the expectant woman.

9) A client in labor with cervical dilation of 9 cm is experiencing contractions every 2 minutes that are 60 to 90 seconds in duration and is complaining of excruciating rectal pressure. In which way should the nurse interpret this complaint? 1. The client's complaint is congruent with her current stage of labor. 2. The client's complaint may indicate the need for delivery via cesarean section. 3. Based upon the client's complaint, she is experiencing the active phase of labor. 4. The client's complaint is consistent with placental separation, which is normal for her current stage of labor. Answer: 1 Explanation: 1. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). 2. The objective findings and client's complaint of increased rectal pressure are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). 3. The objective findings and client's complaint are consistent with the transitional phase of labor, during which the client may experience increased rectal pressure as cervical dilatation approaches 10 cm (3.9 in.). 4. Placental separation occurs after the infant is born. Page Ref: 310 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 15.6 Describe the physiologic and psychologic changes that occur in an expectant woman during each stage of labor in the nursing care management of the expectant woman.

10) Which client requires immediate intervention by the labor and delivery nurse? 1. Primipara in active labor with urine output of 100 mL/hour 2. Primipara that delivered 1 hour ago with white blood cells (WBCs) of 50,000 3. Multipara at 8 cm, systolic blood pressure has increased 35 mm Hg 4. Multipara at 5 cm with a respiratory rate of 22 between contractions Answer: 2 Explanation: 1. This is a normal urine output and requires no further intervention. 2. A white count of 25,000 to 30,000 is normal at the end of labor and during the early postpartum period. This WBC count is abnormally high and requires further assessment and provider notification. 3. The systolic blood pressure will change by up to 35 mm Hg during the first stage of labor and can increase further in the second stage of labor. 4. The respiratory rate increases during labor because uterine contractions increase oxygen requirements. This client requires no further intervention. Page Ref: 316 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 15.7 Explain the maternal systemic responses to labor in the nursing care of the expectant woman. 11) The labor and delivery nurse is preparing a prenatal class about facilitating the progress of labor. Which pain response should the nurse identify as most likely to impede progress in labor? 1. Muscle tension 2. Increased pulse 3. Increased respirations 4. Elevated blood pressure Answer: 1 Explanation: 1. Muscle tension can impede labor progress by increased oxygen and calorie consumption and by creating a mechanical obstruction that the uterine contractions must overcome to achieve labor progress. 2. Increased pulse is a manifestation of pain, but it does not impede labor. 3. Increased respiration is a manifestation of pain, but it does not impede labor. 4. Elevated blood pressure is a manifestation of pain, but it does not impede labor. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 15.7 Explain the maternal systemic responses to labor in the nursing care of the expectant woman. 10 Copyright © 2022 Pearson Education, Inc.

12) A healthy 18-year-old client who is at 40 weeks' gestation experiences vaginal expulsion of stringy mucus followed by blood-tinged secretions unaccompanied by discomfort or any other changes. Based upon these findings, which outcome should the nurse expect for this client within the next 24 to 48 hours? 1. Onset of labor 2. Cesarean section 3. Chorioamnionitis 4. Spontaneous abortion Answer: 1 Explanation: 1. Softening and effacement of the cervix is accompanied by expulsion of the mucous plug and a small amount of blood loss from the exposed cervical capillaries. The resulting pink-tinged secretions are called bloody show. Bloody show is considered a sign that labor will begin within 24 to 48 hours. 2. The client is describing pregnancy-related changes associated with imminent onset of labor. Based upon her report, there is no indication that cesarean section will be necessary. 3. Chorioamnionitis is associated with premature rupture of amniotic membranes (PROM). Based upon the client's report, she is demonstrating mucous plug expulsion and bloody show. 4. The client is most likely demonstrating expulsion of the mucous plug and bloody show, which is considered a sign that labor will begin within 24 to 48 hours. Page Ref: 309 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 15.4 Assess for the premonitory signs of labor when caring for the expectant woman.

13) While caring for a client in labor, the nurse determines that the baby's head has internally rotated. The client's spouse asks about other positional changes that will occur during the labor and birth. In which way should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation? 1. Expulsion, external rotation, and restitution 2. Restitution, flexion, external rotation, and expulsion 3. Descent, internal rotation, external rotation, and extension 4. Flexion, extension, restitution, external rotation, and expulsion Answer: 3 Explanation: 1. The fetus changes position in the following order: descent, internal rotation, external rotation, and extension. 2. The fetus changes position in the following order: descent, internal rotation, external rotation, and extension 3. The fetus changes position in the following order: descent, internal rotation, external rotation, and extension 4. The fetus changes position in the following order: descent, internal rotation, external rotation, and extension Page Ref: 314 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.8 Examine fetal responses to labor.

14) A pregnant client expresses a desire to use the Lamaze method for the upcoming birth of her child. Which elements of this birthing process should the nurse explain to the client? Select all that apply. 1. Guided imagery 2. Sensory memory 3. Dissociative relaxation 4. Controlled muscle relaxation 5. Differentiated breathing patterns Answer: 3, 4, 5 Explanation: 1. Guided imagery is not a technique within the Lamaze method of childbirth. 2. Sensory memory is a technique within the Kitzinger method of childbirth. 3. Dissociative relaxation is used to promote birth as a normal process in the Lamaze method of childbirth. 4. Controlled muscle relaxation is used to promote birth as a normal process in the Lamaze method of childbirth. 5. Specified breathing patterns are used to promote birth as a normal process in the Lamaze method of childbirth. Page Ref: 298 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 15.1 Compare methods of childbirth preparation.

15) A client entering the third trimester of labor is concerned about having enough muscle strength and stamina to give birth. Which exercises should the nurse review with the client to facilitate the birthing process? Select all that apply. 1. Yoga 2. Pelvic tilt 3. Pelvic rock 4. Kegel exercises 5. McRoberts exercises Answer: 2, 3, 4, 5 Explanation: 1. Yoga is not identified as an exercise to facilitate the birthing process. 2. Body-conditioning exercises, such as the pelvic tilt, are taught in childbirth preparation classes. 3. Body-conditioning exercises, such as the pelvic rock, are taught in childbirth preparation classes. 4. Body-conditioning exercises, such as the Kegel exercises, are taught in childbirth preparation classes. 5. Exercises aimed at adducting the legs into an extended McRoberts position help enable the woman to stretch her hamstring muscles, a task usually required during the second stage of labor. Page Ref: 298 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 15.1 Compare methods of childbirth preparation.

16) The nurse is reviewing the different types of fetal presentations with a client nearing the end of her pregnancy. Which presentation should the nurse identify as being ideal? 1.

Answer: 1 Explanation: 1. The vertex presentation is the most common type of presentation. The fetal head is completely flexed onto the chest, and the smallest diameter of the fetal head (suboccipitobregmatic) presents to the maternal pelvis with the occiput as the presenting part. 2. In the sinciput or military presentation, the fetal head is neither flexed nor extended. The occipitofrontal diameter presents to the maternal pelvis, and the top of the head is the presenting part. 3. In the brow presentation, the fetal head is partially extended. The occipitomental diameter, the largest anteroposterior diameter, is presented to the maternal pelvis, and the sinciput is the presenting part. 4. In the face presentation, the fetal head is hyperextended. The submentobregmatic diameter presents to the maternal pelvis, and the face is the presenting part. Page Ref: 303 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 15.2 Describe the five critical factors that influence labor in the assessment of an expectant woman's and fetus's progress in labor and birth.

17) A client is entering the end of the second stage of labor. Which finding should the nurse expect to assess in this client? Select all that apply. 1. Bulging perineum 2. Parting of the labia 3. Crowning of the fetus 4. Increasing bloody show 5. Increasing rectal pressure Answer: 1, 2, 3, 4 Explanation: 1. During the end of the second stage of labor, the perineum bulges as the fetal head enters the birth canal. 2. During the end of the second stage of labor, the labia part as the fetal head enters the birth canal. 3. During the end of the second stage of labor crowning of the fetal head occurs, which indicates that birth is imminent. 4. During the end of the second stage of labor, bloody show will increase. 5. Increasing rectal pressure occurs during the transition stage of labor. Page Ref: 311 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 15.3 Examine an expectant woman's and fetus's response to labor based on the physiologic processes that occur during labor. 18) The nurse suspects that a pregnant client is experiencing true labor. Which finding did the nurse assess to make this clinical determination? Select all that apply. 1. Contractions increase in intensity. 2. Discomfort occurs in the abdomen. 3. Contractions occur at regular intervals. 4. Walking has no effect on the contractions. 5. Time between contractions gradually becomes shorter. Answer: 1, 3, 5 Explanation: 1. In true labor, contractions will increase in intensity. 2. In false labor, the contractions occur in the abdomen. 3. In true labor, the contractions occur at regular intervals. 4. In false labor, walking has no effect on the contractions. 5. In true labor, the time between contractions gradually becomes shorter. Page Ref: 309 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 15.5 Differentiate between false and true labor. 17 Copyright © 2022 Pearson Education, Inc.

19) The spouse is concerned that the client in labor will be hungry since the last time any food was eaten was several hours ago. Which information should the nurse explain as effects of the labor process on the client's gastrointestinal system? Select all that apply. 1. Reduced gastric motility 2. Increased gastric volume 3. Increased gastric motility 4. Reduced absorption of food 5. Prolonged gastric emptying time Answer: 1, 2, 4, 5 Explanation: 1. During labor, gastric motility is reduced. 2. During labor, gastric volume remains increased regardless of the time of the last meal. 3. Gastric motility is decreased, not increased. 4. During labor, absorption of solid food is reduced. 5. During labor, gastric emptying time is prolonged. Page Ref: 316 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.7 Explain the maternal systemic responses to labor in the nursing care of the expectant woman.

20) A client in the beginning stages of labor asks the nurse if the labor process will hurt the baby. Which information should the nurse explain to the client about the fetus's response to labor? Select all that apply. 1. The baby's heart rate will change. 2. The baby feels no pain or sensations. 3. The baby is sensitive to light and sounds. 4. The baby's oxygen level drops about 10%. 5. The blood pressure protects the baby during labor. Answer: 1, 3, 4, 5 Explanation: 1. Early fetal heart rate decelerations can occur with intracranial pressures of 40 to 55 mmHg, as the head pushes against the cervix. 2. The fetus is experiencing labor as the woman labors. 3. Beginning at about 37 or 38 weeks' gestation, the fetus is able to experience sensations of light, sound, and touch. 4. Blood flow is decreased to the fetus at the peak of each contraction, and fetal oxygen saturation drops about 10%. 5. Fetal blood pressure protects the normal fetus during the anoxic periods caused by the contracting uterus during labor. Page Ref: 318 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 15.8 Examine fetal responses to labor.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 16 Intrapartum Nursing Assessment 1) The nurse is admitting a client to the labor and delivery unit. Which aspect of the history requires notifying the healthcare provider? 1. Blood pressure 120/88 2. Dark red vaginal bleeding 3. History of domestic abuse 4. Father is a carrier of sickle-cell trait. Answer: 2 Explanation: 1. Blood pressure is 120/88. Although the diastolic reading is slightly elevated, this is not the top priority. 2. Third-trimester bleeding is caused by either placenta previa or abruptio placentae. Dark red bleeding usually indicates abruptio placentae, which is life-threatening to both the mother and fetus. 3. This client is at risk for harm after delivery but is not in a life-threatening situation at this time. This is not the highest priority for the client. 4. The infant also might have sickle trait, but sickle trait is not life-threatening at this time. Page Ref: 323 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.1 Describe a maternal assessment of the laboring woman that includes the patient history, high-risk screening, and physical and psychosociocultural factors.

2) The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed? 1. "When you check my cervix, you will find out how thinned out it is." 2. "After you assess my pelvis, you will be able to tell when I will deliver." 3. "You are going to do a vaginal examination to see how far dilated my cervix is." 4. "The reason for a pelvic examination is to determine how low in the pelvis my baby is." Answer: 2 Explanation: 1. Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic examination assessment. 2. An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic examination, no information is obtained about the contractions. The nurse will not have enough information following the cervical examination to estimate time of birth. 3. Cervical dilation is one aspect of the pelvic examination assessment. 4. Determining the station of the presenting part is one aspect of the pelvic examination assessment. Page Ref: 326 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 16.2 Evaluate the progress of labor by assessing the laboring woman's contractions, cervical dilatation, and effacement.

3) The nurse is preparing to assess the fetus of a laboring client. Which action should the nurse perform first? 1. Place the client into a left lateral position. 2. Perform the Leopold maneuver to determine fetal position. 3. Dry the maternal abdomen before using the Doppler. 4. Count the fetal heart rate for 30 seconds and multiply by 2. Answer: 2 Explanation: 1. The fetal heart tone assessment should be performed while the client is either supine with a lateral tilt or while in left lateral position. 2. Leopold maneuvers are performed first to determine where to listen for fetal heart tones. This is the first step so that the Doppler device can be placed directly over the heart and multiple unsuccessful attempts to hear the heart rate are avoided. 3. Prior to using the Doppler device, a water-based gel is applied to the skin. 4. Although this is how to auscultate the fetal heart rate, it is better to perform Leopold maneuvers to determine fetal position so that the Doppler device can be placed directly over the heart, and multiple unsuccessful attempts to hear the heart rate are avoided. Page Ref: 327 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.3 Delineate the procedure for performing Leopold maneuvers and the information that can be obtained, including the importance of identifying accurate fetal position prior to performing a fetal heart rate assessment.

4) The student nurse is performing Leopold maneuvers on a client in labor. For which action should the staff nurse intervene? 1. After determining where the back is located, the cervix is assessed. 2. The upper portion of the uterus is palpated, and then the middle section. 3. Following voiding, the client's abdomen is palpated from top to bottom. 4. The client is assisted into the supine position, and the position of the fetus is assessed. Answer: 1 Explanation: 1. The cervical examination is not a part of Leopold maneuvers; abdominal palpation is the only technique used for the Leopold maneuver. 2. This is correct order of the first and second Leopold maneuvers. 3. The client is instructed to void prior to beginning Leopold maneuvers to facilitate comfort; Leopold maneuvers are essentially palpation of the uterus through the abdomen, beginning at the fundus and ending near the cervix. 4. Determination of fetal position and station is the point of Leopold maneuvers. The client is supine to facilitate uterine palpation. Page Ref: 328 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.3 Delineate the procedure for performing Leopold maneuvers and the information that can be obtained, including the importance of identifying accurate fetal position prior to performing a fetal heart rate assessment. 5) The nurse is explaining Leopold maneuvers to a client who is in the early stage of labor. Which information should the nurse explain as being the purpose of the second maneuver? 1. Locate the fetal back. 2. Identify the descent of the presenting part into the pelvis. 3. Determine if the pelvic inlet contains the head or buttocks. 4. Determine if the fetal head or buttocks occupies the uterine fundus. Answer: 1 Explanation: 1. The second Leopold maneuver determines the location of the fetal back. 2. The fourth maneuver determines the flexion of the fetal neck and descent into the pelvis. 3. The third maneuver determines which fetal part is in the pelvic inlet. 4. The first maneuver determines what part of the fetus is in the fundus. Page Ref: 328 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 16.3 Delineate the procedure for performing Leopold maneuvers and the information that can be obtained, including the importance of identifying accurate fetal position prior to performing a fetal heart rate assessment. 4 Copyright © 2022 Pearson Education, Inc.

6) The nurse is preparing to monitor the fetal heart rate (FHR) of a pregnant client. Which information should the nurse explain to the client as being the baseline (BL) of this heart rate? 1. "The baseline FHR excludes periods of marked variability." 2. "Normal baseline FHR ranges from 100 to 180 beats per minute." 3. "The baseline FHR should include periodic or episodic changes in FHR." 4. "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute." Answer: 1 Explanation: 1. The baseline FHR excludes periodic or episodic changes and periods of marked variability. 2. Normal FHR (baseline rate) ranges from 110 to 160 beats per minute. 3. The baseline FHR excludes periodic or episodic changes and periods of marked variability. 4. The baseline rate is the mean FHR during a 10-minute period rounded to increments of 5 beats per minute (bpm). Page Ref: 330 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 16.5 Distinguish between baseline and periodic changes in fetal heart rate monitoring, and the appearance and significance of each. 7) Which pattern, if seen on an electronic fetal monitoring strip, should the nurse explain to a client in labor as being a change in the baseline fetal heart rate? 1. Tachycardia 2. Acceleration 3. Late deceleration 4. Sinusoidal pattern Answer: 1 Explanation: 1. Bradycardia and tachycardia are changes in the fetal heart rate baseline. 2. Accelerations are periodic changes of the fetal heart rate. 3. Late decelerations are periodic changes of the fetal heart rate. 4. A sinusoidal pattern is a periodic change of the fetal heart rate. Page Ref: 330 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 16.5 Distinguish between baseline and periodic changes in fetal heart rate monitoring, and the appearance and significance of each.

8) The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is the best? 1. Determine the color of the leaking amniotic fluid. 2. Apply oxygen to the client at 2 L per nasal cannula. 3. Notify the operating room of the need for a cesarean birth. 4. Assist the client to change from the Fowler position to the left lateral position. Answer: 4 Explanation: 1. The fetus is exhibiting variable decelerations; there is no indication that the amniotic fluid is meconium-stained or bloody. 2. Oxygen is an appropriate intervention for late decelerations, but this fetus is exhibiting variable decelerations. A nasal cannula is rarely used in labor and birth; face masks are preferable. 3. There is no indication that a cesarean delivery is needed. The fetus is exhibiting variable decelerations. 4. The fetus is exhibiting variable decelerations, which are caused by cord compression. Repositioning the client might get the fetus off the cord and eliminate the variable decelerations. Page Ref: 334 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 16.6 Evaluate fetal heart rate tracings using a systematic approach.

9) The nurse explains to a client in labor that the fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement about the most important part of fetal heart monitoring indicates that the client understands the nurse's teaching? 1. "Presence of variability" 2. "Depth of decelerations" 3. "Fetal heart rate baseline" 4. "Absence of variable decelerations" Answer: 1 Explanation: 1. Variability is an indicator of the interplay between the sympathetic nervous system and the parasympathetic nervous system. 2. The depth of decelerations does not indicate central nervous system function. 3. The fetal heart rate baseline does not indicate central nervous system function. 4. Variable decelerations indicate cord compression. Page Ref: 331 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 16.6 Evaluate fetal heart rate tracings using a systematic approach. 10) A client's amniotic fluid is meconium stained. Which action should the nurse take immediately? 1. Change the client's position in bed. 2. Notify the healthcare provider that birth is imminent. 3. Administer oxygen at 2 L per minute. 4. Begin continuous fetal heart rate monitoring. Answer: 4 Explanation: 1. Changing the client's position is not indicated. 2. Meconium-stained amniotic fluid does not indicate that birth is imminent. 3. Oxygen administration is not indicated. 4. Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Page Ref: 328 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 16.6 Evaluate fetal heart rate tracings using a systematic approach.

11) The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first? 1. Facilitate a maternal left lateral position. 2. Alert the healthcare provider of the fetal status. 3. Decrease the rate of infusion of intravenous fluids. 4. Administer oxygen to the client at 4 L per minute via nasal cannula. Answer: 1 Explanation: 1. In the treatment of late decelerations, the mother should immediately be placed in the left lateral position in order to promote maximal uteroplacental blood flow. 2. While the attending healthcare provider should be notified, the priority nursing interventions target alleviation of the causative factors by way of direct client care. Initially, the mother should be placed in the left lateral position. 3. Nursing interventions indicated in the treatment of late decelerations include increasing the rate of administration of intravenous fluids. 4. Initially, the mother should be placed in the left lateral position to promote maximal uteroplacental blood flow. Next, oxygen should be administered at a rate of 7 to 10 L per minute via face mask. Page Ref: 334 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 16.7 Compare nonreassuring fetal heart rate patterns to appropriate nursing responses.

12) The client in labor with meconium-stained amniotic fluid asks why the fetal monitor is necessary because the belt is uncomfortable. Which information should the nurse explain about monitoring? 1. "It helps us to see how the baby is tolerating labor." 2. "It can be removed, and oxygen can be given instead." 3. "It is necessary so we can see how your labor is progressing." 4. "It will prevent complications from the meconium in your fluid." Answer: 1 Explanation: 1. Meconium-stained amniotic fluid often indicates a problem with the fetus, requiring monitoring during labor. 2. Oxygen is an appropriate intervention for late decelerations, but no information is given about the fetal heart rate. Fetal monitoring provides information on the status of the fetus, and it is a necessary assessment when the amniotic fluid is meconium stained. 3. The fetal monitor does not help visualize labor progress. Labor progress is assessed through the pelvic examination, checking to see if the cervix is dilating and the fetus descending into the pelvis. 4. The fetal monitor will provide information on how the baby is tolerating labor, but it does not prevent complications such as meconium aspiration syndrome. Page Ref: 328 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 16.8 Explain the family's responses to electronic fetal monitoring in nursing management.

13) The nurse is observing a student provide care to a client who is in early labor. Which student actions should be corrected? 1. Applying a fetal heart monitor followed by an explanation of the reason for its use 2. Upon entering the room, speaking with the client prior to looking at the fetal heart monitor 3. Using layman's terms to provide the client with an explanation of the reason for electronic fetal monitoring 4. Incorporating cues that arise from intuition or from observations of the client and family as opposed to focusing on the fetal heart monitor Answer: 1 Explanation: 1. Before using the electronic fetal monitor, the nurse needs to fully explain to the client the reason for its use and the information that it can provide. 2. The nurse can acknowledge the client's need to be the central focus by always speaking to and looking at the woman when entering the room, before looking at the monitor. 3. The technical language of electronic fetal monitoring and other procedures may act as a barrier, isolating the client and emphasizing her experience. 4. To prevent dehumanization of the nurse-client relationship, the nurse should incorporate cues that may arise from intuition or from observations of or interactions with the client and family, as opposed to focusing only upon objective monitor-based data. Page Ref: 335 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 16.8 Explain the family's responses to electronic fetal monitoring in nursing management.

14) During an antenatal examination, the nurse becomes concerned that the client is at high risk. Which finding did the nurse use to make this clinical determination? Select all that apply. 1. Smokes one half pack per day of cigarettes. 2. Employer provides maternal leave of absence. 3. Is estranged from family and the baby's father. 4. Loss of 3 lb since last examination 1 month ago. 5. Treated for a sexually transmitted infection (STI) 2 months ago. Answer: 1, 3, 4, 5 Explanation: 1. Smoking while pregnant increases this client's risk during pregnancy. 2. Having an employer that provides maternal leave of absence would not increase this client's risks during pregnancy. 3. Lack of social support systems increases this client's risk during pregnancy. 4. A weight loss could indicate an eating disorder, which would make this client a high risk. 5. STIs increase this client's risk during pregnancy. Page Ref: 323 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.1 Describe a maternal assessment of the laboring woman that includes the patient history, high-risk screening, and physical and psychosociocultural factors. 15) While palpating contractions, the nurse determines that a client is in the latent phase of labor. Which finding did the nurse use to make this determination? Select all that apply. 1. Contractions rated as being moderate to strong 2. Contractions rated as being mild to moderate 3. Contractions occur every 6 minutes lasting for 40 seconds 4. Contractions occur every 2 minutes lasting for 50 seconds 5. Contraction occurs every 10 minutes lasting for 30 seconds Answer: 2, 4, 5 Explanation: 1. Contractions in the active phase are rated as being moderate to strong. 2. Contractions in the latent phase are rated as being mild to moderate. 3. In the latent phase, contractions progress to occurring every 5 to 7 minutes and last for 30 to 40 seconds. 4. In the active phase, contractions occur every 2 to 5 minutes and last for 40 to 60 seconds. 5. In the latent phase, contractions occur every 10 to 30 minutes and last for 30 seconds. Page Ref: 325 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.2 Evaluate the progress of labor by assessing the laboring woman's contractions, cervical dilatation, and effacement. 11 Copyright © 2022 Pearson Education, Inc.

16) A low-risk client is in the second stage of labor. Which action should the nurse take regarding the auscultation of this client's fetal heart rate? Select all that apply. 1. Evaluate after ambulation. 2. Assess heart sounds every 15 minutes. 3. Evaluate before the membrane rupture. 4. Evaluate before providing medications. 5. Count for 30 seconds, and multiply times 2. Answer: 2, 4, 5 Explanation: 1. Fetal heart rate should be assessed before ambulation. 2. For a low-risk client in the second stage of labor heart sounds should be assessed every 15 minutes. 3. Since membrane rupture cannot be predicted, fetal heart rate would be assessed after the rupture of these membranes. 4. Fetal heart rate should be assessed before providing medication. 5. The fetal heart rate should be assessed for 30 seconds and then multiply times 2. Page Ref: 325 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.4 Describe the steps and frequency for performing auscultation of fetal heart rate.

17) The nurse is caring for a high-risk client in the second stage of labor. After which action should the nurse assess the fetal heart rate? Select all that apply. 1. Vaginal examination 2. Urinary catheterization 3. Ingestion of clear liquids 4. Administration of pain medication 5. Change in oxytocin administration Answer: 1, 2, 4, 5 Explanation: 1. For the high-risk client in the second stage of labor fetal heart rate should be assessed after a vaginal examination. 2. For the high-risk client in the second stage of labor fetal heart rate should be assessed after urinary catheterization. 3. The client in labor will be kept at nothing by mouth status. 4. For the high-risk client in the second stage of labor fetal heart rate should be assessed after administration of pain medication. 5. For the high-risk client in the second stage of labor fetal heart rate should be assessed after a change in oxytocin administration. Page Ref: 329 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.4 Describe the steps and frequency for performing auscultation of fetal heart rate.

18) A client's fetal heart rate has a sinusoidal pattern. Which reason should the nurse consider for this pattern? Select all that apply. 1. Fetal anemia 2. Chronic fetal bleed 3. Severe fetal hypoxia 4. Maternal hypotension 5. Umbilical cord compression Answer: 1, 2, 3 Explanation: 1. A sinusoidal pattern is associated with fetal anemia. 2. A sinusoidal pattern is associated with chronic fetal bleed. 3. A sinusoidal pattern is associated with severe fetal hypoxia. 4. The most common cause of late decelerations is maternal hypotension. 5. Variable decelerations occur if the umbilical cord becomes compressed. Page Ref: 335 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.5 Distinguish between baseline and periodic changes in fetal heart rate monitoring, and the appearance and significance of each. 19) The nurse categorizes a client's fetal heart rate tracing as a category 2. Which criteria were used for this categorization? Select all that apply. 1. Tachycardic baseline 2. Decelerations lasted longer than 2 minutes 3. Scalp stimulation did not effect acceleration. 4. Absent variability with recurrent late decelerations. 5. Variable decelerations that slowly return to baseline. Answer: 1, 2, 3, 5 Explanation: 1. Criteria for category 2 includes a tachycardic baseline. 2. Criteria for category 2 includes prolonged decelerations lasting greater than 2 minutes. 3. Criteria for category 2 includes a lack of accelerations with scalp stimulation. 4. Criteria for category 3 includes absent variability with recurrent late decelerations. 5. Criteria for category 2 includes variable deceleration patterns that slowly return to baseline. Page Ref: 336 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 16.6 Evaluate fetal heart rate tracings using a systematic approach.

20) A client's fetal heart rate tracing has a consistent late deceleration pattern. Which action should the nurse take at this time? Select all that apply. 1. Prepare for cesarean birth. 2. Increase intravenous fluids. 3. Monitor maternal blood pressure. 4. Position client on the left side. 5. Apply oxygen 7 to 10 L via face mask. Answer: 3, 4, 5 Explanation: 1. Preparing for cesarean birth would be an action for late decelerations with tachycardia or decreasing variability. 2. Increasing intravenous fluids would be an action for late decelerations with tachycardia or decreasing variability. 3. Nursing actions for a late deceleration pattern include monitoring maternal blood pressure. 4. Nursing actions for a late deceleration pattern include positioning the client on the left side. 5. Nursing actions for a late deceleration pattern include applying oxygen 7 to 10 L via face mask. Page Ref: 334 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 16.7 Compare nonreassuring fetal heart rate patterns to appropriate nursing responses.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 17 The Family in Childbirth: Needs and Care 1) The nurse is orienting a new graduate nurse to the labor and birth unit. Which statement indicates that teaching about a client admission has been effective? 1. "A vaginal examination is performed if delivery appears to be imminent." 2. "Her prenatal record is reviewed for indications of domestic abuse." 3. "She will be positioned supine to facilitate a normal blood pressure." 4. "A urine specimen is obtained by catheter to check for protein and ketones." Answer: 1 Explanation: 1. Unless delivery seems imminent because the client is bearing down or contractions are very close and strong, the vaginal examination is performed after the vital signs are obtained. 2. This would not be an immediate concern but something that will be noted as the patient is in your care and evaluated 3. Side-lying or semi-fowlers reduces the chance of supine hypotensive syndrome and is more comfortable for the patient. 4. Patient will be given a specimen cup to void in; there is no need for a catheter at this time. Page Ref: 346 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 17.1 Identify admission data that should be noted when a woman is admitted to the birthing area.

2) A client states that her water broke 2 hours ago. Which findings should the nurse identify as indications of normal labor? Select all that apply. 1. Protein of +1 in urine 2. Maternal pulse of 160 3. Blood pressure of 120/80 4. Odorless, clear fluid on underwear 5. Fetal heart rate (FHR) of 130 with moderate variability Answer: 3, 4, 5 Explanation: 1. This may be a sign of preeclampsia not indicative of normal labor. 2. This is an elevated heart rate and not a normal sign of labor. 3. A blood pressure of 120/80 is a normal finding. 4. Fluid clear and without odor is a normal indication. 5. A normal fetal heart rate during labor is FHR 120 to 160 with moderate variability. Page Ref: 348 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 17.1 Identify admission data that should be noted when a woman is admitted to the birthing area. 3) The client in labor arrives at the birthing unit with her partner. Which step of the admission process should be completed first? 1. Welcoming the couple 2. The sterile vaginal examination 3. Auscultation of the fetal heart rate 4. Checking for ruptured membranes Answer: 1 Explanation: 1. Establishing rapport will decrease anxiety of the couple and facilitate a more pleasant birth experience. 2. The vaginal exam is performed after the couple is greeted and vital signs are obtained including FHR. 3. This is the 2nd step in the admission process following greeting the couple and is included in obtaining vital signs. 4. This can be checked during the vaginal exam and is not the first assessment during the admission. Page Ref: 346 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.2 Describe the nursing care of a woman and her partner/family upon admission to the birthing area. 2 Copyright © 2022 Pearson Education, Inc.

4) An expectant father has been at the bedside of his laboring partner for more than 12 hours. Which action should the nurse take? 1. Insist that he leave the room for at least the next hour. 2. Offer to remain with his partner while he takes a break. 3. Suggest that the patient's mother might be of more help. 4. Tell him he is not being as effective as he was and that he needs to let someone else take over. Answer: 2 Explanation: 1. The nurse should offer support and rest periods, but it is not mandatory for the father to take a break if he does not want to. 2. Support persons frequently are reluctant to leave the laboring woman to take care of their own needs. Offering to stay with the woman so that he can take a break reassures him that his partner will be well cared for in his absence. 3. The nurse should not imply that the father is not being helpful. 4. This statement is not supportive and is not helpful to the support person at any time in the process. Page Ref: 347 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.2 Describe the nursing care of a woman and her partner/family upon admission to the birthing area.

5) The client in labor has moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a −2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Obtain a clean-catch urine specimen. 2. Apply an internal fetal scalp electrode. 3. Keep the patient on bed rest at this time. 4. Encourage the husband to remain in the room. Answer: 3 Explanation: 1. This should have been obtained on admission, and it is not suggested that the patient get up at this time to prevent cord prolapse. 2. The fetal heart rate is normal therefore an FSE is not indicated at this time. 3. Because the membranes are ruptured and the head is high in the pelvis at a −2 station, the client should be maintained on bed rest to prevent cord prolapse. 4. The husband does not need to stay at the bedside as birth is not imminent. Page Ref: 349 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.3 Use assessment data to determine the nursing interventions to meet the psychologic, social, physiologic, and spiritual needs of the woman during each stage of labor.

6) A client scheduled for elective cesarean birth in 4 hours asks for a sip of coffee with creamer. In which way should the nurse respond? 1. "You can drink black coffee." 2. "You may have coffee with creamer." 3. "You are only allowed to drink water right now." 4. "Since you are having surgery today, you're not allowed to have anything to eat or drink." Answer: 1 Explanation: 1. Evidence-based practice research and new guidelines indicate that clear fluids can be consumed throughout labor and up to 2 hours before an elective cesarean birth. Research shows that the volume of liquid consumed is less important than the presence of particulate matter ingested because this increases the risk of aspiration. 2. Patient are allowed clear liquids up to 2 hours before their cesarean, but creamer is not a clear liquid. 3. Water is a clear liquid but so is black coffee, so they are allowed to drink it up to 2 hours before surgery. 4. Patients are allowed per Evidence-based practice to have clear liquids up to 2 hours before surgery. Page Ref: 348 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.4 Compare methods of promoting comfort during the first and second stages of labor.

7) What is the purpose for the client in labor to utilize different breathing techniques? Select all that apply. 1. Reduces pain 2. A source of relaxation 3. A source of distraction 4. Speeds up the delivery process 5. An increased ability to cope with contractions Answer: 2, 3, 5 Explanation: 1. Breathing is not a pain reducer; it assists in distraction and relaxation. 2. When used correctly, breathing techniques can increase the woman's pain threshold, and permit relaxation. 3. When used correctly, breathing techniques can enhance the ability to cope with contractions. 4. Breathing is not going to speed up the delivery; it works on distraction from pain and relaxation. 5. When used correctly, breathing techniques can provide a sense of control, and allow the uterus to function more effectively. Page Ref: 352 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 17.4 Compare methods of promoting comfort during the first and second stages of labor.

8) Five minutes after delivery, the neonate's body is pink with blue extremities. The heart rate is 150. The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate? 1. Rescue breathing and stimulation 2. Stimulation and resuscitative efforts 3. Nasopharyngeal suctioning and blow-by oxygen 4. Oxygen via face mask and endotracheal suctioning Answer: 3 Explanation: 1. The patient is breathing and doesn't require rescue breathing and stimulation. 2. The baby is breathing so it does not require resuscitation or stimulation. 3. The neonate's Apgar score is 9; a score of 7 to 10 indicates a newborn in good condition who requires only nasopharyngeal suctioning and perhaps some oxygen near the face (called "blowby" oxygen). The baby does not need rescue breathing stimulation, resuscitation, oxygen via face mask, or endotracheal suctioning. 4. The neonates Apgar score of 9 requires Nasopharyngeal suctioning not endotracheal suctioning. Oxygen requirements are blow by only. Page Ref: 357 Cognitive Level: Evaluating Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Planning Learning Outcome: 17.5 Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

9) The neonatal nurse specialist is describing neonatal care to nursing students. Which statement should the specialist include when describing a proper method for preventing heat loss in the neonate? 1. "After delivery, the newborn is immediately placed in skin-to-skin contact with the mother." 2. "Immediately after delivery, the newborn is wrapped in a blanket and placed on the mother's chest." 3. "If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat." 4. "If a radiant-heated unit is used to keep the neonate warm, the neonate is dried, wrapped in a dry blanket, and placed under the radiant heat." Answer: 3 Explanation: 1. Newborns should be dried prior to skin to skin to reduce heat loss. 2. When preventing heat loss, the newborn should be dried immediately and either placed in the radiant heater without blankets or skin to skin. 3. If the newborn is under a radiant-heated unit, the neonate is dried, placed on a dry blanket, and left uncovered under the radiant heat. Because radiant heat warms the outer surface of objects, a newborn wrapped in blankets will receive no benefit from radiant heat. 4. The newborn should not be wrapped in blankets in the radiant heater as it will only heat the blankets and not the newborn. Page Ref: 356 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 17.5 Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

10) One minute after delivery, the following is assessed in a neonate: heart rate 120 beats per minute, vigorous cry, actively moving, resists attempts to straighten an arm, facial grimace with sole flicking, body pink, and extremities blue. Which Apgar score should the nurse assign to this infant? 1. 6 2. 7 3. 8 4. 9 Answer: 3 Explanation: 1. The neonate has an Apgar score of 8: the neonates hr of 120 is 2 points; vigorous cry is 2 points; active movement is 2 points; facial grimace is 1 point; and the body color is 1 point. 2. The neonate has an Apgar score of 8: the neonates hr of 120 is 2 points; vigorous cry is 2 points; active movement is 2 points; facial grimace is 1 point, and the body color is 1 point. 3. Heart rate of greater than 100 beats per minute correlates with 2 points, and vigorous cry correlates with 2 points. Active movement of extremities correlates with 2 points. Grimacing in response to flicking of the soles correlates with 1 point, and a pink body with blue extremities correlates with 1 point. This infant's Apgar score is 8. 4. The neonate has an Apgar score of 8: the neonates hr of 120 is 2 points; vigorous cry is 2 points; active movement is 2 points; facial grimace is 1 point; and the body color is 1 point. Page Ref: 357 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 17.5 Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

11) Upon delivery of the newborn, which action most promotes parental attachment? 1. Placing the newborn under the radiant warmer 2. Placing the newborn on the maternal abdomen 3. Taking the newborn to the nursery for the initial assessment 4. Allowing the mother a chance to rest immediately after delivery Answer: 2 Explanation: 1. Placing the newborn under the radiant warmer is keeping the newborn from the parent and not promoting attachment. 2. Placing the baby on the maternal abdomen promotes attachment and bonding and gives the mother a chance to interact with her baby immediately. 3. Taking the newborn from the parent is keeping the newborn from the parent and not promoting attachment. 4. Rest is important for the mother but is not allowing her to bond with the newborn, placing the newborn on the abdomen is best in this situation. Page Ref: 356 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.5 Explain the immediate needs and physical assessment of the newborn following birth in the provision of nursing care.

12) A young adolescent is in active labor but did not know that she was pregnant. Which action should the nurse take? 1. Assess blood pressure, and check for proteinuria. 2. Obtain a Social Services referral to discuss adoption. 3. Determine who might be the father of the baby for paternity testing. 4. Ask the client what kind of birthing experience she would like to have. Answer: 1 Explanation: 1. Preeclampsia is more common among adolescents than in young adults, and it is potentially life-threatening to both the mother and fetus. This assessment is the highest priority. 2. This is making an assumption regarding the mother's decisions regarding the pregnancy and newborn. Assessing for proteinuria due to the mother not having prenatal care is most important. 3. The identity of the father is not important at this time. Assessing the patient's vital signs and checking for proteinuria is. 4. This can come after Assessing the patient's vital signs and checking for proteinuria. Page Ref: 361 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.6 Examine the unique needs of the adolescent during birth in the provision of nursing care. 13) What should the nurse's priority be when caring for an adolescent in labor? 1. Support persons 2. Developmental level 3. Cultural background 4. Plans for keeping the infant Answer: 2 Explanation: 1. The support person is not the nursing priority in adolescent care during labor. Understanding the developmental level of the patient is very important to care for them. 2. Knowing the adolescent's level of development is important because cognitive development is incomplete, which will affect the birthing experience. 3. Cultural background is a consideration in caring for the adolescent in labor but not the priority. 4. This is a topic that should not be a priority as the patient is in labor, but it is a consideration. The developmental level of the patient is the priority. Page Ref: 361 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 17.6 Examine the unique needs of the adolescent during birth in the provision of nursing care. 11 Copyright © 2022 Pearson Education, Inc.

14) The nurse encounters a woman giving birth at the local shopping mall. Which action should the nurse take first? 1. Visualize the perineum. 2. Apply counterpressure to the perineum. 3. Ask a bystander for a dry piece of clothing. 4. Determine if the membranes have ruptured. Answer: 1 Explanation: 1. Inspecting the perineum is the only method of determining whether the client is going to give birth imminently. This is the top priority. 2. This is a technique that is done when the birth is imminent, but determining if birth is imminent has to occur first. 3. A dry cloth will be helpful in the process, but the first step is to determine if birth is imminent. 4. The rupture of membranes may be assessed by visualizing the perineum after determining if birth is imminent. Page Ref: 362 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 17.7 Describe the role and responsibilities of the nurse in the management of a precipitous labor and birth. 15) Ketones are present in a urine specimen of a client in the beginning phases of labor. Which reason should the nurse consider for this laboratory finding? Select all that apply. 1. Edema 2. Vomiting 3. Dehydration 4. Preeclampsia 5. Insulin resistance Answer: 2, 3, 5 Explanation: 1. Edema is not associated with Ketones in the urine. 2. Ketones in the urine can be caused by the patient vomiting. 3. Ketones in the urine can be seen in a patient with dehydration. 4. Preeclampsia causes protein in the urine not ketones. 5. Ketones in the urine can be seen in patients who have insulin resistance. Page Ref: 346 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 17.1 Identify admission data that should be noted when a woman is admitted to the birthing area. 12 Copyright © 2022 Pearson Education, Inc.

16) The nurse is preparing to admit a pregnant client who is Muslim to the birthing center. Which information should the nurse keep in mind during the labor process? Select all that apply. 1. Have long-sleeved gowns available. 2. Offer warm fluids to sip during the labor process. 3. Ask the spouse for permission before examining the client. 4. Ensure female healthcare providers examine the client. 5. Provide the spouse with water to cleanse the newborn upon birth. Answer: 1, 3, 4, 5 Explanation: 1. The woman may prefer to wear two long-sleeved gowns to enhance modesty. 2. Warm fluids are not indicated because the patient is of the Muslim culture. 3. In some Muslim families, the husband or a male elder makes healthcare decisions for women in the family. The RN should determine if that is the desire of the patient and then ask the spouse before examining the client or calling for a specialist to consult with this client. 4. .It is important for a female healthcare provider to perform examinations whenever possible. 5. After the birth, the father of the Muslim child may clean the newborn. It is essential to have bathing supplies available for the spouse to use. Page Ref: 347 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care; Knowledge; 1. The role of family, culture, and community in a person's development | Nursing/Integrated Concepts: Planning Learning Outcome: 17.3 Use assessment data to determine the nursing interventions to meet the psychologic, social, physiologic, and spiritual needs of the woman during each stage of labor.

17) A client in labor did not attend prenatal classes and is experiencing severe pain. In which breathing technique should the nurse instruct the client to help with relaxation and control? Select all that apply. 1. Kussmaul breathing 2. Abdominal breathing 3. Slow-paced breathing 4. Pant-pant-blow breathing 5. Modified-paced breathing Answer: 2, 4 Explanation: 1. Kussmaul breathing is not a technique but a clinical sign that the body is too acidic and is trying to compensate. 2. If the client has not learned a controlled breathing technique, teaching may be difficult during active labor. In this instance, the nurse can teach abdominal breathing. In abdominal breathing, the woman moves the abdominal wall upward as she inhales and downward as she exhales. This method tends to lift the abdominal wall off the contracting uterus and thus may provide some pain relief. The breathing is deep and rhythmic. 3. This may be too hard to teach during active labor when the patient is in pain. 4. If the client has not learned a controlled breathing technique, teaching may be difficult during active labor. In this instance, the nurse can teach pant-pant-blow breathing. As transition approaches, the woman may feel the need to breathe more rapidly. To avoid breathing too rapidly, the woman can use the pant-pant-blow breathing pattern. 5. This may be too hard to teach during active labor when the patient is in pain. Page Ref: 352 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 17.4 Compare methods of promoting comfort during the first and second stages of labor.

18) The nurse is caring for a client in the second stage of labor. Which assessment finding indicates that birth is imminent? Select all that apply. 1. Drop in blood pressure 2. Increased bloody show 3. Bulging of the perineum 4. Subjective feeling of faintness 5. Uncontrollable urge to bear down Answer: 2, 3, 5 Explanation: 1. A drop in blood pressure is not one of the three signs of imminent birth. 2. Birth is imminent if the woman has increased bloody show. 3. Birth is imminent if the woman has bulging of the perineum. 4. Feeling faint is not one of the three signs of imminent birth. 5. Birth is imminent if the woman has an uncontrollable urge to bear down. Page Ref: 355 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 17.3 Use assessment data to determine the nursing interventions to meet the psychologic, social, physiologic, and spiritual needs of the woman during each stage of labor.

19) The nurse is caring for a 13-year-old client who is in labor. Which action should the nurse take to support this client's needs? Select all that apply. 1. Provide simple and concrete explanations. 2. Stay with the client during the labor process. 3. Provide soothing encouragement during the transition phase. 4. Provide positive reinforcement with a nonjudgmental manner. 5. Remain calm, and provide clear directions during the second stage. Answer: 1, 2, 3, 4, 5 Explanation: 1. For the very young adolescent client, instructions and explanations should be simple and concrete. 2. The very young adolescent needs someone to rely on at all times during labor. 3. During the transition phase, the young teenager may become withdrawn and unable to express her need to be nurtured. Soothing encouragement helps her maintain control, and meets her needs for dependence. 4. The adolescent given positive reinforcement for "work well done" will leave the experience with increased self-esteem despite the emotional problems that may accompany her situation. 5. During the second stage of labor, it is important for the nurse to remain calm and give clear, simple directions to help the teen cope with feelings of helplessness. Page Ref: 361 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.6 Examine the unique needs of the adolescent during birth in the provision of nursing care. 20) The nurse is assisting with a precipitous birth. In which order should the nurse perform the following actions after the birth of the fetal head? 1. Instruct the client to push. 2. Suction the baby's mouth, throat, and nose. 3. Exert upward traction to the fetal head to facilitate birth of the posterior shoulder. 4. Exert downward traction on the fetal head to facilitate movement of the anterior shoulder. Answer: 2, 4, 3, 1 Page Ref: 363 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 17.7 Describe the role and responsibilities of the nurse in the management of a precipitous labor and birth.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 18 Pharmacologic Pain Management 1) A client in labor who rates pain as 9 on a scale from 1 to 10 requests pain medication after refusing epidural anesthesia. Which action should the nurse take prior to administering the medication? 1. Offer epidural anesthesia again. 2. Administer oxygen via face mask at 6 to 10 L per minute. 3. Obtain maternal vital signs, and assess the fetal heart rate (FHR). 4. Instruct on the actions and contraindications associated with the medication. Answer: 4 Explanation: 1. The client has refused epidural anesthesia but is authorized to receive another medication. 2. Routine oxygen administration is not indicated for administration of medication to an asymptomatic client in labor. 3. Prior to obtaining maternal vital signs and assessing FHR, the nurse should advise the client as to the actions and contraindications associated with the medication. 4. Prior to administering the medication, the nurse must explain the pharmacologic effects of the medication. Page Ref: 366 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 18.1 Describe the use, administration, dose, onset of action, and adverse effects of systemic drugs to promote pain relief during the nursing management of the woman in labor and her fetus.

2) A client in labor wants to have a medication-free birth. Which information should the nurse include when discussing alternatives to pain medication with this client? 1. Emphasize that no medication will be given. 2. Review that the use of medications allows for rest and less fatigue. 3. Explain that pain relief will allow a more enjoyable birth experience. 4. Summarize how maternal pain and stress can have a more adverse effect on the fetus than would a small amount of analgesia. Answer: 4 Explanation: 1. It is important to respect the client's wishes when possible. Once the effects are explained, it is still the client's choice whether to receive medication. 2. While pain relief can allow the client to be less fatigued, it might be the view of the nurse but not the client. 3. While pain relief can lead to a more enjoyable experience, it might be the view of the nurse but not the client. 4. The decision not to medicate should be an informed one, and it is possible that the client does not know about the effects pain and stress can have on the fetus. Once the effects are explained, it is still the client's choice whether to receive medication. Page Ref: 365 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.1 Describe the use, administration, dose, onset of action, and adverse effects of systemic drugs to promote pain relief during the nursing management of the woman in labor and her fetus.

3) The nurse has presented a teaching session on pain relief options to a prenatal class. Which client statement indicates that additional teaching is needed? 1. "An epidural can be continuous or one dose." 2. "General anesthesia is usually recommended for a cesarean section." 3. "Narcotics can be given through a client's epidural infusion catheter." 4. "A pudendal block usually works well to control pain during episiotomy repair." Answer: 2 Explanation: 1. Epidural anesthesia can be administered in a single dose or via continuous infusion. 2. Compared to general anesthesia, spinal anesthesia is usually the anesthetic of choice indicated in the management of clients undergoing cesarean section. 3. To provide analgesia for approximately 24 hours after the birth, the analgesia provider may inject an opioid, such as morphine sulfate (Duramorph) or fentanyl (Sublimaze), into the epidural space immediately after the birth. 4. A pudendal block technique is used in the second stage of labor for the provision of perineal anesthesia for the latter part of the first stage of labor, the second stage, birth, and episiotomy repair. Page Ref: 373 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 18.2 Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, techniques, and nursing management of the laboring woman and her fetus.

4) The charge nurse is reviewing the plans of care for four clients in labor. Which care plan requires additional information before implementing? 1. Administration of a spinal anesthetic to a client who is scheduled for a vaginal delivery 2. Administration of a spinal anesthetic to a client with a history of irritable bowel syndrome (IBS) 3. Administration of epidural anesthesia to a client who is in the first stage of labor and has a shellfish allergy 4. Administration of epidural anesthesia to a client with a history of vomiting secondary to hyperemesis gravidarum Answer: 4 Explanation: 1. Spinal anesthetics may be used to provide anesthesia for cesarean birth and occasionally for vaginal birth. 2. Spinal anesthesia is not contraindicated for irritable bowel syndrome (IBS). 3. A lumbar epidural relieves pain associated with the first and second stages of labor. An allergy to shellfish is not a contraindication to epidural anesthesia. 4. Contraindications to epidural anesthesia include severe hypovolemia of any etiology. The client with hyperemesis gravidarum should be evaluated for severity of dehydration prior to administration of epidural anesthesia. Page Ref: 370 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 18.2 Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, techniques, and nursing management of the laboring woman and her fetus.

5) Which nursing action can prevent or detect common side effects of epidural anesthesia? Select all that apply. 1. Preloading the client with a rapid infusion of IV fluids 2. Continuing the client on oral fluids only to prevent hypotension 3. Assisting the client to empty the bladder before the anesthesia is started 4. Use of intermittent fetal heart rate (FHR) monitoring so the client can use the birthing ball 5. Monitoring the fetal heart rate (FHR) for late deceleration and decrease in rate Answer: 1, 3, 5 Explanation: 1. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. 2. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. The amount of oral fluids that would be required to prevent hypotension makes this approach inappropriate for the client in labor. 3. The epidural decreases the urge to urinate. The client's bladder should be assessed frequently for distention. 4. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential. 5. Hypotension can be prevented by preloading with rapid IV infusion followed by continuous IV infusion. Variability of FHR and late decelerations can occur if maternal hypotension occurs. Continuing FHR monitoring is essential. Page Ref: 370 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.2 Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, techniques, and nursing management of the laboring woman and her fetus.

6) Prior to receiving lumbar epidural anesthesia, in which position should the nurse place the client in labor? 1. Lying prone with a pillow under the chest 2. On the right side in the center of the bed with the back curved 3. On the left side with the bottom leg straight and the top leg slightly flexed 4. Sitting on the edge of the bed with the back slightly curved and feet on a stool Answer: 4 Explanation: 1. This position is not consistent with access to the epidural spaces. 2. Especially in pregnant women, this position is not ideal for facilitating access to the epidural space. 3. This position is not consistent with access to the epidural spaces. 4. Sitting on the edge of the bed with the back slightly curved and the feet on a stool allows the epidural spaces to be accessed more easily. Page Ref: 370 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.2 Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, techniques, and nursing management of the laboring woman and her fetus.

7) A client experiencing contractions every 8 to 20 minutes that last 20 to 30 seconds requests pain medication. Which information should the nurse state as the effect of analgesics given at this time? 1. Prolonged labor 2. Maternal hypotension 3. Fetal respiratory depression 4. Decreased analgesic effectiveness at the end of labor Answer: 1 Explanation: 1. Pain medication given before labor becomes established is likely to prolong the labor process. 2. Analgesics might lower the blood pressure, but this effect does not cause the contraction pattern to be altered. 3. Pain medication given before established labor does not cause fetal respiratory depression unless the client delivers within an hour of receiving the medication. This is not likely if labor is not established. 4. Medication given early in the labor process does not become less effective at the end of labor. Page Ref: 366 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.1 Describe the use, administration, dose, onset of action, and adverse effects of systemic drugs to promote pain relief during the nursing management of the woman in labor and her fetus.

8) A client in labor who is requesting an epidural asks if the baby will be harmed. In which way should the nurse respond? 1. "Epidural anesthesia is very safe, and there are no potential side effects that can affect your baby." 2. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." 3. "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." 4. "Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems." Answer: 2 Explanation: 1. While proficient administration and monitoring of epidural anesthesia allow for a high degree of safety with this technique, maternal hypotension associated with epidural anesthesia may produce harmful fetal effects. 2. Continuous electronic fetal monitoring to assess fetal status is indicated in the care of pregnant clients who receive epidural anesthesia, and allows for a more direct assessment of fetal status than does frequent monitoring of maternal blood pressure and pulse, which is also indicated in the care of this client. 3. While frequent monitoring of maternal blood pressure and pulse is indicated in the care of a client who receives an epidural during labor, continuous electronic fetal monitoring is also indicated for assessment of fetal status, and allows for a more direct fetal assessment. 4. While administration of a bolus of IV fluid is indicated in preparation for epidural placement and reduces the risk for maternal hypotension, this intervention neither guarantees the prevention of related complications nor allows for assessment of fetal status. Page Ref: 370 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.2 Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, techniques, and nursing management of the laboring woman and her fetus.

9) A client in labor who is receiving a continuous infusion of a local anesthetic through an epidural catheter asks if ear ringing is supposed to occur. Which condition should the nurse suspect the client is experiencing? 1. Dehydration 2. Hypotension 3. Allergic reaction 4. Local anesthetic toxicity Answer: 4 Explanation: 1. Sensation of ringing in the ears is not an allergic reaction. 2. Although maternal hypotension is associated with epidural anesthesia, a sensation of ringing in the ears is associated with local anesthetic toxicity. 3. Sensation of ringing in the ears is not associated with hydration status. 4. Sensation of ringing in the ears is associated with local anesthetic toxicity. Page Ref: 369 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 18.3 Explain the possible complications of regional anesthesia in nursing management of the laboring woman and her fetus. 10) The blood pressure of a client receiving continuous epidural anesthesia for labor has changed from 132/78 mmHg to 78/42 mmHg. Which action should the nurse perform first? 1. Administer oxygen. 2. Administer ephedrine 5 to 10 mg intravenously. 3. Verify the client is positioned to promote left uterine displacement. 4. Increase the flow rate of infusion of intravenous crystalloid solution. Answer: 1 Explanation: 1. If hypotension occurs secondary to epidural anesthesia, the nurse should apply oxygen via face mask first. 2. The nurse should notify the anesthesiologist for treatment orders before administering ephedrine. 3. Verification of body position is not identified as a step in the treatment of acute hypotension with an epidural infusion. 4. Administering a bolus of crystalloid fluid occurs after oxygen is applied to the client. Page Ref: 369 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.3 Explain the possible complications of regional anesthesia in nursing management of the laboring woman and her fetus. 9 Copyright © 2022 Pearson Education, Inc.

11) A client in labor is concerned about needing a cesarean section and being asleep during the birth of her baby. Which nursing response is the most appropriate? 1. "Your anesthesia provider will require that you go to sleep for surgery." 2. "If a cesarean section is needed, that does not necessarily mean you will need to go to sleep for surgery." 3. "We will do our best to make sure you deliver vaginally, so you do not need to have a cesarean section." 4. "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly." Answer: 2 Explanation: 1. General anesthesia may be needed for cesarean birth and for surgical intervention with some complications. In modern obstetrics, spinal anesthesia is often administered for delivery via cesarean section. 2. While general anesthesia may be needed for cesarean birth and for surgical intervention with some complications, in modern obstetrics, general anesthesia is not used for all obstetric births. 3. Reassuring the client in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section. 4. Reassuring the client in this manner does not address the erroneous belief that general anesthesia is mandatory for women undergoing cesarean section. Page Ref: 368 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.5 Describe the major complications of general anesthesia during labor in nursing management of the woman in labor and her fetus.

12) A client in labor is being prepared for epidural anesthesia. Which action should the nurse expect to perform in order to prevent the most common complication associated with this anesthesia? 1. Observe fetal heart rate variability. 2. Place the client in the semi-Fowler position. 3. Teach the client appropriate breathing techniques. 4. Rapidly infuse 500 to 1000 mL of intravenous fluids. Answer: 4 Explanation: 1. Monitoring for fetal heart rate variability will not prevent the most common complication, which is maternal hypotension. 2. Placing the client in the semi-Fowler position will not prevent the most common complication, maternal hypotension. 3. Breathing techniques will not prevent the most common complication, maternal hypotension. 4. Administering a fluid bolus prior to an epidural generally prevents maternal hypotension, which is the most common disadvantage of the procedure. Page Ref: 370 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.3 Explain the possible complications of regional anesthesia in nursing management of the laboring woman and her fetus.

13) The newborn of a client who received nalbuphine hydrochloride (Nubain) for pain control was born less than an hour after the medication was given and is exhibiting signs of respiratory depression. Which medication should the nurse prepare to administer to the newborn? 1. Naloxone (Narcan) 2. Fentanyl (Sublimaze) 3. Pentobarbital (Nembutal) 4. Butorphanol tartrate (Stadol) Answer: 1 Explanation: 1. Narcan is an opiate antagonist, which would reverse the effects of the Nubain. 2. Fentanyl is a short-acting opiate that has been used during labor to relieve pain and induce sedation. It is not an opiate antagonist. 3. Pentobarbital is a sedative. It is not an opiate antagonist. 4. Butorphanol tartrate is a synthetic agonist—antagonist opioid analgesic agent. It is not an opiate antagonist. Page Ref: 367 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.1 Describe the use, administration, dose, onset of action, and adverse effects of systemic drugs to promote pain relief during the nursing management of the woman in labor and her fetus.

14) A client at 39 weeks' gestation is having a cesarean birth with general anesthesia. Which potential challenge is the most relevant to the anesthesia care of this client? 1. Broad ligament hematoma 2. Difficulty with maternal intubation 3. Hypotension due to the intense blockade of sympathetic fibers 4. Fetal depression that is inversely proportional to maternal anesthetic depth and duration Answer: 2 Explanation: 1. Broad ligament hematoma is a complication associated with pudendal blockade. 2. Difficulty with maternal intubation is a primary challenge of general anesthesia care for pregnant clients. 3. Regional anesthesia, including epidural anesthesia, is associated with an intense blockade of sympathetic fibers that results in a high incidence of hypotension. 4. Fetal depression associated with general anesthesia is directly proportional to maternal anesthetic depth and duration. Page Ref: 375 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 18.5 Describe the major complications of general anesthesia during labor in nursing management of the woman in labor and her fetus.

15) A postpartum client who received spinal anesthesia for the delivery has not voided for 5 hours and is concerned about nerve damage. In which way should the nurse respond about this concern? 1. "Spinal anesthesia can sometimes cause nerve damage." 2. "You are probably dehydrated. Please increase your water intake." 3. "It may be several hours before you're able to control your urination." 4. "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you." Answer: 3 Explanation: 1. Although nerve damage is a rare occurrence in relation to spinal anesthesia, there are no objective data to suggest that this woman has experienced nerve damage. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. 2. There are no data to suggest the woman is dehydrated. Rather, she is likely demonstrating a common side effect of spinal anesthesia. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. 3. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. 4. Restoration of bladder control may take 8 to 12 hours following a spinal anesthetic. Page Ref: 370 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.2 Compare the major types of regional analgesia and anesthesia, including area affected, advantages, disadvantages, techniques, and nursing management of the laboring woman and her fetus.

16) A client in labor is having a pudendal block. For which adverse effects should the nurse assess this client? Select all that apply. 1. Infection 2. Spinal headache 3. Perforated rectum 4. Sciatic nerve trauma 5. Broad ligament hematoma Answer: 3, 4, 5 Explanation: 1. An infection is not associated with a pudendal block. 2. A spinal headache is not associated with a pudendal block. 3. Disadvantages of the pudendal block include possible perforation of the rectum. 4. Disadvantages of the pudendal block include possible trauma to the sciatic nerve. 5. Disadvantages of the pudendal block include possible broad ligament hematoma. Page Ref: 374 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 18.3 Explain the possible complications of regional anesthesia in nursing management of the laboring woman and her fetus. 17) A client in labor received a dose of meperidine (Demerol) for pain control. Which assessment findings should the nurse suspect are adverse effects of this medication? Select all that apply. 1. Nausea 2. Pruritus 3. Sedation 4. Bradycardia 5. Hypotension Answer: 1, 2, 3 Explanation: 1. Nausea is an adverse effect of meperidine. 2. Pruritus is an adverse effect of meperidine. 3. Sedation is an adverse effect of meperidine. 4. Bradycardia is an adverse effect of fentanyl. 5. Hypotension is an adverse effect of nalbuphine hydrochloride and fentanyl. Page Ref: 367 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 18.1 Describe the use, administration, dose, onset of action, and adverse effects of systemic drugs to promote pain relief during the nursing management of the woman in labor and her fetus. 15 Copyright © 2022 Pearson Education, Inc.

18) A client in labor needs an emergency cesarean section. Which action should the nurse include when preparing this client for rapid induction of labor? Select all that apply. 1. Place a wedge under the right hip. 2. Insert an indwelling urinary catheter. 3. Insert an intravenous infusion catheter. 4. Provide a bolus of 1 L of intravenous fluid. 5. Preoxygenate with 3 to 5 minutes of 100% oxygen. Answer: 1, 2, 3, 5 Explanation: 1. Before induction of anesthesia, a wedge is placed under the woman's right hip to displace the uterus, and prevent vena caval compression in the supine position. 2. An indwelling bladder catheter is usually inserted before surgery for women undergoing cesarean birth. 3. Before induction of anesthesia, intravenous fluids are started so that access to the intravascular system is immediately available. 4. A bolus of intravenous fluid is provided prior to an epidural; however, it is not indicated for general anesthesia. 5. Before induction of anesthesia, the client should be preoxygenated with 3 to 5 minutes of 100% oxygen. Page Ref: 375 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.4 Describe the nursing management for the laboring woman and her fetus related to general anesthesia.

19) The nurse is preparing a client in labor for an emergency cesarean section. Which medication should the nurse expect to be prescribed to prevent the effects of aspirated gastric contents? Select all that apply. 1. Famotidine (Pepcid) 2. Cimetidine (Tagamet) 3. Omeprazole (Prilosec) 4. Pantoprazole (Protonix) 5. Metoclopramide (Reglan) Answer: 1, 2, 5 Explanation: 1. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Famotidine is used to help empty gastric contents. 2. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Cimetidine is used to help empty gastric contents. 3. Omeprazole is a proton pump inhibitor and is not identified as being used before general anesthesia to help empty gastric contents. 4. Pantoprazole is a proton pump inhibitor and is not identified as being used before general anesthesia to help empty gastric contents. 5. Prophylactic antacid therapy to reduce the acidic content of the stomach before general anesthesia is common practice. Metoclopramide is used to help empty gastric contents. Page Ref: 375 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 18.5 Describe the major complications of general anesthesia during labor in nursing management of the woman in labor and her fetus. 20) The newborn of a client who received nalbuphine hydrochloride (Nubain) 20 minutes before delivery is demonstrating respiratory depression. The infant, weighing 9.9 lb, is prescribed naloxone (Narcan) 0.1 mg/kg. How many milliliters of the medication should the nurse administer to the newborn? (Calculate to the hundredth decimal point.) Answer: 0.45 mL Explanation: First, calculate the newborn's weight in kilograms by dividing the weight in pounds by 2.2, or 9.9/2.2 = 4.5 kg. Then, multiply the prescribed dose of 0.1 mg × 4.5 kg = 0.45 mL. The nurse should provide the newborn with 0.45 mL of naloxone. Page Ref: 367 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 18.1 Describe the use, administration, dose, onset of action, and adverse effects of systemic drugs to promote pain relief during the nursing management of the woman in labor and her fetus. 17 Copyright © 2022 Pearson Education, Inc.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 19 Childbirth at Risk: Prelabor and Intrapartum Complications 1) The nurse is caring for a client at 30 weeks' gestation who is experiencing preterm premature rupture of membranes (PPROM). Which statement indicates that the client needs additional teaching? 1. "If I have bleeding in the third trimester of my next pregnancy, I might rupture membranes again." 2. "If I want to become pregnant again, I will have to plan on being on bed rest for the whole pregnancy." 3. "If I develop a urinary tract infection in my next pregnancy, I might rupture membranes early again." 4. "If I were having a singleton pregnancy instead of twins, my membranes would probably not have ruptured." Answer: 2 Explanation: 1. Second- and third-trimester bleeding increases the risk for PPROM. 2. There is no evidence indicating that bed rest in a subsequent pregnancy decreases the risk for PPROM. 3. A urinary tract infection (UTI) increases the risk for PPROM. 4. Multifetal gestation increases the risk for PPROM. Page Ref: 379 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 19.1 Explain the possible causes, risk factors, and clinical therapy for premature rupture of the membranes or preterm labor in determining the nursing management of the woman and her fetus/newborn.

2) The clinical instructor reviews postoperative care of cerclage with a group of nursing students. Which student statement indicates the need for further information? 1. "Sometimes cerclage can be performed on an outclient basis." 2. "If cerclage is performed emergently, the client will usually be hospitalized for at least 5 days." 3. "After 37 weeks' gestation, the client's cerclage may be cut in order to allow for vaginal delivery." 4. "If the client's amniotic sac is bulging, the cerclage is contraindicated, and the procedure cannot be performed." Answer: 4 Explanation: 1. An uncomplicated elective cerclage may be done as an outclient. 2. An emergency cerclage requires hospitalization for 5 to 7 days or longer. 3. After 37 completed weeks' gestation, the suture may be cut and vaginal birth permitted, or the suture may be left in place and a cesarean birth performed. 4. Decompression of a bulging amniotic sac is not a contraindication to cerclage; rather, the amniotic sac must be decompressed immediately before the procedure. Page Ref: 391 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 19.3 Identify the causes and risk factors of cervical insufficiency, and describe its clinical therapy. 3) A pregnant client is diagnosed with cervical insufficiency. In which way should the nurse expect this client to explain symptoms of this condition? 1. "I've been having contractions every 4 hours." 2. "I'm not having any pain, and I do not feel any contractions." 3. "My cervical pain has gotten much worse over the past 2 days." 4. "I'm not having any pain, but my contractions are getting stronger." Answer: 2 Explanation: 1. Contractions are not associated with cervical insufficiency. 2. Cervical insufficiency is painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix. 3. Cervical pain is not a manifestation of cervical insufficiency. 4. Contractions are not associated with cervical insufficiency. Page Ref: 390 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 19.3 Identify the causes and risk factors of cervical insufficiency, and describe its clinical therapy. 2 Copyright © 2022 Pearson Education, Inc.

4) The nurse has received end of shift report in the high-risk maternity unit. Which client should the nurse see first? 1. 35 weeks' gestation with grade 1 abruptio placentae in labor who has a strong urge to push 2. 30 weeks' gestation with placenta previa whose fetal monitor strip shows late decelerations 3. 26 weeks' gestation with placenta previa experiencing blood on toilet tissue after a bowel movement 4. 37 weeks' gestation with pregnancy-induced hypertension whose membranes ruptured spontaneously Answer: 3 Explanation: 1. Grade 1 abruptio placentae create slight vaginal bleeding. The urge to push indicates that delivery is near. This client is not the highest priority. 2. Late decelerations are an abnormal finding, but put only the fetus at risk. This client is not the highest priority. 3. Bleeding with a placenta previa is a complication that can be life-threatening to both the mother and baby. This client is the highest priority. 4. Although pregnancy-induced hypertension increases the risk for developing abruptio placentae, there is no indication that this client is experiencing this complication. This client is not the highest priority. Page Ref: 384 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 19.2 Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

5) The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. Which risk factors should the nurse include about this health problem? Select all that apply. 1. Multiparity 2. Preterm labor 3. Diabetes mellitus 4. Abruptio placentae 5. Prolonged retention of a fetus after demise Answer: 4, 5 Explanation: 1. Multiparity does not cause the same release of thromboplastin that triggers DIC. 2. Preterm labor does not cause the same release of thromboplastin that triggers DIC. 3. Diabetes does not cause the same release of thromboplastin that triggers DIC. 4. Abruptio placentae leave intrauterine arteries open and bleeding. This results in release of thromboplastin into the maternal blood supply, and triggers the development of DIC. 5. In prolonged retention of the fetus after demise, thromboplastin is released from the degenerating fetal tissues into the maternal bloodstream, which activates the extrinsic clotting system. This triggers the formation of multiple tiny clots, which deplete the fibrinogen and factors V and VII, and result in DIC. Page Ref: 388 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 19.2 Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

6) A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. Which treatment should the nurse expect in the management of this client? 1. Assessing blood pressure every 2 hours 2. Evaluating the fetal heart rate with an internal monitor 3. Limiting vaginal examinations to only one per 24-hour period 4. Monitoring for blood loss, pain, and uterine contractibility Answer: 4 Explanation: 1. Blood pressure measurements every 2 hours are unnecessary. They can be done on a routine basis or prn. 2. Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore, the fetal scalp cannot be accessed to apply an internal monitor. 3. Vaginal examinations are contraindicated because the examination can stimulate bleeding. 4. Blood loss, pain, and uterine contractibility need to be assessed for client comfort and safety. Page Ref: 385 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 19.2 Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care. 7) A multigravida client with suspected abruptio placentae is admitted in active labor. Which problems should the nurse identify as appropriate for this client? Select all that apply. 1. Pain 2. Anxiety 3. Fluid loss 4. Self-care deficits 5. Change in perfusion Answer: 2, 3, 5 Explanation: 1. Pain is not identified as a potential problem in the client with abruptio placentae. 2. Abruptio placentae can cause anxiety for both the client and fetus. 3. Maternal mortality and perinatal fetal mortality are concerns due to blood loss. 4. There is no evidence that the client will experience self-care deficits. 5. Maternal mortality and perinatal fetal mortality are concerns due to hypoxia. Page Ref: 388 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Diagnosis Learning Outcome: 19.2 Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care. 5 Copyright © 2022 Pearson Education, Inc.

8) A pregnant client is diagnosed with central abruptio placentae. Which pathophysiological change should the nurse infer about the client's condition? 1. The slight separation of the client's placenta from the uterine wall will not produce any bleeding. 2. The total separation of the client's placenta from the uterine wall will lead to massive hemorrhage. 3. Blood is trapped between the client's placenta and the uterine wall, and there may be concealed bleeding. 4. Blood is passing between the fetal membranes and the client's uterine wall, which will lead to some vaginal bleeding. Answer: 3 Explanation: 1. This describes a marginal placenta separation, grade 1. 2. With complete separation, there is total separation of the placenta from the uterine wall, and massive bleeding ensues. 3. With the central type of placental separation, blood is trapped between the placenta and uterine wall with concealed bleeding. 4. This describes a marginal placenta separation, grade 1. Page Ref: 387 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 19.2 Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

9) The home health nurse is visiting the home of a client who is 18 weeks' pregnant with twins. Which nursing action is the most important? 1. Assess the client's blood pressure in the upper right arm. 2. Collect a cervicovaginal fetal fibronectin (fFN) specimen. 3. Teach the client about foods that are good sources of protein. 4. Determine whether the pregnancy is a result of infertility treatment. Answer: 3 Explanation: 1. Preeclampsia is not diagnosed until the 20th week of gestation. This client is only at 18 weeks. Further, blood pressure can be assessed in either arm when the client is in a sitting position; in a side-lying position, the blood pressure should be assessed in the upper arm. 2. Preterm labor is not diagnosed until 20 weeks. This client is only at 18 weeks. Fetal fibronectin (fFN) testing is not indicated at this time. 3. A diet containing 3500 kcal (minimum) and 175 g protein is recommended for a client with normal-weight twins. Teaching about protein sources facilitates adequate fetal growth. 4. Although the incidence of multifetal pregnancy is higher in pregnancies resulting from infertility treatment than in those that are spontaneous pregnancies, the cause of the multifetal pregnancy does not impact nursing care. Page Ref: 392 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 19.4 Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the nursing management of the woman with multiple gestation.

10) The nurse is counseling a newly pregnant gravida 1 at 8 weeks' gestation with twins about the need for increased caloric intake. Which information should the nurse emphasize as being the minimum recommended intake? 1. 2500 kcal and 120 g protein 2. 3000 kcal and 150 g protein 3. 3500 kcal and 175 g protein 4. 4000 kcal and 190 g protein Answer: 3 Explanation: 1. This is less than recommended for a twin-gestation pregnancy. 2. This is less than recommended for a twin-gestation pregnancy. 3. This is the recommended caloric and protein intake in a twin-gestation pregnancy. 4. This is recommended if the twins are underweight. Page Ref: 392 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 19.4 Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the nursing management of the woman with multiple gestation. 11) A client pregnant with twins asks if the pregnancy will be uncomplicated. In which way should the nurse respond to this client? 1. "The perinatal mortality rate for monoamniotic siblings is 50%." 2. "Twins are less likely to have complications than are singleton births." 3. "Spontaneously conceived twins are less likely to develop complications." 4. "Primiparous women pregnant with twins are less likely to develop complications." Answer: 3 Explanation: 1. The perinatal mortality rate for monoamniotic siblings is 10% to 32%. 2. Twins are more likely to have complications than are singleton births. 3. This is true. Spontaneously conceived twins are less likely to develop complications. 4. Primiparous women with twin pregnancies are more likely to develop complications. Page Ref: 392 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 19.4 Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the nursing management of the woman with multiple gestation.

12) A client at 38 weeks' gestation is diagnosed with oligohydramnios. Which statement indicates that teaching has been effective? 1. "When I go into labor, I should come to the hospital right away." 2. "My gestational diabetes may have caused this problem to develop." 3. "Women with this condition usually go into labor after their due date." 4. "This problem is common and will likely occur with my next pregnancy." Answer: 1 Explanation: 1. The incidence of cord compression and resulting fetal distress is high when there is an inadequate amount of amniotic fluid to cushion the umbilical cord. Thus, the client with oligohydramnios should come to the hospital in early labor to detect any fetal intolerance of labor that might develop. 2. Gestational diabetes can lead to polyhydramnios but does not cause oligohydramnios. 3. The risk of fetal demise is increased with oligohydramnios. Labor is usually induced when the client reaches term pregnancy to prevent fetal demise. 4. Oligohydramnios occurs in 1% to 3% of pregnancies. It rarely recurs in subsequent pregnancies. Page Ref: 394 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 19.5 Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing management of the woman with polyhydramnios and oligohydramnios.

13) A pregnant client diagnosed with polyhydramnios asks for more information about this health problem. Which information should the nurse include in this teaching? Select all that apply. 1. The exact cause is unknown. 2. It can cause shortness of breath and edema. 3. It can be associated with maternal diabetes. 4. It occurs in large-for-gestational-age infants. 5. It is associated with renal malformation or dysfunction. Answer: 1, 2, 3 Explanation: 1. The exact cause of hydramnios is unknown. 2. Hydramnios can cause maternal shortness of breath and edema. 3. Hydramnios is associated with maternal diabetes. 4. Hydramnios is not associated with large-for-gestational-age infants. 5. Renal malformation or dysfunction and postmaturity can cause oligohydramnios. Page Ref: 393-394 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 19.5 Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing management of the woman with polyhydramnios and oligohydramnios.

14) When caring for a client with oligohydramnios, on which areas should the nurse focus? Select all that apply. 1. A Induction is typically scheduled. 2. Early decelerations are more likely. 3. Fetal pulmonary hypoplasia can develop. 4. There is an increased risk of cord compression. 5. Labor progress is often more rapid than average. Answer: 1, 2, 3, 4 Explanation: 1. As soon as the fetus is term, induction is typically scheduled because the fetus is at an increased risk for intrauterine fetal demise. 2. Decreased amniotic fluid can contribute to fetal head compression, which can manifest itself as early decelerations. 3. Because there is less fluid available for the fetus to use during fetal breathing movements, pulmonary hypoplasia may develop. 4. Less amniotic fluid lessens the cushioning effect, and cord compression is more likely. 5. Labor progress is slower than average due to the decreased fluid volume. Page Ref: 394 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 19.5 Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing management of the woman with polyhydramnios and oligohydramnios.

15) For which reason should the nurse suspect polyhydramnios in a pregnant client? 1. The client is pregnant with twins. 2. The quadruple screen comes back positive. 3. There is less amniotic fluid than normal for gestation. 4. The fundal height increases disproportionately to the gestation. Answer: 4 Explanation: 1. Hydramnios is not suspected simply by virtue of a twin gestation. 2. A quadruple screen is not used to determine hydramnios. 3. Hydramnios occurs when there is more amniotic fluid than normal for gestation. 4. The increased amount of amniotic fluid will increase the fundal height disproportionately to the gestation. Page Ref: 394 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 19.5 Compare the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing management of the woman with polyhydramnios and oligohydramnios. 16) A client with premature rupture of membranes received 4 g of magnesium sulfate at 1600 hours, followed by 2 g/hr beginning at 1700 hours. Birth occurred at 0130 hours. How many grams of magnesium sulfate did this client receive? Calculate to the nearest whole number. Answer: 21 g Explanation: The client received 4 g of magnesium sulfate at 1600 hours, followed by 2 g every hour beginning at 1700 hours to 0130 hours. This is a total of 8.5 hours of receiving the medication. The amount of medication provided is 4 g + (2 g × 8.5) = 4 + 17 = 21 g. Page Ref: 380 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 19.1 Explain the possible causes, risk factors, and clinical therapy for premature rupture of the membranes or preterm labor in determining the nursing management of the woman and her fetus/newborn.

17) The nurse is caring for the newborn of a client who received magnesium sulfate for preterm labor. Which fetal effects should the nurse attribute to the client's medication treatment? Select all that apply. 1. Flushing 2. Lethargy 3. Hypotonia 4. Poor sucking reflex 5. Respiratory depression Answer: 2, 3, 5 Explanation: 1. Flushing is a maternal adverse effect of magnesium sulfate. 2. Fetal side effects of magnesium sulfate may include lethargy that persists for 1 or 2 days following birth. 3. Fetal side effects of magnesium sulfate may include hypotonia that persists for 1 or 2 days following birth. 4. Poor sucking reflex is not an adverse effect of magnesium sulfate. 5. Respiratory depression in the newborn can also occur after maternal magnesium sulfate. Page Ref: 382 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 19.1 Explain the possible causes, risk factors, and clinical therapy for premature rupture of the membranes or preterm labor in determining the nursing management of the woman and her fetus/newborn.

18) The nurse selects the following diagram to instruct a pregnant client with placenta previa. What should the nurse specifically teach the client about this health problem?

1. The edge of the placenta is covered. 2. The placenta completely covers the internal os. 3. The placenta is implanted with partial covering of the internal os. 4. The placenta is implanted in the lower uterine segment not covering the os. Answer: 1 Explanation: 1. In a marginal placenta previa, the edge of the placenta is covered. 2. The internal os is completely covered in a complete placenta previa. 3. The internal os is partially covered in a partial placenta previa. 4. In a low-lying placenta previa, the placenta is implanted in the lower uterine segment but does not cover the os. Page Ref: 385 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 19.2 Compare placenta previa and abruptio placentae, including implications for the mother and fetus, as well as nursing care.

19) A pregnant client is scheduled for a transabdominal cerclage. Which teaching information should the nurse prepare for this client? Select all that apply. 1. Cesarean section birth 2. Preoperative laparotomy 3. Potential for hydramnios 4. Risk for abruptio placentae 5. Premature rupture of membranes Answer: 1, 2 Explanation: 1. Transabdominal cerclage placement typically results in a cesarean section birth. 2. Transabdominal cerclage placement requires a laparotomy for placement and removal. 3. Transabdominal cerclage placement does not increase the risk for hydramnios. 4. Transabdominal cerclage placement does not increase the risk for abruptio placentae. 5. Transabdominal cerclage placement does not increase the risk for premature rupture of membranes. Page Ref: 391 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 19.3 Identify the causes and risk factors of cervical insufficiency, and describe its clinical therapy. 20) A client who weighed 60 kg before becoming pregnant with twins is having a routine prenatal examination at gestational week 24. What should be this client's weight in kilograms at this time? (Round to the nearest whole number.) Answer: 71 kg Explanation: A total weight gain of 40 to 45 lb with a 24-lb gain by 24 weeks is recommended for a client with a multiple-gestation pregnancy. To calculate the client's weight, first determine the prepregnancy weight in pounds by multiplying the weight in kilograms by 2.2, or 60 × 2.2 = 132 lb. If the weight gain should be 24 lb by week 24, add 24 lb to 132, or 132 + 24 = 156. Then, divide the weight in kilograms by 2.2, or 156/2.2 = 70.9 or 71 kg. Page Ref: 392 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 19.4 Explain the maternal and fetal/neonatal implications and the clinical therapy in determining the nursing management of the woman with multiple gestation.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 20 Childbirth at Risk: Labor-Related Complications 1) After a lengthy labor and delivery, a client suddenly complains of chest pain and dyspnea. The client is cyanotic, has tachycardia and blood pressure decreased to 78/36 mmHg. Based on these assessment findings, which health problem is the client experiencing? 1. Infection 2. Placenta accreta 3. Hypertensive crisis 4. Amniotic fluid embolus Answer: 4 Explanation: 1. These are not manifestations of an infection. 2. Placenta accreta occurs when the chorionic villi attach directly to the uterine myometrium. The major complications of placenta accreta include maternal hemorrhage and failure of the placenta to separate following birth of the infant. 3. The client is hypotensive. 4. Signs and symptoms of amniotic fluid embolus include chest pain, dyspnea, tachycardia, hypotension, and cyanosis. The condition may progress to hemorrhage, shock, and death. Page Ref: 411 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.7 Summarize the identification, maternal and fetal/neonatal implications, clinical therapy, and nursing management of the woman with amniotic fluid embolism (anaphylactoid syndrome of pregnancy).

2) A client who is pregnant with her first child has been laboring for 14 hours with very minimal progress. Cervical dilatation and effacement are slow, and the nurse is unable to verify engagement of the presenting fetal part. Which condition should the nurse suspect may be affecting the client's labor? 1. Prolapsed cord 2. Placenta accreta 3. Cephalopelvic disproportion (CPD) 4. Occiput anterior (OA) fetal position Answer: 3 Explanation: 1. A prolapsed cord is an umbilical cord that precedes the fetal presenting part. Fetal bradycardia is a critical indicator of prolapsed cord. 2. Placenta accreta, in which the chorionic villi attach directly to the uterine myometrium, is associated with maternal hemorrhage and failed placental separation after birth. 3. The nurse should suspect CPD when labor is prolonged, cervical dilatation and effacement are slow, and engagement of the presenting part is delayed. 4. The occiput anterior (OA) fetal position is amenable to delivery and would not represent a barrier to labor. Page Ref: 411 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.3 Relate the various types of fetal malposition and malpresentation to the nursing management for each.

3) The nurse is making client assignments for the next shift. Which client is most likely to experience a complicated labor pattern? 1. 34-year-old gravida 6 at 39 weeks' gestation with twins 2. 43-year-old gravida 2 at 37 weeks' gestation with hypertension 3. 22-year-old gravida 1 at 23 weeks' gestation with ruptured membranes 4. 30-year-old gravida 3 at 41 weeks' gestation and estimated fetal weight 7 lb, 8 oz Answer: 1 Explanation: 1. Twins at term will cause overdistention of the uterus, putting the client at risk for development of a hypotonic labor pattern. Her high parity also increases the risk for a hypotonic labor pattern. 2. Hypertension does not impact labor pattern; this client has no risk factors for either hypertonic or hypotonic labor pattern development. 3. Although this client is high-risk, especially for infection, neonatal lung immaturity, and respiratory distress syndrome, this client has no risk factors for an abnormal labor pattern. 4. This client has an average-sized fetus and no risk factors for either hypertonic or hypotonic labor pattern development. Page Ref: 400 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.1 Compare tachysystolic and hypotonic labor patterns, including the risks, clinical therapy, and nursing management.

4) A client at 39 weeks' gestation was assessed 2 hours ago as being 3 cm dilated, 40% effaced, and +1 station and experienced contractions every 5 minutes with duration 40 seconds and intensity 50 mmHg. Currently, the client is 4 cm dilated, 40% effaced, and +1 station with frequency of contractions every 3 minutes with 40 to 50 seconds' duration with intensity of 40 mmHg. Which action should the nurse make a priority at this time? 1. Start oxygen at 8 L/min. 2. Give terbutaline to stop the preterm labor. 3. Have anesthesia provider give the client an epidural. 4. Begin oxytocin after assessing for cephalopelvic disproportion (CPD). Answer: 4 Explanation: 1. Oxygen will not hurt, but it is not the priority. 2. Terbutaline would not be recommended. The contraction pattern is incoordinate, but they need to be enhanced, not stopped. 3. An epidural will not change the incoordinate contraction pattern. 4. The client is having hypotonic contractions. The presence of CPD can prolong labor, so it is important to rule this out. Oxytocin (Pitocin) can create a more productive labor pattern by strengthening the contractions. Page Ref: 400 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.1 Compare tachysystolic and hypotonic labor patterns, including the risks, clinical therapy, and nursing management.

5) A primiparous client is at 42 weeks' gestation. Which order should the nurse question? 1. Begin nonstress test now. 2. Return to the clinic in 1 week. 3. Obtain biophysical profile today. 4. Schedule labor induction for tomorrow. Answer: 2 Explanation: 1. The nonstress test is a commonly used assessment for the postterm fetus. 2. A postterm pregnancy is high risk. Fetal assessments must be obtained to verify fetal wellbeing or the need for delivery via induction or cesarean. One week is too long a time period between assessments. 3. A biophysical profile is a commonly used assessment for the postterm fetus. 4. Labor induction is likely to occur with postterm pregnancies because the aging placenta becomes less efficient at transporting oxygen and nutrients and because the risk of fetal macrosomia increases with length of gestation. Page Ref: 402 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 20.2 Describe the risks and clinical therapy in determining the nursing management of postterm pregnancy on the childbearing family.

6) A multiparous client at term is in active labor with intact membranes. A Leopold maneuver indicates the fetus is in a transverse lie with a shoulder presentation. Which healthcare provider order is the most important? 1. Artificially rupture membranes. 2. Apply internal fetal scalp electrode. 3. Alert the surgical team of urgent cesarean. 4. Monitor maternal blood pressure every 15 minutes. Answer: 3 Explanation: 1. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 2. An internal fetal scalp electrode cannot be applied until membranes have ruptured. Artificial rupture of membranes is contraindicated with a transverse lie because of the high risk for prolapsed cord. 3. This is the highest priority because of the transverse lie and the risk of fetal hypoxia secondary to prolapsed cord if the membranes rupture. 4. The fetus is at risk for hypoxia secondary to prolapsed cord if the membranes rupture. The maternal blood pressure is less important than getting the cesarean under way. Page Ref: 407 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 20.3 Relate the various types of fetal malposition and malpresentation to the nursing management for each. 7) Which labor pattern should the nurse anticipate for a fetal occiput posterior position? 1. Precipitous 2. Rapid during transition 3. Shorter than average during the latent phase 4. Prolonged with regard to the overall length of labor Answer: 4 Explanation: 1. Overall labor is often prolonged, not precipitous. 2. Overall labor is often prolonged, not more rapid. 3. Overall labor is often prolonged, not shorter. 4. The malposition does not allow the smallest diameter of the fetal head to come down the birth canal, and this can prolong the overall length of labor. Page Ref: 402 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.3 Relate the various types of fetal malposition and malpresentation to the nursing management for each. 6 Copyright © 2022 Pearson Education, Inc.

8) A client's fetus is estimated to weigh 4500 g (9 lb, 14 oz). Which statement indicates that additional teaching about the size of the baby is needed? 1. "His blood sugars could be high after he is born." 2. "I am at risk for excessive bleeding after delivery." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collar bone broken." Answer: 1 Explanation: 1. Hypoglycemia, not hyperglycemia, is a potential complication experienced by a macrosomic fetus. 2. Because of the excessive size of the uterus with a macrosomic fetus, uterine atony leading to postpartum hemorrhage is a risk. 3. Perineal trauma due to the large fetus is a possible complication of vaginal delivery of a macrosomic fetus. 4. Shoulder dystocia is more common among large fetuses, and a broken clavicle could result. Page Ref: 408 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 20.4 Explain the identification, risks, and clinical therapy in determining the nursing management of the woman and fetus at risk for fetal macrosomia.

9) The membranes of a client in labor have spontaneously ruptured, and the fluid is meconium stained. The fetal heart tones are 100 to 105. Which nursing action is the most important? 1. Notify the surgical team of an impending cesarean. 2. Change the client's position from Fowler to left lateral. 3. Insert a Foley catheter with the assistance of another nurse. 4. Decrease the IV of lactated Ringer solution to 50 mL/hour. Answer: 2 Explanation: 1. The decision to go to cesarean birth is a medical decision. The nurse may not make medical decisions. 2. Improving uterine blood flow to increase fetal oxygenation is the top priority when fetal bradycardia is present. Left lateral position increases uterine blood flow. 3. If a cesarean is needed, a Foley catheter will be needed. But at this time, this is a low priority. 4. Increasing IV fluids will facilitate uterine blood flow and fetal oxygenation if the client is hypotensive. Decreasing the IV rate will not improve fetal heart tones. Page Ref: 409 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 20.5 Relate the maternal implications, clinical therapy, prenatal history, and conditions that may be associated with nonreassuring fetal status to the nursing management of the mother and fetus.

10) The nurse is caring for a client who is a gravida 5 in active labor. The membranes spontaneously rupture with a large amount of clear amniotic fluid. Which nursing action is the most important to take at this time? 1. Perform a Leopold maneuver. 2. Complete a sterile vaginal examination. 3. Obtain an order for pain medication. 4. Assess the odor of the amniotic fluid. Answer: 2 Explanation: 1. This assessment is not called for at this time. 2. Checking the cervix will determine whether the cord prolapsed when the membranes ruptured. A prolapsed cord leads to rapid onset of fetal hypoxia, which can lead to fetal death within minutes if not treated. 3. Pain medication is a low priority at this time. 4. Although it is important to assess amniotic fluid for odors, checking the cervix to assess for cord prolapse is a higher priority. Page Ref: 410 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 20.6 Describe the nursing management of the mother and fetus with a prolapsed umbilical cord.

11) The charge nurse is reviewing charting completed on clients in the maternal-child triage unit. Which entry requires immediate intervention? 1. Multipara at 32 weeks: "Oligohydramnios per ultrasound secondary to fetal renal agenesis." 2. Primipara at 41 weeks: "Client reports leaking clear fluid from her vagina for 7 hours." 3. Primipara at 24 weeks diagnosed with polyhydramnios: "Client reporting shortness of breath." 4. Multipara at 34 weeks diagnosed with oligohydramnios: "Cervix 6 cm, −2 station, up to walk in hallway." Answer: 4 Explanation: 1. Renal agenesis will lead to oligohydramnios because of the lack of fetal urine production. This client will be grieving but is not experiencing physical complications. 2. Leakage of clear fluid is normal; leaking for several hours can lead to oligohydramnios, which in turn can lead to variable decelerations. This client might be experiencing a complication, but it is a lower priority than the client with the possibility of a prolapsed cord. 3. Although this client is uncomfortable, shortness of breath often accompanies polyhydramnios. It can require removal of some amniotic fluid through amniocentesis to facilitate comfort, but this is not a life-threatening emergency. 4. Active labor in a preterm multipara with the presenting part high in the pelvis is at high risk for prolapse of the cord when the membranes rupture. This client should be on bed rest until the membranes rupture, and the presenting part has descended well into the pelvis. This client is at the highest risk for physical complication (cord prolapse) and therefore is the highest priority. Page Ref: 402 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.6 Describe the nursing management of the mother and fetus with a prolapsed umbilical cord.

12) A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). Which action should the nurse take? 1. Encourage oral fluids and carbohydrate intake. 2. Assess the cervix for change every 8 hours. 3. Inform the couple that labor might be prolonged. 4. Assist the client to squat during the second stage. Answer: 4 Explanation: 1. A client with a large fetus and a small pelvis has a higher-than-average chance of needing a cesarean section. This client should either be given only clear liquids or be NPO to reduce the risk of aspiration should a cesarean section need to be performed. 2. The cervix is normally assessed when the client's labor status appears to have changed, or in order to determine whether cervical change is taking place. The cervix would be assessed more frequently if a client was in the active phase of labor, and cephalopelvic disproportion was a risk. Every 8 hours is too far apart. 3. Although it is true that labor with a large fetus and a small pelvis could be prolonged, informing the couple of this fact is a psychosocial intervention. Physiologic interventions are a higher priority. 4. Squatting increases the diameter of the pelvic outlet and might facilitate vaginal birth when cephalopelvic disproportion is a risk. Page Ref: 412 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 20.8 Explain the types, maternal and fetal/neonatal implications, and clinical therapy in determining the nursing management of the woman with cephalopelvic disproportion.

13) A client who delivered 30 minutes ago is being prepared for manual removal of the placenta. Which action should the nurse take? 1. Bottle-feed the infant. 2. Send the placenta to pathology. 3. Start an IV infusion. 4. Apply antiembolism stockings. Answer: 3 Explanation: 1. The client's partner or family member, or a nursery nurse, can feed the infant. The client is at risk for excessive blood loss due to retained placenta, and preparation for manual removal of the placenta is a higher priority at this time. 2. The placenta might be sent to pathology after it is removed, but preparing the client for manual removal of the placenta now is a higher priority. 3. The client undergoing manual removal of the placenta will need either IV sedation or general anesthesia. An IV is necessary. 4. Antiembolism stockings are used after major surgery that leads to immobility, thus increasing the risk of embolism. However, antiembolism stockings are not needed for this client because manual removal of the placenta is not major surgery and does not lead to postprocedure immobility. Page Ref: 412 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 20.9 Identify common complications of the third and fourth stages of labor.

14) A client with cephalopelvic disproportion (CPD) develops tachysystolic labor patterns. Which treatment should the nurse anticipate? 1. Amniotomy 2. Cesarean section 3. Nipple stimulation 4. Oxytocin administration Answer: 2 Explanation: 1. Amniotomy is used to induce labor; however, a vaginal delivery is unlikely. 2. Cesarean section is the most likely course of action. With CPD, a cesarean birth is indicated, as vaginal delivery cannot be performed. 3. Nipple stimulation is used to induce labor; however, a vaginal delivery is unlikely. 4. Oxytocin is used to induce labor; however, a vaginal delivery is unlikely. Page Ref: 412 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 20.8 Explain the types, maternal and fetal/neonatal implications, and clinical therapy in determining the nursing management of the woman with cephalopelvic disproportion. 15) For delivery, a client received a midline episiotomy, which extended into a third-degree laceration. Which information should the nurse include when explaining the location of the episiotomy to the client? 1. "Up near your urethra." 2. "Into the muscle layer." 3. "Through your rectal mucosa." 4. "Through your rectal sphincter." Answer: 4 Explanation: 1. A periurethral laceration is near the urethra. 2. A first-degree laceration involves only the skin. A second-degree laceration involves skin and muscle. 3. A fourth-degree laceration is through the rectal mucosa. 4. A third-degree laceration includes the rectal sphincter. Page Ref: 412 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 20.9 Identify common complications of the third and fourth stages of labor.

16) The multiparous client at 33 weeks has experienced an intrauterine fetal demise. Which finding requires immediate intervention? 1. Temperature 99°F 2. Fibrinogen level 50 mg/dL 3. Platelet count 210,000/cmm 4. Family refusing fetal autopsy Answer: 2 Explanation: 1. Women with intrauterine fetal demise can demonstrate signs of an infection; however, this temperature is not high enough to indicate this problem. 2. Intrauterine fetal demise can cause disseminated intravascular coagulopathy (DIC); the normal fibrinogen level is 200 to 400 mg/dL. This is a very low fibrinogen level, and indicates that the client is in DIC. 3. Intrauterine fetal demise can lead to disseminated intravascular coagulopathy (DIC), but this is a normal platelet count. 4. Some religious traditions prohibit autopsy. Disseminated intravascular coagulopathy (DIC) is a higher priority. Page Ref: 414 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.10 Explain the etiology, diagnosis, and phases of grief in determining the nursing management of the family experiencing perinatal loss.

17) A client delivered a fetus with the following head shape:

On which area should the nurse focus when assessing this newborn? Select all that apply. 1. Airway 2. Amount of bruising 3. Meconium aspiration 4. Degree of facial edema 5. Neck and head movement Answer: 1, 2, 4, 5 Explanation: 1. Because of neck compression, the trachea and larynx may be compressed, compromising this newborn's airway. 2. Because of the presentation, bruising may occur to the face. 3. Meconium aspiration is not associated with this type of delivery. 4. Because of the presentation, facial edema may occur. 5. Because of cerebral and neck compression, neck and head range of motion may be compromised. Page Ref: 403 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.3 Relate the various types of fetal malposition and malpresentation to the nursing management for each.

18) The nurse palpates the following when conducting a vaginal assessment on a client in labor:

Which action should the nurse take to address this finding? 1. Position the client on the left side. 2. Prepare the client for cesarean section. 3. Place a wedge under the client's right hip. 4. Increase intravenous fluids, and apply oxygen. Answer: 2 Explanation: 1. Positioning on the left side will not change the fetal position. 2. The fetus is in the transverse lie. The client needs to be prepared for a cesarean birth. 3. Placing a wedge under the right hip will not change the fetal position. 4. The client is not in any acute distress. Intravenous fluid bolus and oxygen are not required. Page Ref: 407 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 20.3 Relate the various types of fetal malposition and malpresentation to the nursing management for each.

19) The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply. 1. Prolonged decelerations 2. Persistent late decelerations 3. Last fetal movement 5 minutes ago 4. Fetal heart rate 140 beats per minute 5. Persistent and severe variable decelerations Answer: 1, 2, 5 Explanation: 1. The presence of prolonged decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 2. The presence of persistent late decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. 3. Fetal activity is not used as an indication for intrauterine resuscitation. 4. A fetal heart rate of 140 bpm is within normal limits. 5. The presence of persistent and severe variable decelerations is a sign of nonreassuring fetal status. Intrauterine resuscitation should be started without delay. Page Ref: 409 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 20.5 Relate the maternal implications, clinical therapy, prenatal history, and conditions that may be associated with nonreassuring fetal status to the nursing management of the mother and fetus.

20) The nurse is preparing instruction on placental and umbilical cord variations. Which diagram should the nurse use to explain succenturiate placenta? 1.

Answer: 3 Explanation: 1. This is an image of a circumvallate placenta where a double fold of chorion and amnion form a ring around the umbilical cord, on the fetal side of the placenta. 2. This is an image of a battledore placenta where the umbilical cord is inserted at or near the placental margin. 3. This is an image of a succenturiate placenta where one or more accessory lobes of fetal villi develop on the placenta. 4. This is an image of velamentous insertion of the umbilical cord where the vessels of the umbilical cord divide some distance from the placenta in the placental membranes. Page Ref: 413 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 20.9 Identify common complications of the third and fourth stages of labor.

21) The nurse is caring for a client who delivered a 38 weeks' gestation stillborn fetus. Which action should the nurse take to support the client at this time? Select all that apply. 1. Remove the fetus from the room. 2. Clean the fetus and wrap in a blanket. 3. Ask the client if she would like to hold the baby. 4. Instruct on postdelivery care to be completed in the home. 5. Ask if other family members would like to spend time with the baby. Answer: 2, 3, 4 Explanation: 1. The fetus should not be removed from the room unless the client asks that the fetus be removed. 2. The fetus should be bathed/cleansed and wrapped in a blanket in preparation for viewing. 3. The client should be asked her preference for viewing and holding the baby. 4. It is inappropriate for the nurse to instruct the client on home care needed after delivery at this time. The client and family are having a highly emotional experience, which should not be ignored. 5. Oftentimes, other family members will be present, and they should be asked of their desire to spend time with the baby. Page Ref: 417 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation/Caring Learning Outcome: 20.10 Explain the etiology, diagnosis, and phases of grief in determining the nursing management of the family experiencing perinatal loss.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 21 Birth-Related Procedures 1) The nurse is scheduling a client for an external cephalic version (ECV). Which finding in the client's chart requires immediate intervention? 1. "Multipara, transverse lie." 2. "Primipara failed ECV last week." 3. "Primipara, frank breech ballotable." 4. "Multipara, 32 weeks, complete breech." Answer: 4 Explanation: 1. This client has no contraindication to ECV. 2. Although this client is less likely to have a successful ECV this week if it were unsuccessful last week, there is no contraindication to attempting the procedure. 3. This client has no contraindication to ECV. 4. ECV is not attempted until 36 weeks. This client is too early in her pregnancy for ECV. Page Ref: 422 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 21.1 Explain the methods, purpose, and contraindications of external and podalic versions that determine nursing management.

2) The clinical nurse coordinator is reviewing the care of clients who undergo artificial rupture of membranes (AROM) by way of amniotomy with a group of nursing students. Which student statement indicates that the teaching has been effective? 1. "Amniotomy is contraindicated for use in labor augmentation." 2. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." 3. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'" 4. "In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed." Answer: 2 Explanation: 1. Amniotomy is an accepted method of labor augmentation. 2. Following .AROM, because there is now an open pathway for organisms to ascend into the uterus, the number of vaginal examinations must be kept to a minimum to reduce the chance of introducing an infection. 3. Women need to know that amniotic fluid is constantly produced because some women may worry that they will experience a "dry birth." 4. In all cases, the .FHR is assessed just before and immediately after the amniotomy, and the two FHR assessments are compared. Page Ref: 423 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 21.2 Describe the use of amniotomy in the nursing management of the woman and fetus.

3) A client at 39 weeks' gestation being prepared for labor induction feels as though the baby has "flipped." Which action should the nurse take? 1. Evaluate fetal maturity. 2. Administer dinoprostone (Cervidil) vaginal gel. 3. Implement continuous electronic fetal monitoring (EFM). 4. Notify the healthcare provider that the client feels as though the baby has changed position. Answer: 4 Explanation: 1. Malpresentation, such as breech, is a relative contraindication to induction of labor. Before proceeding with preparation for induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. 2. Dinoprostone (Cervidil) is used to facilitate cervical ripening, which might be premature since the fetal position needs to be evaluated before proceeding with the induction. 3. EFM will not provide enough information regarding the position of the fetus. 4. Because malpresentation, such as breech, is a relative contraindication to induction of labor, the client will require additional evaluation by the healthcare provider before proceeding. Page Ref: 425 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 21.3 Compare the methods for inducing labor, explaining their advantages and disadvantages in determining the nursing management of women during labor induction.

4) The nurse is completing discharge teaching for a client who delivered 2 days ago. Which statement indicates that further information is required? 1. "I can take ibuprofen (Motrin) when my perineum starts to hurt." 2. "Soaking in the tub will help my mediolateral episiotomy to heal." 3. "The tear I have through my rectum is unrelated to my episiotomy." 4. "Because I have a midline episiotomy, I should keep my perineum clean." Answer: 3 Explanation: 1. Healing episiotomies can be very painful, and pain medication should be provided for clients experiencing pain. 2. Warm tub baths are helpful to facilitate both comfort and healing of an episiotomy. 3. This statement is incorrect. Midline episiotomies tend to tear posteriorly toward the rectum. 4. When a client has an episiotomy, perineal hygiene is important to prevent infection and facilitate healing. Page Ref: 429 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 21.4 Describe the measures to prevent episiotomy, the types of episiotomy performed, and the associated nursing management. 5) A client who received a mediolateral episiotomy to facilitate vacuum extraction birth asks what kind of episiotomy was performed. In which way should the nurse explain the location of the episiotomy? 1. "It goes straight back toward your rectum." 2. "It is from your vagina toward the urethra." 3. "It is cut diagonally away from your vagina." 4. "It extends from your vagina into your rectum." Answer: 3 Explanation: 1. Midline episiotomy is straight back from the vagina toward the rectum. 2. Episiotomies are not cut anteriorly toward the urethra. 3. Mediolateral episiotomy is angled from the vaginal opening toward the buttock. 4. Extension into the rectum is a fourth-degree laceration. Page Ref: 430 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 21.4 Describe the measures to prevent episiotomy, the types of episiotomy performed, and the associated nursing management. 4 Copyright © 2022 Pearson Education, Inc.

6) A client recovering from delivery asks for another ice pack to place on the site of a midline episiotomy. In which way should the nurse respond to this request? 1. "I will get you one right away." 2. "You only need to use one ice pack." 3. "You need to leave it off for at least 20 minutes and then reapply." 4. "I will bring you an extra so that you can change it when you are ready." Answer: 3 Explanation: 1. Providing an additional ice pack before 20 minutes have passed would increase the perineal edema. 2. More than one ice pack must be used in order to apply ice for 20 minutes on, followed by 20 minutes off. 3. Optimal effects from the use of an ice pack occur when it is applied for 20 to 30 minutes and then removed for at least 20 minutes before being reapplied. 4. An ice pack that is provided now for use in 20 minutes would be melted before being used. Page Ref: 431 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 21.4 Describe the measures to prevent episiotomy, the types of episiotomy performed, and the associated nursing management.

7) The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention? 1. Bladder is emptied using a straight catheter. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. Regional anesthesia is administered via pudendal block. Answer: 2 Explanation: 1. The urinary bladder is emptied to prevent the full bladder from impeding descent of the fetal head. 2. The client should only push during contractions, not between contractions. 3. These are normal fetal heart tones. No intervention is needed. 4. Regional anesthesia is important to facilitate application of the forceps and cooperation with pushing efforts. Page Ref: 433 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 21.5 Explain the indications and maternal and neonatal risks that impact nursing management during forceps-assisted birth. 8) A client experiencing a difficult labor has a vacuum extraction birth. Which finding should the nurse expect with this type of delivery? 1. The head is delivered after eight pulls during contractions. 2. The location of the vacuum is apparent on the fetal scalp after birth. 3. A bruise is present on the occiput that does not cross the suture line. 4. Positive pressure is applied by the vacuum extraction during contractions. Answer: 2 Explanation: 1. Use of the vacuum extraction for eight contractions is too many and can create damage to the fetal head. If fetal descent does not occur with the first two pulls, the procedure should be discontinued, and cesarean birth should take place. 2. Caput in the shape of the vacuum cup is usually present immediately after birth and resolves in 2 to 3 days. 3. This is a cephalohematoma and is a complication of vacuum extraction birth. 4. Negative pressure is suction, which is needed to use the vacuum extractor to facilitate birth. Page Ref: 433 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 21.6 Describe the use of and risk of vacuum extraction to assist birth. 6 Copyright © 2022 Pearson Education, Inc.

9) A client experiencing a difficult labor is going to have vacuum extraction to facilitate delivery. Which statement indicates that the client needs additional information about vacuum extraction assistance? 1. "The baby's head might have a bruise from the vacuum cup." 2. "The vacuum will be applied for a total of 10 minutes or less." 3. "I can stop pushing and just rest if the vacuum extractor is used." 4. "A small cup will be put onto the baby's head, and a gentle suction will be applied." Answer: 3 Explanation: 1. The vacuum extractor might leave a bruise on the scalp where the device is placed. 2. The vacuum extractor is applied to the scalp for up to 10 minutes total. 3. Vacuum extraction is an assistive delivery, and the client must continue with pushing efforts to accomplish the birth. 4. The vacuum extractor is a small cup-shaped device that is applied to the scalp. Page Ref: 433 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 21.6 Describe the use of and risk of vacuum extraction to assist birth.

10) The risk management nurse is reviewing labor and delivery statistics over the last 2 years in an effort to decrease costs of maternity care. Which finding contributes to increased healthcare costs in clients undergoing cesarean birth by request? 1. Prolonged anemia, requiring blood transfusions every few months 2. Increased abnormal placenta implantation in subsequent pregnancies 3. Decreased use of general anesthesia with greater use of epidural anesthesia 4. Coordination of career projects of both partners leading to increased income Answer: 2 Explanation: 1. This is not a complication of cesarean birth by request. 2. Placenta implantation problems are more common after cesarean birth and increase healthcare costs because of the high-risk care and testing required. 3. Which anesthesia method is used is not a significant factor in healthcare costs of cesarean birth by request. The need for anesthesia, use of the operating suite, equipment use, personnel, and other factors are more responsible for greater costs of cesarean birth compared with vaginal birth. 4. The income of the couple does not affect healthcare costs directly. Page Ref: 464 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: IV.B.1. Seek information about outcomes of care for populations served in care setting │ AACN 2021 Domains and Competencies: 5.1 Apply quality improvement principles in care delivery. │ NLN Competencies: Knowledge and Science; Practice; Document via electronic health records; use software applications related to nursing practice │ Nursing/Integrated Concepts: Assessment Learning Outcome: 21.7 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management.

11) The client is instructing a client recovering from a classic uterine incision for a cesarean birth. Which statement indicates that the client understands implications for future pregnancies that are secondary to this type of incision? 1. "I can only have one more baby." 2. "The next time I have a baby, I can try to deliver vaginally." 3. "Every time I have a baby, I will have to have a cesarean delivery." 4. "The risk of rupturing my uterus is too high for me to have any more babies." Answer: 3 Explanation: 1. Future pregnancies are not limited to one. 2. Attempting a vaginal birth is contraindicated, and future births will be planned cesareans. 3. A classic uterine incision is made in the upper uterine segment and holds an increased risk of rupture in subsequent pregnancy, labor, and birth. 4. Future pregnancies are not prohibited. Page Ref: 434 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 21.7 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. 12) The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. Which assessment should the nurse make before the client is draped for surgery? 1. Vaginal examination 2. Fetal heart tones 3. Maternal temperature 4. Maternal urine output Answer: 2 Explanation: 1. Vaginal examination is unnecessary when CPD is present. 2. Fetal heart tones are assessed just prior to the start of surgery because the supine position can lead to fetal hypoxia. 3. Maternal temperature is monitored by anesthesia personnel. 4. Maternal urine output is not significant at this point. Page Ref: 437 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 21.7 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management. 9 Copyright © 2022 Pearson Education, Inc.

13) The nurse is teaching a class on vaginal birth after cesarean (VBAC). Which participant statement indicates that additional information is needed? 1. "Because my hospital is so small and in a rural area, they will not let me attempt a VBAC." 2. "Since the scar on my belly goes down from my navel, I am not a candidate for a VBAC." 3. "The rate of complications from VBAC is lower than the rate of complications from a cesarean." 4. "My first baby was in a breech position, so this pregnancy I can try a VBAC if the baby is head-down." Answer: 2 Explanation: 1. A repeat cesarean must be able to be performed immediately to safely attempt a VBAC. Many small and rural hospitals do not have surgical and anesthesia staff available at night or on weekends and holidays and, therefore, do not allow clients to have a VBAC. 2. Skin incision is not indicative of uterine incision. Only the uterine incision is a factor in deciding if VBAC is advisable. Classic vertical incisions on the uterus have a higher rate of rupture and should not be attempted. 3. The incidence of uterine rupture is 0.5% to 0.9%. Women who have a successful VBAC have lower incidences of infection, less blood loss, fewer blood transfusions, and shorter hospital stays. 4. Nonrepeating conditions such as any nonvertex presentation might make VBAC a viable option as long as this pregnancy is vertex. Page Ref: 438 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 21.8 Examine the risks, guidelines, and nursing management of the woman undergoing trial of labor after cesarean.

14) A client in the midst of labor and delivery of twins is being considered for a podalic version. Which assessment should be completed before this version to be considered? Select all that apply. 1. Previous cesarean birth 2. Second fetus does not descend 3. Premature rupture of membranes 4. Presence of third-trimester bleeding 5. Second fetus heart rate nonreassuring Answer: 2, 5 Explanation: 1. A previous cesarean birth is a contraindication for a version. 2. A podalic version is used only with the second fetus during a vaginal twin birth and only if the twin does not descend readily. 3. Premature rupture of membranes is a contraindication for a version. 4. Presence of third-trimester bleeding is a contraindication for a version. 5. A podalic version is used only with the second fetus during a vaginal twin birth and only if the heart rate is nonreassuring. Page Ref: 422 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Assessment Learning Outcome: 21.1 Explain the methods, purpose, and contraindications of external and podalic versions that determine nursing management.

15) A client at 40 weeks' gestation is being considered for cervical ripening. Which criteria should the nurse use to determine the client's success for induction? Select all that apply. 1. Position 2. Effacement 3. Consistency 4. Fetal heart rate 5. Cervical dilatation Answer: 1, 2, 3, 5 Explanation: 1. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include position. 2. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include effacement. 3. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include consistency. 4. A prelabor scoring system was developed that is helpful to predict the potential success of induction. The fetal heart rate is not a component that is evaluated. 5. A prelabor scoring system was developed that is helpful to predict the potential success of induction. Components evaluated include cervical dilatation. Page Ref: 424 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 21.3 Compare the methods for inducing labor, explaining their advantages and disadvantages in determining the nursing management of women during labor induction.

16) A client at 40 weeks' gestation is prescribed dinoprostone (Cervidil) for cervical ripening. Which information should the nurse include when teaching the client about this medication? Select all that apply. 1. Cramping can occur. 2. Uterine irritability is expected. 3. Membrane rupture is a sign of labor. 4. Leakage of the gel should be reported. 5. Strong regular contractions are expected. Answer: 1, 2, 3 Explanation: 1. Cramping is a common reaction to the medication. 2. Uterine irritability is a common reaction to the medication. 3. Membrane rupture is a sign of labor and not a reaction to the medication. 4. Leakage of the gel is a common reaction that does not need to be reported. 5. Strong regular contractions are a sign of labor and not a reaction to the medication. Page Ref: 424 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 21.3 Compare the methods for inducing labor, explaining their advantages and disadvantages in determining the nursing management of women during labor induction.

17) The nurse is reviewing the medical history of a pregnant client being considered for cervical ripening. Which data indicate that the order for misoprostol (Cytotec) should be reconsidered? Select all that apply. 1. Current fetal heart rate is tachycardic. 2. Client had one cesarean live birth 3 years ago. 3. Uterine contractions are occurring every 2 minutes. 4. Client has 2+ pedal edema and elevated blood pressure. 5. There is a history of placenta previa with one previous pregnancy. Answer: 1, 2, 3 Explanation: 1. Absolute contraindications for the use of misoprostol include fetal tachycardia. 2. Absolute contraindications for the use of misoprostol include a history of previous cesarean birth. 3. Absolute contraindications for the use of misoprostol include the presence of uterine contractions 3 times in 10 minutes. 4. Evidence of maternal preeclampsia or eclampsia is not an absolute contraindication for the use of misoprostol. 5. Absolute contraindications for the use of misoprostol include the presence of placenta previa, not a history of placenta previa with a previous pregnancy. Page Ref: 425 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 21.3 Compare the methods for inducing labor, explaining their advantages and disadvantages in determining the nursing management of women during labor induction. 18) A pregnant client receiving oxytocin for labor induction begins demonstrating adverse effects of the medication. In which order should the nurse provide care to this client? 1. Notify the healthcare provider. 2. Discontinue the oxytocin infusion. 3. Position the client onto the left side. 4. Infuse prescribed intravenous fluids. 5. Administer oxygen 8 to 10 L per tight face mask. Answer: 2, 4, 3, 5, 1 Page Ref: 427 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 21.3 Compare the methods for inducing labor, explaining their advantages and disadvantages in determining the nursing management of women during labor induction. 14 Copyright © 2022 Pearson Education, Inc.

19) The nurse is instructing a pregnant client scheduled for an elective cesarean birth on the different types of incisions. Where should the nurse identify the location of the Sellheim incision during this teaching?

Answer:

Explanation: The Sellheim incision is a vertical incision in the lower uterine segment. Page Ref: 462 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 21.7 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management.

20) A client is recovering from general anesthesia after an emergency cesarean birth. Which actions should the nurse take when providing care to this client? Select all that apply. 1. Position on the left side. 2. Observe urine for hematuria. 3. Assess level of anesthesia every 15 minutes. 4. Evaluate perineal pad every 15 minutes for 1 hour. 5. Gently palpate the fundus with vital signs assessment. Answer: 1, 2, 4, 5 Explanation: 1. If the client has been under general anesthesia, she should be positioned on her side to facilitate drainage of secretions. 2. It is important to observe the urine for a bloody tinge, which could mean surgical trauma to the bladder. 3. Assessment of the level of anesthesia is performed for a client recovering from spinal anesthesia. 4. After a cesarean section, evaluate the dressing and perineal pad every 15 minutes for at least 1 hour. 5. The fundus should be gently palpated to determine whether it is remaining firm. Page Ref: 438 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 21.7 Explain the indications for cesarean birth, impact on the family unit, preparation and teaching needs, and associated nursing management.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 22 The Physiologic Responses of the Newborn to Birth 1) The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention? 1. Mean blood pressure 55 mmHg 2. Pulse rate 145, systolic murmur heard 3. Pauses in respiration lasting 30 seconds 4. Respiratory rate 60; crackles present bilaterally Answer: 3 Explanation: 1. This is a normal finding in an infant at 1 hour of life. 2. This pulse rate is normal. Systolic murmurs are very unlikely to indicate serious pathology and are usually caused by incomplete closure of the ductus arteriosus or foramen ovale. 3. Pauses in respirations greater than 20 seconds are considered episodes of apnea and require further intervention. 4. This respiratory rate is normal; crackles are commonly heard in the first few hours after birth as the infant reabsorbs the fluid in the lungs that was present at birth. Page Ref: 444 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 22.1 Summarize the cardiopulmonary changes that must occur for the newborn to successfully transition to extrauterine life.

2) The newborn at 24 hours of age has a red blood cell (RBC) count of 5.4 million per milliliter. Which entry should the nurse expect to find in the newborn's chart to explain this laboratory value? 1. Cord clamping delayed until pulsation ceased. 2. Infant is breastfed 15 to 20 minutes every 3 hours. 3. CBC drawn from the anterior surface of the left hand. 4. Placental abruption noted to be 80% at time of delivery. Answer: 1 Explanation: 1. Delayed cord clamping can result in a slightly higher-than-average RBC count. 2. Breastfeeding does not impact RBC counts in the first day of life. 3. Venous blood has lower RBC counts than do capillary blood samples. 4. Maternal or fetal blood loss causes hypovolemia and low RBC counts (less than 5.2 million per milliliter). Page Ref: 447 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 22.2 Identify the differences in fetal and adult hemoglobin and why this is important in the transition to extrauterine life.

3) The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? Select all that apply. 1. "Our baby will have a much faster rate of breathing if he is not dressed warmly enough." 2. "When we change the baby's diaper, we should change any wet clothing or blankets, too." 3. "It is important that we dry the baby off as soon as we give him a bath or shampoo his hair." 4. "We should make sure that we keep our home air-conditioned so the baby does not overheat." 5. "If the baby's body temperature gets too low, he will warm himself up without any shivering." Answer: 1, 2, 3, 5 Explanation: 1. A neonate with a low body temperature will increase oxygen consumption, which can lead to respiratory distress. 2. Changing wet clothing or blankets immediately prevents evaporation, one mechanism of heat loss. 3. Drying a wet baby prevents evaporation, one mechanism of heat loss. 4. Babies need to be kept warm. Cold ambient temperatures will increase the oxygen consumption of a newborn and can lead to respiratory distress. 5. Nonshivering thermogenesis is the mechanism used by newborns to warm themselves. Page Ref: 448 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 22.3 Relate the process of thermogenesis in the newborn and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

4) The nurse is planning the care of a 1-day-old infant. Which intervention would protect the newborn from heat loss by convection? 1. Drying the newborn thoroughly 2. Prewarming the examination table 3. Removing wet linens from the isolette 4. Placing the newborn away from air currents Answer: 4 Explanation: 1. Drying the newborn thoroughly immediately after birth or after a bath will prevent heat loss by evaporation. 2. Prewarming the examination table reduces heat loss by conduction. 3. Removing wet linens that are not in direct contact with the newborn from the isolette reduces heat loss by radiation. 4. Placing the newborn away from air currents reduces heat loss by convection. Page Ref: 448 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 22.3 Relate the process of thermogenesis in the newborn and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

5) The nurse is planning an educational presentation on hyperbilirubinemia for nursery nurses. Which statement is the most important to include in the presentation? 1. Antibiotics decrease the incidence of hyperbilirubinemia. 2. Total bilirubin is the sum of the direct and indirect levels. 3. Conjugated bilirubin is eliminated in the conjugated state. 4. Unconjugated bilirubin is neurotoxic and cannot cross the placenta. Answer: 2 Explanation: 1. Because of the role of gut bacteria in converting conjugated bilirubin into urobilinogen, neonates who have been administered antibiotics have an increased incidence of hyperbilirubinemia. 2. This is true. Conjugated bilirubin is also referred to as direct, while unconjugated bilirubin is also referred to as indirect. 3. Conjugated bilirubin can be transformed back into unconjugated bilirubin prior to excretion by β-glucuronidase enzyme if gut bacteria have not transformed it into urobilinogen. 4. Unconjugated bilirubin is neurotoxic but crosses the placenta during fetal life for the maternal gastrointestinal system to conjugate and excrete. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 22.4 Identify the reasons a newborn may develop jaundice and nursing interventions to decrease the probability of jaundice.

6) A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice in a 37-hour-old newborn. Which information should the nurse gather first? 1. Skin color 2. Fluid intake 3. Bilirubin level 4. Stool characteristics Answer: 1 Explanation: 1. Yellow coloration of the skin and sclerae is a sign of physiologic jaundice that appears after the first 24 hours postnatally. Inspection of the skin would be the first step in assessing for jaundice. 2. Inadequate fluid intake can predispose an infant toward becoming jaundiced and is best determined by the number of wet diapers per day. 3. Skin color begins to appear yellow once the serum levels of bilirubin are about 4 to 6 mg/dL. 4. The stool characteristic of yellow-brown coloration indicates excretion of bilirubin. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 22.4 Identify the reasons a newborn may develop jaundice and nursing interventions to decrease the probability of jaundice.

7) The nurse is reviewing the medical records of several newborns. Which infant requires immediate intervention? 1. 24-hour-old term male with total bilirubin level of 2 2. 3-day-old term bottle-fed female with bilirubin of 11 3. 2-week-old postterm breastfed male with bilirubin of 10 4. 12-hour-old preterm female exhibiting icterus and lethargy Answer: 4 Explanation: 1. Total bilirubin levels under 3 are expected in the first 24 hours of life. 2. Physiologic jaundice peaks between days 3 and 5; a total bilirubin level of 11 is not treated with phototherapy, regardless of feeding method. 3. Breast milk jaundice peaks at 2 to 3 weeks of age and commonly presents with a total bilirubin level of 5 to 10. 4. Jaundice is an indication of hyperbilirubinemia and is not an expected finding in the first day of life. Lethargy can be a sign of kernicterus developing. Preterm infants are more likely to develop jaundice. Page Ref: 450 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 22.4 Identify the reasons a newborn may develop jaundice and nursing interventions to decrease the probability of jaundice.

8) A new grandfather is marveling over his 12-hour-old newborn grandson. Which statement indicates that the grandfather needs additional education? 1. "I cannot believe he can already digest fats, carbohydrates, and proteins." 2. "It is amazing that his whole digestive tract moves things along at birth." 3. "Incredibly, his stomach capacity is already a cupful when he was born." 4. "He will lose some weight but then miraculously regain it by about 10 days." Answer: 3 Explanation: 1. At birth, neonates can digest fats, simple carbohydrates, and proteins. 2. Gastric emptying and intestinal peristalsis occur during in utero life; the first bowel movement usually occurs in the first day of life. 3. A newborn's stomach capacity is only 50 to 60 mL; overfeeding of bottle-fed infants tends to cause regurgitation and abdominal discomfort, exhibited by crying. 4. Neonates lose 5% to 10 % of their birth weight in the first days after life, especially if they are breastfed. They should have regained the lost weight and should be back to their birth weight by 10 days of age. Page Ref: 453 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 22.5 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

9) A postpartum client calls the nursery to report that her 3-day-old newborn has passed a bright green stool. In which way should the nurse respond to the client? 1. "Your newborn has diarrhea." 2. "This is a normal occurrence." 3. "There may be a possible food allergy." 4. "Take your newborn to the pediatrician." Answer: 2 Explanation: 1. The green color of stool is not characterized as diarrhea, but is a transitional stool that consists of part meconium and part fecal material. 2. By the third day of life, the newborn's stools appear brown to green in color. 3. The green color of stool is not due to food allergies. 4. It is not necessary for the client to take her newborn to the pediatrician. Page Ref: 454 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 22.5 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. 10) The home care nurse notes jaundice on the skin over the sternum of a 3-day-old infant. Which information should the nurse explain to the parents about this finding? 1. "The liver of an infant is not fully mature and does not conjugate the bilirubin for excretion." 2. "The yellow color of your baby's skin indicates that you are breastfeeding too often." 3. "This is an abnormal finding related to your baby's bowels not excreting bilirubin as they should." 4. "The infant received too many red blood cells after delivery because the cord was not clamped immediately." Answer: 1 Explanation: 1. Physiologic jaundice is a common occurrence and peaks on day 3 or 4. 2. Frequent feeding will decrease jaundice. 3. Bilirubin binds to the proteins in breast milk and formula for excretion through the bowels. 4. It happens in part because of the red blood cell destruction that infants experience combined with liver immaturity, which leads to less efficient conjugation of bilirubin for excretion. Page Ref: 450 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 22.5 Delineate the functional abilities of the newborn's gastrointestinal tract and liver. 9 Copyright © 2022 Pearson Education, Inc.

11) The nurse manager of the neonatal intensive care unit is preparing a handout for new parents. Which statement should the nurse include? 1. Neonates have a tendency to become dehydrated. 2. Sugar is always present in the urine of a newborn. 3. The kidneys are fully functional by 30 weeks' gestation. 4. Newborns can eliminate excess fluid as quickly as an adult. Answer: 1 Explanation: 1. Neonates cannot concentrate their urine or pull water back into the vascular volume, and thus can become dehydrated easily. 2. Glucose is not identified as always being present in the urine of a newborn. 3. Full nephron function does not develop until 34 to 36 weeks. 4. Newborns have difficulty eliminating excess fluid because of their relatively low glomerular filtration rate during the first 2 weeks of life. Page Ref: 454 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 22.6 Relate the development of the newborn's kidneys to the newborn's ability to maintain fluid and electrolyte balance. 12) The nurse is instructing the parents of a newborn about the number of wet diapers to expect each day. Which statement by the parents indicates that further education is necessary? 1. "Our baby was born with kidneys that are too small." 2. "Feeding our baby frequently will help the kidneys function." 3. "Kidney function in an infant is very different from in an adult." 4. "A baby's kidneys do not concentrate urine well for several months." Answer: 1 Explanation: 1. Size of the kidneys is rarely an issue. 2. Frequent feeding helps maintain the fluid volume. 3. The ability to concentrate urine develops by 3 months of age. The inability to concentrate urine due to limited tubular reabsorption and lower glomerular filtration rate are the main differences between kidney function in a newborn and normal adult. 4. Counting wet diapers indicates urine output in relation to fluid intake. Page Ref: 454 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 22.6 Relate the development of the newborn's kidneys to the newborn's ability to maintain fluid and electrolyte balance. 10 Copyright © 2022 Pearson Education, Inc.

13) The nurse notes that a 1-day-old infant's immunoglobulin M (IgM) antibodies are elevated. Which is the least likely cause for this elevation? 1. Placental leakage 2. Intrauterine exposure to syphilis 3. Intrauterine exposure to TORCH (toxoplasmosis, rubella, cytomegalovirus, herpesvirus hominis type 2 infection) syndrome 4. Maternal-fetal transfer of IgM while in utero Answer: 4 Explanation: 1. Elevated levels of IgM at birth may indicate placental leaks. 2. Elevations in IgM may be due to newborn exposure to an intrauterine infection such as syphilis. 3. Elevations in IgM at birth may be due to newborn exposure to an intrauterine infection such as TORCH syndrome. 4. Because IgM does not normally cross the placenta, most or all of it is produced by the fetus beginning at 10 to 15 weeks' gestation. Page Ref: 455 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 22.7 Describe basic newborn immunologic responses.

14) The mother of a 2-day-old infant newly diagnosed with sepsis asks why she could not detect the symptoms. Which response should the nurse make to this mother? 1. "Your mothering skills will improve with time. You should take the newborn class." 2. "Newborns have immature immune function at birth, and illness is very hard to detect." 3. "Your baby did not get enough active acquired immunity from you during the pregnancy." 4. "The immunity your baby gets in utero does not start to function until 4 to 8 weeks of age." Answer: 2 Explanation: 1. This response does not address the physiology of neonatal infection and is not therapeutic because it is blaming. 2. The immune system of a newborn lacks response to pyrogens and presents a limited inflammatory response; thus, the signs and symptoms of infection are often subtle and nonspecific in the newborn. 3. The mother develops active acquired immunity, which is passed to the newborn transplacentally as passive acquired immunity. This immunity is to the illnesses and infections she has had or been immunized against. 4. The passive acquired immunity a newborn receives from its mother is effective at birth and lasts from 4 weeks to 8 months, depending on the specific antibody. Page Ref: 454 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 22.7 Describe basic newborn immunologic responses.

15) Nursing students describe actions while practicing physical assessment of a newborn using a model. Which nursing student's statement indicates the need for further teaching? 1. "I auscultated the infant's heart tones for 1 minute." 2. "I palpated peripheral pulses in all the newborn's extremities." 3. "I obtained a higher blood pressure on the legs than on the arms." 4. "I obtained the infant's heart rate by observing the cardiac monitor." Answer: 4 Explanation: 1. Apical pulse rates should be obtained by auscultation for a full minute, preferably when the newborn is asleep. 2. Peripheral pulses of all extremities should also be evaluated to detect any inequalities or unusual characteristics. 3. Blood pressure in the lower extremities is usually higher than that in the upper extremities. 4. Physical assessment of the newborn's heart rate requires auscultation of the apical pulse for a full minute. Page Ref: 445 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 22.1 Summarize the cardiopulmonary changes that must occur for the newborn to successfully transition to extrauterine life.

16) The new father asks what his baby will experience while sleeping and awake. In which way should the nurse respond? 1. "Babies have several sleep and alert states. Keep watching, and you will notice them." 2. "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep." 3. "You may have noticed that your child was in an alert awake state for an hour after his birth." 4. "Birth is hard work for babies; it takes them a week or 2 to recover and become more awake." Answer: 2 Explanation: 1. Although it is true that babies have several sleep and alert states, the wording of this response is condescending and not therapeutic. This is not the best response. 2. This statement is true. Teaching the parents how to detect the two sleep stages helps them tune into their infant's behavioral states. 3. Although this statement is true, it does not respond to the father's question about sleeping now. 4. Recovery from the birth process only takes a day or 2. During that time, feedings should take place when the baby is in an alert state. Page Ref: 456 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 22.8 Explain the physiologic and behavioral characteristics of newborn neurologic function, patterns of behavior during the periods of reactivity, and possible nursing interventions.

17) The nurse is instructing a group of new parents about normal newborn behavior. Which attendee's statement indicates that teaching was effective? 1. "My baby will be able to hear very well immediately after birth." 2. "My baby will have difficulty seeing me close up right after delivery." 3. "My baby should be discouraged from sucking on a pacifier if being bottle fed." 4. "My baby should be trained to breastfeed by being encouraged to suck on a pacifier before feedings." Answer: 1 Explanation: 1. Newborns have very acute hearing immediately after birth. 2. The newborn is nearsighted and has the best vision at a distance of 8 to 15 inches. 3. For bottle-fed infants, there is no reason to discourage nonnutritive sucking with a pacifier. 4. Pacifiers should be offered to breastfed infants only after breastfeeding is well established or during prolonged times away from the mother, or when stressful or painful procedures are required. Page Ref: 457 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 22.9 Describe the normal sensory-perceptual abilities and behavioral states seen in the newborn period and the associated nursing care. 18) A newborn weighing 8.8 lb is prescribed bottle-feedings every 3 hours to achieve the caloric intake of 120 calories/kg each day. How many calories should be in each ounce of feeding? (Calculate to the nearest whole number.) Answer: 60 calories Explanation: First determine the infant's weight in kilograms by dividing the weight in pounds by 2.2, or 8.8/2.2 = 4 kg. Then, determine the total number of calories per day by multiplying 120 calories × 4 = 480. Then, divide the total calories by 8 (feedings every 3 hours are determined by dividing 24 hours by 3 = 8), or 480/8 = 60 calories. Each feeding should provide the newborn with 60 calories. Page Ref: 453 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 22.5 Delineate the functional abilities of the newborn's gastrointestinal tract and liver.

19) A newborn weighing 7.7 lb has an estimated bladder capacity of 20 mL. If 25 mL/kg of urine is expected to be produced each day, how many diaper changes will this baby need? (Calculate by rounding to the nearest whole number.) Answer: 4 Explanation: First determine the baby's weight in kilograms by dividing 7.7 pounds by 2.2, or 7.7/2.2 = 3.5 kg. Then, multiply the weight by 25 mL/kg = 25 × 3.5 = 87.5, which is the amount of urine produced by the newborn. Then, divide the total amount of urine by the bladder capacity of 20 mL, or 87.5/20 = 4.375. With rounding, the baby will need an estimated 4 diaper changes each day. Page Ref: 454 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 22.6 Relate the development of the newborn's kidneys to the newborn's ability to maintain fluid and electrolyte balance.

20) The nurse is teaching a group of new parents on ways to ensure body heat regulation of their newborns. Which diagram should the nurse use to explain the process of radiation? 1.

Answer: 2 Explanation: 1. This diagram explains the process of convection. 2. This diagram explains the process of radiation. 3. This diagram explains the process of evaporation. 4. This diagram explains the process of conduction. Page Ref: 449 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 22.3 Relate the process of thermogenesis in the newborn and the major mechanisms of heat loss to the challenge of maintaining newborn thermal stability.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 23 Nursing Assessment of the Newborn 1) The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth? 1. Scarf sign 2. Arm recoil 3. Popliteal angle 4. Square window sign Answer: 2 Explanation: 1. The scarf sign is elicited by placing the newborn supine and drawing an arm across the chest toward the newborn's opposite shoulder until resistance is met. A preterm infant's elbow will cross the midline of the chest, whereas a full-term infant's elbow will not cross midline. 2. Recoil time is slower in fatigued newborns. Therefore, arm recoil is best elicited after the first hour of birth so the newborn can recover from the stress of birth. 3. The popliteal angle (degree of knee flexion) is determined with the newborn flat on the back. The thigh is flexed on the abdomen and chest, and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is then measured. Results vary from no resistance in the very immature newborn to an 80-degree angle in the term newborn. 4. The square window sign is elicited by gently flexing the newborn's hand toward the ventral forearm until resistance is felt. The angle formed at the wrist is measured. Page Ref: 465 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.1 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn.

2) Before the nurse begins to dry the newborn off after birth, which assessment finding should be documented to ensure an accurate gestational rating on the Ballard gestational assessment tool? 1. Size of the areolae 2. Creases on the sole 3. Body surface temperature 4. Amount and area of vernix coverage Answer: 4 Explanation: 1. Size of the areolae is not affected by drying of the newborn. 2. Creases on the sole are not affected by drying of the newborn. 3. Body surface temperature is not part of the Ballard gestational assessment tool. 4. Drying the baby after birth will disturb the vernix and potentially alter the score when using the Ballard gestational assessment tool. The nurse first should document the amount and coverage of the vernix before drying the newborn. Page Ref: 462 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 23.1 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. 3) The nurse notes the presence of a cephalohematoma on the head of a newborn. Which information did the nurse use to make this clinical determination? Select all that apply. 1. The head appears asymmetric. 2. The mass overrides the suture line. 3. The mass appears only on one side of the head. 4. The mass appeared on the second day after birth. 5. The mass appears larger when the newborn cries. Answer: 3, 4 Explanation: 1. Molding causes the head to appear asymmetric; this is due to the overriding of cranial bones during labor and birth. 2. Cephalohematomas do not cross the suture lines. 3. Cephalohematomas can be unilateral or bilateral. 4. A cephalohematoma can appear between the first and second day after birth. 5. A cephalohematoma does not increase in size when the newborn cries. Page Ref: 473 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.1 Describe the physical and neuromuscular maturity characteristics assessed to determine the gestational age of the newborn. 2 Copyright © 2022 Pearson Education, Inc.

4) During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. In which way should the nurse document this finding? 1. Nevus flammeus 2. Nevus vasculosus 3. A Mongolian spot 4. Telangiectatic nevi Answer: 4 Explanation: 1. Nevus flammeus (port-wine stain), a capillary angioma, is located directly below the epidermis. 2. Nevus vasculosus (strawberry mark) is a capillary hemangioma. 3. Mongolian spots are macular areas of bluish black pigmentation on the dorsal area of the buttocks. 4. Telangiectatic nevi (stork bites) are pale pink or red spots that appear on the eyelids, nose, lower occipital bone, or the nape of the neck. Page Ref: 471 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

5) A mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be the most appropriate? 1. "Your baby must be dehydrated." 2. "Bring your infant to the clinic immediately." 3. "This is due to overriding of the cranial bones during labor." 4. "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth." Answer: 4 Explanation: 1. Fontanelles can be depressed when the infant is dehydrated. 2. The posterior fontanelle closes within 8 to 12 weeks. This is a normal finding at 16 weeks, and does not require emergency evaluation. 3. Overriding of the cranial bones is referred to as molding, and will diminish within a few days following birth. 4. This is a normal finding at 16 weeks. The posterior fontanelle closes within 8 to 12 weeks. Page Ref: 473 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

6) The nurse attempts to take the vital sign of the newborn, but the newborn is crying. Which intervention would be appropriate? 1. Taking the vital signs 2. Waiting until the newborn stops crying 3. Placing a gloved finger in the newborn's mouth 4. Swaddling the newborn with several warm blankets in an attempt to calm the newborn Answer: 3 Explanation: 1. Crying will increase heart rate and respiratory rate, so vitals should not be taken when the newborn is crying. 2. Assessment of vitals needs to be done at regularly timed intervals, so waiting until the newborn stops crying might be too long of a delay. 3. To soothe a newborn during assessment or other procedures, place a gloved finger into the newborn's mouth. 4. Swaddling an infant with warm blankets can cause the infant to become overheated and increase restlessness. Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings. 7) The nurse is assessing a newborn's musculoskeletal status. In which way should the nurse assess for clubfoot? 1. Stimulate the sole of the foot. 2. Adduct the foot and listen for a click. 3. Extend the foot and observe for pain. 4. Move the foot to midline and determine resistance. Answer: 4 Explanation: 1. Stimulating the sole of the foot will elicit the plantar grasp reflex, and is not an appropriate assessment for clubfoot. 2. Adducting the foot and listening for a click is not an assessment that is done. 3. Extending the foot and observing for pain will not determine or rule out clubfoot. 4. Clubfoot is suspected when the foot will not turn to a midline position or align readily. Page Ref: 479 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings. 5 Copyright © 2022 Pearson Education, Inc.

8) A new mother is concerned because the anterior fontanelle swells when the newborn cries. Which normal findings should the nurse include when teaching the new mother about this concern? Select all that apply. 1. The fontanelles might bulge. 2. The fontanelles might be depressed. 3. The fontanelles can swell with crying. 4. The fontanelles can pulsate with the heartbeat. 5. The fontanelles can swell when stool is passed. Answer: 3, 4, 5 Explanation: 1. Bulging fontanelles signify increased intracranial pressure. 2. Depressed fontanelles indicate dehydration. 3. Newborn fontanelles can swell when the newborn cries. 4. Newborn fontanelles can pulsate with the heartbeat. 5. Newborn fontanelles can swell when the newborn passes a stool. Page Ref: 473 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

9) The nurse is making an initial assessment of a newborn. Which data would be considered normal? 1. Chest circumference 30 cm, head circumference 29 cm 2. Chest circumference 38 cm, head circumference 31.5 cm 3. Chest circumference 32.5 cm, head circumference 38 cm 4. Chest circumference 31.5 cm, head circumference 33.5 cm Answer: 4 Explanation: 1. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 2. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 3. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. 4. The average circumference of the head at birth is 32 to 37 cm. Average chest circumference ranges from 30 to 35 cm at birth. The circumference of the head is approximately 2 cm greater than the circumference of the chest at birth. Page Ref: 486 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

10) A new parent asks why the baby appears to be occasionally cross-eyed. At which time should the nurse instruct the parent that this finding will resolve? 1. 1 year 2. 2 weeks 3. 2 months 4. 4 months Answer: 4 Explanation: 1. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. Strabismus is considered normal up to 6 months. 2. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. Strabismus is considered normal up to 6 months. 3. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. Strabismus is considered normal up to 6 months.. 4. The newborn can demonstrate transient strabismus caused by poor neuromuscular control of the eye muscles. Strabismus is considered normal up to 6 months. Page Ref: 487 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

11) The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. In which way should the nurse interpret this finding? 1. Prematurity 2. Facial paralysis 3. A normal position 4. A possible chromosomal abnormality Answer: 3 Explanation: 1. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 2. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 3. The top of the ear (pinna) should be parallel to the outer and inner canthus of the eye in the normal newborn. 4. Low-set ears could indicate a chromosomal abnormality. Page Ref: 475 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

12) The nurse is assessing newborns in the nursery. Which assessment finding places a newborn at risk for developing physiologic jaundice? 1. Molding 2. Mongolian spots 3. Cephalohematoma 4. Telangiectatic nevi Answer: 3 Explanation: 1. Molding is caused by overriding of the cranial bones. 2. Mongolian spots are macular areas of bluish black pigmentation on the dorsal area of the buttocks. 3. A cephalohematoma is a collection of blood resulting from ruptured blood vessels between the surface of a cranial bone and the periosteal membrane. The red blood cells present in the cephalohematoma begin to break down, which can lead to an increase in bilirubin levels in the blood. 4. Telangiectatic nevi are pale pink or red spots found on the eyelids, nose, lower occipital bone, or nape of the neck. Page Ref: 486 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.2 Summarize the components of a systematic physical assessment of the newborn and the significance of normal variations and abnormal findings.

13) While eliciting the Moro reflex in a newborn, the nurse notes that only the right arm moves. Which area should the nurse immediately assess based upon this finding? 1. The clavicle 2. Babinski reflex 3. The rooting reflex 4. Ortolani maneuver Answer: 1 Explanation: 1. When the Moro reflex is elicited, the newborn will straighten both arms and hands outward while the knees are flexed, then slowly return the arms to the chest, as in an embrace. If this response is not elicited, the nurse will assess the clavicle. If the clavicle is fractured, the response will be demonstrated on the unaffected side only. 2. The Babinski reflex tests for upper neuron abnormalities. 3. The rooting reflex is elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck (if not fed recently). 4. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia. Page Ref: 476 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.5 Identify the reflexes that may be present at birth.

14) The nurse wants to demonstrate to a new family their infant's individuality. Which assessment tool should the nurse use? 1. Ortolani maneuver 2. Ballard Maturity Scale 3. Dubowitz Gestational Age Scale 4. Brazelton Neonatal Behavioral Assessment Scale Answer: 4 Explanation: 1. The Ortolani maneuver is an assessment technique that rules out the possibility of congenital hip dysplasia. 2. The Ballard Maturity Scale is a tool that assesses external physical characteristics and neurologic or neuromuscular development. 3. The Dubowitz Gestational Age Scale is a tool that assesses external physical characteristics and neurologic or neuromuscular development. 4. The Brazelton Neonatal Behavioral Assessment Scale assesses the newborn's state changes, temperament, and individual behavior patterns. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.7 Describe how to use the assessment procedure and results of the newborn physical and the neurologic and behavioral assessments to teach and involve the parents in their baby's care and to allay their concerns.

15) The nurse explains normal newborn behavior to new parents who are concerned about the baby's desire to be held. Which statement indicates that teaching has been effective? 1. "Some babies are easier to deal with than others." 2. "Our baby spends more time in the active alert phase." 3. "We are lucky to have a baby with a calm disposition." 4. "Cuddliness is a social behavior that some babies have." Answer: 4 Explanation: 1. Saying a baby is easier or more difficult to deal with is a judgment, not an assessment. 2. The active alert phase of the sleep-wake cycle is characterized by motor activity. 3. Describing an infant as having a calm disposition is a judgment, not an assessment. 4. Cuddliness or social behavior refers to the newborn's need for, and response to, being held. Page Ref: 483 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 23.7 Describe how to use the assessment procedure and results of the newborn physical and the neurologic and behavioral assessments to teach and involve the parents in their baby's care and to allay their concerns.

16) The nurse is planning to assess a newborn's neurologic status. Which behaviors should the nurse focus on during this assessment? Select all that apply. 1. Cry 2. Reflexes 3. Alertness 4. Motor activity 5. Resting posture Answer: 1, 3, 4, 5 Explanation: 1. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include cry. 2. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Reflexes are elicited; not observed. 3. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include the state of alertness. 4. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include motor activity. 5. The neurologic examination should begin with a period of observation, noting the general physical characteristics and behaviors of the newborn. Important behaviors to assess include resting posture. Page Ref: 479 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.3 Describe the components of a neurologic assessment.

17) The nurse notes that a newborn has tremor-like movements. For which health problems should this newborn be further assessed? Select all that apply. 1. Seizures 2. Bilirubinemia 3. Hypocalcemia 4. Hypoglycemia 5. Substance withdrawal Answer: 1, 3, 4, 5 Explanation: 1. Tremors or tremor-like movements must be evaluated to differentiate the tremors from seizures. 2. Bilirubinemia is not identified as causing tremors in a newborn. 3. Tremors may be related to hypocalcemia. 4. Tremors may be related to hypoglycemia. 5. Tremors may be related to substance withdrawal. Page Ref: 482 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.4 Describe the neurologic/neuromuscular characteristics of the newborn. 18) The nurse suspects that a newborn needs a complete neurologic examination by a healthcare provider. Which finding did the nurse use to make this clinical decision? Select all that apply. 1. Absence of the plantar grasp 2. Absence of the truncal reflex 3. Presence of the stepping reflex 4. Presence of a nonnutritive sucking reflex 5. Presence of bringing the hand to the mouth Answer: 1, 2 Explanation: 1. Absence of the plantar grasp requires neurologic evaluation. 2. Absence of the Galant (truncal) incurvation reflex requires neurologic evaluation. 3. The stepping reflex is an expected finding. 4. Nonnutritive sucking is an expected reflex. 5. Bringing the hand to the mouth is an expected action. Page Ref: 482 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: transition and continuity │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.5 Identify the reflexes that may be present at birth.

19) A newborn is demonstrating signs of needing comfort and security. Which information should the nurse instruct the parents about swaddling this infant? Select all that apply. 1. Swaddling should be loose. 2. Swaddling should be done with the arms at the sides. 3. Swaddling helps the newborn control body movements. 4. Swaddling should permit the newborn access to the mouth. 5. Swaddling should be tightly bound around the infant's torso. Answer: 1, 3, 4 Explanation: 1. Swaddling newborns is a way to provide comfort and security. Blanket swaddling should be loose. 2. Swaddling newborns is a way to provide comfort and security. Tight swaddling with arms at sides is not comforting and may further agitate the infant. 3. Swaddling newborns is a way to provide comfort and security. Swaddling helps the newborn control body movements. 4. Swaddling newborns is a way to provide comfort and security. Blanket swaddling allows the infant easy hand to mouth access to promote self-soothing abilities. 5. Swaddling newborns is a way to provide comfort and security. Tight swaddling is not comforting and may further agitate the infant. Page Ref: 483 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 23.7 Describe how to use the assessment procedure and results of the newborn physical and the neurologic and behavioral assessments to teach and involve the parents in their baby's care and to allay their concerns.

20) The nurse notes that a newborn has a dry scalp. Which recommendation should the nurse include when teaching the parents about the care of this newborn? Select all that apply. 1. Use mild soap. 2. Use baby shampoo. 3. Wash the scalp daily. 4. Apply oil every other day. 5. Rinse the scalp with hot water. Answer: 1, 2, 3 Explanation: 1. For scalp care, the nurse should instruct the parents to shampoo the scalp with mild soap. 2. For scalp care, the nurse should instruct the parents to shampoo the scalp with baby shampoo. 3. For scalp care, the nurse should instruct the parents to shampoo the scalp and anterior fontanel areas daily. 4. For scalp care, the nurse should instruct the parents to avoid the use of oil. 5. Hot water should not be used since this could burn the newborn's delicate tissues and skin. Page Ref: 486 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 23.7 Describe how to use the assessment procedure and results of the newborn physical and the neurologic and behavioral assessments to teach and involve the parents in their baby's care and to allay their concerns.

21) During a home visit, the nurse assesses a 3-day-old infant. Which observation indicates that the infant is responding to environmental stimuli? 1. Flexes knees when toes are tickled. 2. Raises arms when swaddling cloth removed. 3. Places hand in mouth when abdomen rubbed. 4. Moves head toward the sound of the doorbell. Answer: 4 Explanation: 1. Flexing the knees when the toes are tickled is not a response to environmental stimuli. 2. Raising the arms when swaddling cloth removed is not a response to environmental stimuli. 3. Placing the hand in the mouth when the abdomen is rubbed is not a response to environmental stimuli. 4. Newborns can turn to voices soon after birth or by 3 days of age and can become alert at different times with a varying degree of intensity in response to sounds. Page Ref: 483 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.6 Correlate normal behavioral characteristics of the newborn with variations that may be present.

22) The nurse is assessing a newborn. Which criteria will the nurse use to determine the infant's state of responsiveness? 1. Cuddliness 2. Motor activity 3. Self-quieting activity 4. Orientation to stimuli Answer: 2 Explanation: 1. Cuddliness determines the newborn's need for and response to being held. 2. Motor tone of the newborn is assessed in the most characteristic state of responsiveness. This summary assessment includes overall use of tone as the newborn responds to being handled and overall assessment of body tone as the newborn reacts to all stimuli. 3. This assessment is based on how often, how quickly, and how effectively newborns can use their resources to quiet and console themselves when upset or distressed. 4. Orientation to the environment is determined by an ability to respond to clues given by others and by a natural ability to fix on and follow a visual object horizontally and vertically. Page Ref: 483 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 23.6 Correlate normal behavioral characteristics of the newborn with variations that may be present.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 24 The Normal Newborn: Needs and Care 1) Which action must the nurse perform before weighing the newborn during the admission procedure? Select all that apply. 1. Zero the scale. 2. Clean the scale. 3. Cover the scale. 4. Take the infant's temperature. 5. Wrap the infant tightly in a blanket to prevent heat loss. Answer: 1, 2, 3 Explanation: 1. This action should be performed to ensure an accurate measurement. 2. This action should be performed to prevent cross infection. 3. This action should be performed to prevent cross infection. 4. This action should be performed after the weight to monitor heat loss. 5. The nurse should remove all clothing and blankets to ensure an accurate measurement. To prevent heat loss, the infant should instead be placed under a radiant warmer. Page Ref: 497 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: physical comfort and emotional support │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 24.1 Summarize essential information to be obtained about a newborn's birth experience and immediate postnatal period.

2) The nurse receives shift change reports on infants born within the last 4 hours. Which newborn should the nurse see first? 1. Term male, grunting respirations 2. 37-week male, respiratory rate 45 3. 8 lb, 1 oz female, pulse 150 4. 39-week female, temperature 97°F Answer: 1 Explanation: 1. Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly intervention immediately. 2. A normal respiratory rate is 30 to 60 breaths/min. This infant has no unexpected findings. 3. A normal pulse is 110 to 160 beats/min. This infant has no unexpected findings. 4. A normal temperature range is 96.8 to 97.7°F. This infant has no unexpected findings. Page Ref: 499 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 24.2 Explain how the physiologic and behavioral responses of the newborn during the first 4 hours after birth (admission and transitional period) determine the nursing care of the newborn. 3) The nurse assesses a sleeping 1-hour-old, 39-weeks' gestation newborn. Which data should cause the nurse the most concern? 1. Respirations 68/min 2. Blood pressure 72/44 mmHg 3. Skin temperature 97.6°F 4. Heart rate 156 beats/min Answer: 1 Explanation: 1. Normal respiratory rate is 30 to 60 breaths/min. Respirations of 68/min could represent a less-than-expected transition. 2. This blood pressure is within the normal range of 90 to 60/50 to 40 mm Hg. 3. This is within the normal temperature range of 96.8 to 97.7°F. 4. This heart rate is within the normal range of 120 to 160 beats/min. Page Ref: 499 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 24.2 Explain how the physiologic and behavioral responses of the newborn during the first 4 hours after birth (admission and transitional period) determine the nursing care of the newborn. 2 Copyright © 2022 Pearson Education, Inc.

4) Which information is least likely recorded as a part of the initial newborn assessment? 1. Presence or absence of meconium-stained fluid 2. Blood draw for phenylketonuria (PKU) screening 3. Resuscitative measures required in the birthing area 4. Parents' desires regarding circumcision for a male infant Answer: 2 Explanation: 1. The labor and birth record, including the presence or absence of meconiumstained fluid, should be recorded as part of the newborn assessment. 2. Blood is often drawn for laboratory testing, which should be recorded. However, blood draws for PKU screening must occur more than 24 hours after birth. 3. The condition of the newborn, including resuscitative measures required in the birthing area, should be recorded as part of the newborn assessment. 4. Parent-newborn attachment information, including the parents' desires regarding care, should be noted during the newborn assessment. Page Ref: 508 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 24.1 Summarize essential information to be obtained about a newborn's birth experience and immediate postnatal period.

5) The nurse is discussing parent—infant attachment with a prenatal class. Which statement indicates that teaching was successful? 1. "Giving the baby his first bath can really give me a chance to get to know him." 2. "Newborns cannot focus their eyes, so it does not matter how I hold my new baby." 3. "My baby will be very sleepy immediately after birth, so he can go to the nursery." 4. "I should avoid looking directly into the baby's eyes to prevent frightening the baby." Answer: 1 Explanation: 1. When parents give the first bath with the nurse, the nurse can point out behaviors and characteristics that help the parents understand their infant as unique and can model ways to respond to the baby's behavior. 2. Newborns can focus at a distance of 78 inches, the distance from a baby being held to the parent's face. Eye contact is an important aspect of parent-infant attachment and should be promoted, especially in the immediate time after birth. 3. Babies are usually wide awake and alert and responsive in the first few hours after birth. Interacting with the newborn during this first period of reactivity facilitates parent-infant attachment. 4. Eye contact is an important aspect of parent-infant attachment and should be promoted, especially in the immediate time after birth. Page Ref: 498 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 24.6 Identify opportunities to individualize parent teaching and enhance each parent's abilities and confidence while providing newborn care in the birthing unit.

6) The nurse is teaching a class for new parents. Which statement indicates that additional information is needed? 1. "Car seats are installed the same way in different models of cars. Our friends can show us how to install it." 2. "Genitals of babies look swollen and enlarged at birth as a result of the hormones in the mother's circulation." 3. "We can call the nurse help line any time of day or night if we have questions about our baby after we get home." 4. "Baby girls sometimes have a little bloody mucus in their diapers as a reaction to the high estrogen level in the mother." Answer: 1 Explanation: 1. Each model of car seat is installed differently in different makes of car. Directions for car seats should be followed carefully. Car dealerships often offer a car seat installation instruction service. 2. This is a true statement and often a concern of parents. 3. Most pediatrician offices, HMOs, hospitals, and physician groups have a nurse line staffed 24 hours a day, 7 days a week to respond to questions and concerns of parents. When this service exists, parents should be made aware of it and provided with the phone number. 4. This is a true statement. Parents might believe there is something wrong if they are not taught about pseudomenstruation. Page Ref: 508 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 24.7 Identify the safety needs of the newborn in the birthing unit and after discharge.

7) An infant weighing 8 lb, 4 oz at birth weighs 7 lb, 15 oz 3 days later. Which information should the nurse explain to the parents about this change in the newborn's weight? 1. "This weight loss is unusual." 2. "This weight loss is less than expected." 3. "This weight loss is excessive." 4. "This weight loss is within normal limits." Answer: 4 Explanation: 1. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. 2. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. 3. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. 4. This newborn's weight loss is within normal limits. During the first 5 to 10 days of life, caloric intake often is insufficient for weight gain. Therefore, there might be a weight loss of 5% to 10% in term newborns. Page Ref: 501 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 24.4 Describe the common concerns of families regarding their newborn.

8) The nurse is assessing a 2-day-old male infant that has been circumcised. Which finding requires immediate intervention? 1. The umbilical cord clamp has been removed. 2. The mother is ready to breastfeed on demand. 3. The infant maintains temperature when wrapped in a blanket. 4. The infant has had a dry diaper since the circumcision procedure. Answer: 4 Explanation: 1. The umbilical cord clamp should be removed between 24 and 48 hours after birth to reduce the chance of tension injury to the area. 2. This is a positive action that represents the mother's readiness to care for her infant at home. 3. The infant should be able to maintain body temperature without the presence of the radiant warmer. 4. If the infant has not voided since the circumcision procedure, further assessment should be done to determine if a penile injury and/or edema is preventing urinary flow. Page Ref: 503 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 24.3 Identify activities that should be included in a daily care plan for a normal newborn.

9) A change in skin color requires further assessment of which physiologic functions? Select all that apply. 1. Hematocrit 2. Oxygenation 3. Glucose levels 4. Blood pressure 5. Bilirubin levels Answer: 1, 2, 3, 5 Explanation: 1. Changes in skin color may indicate the need for closer assessment of hematocrit. 2. Changes in skin color may indicate the need for closer assessment of cardiopulmonary status. 3. Changes in skin color may indicate the need for closer assessment of glucose. 4. Changes in skin color are not associated with blood pressure. 5. Changes in skin color may indicate the need for closer assessment of bilirubin. Page Ref: 500 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 24.3 Identify activities that should be included in a daily care plan for a normal newborn.

10) A new adolescent mother is concerned about being able to properly care for the newborn at home because her mother thinks she is too young. Which response should the nurse make to this client? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it." Answer: 4 Explanation: 1. Although this statement is true, it does not teach the client anything or increase her confidence in being able to care for her infant. 2. This statement is very judgmental and does not teach the client anything or increase her confidence in being able to care for her infant. 3. Maternal instincts might indeed exist, but this client has expressed a specific fear about being a safe mother. It is best to work with her to teach her skills and increase her confidence. 4. This response is the best because it both teaches the new mother skills she does not have and increases her confidence. Page Ref: 506 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 24.6 Identify opportunities to individualize parent teaching and enhance each parent's abilities and confidence while providing newborn care in the birthing unit.

11) The parents of a newborn are concerned that their baby continues to lose weight despite being held and cuddled. Which information should the nurse instruct these parents? Select all that apply. 1. Excessive handling increases caloric use. 2. Permit the newborn to rest quietly when eyelids flutter. 3. Constant handling increases metabolic rate. 4. Gently flick the sole of the foot to stimulate. 5. Avoid stimulating when eye contact is absent. Answer: 1, 2, 3, 5 Explanation: 1. Excessive handling increases caloric use and causes fatigue, which will affect weight gain. 2. Fluttering eyelids are an indication of fatigue. When this occurs, stimulation should be stopped. 3. Excessive handling increases metabolic rate, which burns more calories. 4. When the infant appears fatigued, stimulation should stop. The parents should wait for the infant to appear alert before stimulating. 5. A subtle cue of fatigue is the loss of eye contact. The infant should be permitted to sleep or rest. Page Ref: 501 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 24.3 Identify activities that should be included in a daily care plan for a normal newborn.

12) The elderly grandmother of a newborn tells the client that rubbing alcohol should be applied to the cord stump to make it dry and fall off faster. Which information should the nurse instruct the client about cord care? Select all that apply. 1. Keep the umbilical cord stump clean. 2. Allow the umbilical cord stump to air dry. 3. Fold the diaper down under the cord stump. 4. Notify the healthcare provider if the cord stump appears dark in color. 5. Apply topical antibiotic ointment to the cord stump after each diaper change. Answer: 1, 2, 3 Explanation: 1. Keeping the umbilical stump clean reduces the chance of infection. 2. Allowing the umbilical stump to air dry reduces the chance of infection. 3. Folding the diaper down under the cord stump prevents contamination of the area. 4. The cord stump will appear dark and dry before falling off. The healthcare provider does not need to be notified. 5. Topical antibiotic ointment does not need to be applied to the cord stump after each diaper change. Page Ref: 501 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 24.5 Describe the influence of cultural values on newborn care.

13) The nurse is caring for a newborn with the following device:

Which information should be included when instructing the parents about the newborn's care? Select all that apply. 1. The device should fall off in 8 days. 2. Apply petroleum jelly to the site after the device falls off. 3. Clean with warm water and mild soap after each diaper change. 4. Apply light pressure with a sterile gauze pad if bleeding occurs. 5. Abstain from applying cream or ointment while the device is present. Answer: 1, 2, 5 Explanation: 1. A Plastibell can be used for circumcision. After the excess prepuce is cut away, the plastic rim remains in place for 3 to 4 days until healing occurs. The bell falls off within 8 days. 2. After the device falls off, petroleum jelly can be applied to the area to protect granulation tissue. 3. The area does not need to be cleansed with soap and water after each diaper change. 4. Bleeding might occur with other forms of circumcision but is not associated with the use of a Plastibell. 5. No ointments or creams should be used while the bell is in place. Page Ref: 503 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 24.3 Identify activities that should be included in a daily care plan for a normal newborn. 12 Copyright © 2022 Pearson Education, Inc.

14) During a postpartum home visit, the nurse reinforces the importance of holding the infant and having tummy time periodically through the day with the new mother. Which observation indicated to the nurse that the mother needed additional teaching? Select all that apply. 1. Rapid respiratory rate 2. Weak gross motor skills 3. Crusted nasal secretions 4. Flat head 5. Sluggish upper body strength Answer: 2, 4, 5 Explanation: 1. Because most newborns are nose breathers for the first few months of life, the nasal passages must be kept clear and clean of secretions. A rapid respiratory rate could indicate that the nasal passages are occluded. Instruction about the bulb syringe should be reinforced at this time. 2. Tummy time enhances gross motor skills. 3. Crusted nasal secretions indicate that the mother needs additional information on the use of the bulb syringe. 4. A flat head occurs when the infant spends too much time in the supine position. The infant needs to be held or placed for tummy time more often. 5. Tummy time enhances upper body strength. Page Ref: 507 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: RelationshipCentered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Assessment/Teaching/Learning Learning Outcome: 24.4 Describe the common concerns of families regarding their newborn.

15) The nurse is preparing to inject a dose of vitamin K to a newborn after delivery. Identify on the diagram where the nurse should provide this injection.

Answer:

Explanation: A one-time-only prophylactic dose of vitamin K 0.5 to 1.0 mg is given intramuscularly in the middle third of the vastus lateralis muscle, located in the lateral aspect of the thigh. The middle third of the vastus lateralis muscle is the preferred site for intramuscular injection in the newborn. Page Ref: 498 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: coordination and integration of care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 24.2 Explain how the physiologic and behavioral responses of the newborn during the first 4 hours after birth (admission and transitional period) determine the nursing care of the newborn.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 25 Newborn Feeding 1) The nurse is not familiar with the cultural background of new parents who have recently immigrated to the United States. Which statement should the nurse make? 1. "You appear to be Muslim. Do you want your son to be circumcised?" 2. "Let me explain how newborn care takes place here in the United States." 3. "Your baby is a U.S. citizen. You must be very happy about that." 4. "Could you explain what your preferences are regarding child care?" Answer: 4 Explanation: 1. Avoid making assumptions about clients based on appearance. It is much better to respectfully ask questions regarding preferences and practices. 2. The nurse should not assume the family does not understand the U.S. healthcare system. It is much better to respectfully ask questions regarding preferences and practices. 3. This is an assumption often based on the false idea that people from other countries only come to have their babies in the United States so they will be citizens and therefore eligible for federal aid. It is much better to respectfully ask questions regarding preferences and practices. 4. Sensitive, nonjudgmental exploration of the family's cultural beliefs regarding newborn care allows the nurse to gain valuable knowledge that will be applied when planning culturally competent care. Page Ref: 519 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.C.5. Recognize personally held attitudes about working with patients from different ethnic, cultural, and social backgrounds │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Knowledge; The role of family, culture, and community in a person's development │ Nursing/Integrated Concepts: Implementation/Culture and Spirituality Learning Outcome: 25.3 Describe the influence of cultural values on newborn care, especially feeding practices.

2) Which statement by a breastfeeding class participant indicates that teaching was effective? Select all that apply. 1. "Breastfeeding is worthwhile, even if it costs more overall." 2. "Breastfed infants get more skin-to-skin contact and sleep better." 3. "Breastfed infants have fewer digestive and respiratory illnesses." 4. "Breastfeeding raises the level of a hormone that makes me feel good." 5. "Breastfeeding is complex and difficult, and I probably will not succeed." Answer: 2, 3, 4 Explanation: 1. Breastfeeding actually costs substantially less than formula feeding, even considering the need for increased calcium and protein intake during lactation. 2. This is a true statement. Newborns are very responsive to touch, and it is vital for the infant's emotional well-being. The tactile stimulation associated with breastfeeding can communicate warmth, closeness, comfort, and the opportunity to learn each other's behavioral cues and needs. 3. This is a true statement. Reduced infections are due to immunologic properties in breast milk and to the fact that breastfed infants are not put to bed with a bottle, a practice known to increase ear infections. 4. Every time an infant suckles, the prolactin level doubles; prolactin creates feelings of euphoria and relaxation. 5. Although there is skill involved in getting a baby to nurse successfully and coordinating the infant's efforts with the maternal efforts, breastfeeding is not perceived as being difficult by the majority of women who attempt to do so. Page Ref: 528 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 25.1 Explain the advantages and disadvantages of breastfeeding and formula-feeding in determining the nursing care of both mother/family and newborn.

3) A pregnant client has not decided on a feeding method for her infant and asks for more information about breastfeeding and formula-feeding. Which client statement indicates that the teaching was successful? 1. "Breastfeeding is more expensive than formula-feeding." 2. "My baby has a lower risk of food allergies if I breastfeed." 3. "Formula-feeding gives the baby protection from infections." 4. "Breast milk cannot be stored; it has to be thrown away after pumping." Answer: 2 Explanation: 1. Formula must be purchased, and therefore, it is expensive. 2. Breast milk provides newborns with immunoglobulins and reduces the risk of food allergies in children. 3. Formula does not provide the baby with protection from infections as breast milk does. 4. Breast milk can be refrigerated or frozen after pumping. Page Ref: 517 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 25.1 Explain the advantages and disadvantages of breastfeeding and formula-feeding in determining the nursing care of both mother/family and newborn.

4) A client who delivered a day ago has chosen to breastfeed her infant. Which observation best indicates that the client understands breastfeeding? 1. The infant is crying when brought to the breast. 2. The client takes off her gown to achieve skin-to-skin contact. 3. The infant is held so that the nipple is accessed by turning the head. 4. The client puts the infant to breast when the baby is asleep to help wake the baby up. Answer: 2 Explanation: 1. Crying is a late cue of hunger. Newborns should be put to breast when they begin rooting, lip-smacking, or tongue-thrusting behaviors. 2. Skin-to-skin contact creates tactile sensations that increase the sucking of newborns. 3. The infant should be held in a "tummy-to-tummy" position so that the head does not have to turn to find the nipple, and access the breast. 4. Breastfeeding is more successful if the infant is in the alert-awake state when put to breast. Putting a newborn to breast is not likely to wake the infant up to feed. Page Ref: 528 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 25.2 Formulate guidelines for helping both breast- and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings.

5) The mother of a newborn with iron deficiency anemia asks if breastfeeding or using a formula high in iron is better for the baby. In which way should the nurse respond? 1. Breastfeeding, because breast milk has higher levels of iron compared to formula 2. Formula-feeding, because formula has higher levels of iron compared to breast milk 3. Breastfeeding, because although breast milk has lower levels of iron compared to formula, it is more easily absorbed by the infant 4. Formula-feeding, because although formula has lower levels of iron compared to breast milk, it is more easily absorbed by the infant Answer: 3 Explanation: 1. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed, if possible. 2. Although formula is iron enriched, the concentration of the nutrient may not be consistent. 3. Breast milk contains lower levels of iron compared to formula, but it is more easily absorbed by the infant, so it will be beneficial to the anemic infant to breastfeed, if possible. 4. Although formula is iron enriched, it is not necessarily more easily absorbed by the infant. Page Ref: 517 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 25.1 Explain the advantages and disadvantages of breastfeeding and formula-feeding in determining the nursing care of both mother/family and newborn. 6) The nurse is assisting a new mother to breastfeed. In which order should the nurse review the steps with the mother? 1. Bring the newborn to the breast. 2. The newborn opens mouth wide. 3. Tickle the newborn's lips with the nipple. 4. Have the newborn face the mother tummy-to-tummy. 5. Position the newborn so the newborn's nose is at level of the nipple. Answer: 5, 4, 1, 3, 2 Page Ref: 520 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 25.2 Formulate guidelines for helping both breast- and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings.

7) The nurse is assisting a mother to bottle-feed her newborn, who has been crying. Which action should the nurse instruct the client to take before feeding the infant? 1. Offer a pacifier. 2. Burp the newborn. 3. Unwrap the newborn. 4. Stroke the newborn's spine and feet. Answer: 2 Explanation: 1. The newborn's cries are indicative of an issue; a pacifier would not solve the problem. 2. If a newborn has been crying prior to feeding, air might have been swallowed; therefore, the newborn should be burped before feeding. Time should be taken to calm the newborn prior to feeding. 3. Unwrapping the newborn stimulates the newborn. 4. Stroking the spine and feet stimulates the newborn. Page Ref: 531 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: information, communication, and education │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 25.2 Formulate guidelines for helping both breast- and formula-feeding mothers to feed their newborns successfully in hospital and community-based settings.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 26 The Newborn at Risk: Conditions Present at Birth 1) The nurse is reviewing clients scheduled for prenatal care. Which client should the nurse identify as being most likely to have a newborn at risk for mortality or morbidity? 1. 37-year-old G8 P2323, works in a chemical factory 2. 16-year-old primipara, began prenatal care at 30 weeks 3. 28-year-old G2 P1001, history of gestational diabetes 4. 23-year-old primipara, low socioeconomic status, unmarried Answer: 1 Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. 2. This client has two risk factors: young age and late onset of prenatal care. 3. This client has gestational diabetes history as the only risk factor. 4. The main risk factor for this client is a low socioeconomic status. Page Ref: 536 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.1 Explain the factors present at birth that indicate an at-risk newborn.

2) A client has delivered a small-for-gestational-age (SGA) infant. Which long-term effect should the nurse recognize that this infant is at risk for experiencing? 1. Permanent disfiguration 2. Paralysis below the hips 3. Poor fine motor coordination 4. Thin and underweight as a child to overweight or obese as an adolescent Answer: 3 Explanation: 1. Although it may occur, disfiguration is not commonly associated with SGA infants. Instead, disfiguration is more likely to remain in infants with congenital anomalies such as cleft lip/cleft palate, even after corrective surgery. 2. Many infants with myelomeningocele will suffer lifelong paralysis below the site of the cyst. Paralysis is not generally associated with SGA infants. 3. SGA infants are likely to develop cognitive disabilities such as poor fine motor coordination, hyperactivity, learning disabilities, and hearing loss. 4. This long-term effect is often seen in children with fetal alcohol syndrome, not SGA. Page Ref: 538 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I. A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 26.2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each.

3) A 38-week newborn is small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? 1. Assess for facial paralysis 2. Maintain a warm environment 3. Monitor for feeding difficulties 4. Monitor for signs of hyperglycemia Answer: 2 Explanation: 1. Large-for-gestational age (LGA) newborns often are prone to birth trauma, such as facial paralysis, due to cephalopelvic disproportion. 2. Hypothermia is a common complication of the SGA newborn; therefore, the newborn's environment must remain warm to decrease heat loss. 3. LGA newborns are more difficult to arouse to a quiet alert state and can have feeding difficulties. 4. SGA newborns are more prone to hypoglycemia. Page Ref: 538 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 26.2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each. 4) A client with type 2 diabetes mellitus delivered a fetus weighing 7 lb, 14 oz 2 hours ago. The infant's blood glucose is currently 45 mg/dL. Which action should the nurse take? 1. Begin an IV of 10% dextrose. 2. Document the findings in the chart. 3. Feed the baby 1 oz of formula. 4. Recheck the blood sugar in 4 hours. Answer: 2 Explanation: 1. The blood glucose of 45 mg/dL is considered a normal blood sugar reading for a neonate. No IV is needed. 2. A blood sugar of 45 mg/dL is a normal finding; documentation is an appropriate action. 3. Feeding would be appropriate if the infant's blood sugar were below 40, but this infant's reading is 45 mg/dL. 4. Infants of diabetic mothers should be fed frequently and should have their blood sugar assessed frequently. Four hours is too long a time frame. Page Ref: 541 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.4 Explain the impact of maternal diabetes mellitus on the newborn. 3 Copyright © 2022 Pearson Education, Inc.

5) An infant was born at 31 weeks' gestation and weighed 1430 g. Which number of calories should this infant receive each day? 1. 72 2. 143 3. 200 4. 258 Answer: 3 Explanation: 1. This is using the formula 50 kcal/g/day, which is not sufficient for this infant's growth. 2. This is using the formula 100 kcal/g/day, which is not sufficient for this infant's growth. 3. This is using the formula 140 kcal/g/day, which is appropriate for this infant's growth. 4. This is using the formula 180 kcal/g/day, which is too many calories for this infant's weight and size to support normal growth. Page Ref: 541 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 26.6 Discuss the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and that are used in developing a plan of care that includes nutritional management.

6) A client pregnant at 41 weeks asks if labor induction is necessary. Which response is the best for the nurse to make? 1. "The healthcare provider wants to be proactive in preventing any problems with your baby if the baby gets any bigger." 2. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." 3. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." 4. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth." Answer: 4 Explanation: 1. Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue. 2. Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. 3. Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. 4. This statement is correct. Babies older than 41 weeks' gestation are prone to developing postmaturity syndrome. Page Ref: 544 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.5 Compare the characteristics and potential complications that influence nursing management of the postterm newborn and the newborn with postmaturity syndrome.

7) The nurse is working with a family that just experienced the birth of their first child at 34 weeks. Which statements indicate that additional teaching is needed? Select all that apply. 1. "Our baby will be in an Isolette to keep him warm." 2. "The growth of our baby will be faster than if he were term." 3. "Breathing might be harder for our baby because he is early." 4. "Tube feedings will be required because his stomach is small." 5. "Because he came early, he will not produce urine for 2 days." Answer: 2, 4, 5 Explanation: 1. Preterm infants have little subcutaneous fat and have difficulty maintaining their body temperature. An Isolette or overhead warmer is used to keep the baby warm. 2. Preterm infants grow more slowly than do term infants. 3. Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants. 4. Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. 5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine. Page Ref: 545-547 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 26.6 Discuss the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and that are used in developing a plan of care that includes nutritional management.

8) The nurse is caring for an infant with abdominal contents protruding at the location of the umbilicus. Which statement differentiates between omphalocele and gastroschisis? 1. With omphalocele, the abdominal contents are not covered with a sac; with gastroschisis, the abdominal contents are covered by a sac. 2. With omphalocele, the abdominal contents are covered with a sac; with gastroschisis, the abdominal contents are not covered by a sac. 3. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. 4. With omphalocele, the abdominal contents protrude to the right of an intact umbilical cord; with gastroschisis, the abdominal contents protrude into the base of the umbilical cord. Answer: 3 Explanation: 1. If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis. 2. If the abdominal contents are covered by a sac, it is omphalocele. However, if the abdominal contents are not covered by a sac, it could be either omphalocele or gastroschisis. The better way to differentiate between omphalocele and gastroschisis is that the abdominal contents protrude into the base of the umbilical cord in omphalocele but protrude to the right of the umbilical cord in gastroschisis. 3. This is the correct way to differentiate between omphalocele and gastroschisis. 4. This is the opposite description of gastroschisis and omphalocele. With omphalocele, the abdominal contents protrude into the base of the umbilical cord; with gastroschisis, the abdominal contents protrude to the right of an intact umbilical cord. Page Ref: 560-561 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.7 Summarize the nursing assessments of and initial interventions for a newborn with selected congenital anomalies.

9) The nurse is assessing a 36-week gestational age newborn. Which assessment findings indicate that a cardiac defect is present? Select all that apply. 1. Cyanosis 2. Abdominal bruit 3. Peripheral pulses 4. Signs of heart failure 5. Presence of a heart murmur Answer: 1, 4, 5 Explanation: 1. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is cyanosis. 2. An abdominal bruit is not a sign of a cardiac defect in a newborn. 3. Peripheral pulses are not assessed to determine the presence of a cardiac defect in a newborn. 4. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is signs of heart failure. 5. The primary goal of the neonatal nurse is to identify cardiac defects early and initiate referral to the healthcare provider. One of the most common manifestations of a cardiac defect is the presence of a heart murmur. Page Ref: 570 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.8 Identify physical examination findings during the early newborn period that would make the nurse suspect a congenital cardiac defect or congestive heart failure.

10) In the special care nursery, the nurse places an infant with hydrocephalus in the prone position and is careful to thoroughly cleanse the perineum after bowel movements. Which condition was this infant most likely born with? 1. Omphalocele 2. Gastroschisis 3. Myelomeningocele 4. Diaphragmatic hernia Answer: 3 Explanation: 1. Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with omphalocele. 2. Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal organs' being located on the outside of the body. Positioning on the abdomen would be detrimental. Hydrocephalus is not associated with this condition. 3. Myelomeningocele is a neural tube defect in which the meninges and spinal cord are exposed. Surgical repair is undertaken to prevent encephalitis. Meticulous cleaning of the perineum helps prevent infection. The infant is positioned prone to prevent pressure on the defect. Hydrocephalus often is present. 4. Diaphragmatic hernia is incomplete formation of the diaphragm, resulting in bowel and sometimes stomach extending upward through the defect and being located in the chest cavity. Respiratory distress is the primary symptom. Surgical repair is required for normal respiratory function if the lungs have not been compromised by crowding from abdominal organs. Positioning should be high Fowler to facilitate respiratory efforts. Hydrocephalus is not associated with this condition. Page Ref: 562 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.7 Summarize the nursing assessments of and initial interventions for a newborn with selected congenital anomalies.

11) A newborn is diagnosed with fetal alcohol syndrome (FAS). Which statement indicates that the parents require additional teaching about this health problem? 1. "He might be a fussy baby because of this." 2. "His face looks like it does due to this problem." 3. "Cuddling and rocking will help him stay calm." 4. "Our baby's heart murmur is from this syndrome." Answer: 3 Explanation: 1. FAS babies are easily overstimulated and have feeding difficulties, leading to more crying than an average baby does. 2. Facial characteristics of the FAS child include a broad and flat nasal bridge, wide-set eyes, small chin, and smooth philtrum. 3. FAS babies are easily overstimulated and tend to cry more if swaddled, cuddled, or rocked. A dark and quiet environment helps keep the child calm. 4. Ventral and atrial septal defects are common in babies with FAS. Page Ref: 563 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Evaluation/Teaching/Learning Learning Outcome: 26.9 Explain the special care needed by an alcohol- or drug-exposed newborn.

12) The nurse is caring for a newborn born to a client who abused drugs while pregnant. Which assessment findings would be common for this newborn? Select all that apply. 1. Hyperirritability 2. Transient tachypnea 3. Exaggerated reflexes 4. Decreased muscle tone 5. Depressed respiratory effort Answer: 1, 2, 3 Explanation: 1. The newborn of a woman who abused drugs during her pregnancy is predisposed to hyperexcitability. 2. The newborn of a woman who abused drugs during her pregnancy is predisposed to transient tachypnea. 3. The newborn of a woman who abused drugs during her pregnancy is predisposed to exaggerated reflexes. 4. The newborn of a woman who abused drugs during her pregnancy will not routinely demonstrate decreased muscle tone. 5. The newborn of a woman who abused drugs during her pregnancy will not routinely demonstrate depressed respiratory effort. Page Ref: 563 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.9 Explain the special care needed by an alcohol- or drug-exposed newborn.

13) Which item should be considered as potentially infectious when providing care to a newborn of a client who is HIV positive? Select all that apply. 1. Feces 2. Urine 3. Blood 4. Soiled linens 5. Feeding bottle Answer: 1, 2, 3, 4 Explanation: 1. Body fluids such as feces are considered potentially infectious. 2. Body fluids such as urine are considered potentially infectious. 3. Body fluids such as blood are considered potentially infectious. 4. Because body fluids are considered potentially infectious, soiled linens are also potentially infectious. 5. A feeding bottle is not identified as being potentially infectious. Page Ref: 569 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.10 Relate the consequences of maternal HIV/ AIDS to the nursing management of newborns at risk for HIV/AIDS in the neonatal period and the issues for their caregivers. 14) A newborn is diagnosed with tetralogy of Fallot. Which findings indicate that this client is experiencing heart failure? Select all that apply. 1. Tachypnea 2. Diaphoresis 3. Tachycardia 4. Hepatomegaly 5. Splenomegaly Answer: 1, 2, 3, 4 Explanation: 1. Manifestations of heart failure in a newborn include tachypnea. 2. Manifestations of heart failure in a newborn include diaphoresis. 3. Manifestations of heart failure in a newborn include tachycardia. 4. Manifestations of heart failure in a newborn include hepatomegaly. 5. Splenomegaly is not a manifestation of heart failure in a newborn. Page Ref: 570 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.8 Identify physical examination findings during the early newborn period that would make the nurse suspect a congenital cardiac defect or congestive heart failure. 12 Copyright © 2022 Pearson Education, Inc.

15) The newborn of a mother with type 2 diabetes mellitus is experiencing tremors. Which nursing action has the highest priority? 1. Obtain a bilirubin level. 2. Obtain a blood calcium level. 3. Measure the newborn's temperature. 4. Place a pulse oximeter on the newborn. Answer: 2 Explanation: 1. Bilirubin level also might be necessary to monitor, but will not cause tremors in the newborn. 2. Tremors are the classic sign for hypocalcemia. Clients with diabetes who deliver newborns tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. 3. Body temperature also might be necessary to monitor, but will not cause tremors in the newborn. 4. Oxygen saturation also might be necessary to monitor, but will not cause tremors in the newborn. Page Ref: 543 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.4 Explain the impact of maternal diabetes mellitus on the newborn. 16) A newborn has just been admitted to the special care nursery. Which criteria should the nurse use to determine this newborn's classification and neonatal mortality risk? Select all that apply. 1. Length 2. Birth weight 3. Gestational age 4. Amount of lanugo 5. Occipital—frontal head circumference Answer: 1, 2, 3, 5 Explanation: 1. A newborn is assigned to a category depending on length. 2. A newborn is assigned to a category depending on birth weight. 3. A newborn is assigned to a category depending on gestational age. 4. Amount of lanugo is not used to determine the newborn's classification and neonatal mortality risk. 5. A newborn is assigned to a category depending on occipital—frontal head circumference. Page Ref: 536 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.1 Explain the factors present at birth that indicate an at-risk newborn. 13 Copyright © 2022 Pearson Education, Inc.

17) A small-for-gestational-age (SGA) newborn weighing 2000 g is prescribed to receive 130 kcal/kg/day of oral feeding to achieve a daily weight gain of 30 g. What should this newborn weigh after 2 weeks of receiving these feedings? (Calculate to the nearest whole number.) Answer: 2420 g Explanation: If the newborn is to gain 30 g each day, for 14 days, multiply 30 g × 14 = 420 g of weight gain. After 2 weeks, the newborn should weigh 2420 g. Page Ref: 538 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.2 Compare the underlying etiologies of the physiologic complications of small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr AGA) newborns and the nursing management for each. 18) An infant of a diabetic mother (IDM) weighing 11 lb is prescribed to receive an infusion of dextrose 10% and water at the rate of 5 mg/kg/min until blood glucose level remains about 45 mg/dL. How many milligrams of dextrose will the infant receive in 30 minutes? (Calculate to the nearest whole number.) Answer: 750 mg Explanation: First calculate the infant's weight in kilograms by dividing the weight in pounds by 2.2 or 11/2.2 = 5 kg. Then, determine the milligrams of glucose to provide per minute by multiplying 5 mg × 5 kg = 25 mg per minute. To determine the amount of glucose to provide in 30 minutes, multiply the amount of glucose per minute by 30 or 25 mg × 30 = 750 mg. Page Ref: 540 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.4 Explain the impact of maternal diabetes mellitus on the newborn.

19) The nurse is preparing teaching for the parents of a premature infant weighing 4.4 lb. How much urine in ounces should the nurse instruct the parents that the infant will produce in 1 day if the rate of production is 2 mL/kg/hr? (Calculate to the nearest whole number.) Answer: 3 oz Explanation: First determine the newborn's weight in kilograms by dividing the weight in pounds by 2.2, or 4.4/2.2 = 2 kg. Then, determine the amount of urine produced in 1 hour by multiplying 2 mL × 2 kg = 4 mL/hr. Then, multiply the amount of urine produced each hour by 24 hours, or 4 mL × 24 = 96 mL. To determine the amount of urine in ounces, divide the total amount of daily urine in milliliters by 30 mL, or 96/30 = 3.2. When rounding to the nearest whole number, the amount of urine that the infant will produce in 1 day is 3 oz. Page Ref: 547 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.6 Discuss the physiologic and behavioral characteristics of the preterm newborn that predispose each body system to various complications and that are used in developing a plan of care that includes nutritional management. 20) A full-term infant weighing 8.8 lb is delivered by a client who is HIV positive. The newborn is prescribed zidovudine (AZT) 2 mg/kg/dose every 6 hours for 6 weeks. Realizing that the newborn's weight is going to increase over the 6-week course of treatment, what is the total minimal amount of medication in milligrams that this infant will receive in 1 week? (Calculate to the nearest whole number.) Answer: 224 mg Explanation: First determine the infant's weight in kilograms by dividing the weight in pounds by 2.2, or 8.8/2.2 = 4 kg. Then, multiply the prescribed dose of 2 mg by the weight in kilograms, or 2 × 4 = 8 mg. If the infant is to receive a dose every 6 hours, multiply the single dose amount of 8 mg × 4 = 32 mg of the medication each day. For 7 days, multiply the daily dose in milligrams by 7, or 32 × 7 = 224 mg. Page Ref: 568 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 26.10 Relate the consequences of maternal HIV/ AIDS to the nursing management of newborns at risk for HIV/AIDS in the neonatal period and the issues for their caregivers.

21) The nurse is caring for a newborn with shoulder dystocia. For which condition should the nurse assess this infant? Select all that apply. 1. Brachial palsy 2. Facial bruising 3. Facial paralysis 4. Fractured clavicle 5. Depressed skull fracture Answer: 1, 3, 4, 5 Explanation: 1. Because of shoulder dystocia, the newborn is at risk for brachial palsy. 2. Facial bruising is not associated with shoulder dystocia. 3. Because of shoulder dystocia, the newborn is at risk for facial paralysis. 4. Because of shoulder dystocia, the newborn is at risk for a fractured clavicle. 5. Because of shoulder dystocia, the newborn is at risk for a depressed skull fracture. Page Ref: 542 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.3 Describe the potential complications for large-for-gestational-age (LGA) newborns. 22) A newborn is diagnosed with erythroblastosis fetalis. For which disorder should the nurse assess this infant? Select all that apply. 1. Hypokalemia 2. Polycythemia 3. Hypoglycemia 4. Hypernatremia 5. Hyperviscosity Answer: 2, 3, 5 Explanation: 1. The complication of hypokalemia is not associated with erythroblastosis fetalis. 2. The complication of polycythemia is most often seen in newborns with erythroblastosis fetalis. 3. The complication of hypoglycemia is most often seen in newborns with erythroblastosis fetalis. 4. The complication of hypernatremia is not associated with erythroblastosis fetalis. 5. The complication of hyperviscosity is most often seen in newborns with erythroblastosis fetalis. Page Ref: 542 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 26.3 Describe the potential complications for large-for-gestational-age (LGA) newborns. 16 Copyright © 2022 Pearson Education, Inc.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 27 The Newborn at Risk: Birth-Related Stressors 1) At birth, an infant newborn has a heart rate of 100, is not breathing, and is limp and bluish in color. Which nursing action is the best? 1. Assess blood pressure. 2. Deep suction the airways. 3. Begin chest compressions. 4. Begin bag-and-mask ventilation. Answer: 4 Explanation: 1. Establishment of airway and breathing take priority over assessment of blood pressure. 2. This would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid. 3. Chest compressions are not initiated until the heart rate is less than 60, and respirations have been established. 4. When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure. Page Ref: 576 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.1 Discuss how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on prenatal/labor record and observable physiologic indicators.

2) A 2-hour-old newborn delivered by cesarean section at 38 weeks with clear amniotic fluid has a respiratory rate of 80 with grunting and nasal flaring. The mother experienced preeclampsia while pregnant. Which reason should the nurse suspect is the most likely cause of this infant's condition? 1. Prematurity of the neonate 2. Respiratory distress syndrome 3. Meconium aspiration syndrome 4. Transient tachypnea of the newborn Answer: 4 Explanation: 1. The infant is not premature. Prematurity alone does not cause respiratory distress; the lack of surfactant causes respiratory distress syndrome. 2. The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome. 3. There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome. 4. The infant is term and born by cesarean section. The baby is the most likely experiencing transient tachypnea of the newborn. Page Ref: 581 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, and meconium aspiration syndrome) in the newborn and the nursing care required.

3) The nurse caring for a newborn on a ventilator for respiratory distress syndrome (RDS) informs the parents that the newborn is improving. Which finding supports the nurse's assessment? 1. Increased PCO2 2. Increased urination 3. Decreased urine output 4. Increased pulmonary vascular resistance Answer: 2 Explanation: 1. Increased PCO2 results from alveolar hypoventilation. 2. In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination may be an early clue that the baby's condition is improving. As fluid moves out of the lungs into the bloodstream, alveoli open, and kidney perfusion increases; this results in increased voiding. 3. As fluid moves out of the lungs and into the bloodstream, alveoli open, and kidney perfusion increases, thereby increasing urine output. 4. Pulmonary vascular resistance increases with hypoxia. Page Ref: 581 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 27.2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, and meconium aspiration syndrome) in the newborn and the nursing care required.

4) The nurse is caring for an infant who delivered in a car on the way to the hospital and has developed cold stress. Which finding requires immediate intervention? 1. Blood glucose level of 45 2. Vasoconstriction and pallor 3. Room temperature IV running 4. Positioned under radiant warmer Answer: 3 Explanation: 1. This is an adequate blood sugar in a neonate. Less than 40 is hypoglycemic. 2. Vasoconstriction is the first physiologic response to a lowering temperature and will cause pallor. 3. IV fluids should be warmed prior to administration and wrapped in a blanket or other insulating material to keep them warm. Room temperature IV fluids will increase the cold stress. 4. Radiant warmers are used to gradually increase the neonate's temperature. Page Ref: 590 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.3 Discuss selected types of metabolic abnormalities (including cold stress and hypoglycemia), their effects on the newborn, and the nursing implications.

5) Place the following nursing interventions related to resuscitation in the correct order according to complexity of the method and seriousness of the infant's condition. 1. Perform chest compressions. 2. Administer epinephrine. 3. Rub the infant's back with a blanket. 4. Administer 21% oxygen in a positive-pressure ventilator. 5. Administer 100% oxygen in a positive-pressure ventilator. Answer: 3, 4, 5, 1, 2 Explanation: 1. Chest compressions should only be performed if the infant's heart rate is below 60 beats/min despite 30 seconds of effective positive-pressure ventilation. 2. Epinephrine should be administered when the heart rate remains below 60 beats/min despite 45 to 60 seconds of chest compressions and ventilation. 3. Rubbing the infant's back is the least invasive therapy and should be attempted before any other resuscitation method. 4. If rubbing the back does not establish adequate breathing, the infant should be placed on 21% oxygen with a positive-pressure ventilator. 5. Oxygen should be increased from 21% to 100% before chest compressions begin. Page Ref: 576 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.1 Discuss how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on prenatal/labor record and observable physiologic indicators.

6) An infant with type O Rh-positive blood becomes visibly jaundiced at 12 hours of age. The mother with type O Rh-negative blood asks why this has occurred. In which way should the nurse respond? 1. "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." 2. "Your body has made antibodies against the baby's blood that are destroying her red blood cells." 3. ""The red blood cells of your baby are breaking down because you both have type O blood." 4. "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed." Answer: 2 Explanation: 1. Although this statement is true, the term "alloimmunization" is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology. 2. Alloimmune hemolytic disease, also known as erythroblastosis fetalis, occurs when an Rhnegative mother is pregnant with an Rh-positive fetus and maternal antibodies cross the placenta. Maternal antibodies enter the fetal circulation, then attach to and destroy the fetal RBCs. The fetal system responds by increasing RBC production. Jaundice is the result. 3. Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if the mother is O and the baby is A or B. 4. The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice. Page Ref: 592 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.5 Explain how Rh incompatibility or ABO incompatibility can lead to the development of hyperbilirubinemia.

7) A student nurse is caring for a neonate undergoing intensive phototherapy. Which action indicates that the student understands how to provide care for an infant undergoing intensive phototherapy? 1. Assesses temperature every 6 hours. 2. Assesses urine specific gravity with each voiding. 3. Removes eye coverings to help keep the baby calm. 4. Removes the infant from the Isolette for diaper changes. Answer: 2 Explanation: 1. Every 6 hours is too infrequent; the temperature should be assessed every 4 hours to assess for hyperthermia or hypothermia. 2. When excreted, the newborn's urine will be much darker in color/appearance because of the excreted higher conjugated bilirubin content. Darker urine can also indicate dehydration. Assessing the specific gravity will help differentiate the reason for the change in urine color. 3. Eyes should be covered at all times. 4. The infant's care should be clustered to keep the infant under the lights as much as possible. The diaper should have been changed while under the lights in the Isolette. Page Ref: 594 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Evaluation Learning Outcome: 27.6 Identify nursing responsibilities and rationale in caring for the newborn receiving phototherapy.

8) An infant born to a client with type 2 diabetes mellitus is lethargic, has a high-pitched cry, and has an initial plasma glucose level of 19 mg/dL. Which action should the nurse take immediately? 1. Have the mother breastfeed the infant. 2. Start an IV with D5W dextrose solution. 3. Start an IV with D10W dextrose solution. 4. Wait 30 minutes and retest plasma glucose levels. Answer: 3 Explanation: 1. This is an appropriate nursing action if the infant's plasma glucose levels are between 25 and 40 mg/dL. This infant needs more aggressive treatment. 2. D5W dextrose is primarily use to either prevent hypoglycemia or titrate down the concentration of administered glucose when the infant is transitioning off the glucose. A higher concentration of glucose is required for severely hypoglycemic infants. 3. This is the proper nursing action. Infants with severe hypoglycemia should be aggressively treated with IV infusion of D10W dextrose. 4. This infant is suffering from severe hypoglycemia. Aggressive treatment with D10W dextrose by IV is recommended. Page Ref: 590 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.3 Discuss selected types of metabolic abnormalities (including cold stress and hypoglycemia), their effects on the newborn, and the nursing implications.

9) The mother of a 4-day-old infant is concerned that the infant's skin tone is yellow, and asks if the baby should be hospitalized. Which reason should the nurse consider as causing this infant's skin color change? 1. Pathologic jaundice 2. Physiologic jaundice 3. Acute bilirubin encephalopathy 4. Hemolytic disease of the newborn Answer: 3 Explanation: 1. Pathologic jaundice usually appears before 24 hours of life and is the result of a more serious underlying condition. 2. Infants can develop physiologic jaundice 4 to 5 days after birth as a result of a shortened red blood cell life span, slow uptake of bilirubin by the liver, a lack of intestinal bacteria, or poorly established hydration from initial breastfeeding. 3. Acute bilirubin encephalopathy, or kernicterus, is a serious medical condition resulting from very high bilirubin levels as a result of pathologic jaundice. This is unlikely to occur with physiologic jaundice. 4. Hemolytic disease of the newborn occurs as a result of blood incompatibility between the mother and infant and is usually diagnosed shortly after birth. Page Ref: 592 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.4 Differentiate between physiologic and pathologic jaundice according to timing of onset (in hours), cause, possible sequelae, and specific management.

10) The nurse is caring for a newborn born to a client who experienced abruptio placentae. Which assessment findings suggest that the infant is experiencing anemia? Select all that apply. 1. Pallor 2. Tachypnea 3. Tachycardia 4. Elevated blood pressure 5. Capillary refill 6 seconds Answer: 1, 2, 3, 5 Explanation: 1. Pallor is a manifestation of anemia in a newborn. 2. Tachypnea is a manifestation of anemia that is compromised in a newborn. 3. Tachycardia is a manifestation of anemia in a newborn. 4. Low blood pressure is a manifestation of anemia in a newborn. 5. Capillary refill greater than 3 seconds is an indication of anemia in a newborn. Page Ref: 598 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.7 Describe the causes and nursing management of newborns with anemia. 11) A newborn is diagnosed with sepsis. Which finding should the nurse use to suspect this health problem? 1. Irritability and flushing of the skin at 8 hours of age 2. Respiratory distress syndrome developed 48 hours after birth 3. Bradycardia and tachypnea develop when the infant is 36 hours old 4. Temperature of 97.0°F 2 hours after warming the infant from 97.4°F Answer: 4 Explanation: 1. Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, especially if skin is cool and clammy. 2. Respiratory distress developing at 12 to 24 hours of age might indicate sepsis. 3. Tachycardia and periods of apnea are seen with sepsis, especially within the first 24 hours of life. 4. Temperature instability is often seen with sepsis. Fever is rare in a newborn. Page Ref: 602 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.8 Describe the nursing assessments that would lead the nurse to suspect newborn sepsis.

12) A newborn delivered via cesarean birth at 32 weeks to a mother who experienced placenta previa has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds. Which interventions are indicated for the care of this newborn? Select all that apply. 1. Start the infant on phototherapy. 2. Start the infant on iron supplements. 3. Have isotonic saline ready for transfusion. 4. Draw several vials of blood for laboratory testing. 5. Monitor the infant's cardiac and respiratory status. 6. Have O-negative packed red cells ready for a transfusion. Answer: 2, 5, 6 Explanation: 1. Phototherapy should only be started if the infant has jaundice. 2. Iron supplements should be given to help increase red blood cell production. 3. Isotonic saline transfusion is not used to treat anemia. 4. Blood draws should be kept to a minimum for clients with anemia. 5. This is an appropriate nursing intervention. Monitoring the infant's cardiac and respiratory status will allow the nurse to detect symptoms of shock and assess the effectiveness of treatment. 6. Clients with severe anemia will need a blood transfusion. If the infant's blood type is not known, O-negative packed red cells can be used for transfusions. If the infant's blood type is known, the appropriate typed and cross-matched packed red cells should be used. Page Ref: 598 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.7 Describe the causes and nursing management of newborns with anemia.

13) The day after a vaginal delivery, a client develops painful vesicular lesions on the perineum and vulva, which are diagnosed as a primary herpes type 2 infection. Which care should the newborn receive? 1. Intravenous acyclovir (Zovirax) and contact precautions 2. Cultures of blood and cerebrospinal fluid and serial chest x-rays every 12 hours 3. Parental rooming-in and four intramuscular injections of penicillin 4. Meticulous hand washing and antibiotic eye ointment administration Answer: 1 Explanation: 1. For a herpes type 2 infection, intravenous acyclovir (Zovirax) is indicated. Contact precautions should be implemented. 2. These cultures are appropriate, but chest x-rays are not indicated. Chest x-rays are obtained if the neonate is thought to have group B streptococcal pneumonia. 3. Parental rooming-in is encouraged, but penicillin does not treat viral illness. Penicillin is the drug of choice for syphilitic infections. 4. Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or Chlamydia. Page Ref: 600 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, Herpesviridae family (HSV or CMV), and chlamydia, to the nursing management of babies in the neonatal period.

14) The mother of a severely premature infant is being prepared to see her baby for the first time. The infant has an IV and a feeding tube, is receiving phototherapy, and is being monitored for cardiac and respiratory functioning. Which information would be the least supportive for the mother at this time? 1. Wash hands before holding the infant. 2. The infant has tubes and monitoring equipment in place. 3. The appearance of the different machines and tubes attached to the infant. 4. Avoid touching the infant because the baby's skin is fragile and could be easily hurt. Answer: 4 Explanation: 1. If the mother is going to hold her infant, she will need to thoroughly wash her hands to decrease the risk of infection. 2. The nurse should prepare the mother for what her infant will look like, especially if the infant is hooked up to several machines or tubes. 3. Seeing her child for the first time can be emotionally difficult for a mother, but a description of the equipment and its purpose will help the mother understand the care her child is receiving and help ease her anxiety. 4. Physical contact between the mother and infant will facilitate bonding and should be encouraged. Page Ref: 604 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 27.11 Describe the interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns.

15) The nurse is caring for a newborn with hypoglycemia. Which areas on the diagram should the nurse use to obtain blood to assess this newborn's blood glucose levels? Select all that apply.

Answer: 4, 5 Explanation: 1. This is not identified as an area to obtain blood to assess glucose level in a newborn. 2. This is not identified as an area to obtain blood to assess glucose level in a newborn. 3. This area could puncture an artery and is not identified as an area to obtain blood to assess glucose level in a newborn. 4. This is an ideal area to obtain blood to assess glucose level in a newborn. This area avoids arteries and major nerves. 5. This is an ideal area to obtain blood to assess glucose level in a newborn. This area avoids arteries and major nerves. Page Ref: 590 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.3 Discuss selected types of metabolic abnormalities (including cold stress and hypoglycemia), their effects on the newborn, and the nursing implications.

16) An infant weighing 1500 g is prescribed intravenous normal saline 10 mL/kg. How many milliliters of fluid should the nurse expect to provide this infant? (Calculate to the nearest whole number.) Answer: 100 mL Explanation: First, convert this infant's weight in grams to kilograms by dividing the weight in grams by 1000, or 1500 g/1000 = 1.5 kg. Then, multiply the prescribed dose of 10 mL of fluid by the weight in kilograms, or 10 mL × 10 = 100 mL. The nurse should prepare to administer 100 mL of fluid to this infant. Page Ref: 578 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.1 Discuss how to identify newborns in need of resuscitation and the appropriate method of resuscitation based on prenatal/labor record and observable physiologic indicators. 17) A newborn is admitted to the neonatal intensive care unit with suspected meconium aspiration. Which care should the nurse expect to provide to this client? Select all that apply. 1. Dopamine infusion 2. High-pressure ventilation 3. High-level oxygen therapy 4. Surfactant replacement therapy 5. High-volume intravenous fluids Answer: 1, 2, 3, 4 Explanation: 1. For meconium aspiration, dopamine may be prescribed to maintain systemic blood pressure. 2. High-pressure ventilation may be needed to cause sufficient expiratory expansion of obstructed terminal airways or to stabilize airways that are weakened by inflammation. 3. Treatment of meconium aspiration usually involves delivery of high levels of oxygen. 4. Surfactant replacement therapy is most effective when given as a prophylactic measure. 5. Fluids may be restricted in the first 48 to 72 hours because of the risk of cerebral edema. Page Ref: 588 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, and meconium aspiration syndrome) in the newborn and the nursing care required.

18) During a home visit, the nurse suspects that a newborn is experiencing chlamydial conjunctivitis. Which finding did the nurse assess to make this clinical determination? Select all that apply. 1. Eyelid swelling 2. Yellow discharge 3. Eye inflammation 4. Purulent discharge 5. Corneal ulcerations Answer: 1, 2, 3 Explanation: 1. Manifestations of chlamydial conjunctivitis include eyelid swelling 5 to 14 days after birth. 2. Manifestations of chlamydial conjunctivitis include yellow discharge. 3. Manifestations of chlamydial conjunctivitis include eye inflammation. 4. Purulent discharge is a manifestation of ophthalmia neonatorum caused by gonorrhea. 5. Corneal ulceration is a manifestation of ophthalmia neonatorum caused by gonorrhea. Page Ref: 600 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, Herpesviridae family (HSV or CMV), and chlamydia, to the nursing management of babies in the neonatal period. 19) A newborn weighing 8 lb, 4 oz is prescribed intravenous vancomycin 30 mg/kg/day in divided doses every 8 hours. How many milligrams of the medication should the nurse prepare to administer to this infant for every dose? (Calculate to the nearest tenth decimal point.) Answer: 37.5 mg Explanation: First, determine the infant's weight in kilograms. The current weight is 8 lb and 4 oz. Determine the weight in metric measurement by dividing 4 oz/16 oz. The infant weighs 8.25 lb. Next, divide the weight in pounds by 2.2 to determine the weight in kilograms, or 8.25/2.2 = 3.75 kg. Then, multiply the prescribed medication dose of 30 mg by the weight, or 30 mg × 3.75 = 112.5 mg, which is the total daily dose. To determine the amount of medication to provide for each dose, every 8 hours, divide the total dose by 3, or 112.5/3 = 37.5 mg. Each dose will be 37.5 mg. Page Ref: 602 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.8 Describe the nursing assessments that would lead the nurse to suspect newborn sepsis. 16 Copyright © 2022 Pearson Education, Inc.

20) The nurse is concerned that a new mother is going to have difficulty caring for her newborn once the baby is discharged from the neonatal intensive care unit. Which client behaviors are consistent with nonadaptive responses? Select all that apply. 1. Refusing to touch the infant 2. Grimacing when holding the infant 3. Expressing fear of taking the infant home 4. Asking staff questions about the infant's care 5. Blaming spouse for the infant's health problems Answer: 1, 2, 3, 5 Explanation: 1. Nonadaptive responses include a lack of interaction with the infant during hospitalization. 2. Nonadaptive responses include a negative view of the infant. 3. Nonadaptive responses include a fear of going home with the infant. 4. Asking staff questions about the infant's care is an adaptive response. 5. Nonadaptive responses include blaming others for the infant's condition. Page Ref: 605 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.11 Describe the interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns.

21) A newborn who was born in meconium-stained amniotic fluid is diagnosed with severe respiratory distress suspected as being caused by a group B streptococcus infection. Which action should the nurse take when caring for this newborn? Select all that apply. 1. Send nasopharynx culture. 2. Begin contact precautions. 3. Evaluate for hearing deficit. 4. Prepare for a CT scan of the brain. 5. Administer antibiotics as prescribed. Answer: 1, 5 Explanation: 1. For the infant with a suspected group B streptococcus infection, the nasopharynx should be cultured. 2. There is no reason for the infant to be in contact precautions. 3. Hearing deficit is not associated with this infection. 4. A CT scan is not needed for this infection. 5. For the infant with a suspected group B streptococcus infection, antibiotics should be given as prescribed. Page Ref: 599 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 27.9 Delineate the nursing care of the newborn with an infection. 22) A newborn is suspected of having cytomegalovirus (CMV). Which finding should the nurse expect to assess in this infant? Select all that apply. 1. Lethargy 2. Hypotonia 3. Tachycardia 4. Poor feeding 5. Subnormal temperature Answer: 1, 2, 4 Explanation: 1. Lethargy is a finding associated with CMV. 2. Hypotonia is a finding associated with CMV. 3. Tachycardia is associated with herpes type 2 infection. 4. Poor feeding is associated with CMV. 5. A subnormal temperature is associated with herpes type 2 infection. Page Ref: 600 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 27.9 Delineate the nursing care of the newborn with an infection. 18 Copyright © 2022 Pearson Education, Inc.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 28 Postpartum Adaptation and Nursing Assessment 1) The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first? 1. Multipara, second day postcesarean, moderate lochia serosa 2. Primipara, day of delivery, fundus firm 2 cm above umbilicus 3. Multipara, first postpartum day, 4 cm diastasis recti abdominis 4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants Answer: 2 Explanation: 1. This client is not experiencing any unexpected findings. 2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding. 3. This finding is normal, especially in a multiparous client. 4. Bowel sounds are often decreased after delivery. Page Ref: 614 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its prepregnant state.

2) Which amount of weight loss, in pounds, should the nurse expect in an average postpartum client? 1. 5 to 8 2. 10 to 12 3. 12 to 15 4. 15 to 20 Answer: 2 Explanation: 1. A loss of 5 to 8 lb might occur after a preterm birth. 2. A loss of 10 to 12 lb is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid. 3. A loss of 12 to 15 lb does not match the usual weight of placenta, amniotic fluid, and full-term infant weight. 4. A loss of 15 to 20 lb might occur after a multiple birth. Page Ref: 618 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its prepregnant state. 3) Which information should the nurse assess to determine healing of the uterus at the placental site? 1. Laboratory values 2. Uterine size 3. Blood pressure 4. Type, amount, and consistency of lochia Answer: 4 Explanation: 1. Laboratory values are too vague, since the actual values are not identified. 2. Uterine size alone is not enough to assess the placental site. 3. Blood pressure varies slightly in the normal postpartum client and would not affect the placental site. 4. Type, amount, and consistency of lochia determine the stage of healing of the placental site, which occurs by a process of exfoliation. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its prepregnant state.

4) On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. Which reason should the nurse identify for the client's memory lapse? 1. Epidural anesthesia 2. The taking-in phase 3. The taking-hold phase 4. Postpartum hemorrhage Answer: 2 Explanation: 1. Epidural anesthesia is a pharmacologic approach to pain control. 2. The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest. 3. The taking-hold phase occurs by the second or third day, when the mother is ready to resume control of life and is open to teaching. 4. Postpartum hemorrhage is a serious complication and will need medical intervention. Page Ref: 619 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.2 Identify the psychologic adjustments that normally occur during the postpartum period.

5) The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene? 1. Asking the client to void before applying clean gloves 2. Instructing visitors to leave the room prior to beginning the assessment 3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment 4. Discussing the effectiveness of comfort measures while performing the perineal assessment Answer: 2 Explanation: 1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids. 2. The nurse should allow the client to choose whether visitors leave or remain in the room during the assessment. 3. The supine position prevents a falsely high assessment of fundal height. 4. The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures. Page Ref: 622 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.3 Describe the physiologic and psychologic components of a systematic postpartum assessment.

6) In which order should the nurse conduct the examination of a postpartum client? 1. L—lochia 2. B—bowel 3. B—breast 4. U—uterus 5. B—bladder 6. E—emotional 7. H—Homans/hemorrhoids 8. E—episiotomy/laceration/edema Answer: 3, 4, 5, 2, 1, 8, 7, 6 Explanation: 1. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B— bowel, L—lochia, E—episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 2. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 3. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 4. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 5. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 6. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 7. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. 8. An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B—breast, U—uterus, B—bladder, B—bowel, L—lochia, E— episiotomy/laceration/edema, H—Homans/hemorrhoids, E—emotional. Page Ref: 624 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.3 Describe the physiologic and psychologic components of a systematic postpartum assessment.

7) A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. Which information should the nurse explain about this occurrence? 1. "Do not worry. I will make sure everything is fine." 2. "We see this from time to time. It's not a big deal." 3. "Blood has pooled in the vagina while you were in bed." 4. "The gush is an indication that your fundus is not contracting." Answer: 3 Explanation: 1. This response is not therapeutic because it focuses on the nurse and has a "do not worry" aspect that is demeaning. 2. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not address the client's concern. 3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semisitting in bed, which leads to a gush when fundal massage is performed. 4. The fundus might be contracting well. The gush is from pooled lochia in the vagina. Page Ref: 615 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment; Practice; transcultural approaches to health | Nursing/Integrated Concepts: Implementation Learning Outcome: 28.4 Identify the common concerns of the mother that are considered in a postpartum assessment. 8) A postpartum client is not going to breastfeed her newborn. Which information should the nurse include when teaching this client about breast care? 1. The let-down reflex 2. Lactation suppression 3. The purpose of fundal massage 4. The cause of afterpains Answer: 2 Explanation: 1. The let-down reflex is an important teaching point for breastfeeding patients. 2. It is important to teach nonbreastfeeding patients about lactation suppression after delivery. 3. The purpose of fundal massage should be addressed when assessing the uterus and fundus, not when assessing the breasts. 4. Afterpains can be stimulated by breastfeeding. The nurse will not likely teach a nonbreastfeeding primipara about afterpains. Page Ref: 624 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 28.4 Identify the common concerns of the mother that are considered in a postpartum assessment. 6 Copyright © 2022 Pearson Education, Inc.

9) Every time the nurse enters the client's room, the client, who delivered 3 hours ago, asks the nurse something else about the birth experience. Which action should the nurse take? 1. Answer questions quickly, and try to divert attention to other subjects. 2. Review documentation of the birth experience, and discuss it with the client. 3. Contact the healthcare provider because of changes in the client's memory. 4. Submit a referral to Social Services because of concerns about obsessive behavior. Answer: 2 Explanation: 1. Answering questions quickly and trying to divert attention to other subjects trivializes the questions and does not allow the client to sort out the reality from the subjective experience. 2. Reviewing the documentation of the birth experience and discussing it with the client helps the client integrate the experience and talk about perceptions of the labor and delivery experience. 3. The client is not demonstrating changes in memory. The healthcare provider does not need to be contacted. 4. Submitting a referral to Social Services because of obsessive behavior is not appropriate. The client is demonstrating normal behavior. Page Ref: 619 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 28.2 Identify the psychologic adjustments that normally occur during the postpartum period.

10) A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. Which action should the nurse take? 1. Contact Social Services with concerns of neglect. 2. Teach the client how to interact appropriately with the infant. 3. Take the infant to the nursery so the baby can receive more consistent care. 4. Provide the care the infant needs while continuing to evaluate the mother's actions. Answer: 2 Explanation: 1. The mother may only need some education on how to care for her infant. If the nurse consistently teaches the mother and encourages mother-infant interaction, and the mother continues to ignore the child, then it may be appropriate to contact Social Services in extreme circumstances. 2. New mothers may be hesitant to care for the infant because of feelings of inadequacy. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention. 3. Instead of encouraging mother-infant bonding, this action may emotionally distance the mother from her child even more. It may also confirm the mother's feelings of inadequacy. 4. While this action does provide for the needs of the newborn during the hospital stay, it does not help the mother know how to care for her child once she returns home. Page Ref: 627 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Implementation Learning Outcome: 28.5 Examine the physical and developmental tasks that the mother must accomplish during the postpartum period.

11) The nurse is making a visit to the home of a new mother. Which observation indicates that the mother and infant are in the phase of mutual regulation? 1. The infant grasps the mother's finger while nursing. 2. The mother vocalizes feelings of frustration with her infant. 3. The infant begins to seek out the mother over other individuals. 4. The mother spends more time making eye-to-eye contact with the infant. Answer: 2 Explanation: 1. Actions that make the infant more attractive to the mother, such as grasping a finger, usually occur during the acquaintance phase. 2. The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship. 3. When the relationship between mother and infant reaches reciprocity, the infant will seek to interact with the mother more. 4. Holding the infant in the en face position is likely to occur most often in the acquaintance phase. Page Ref: 621 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.7 Relate how the nursing assessment of early attachment incorporates factors that influence development of a positive parent-newborn attachment.

12) The nurse is preparing material to instruct a client who has given birth to her first child. Which aspect of teaching is the most important? 1. Determine if father-infant attachment is taking place. 2. Discuss adaptation to grandparenthood by her parents. 3. Describe the likely reaction of siblings to the new baby. 4. Assist the mother in identifying behavior cues of the baby. Answer: 4 Explanation: 1. Although father-infant attachment is important, the mother is the main client, and teaching her directly is a higher priority. 2. Adaptation to grandparenthood is a task for her parents and not a high priority for teaching the new mother. 3. This is not appropriate because the baby has no siblings. 4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment. Page Ref: 628 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Relationship-Centered Care; Practice; learn cooperatively │ Nursing/Integrated Concepts: Planning/Teaching/Learning Learning Outcome: 28.5 Examine the physical and developmental tasks that the mother must accomplish during the postpartum period. 13) The nurse is performing an assessment of early attachment. Which action indicates that the client is pleased with the baby's appearance and sex? 1. The mother enfolds the infant in her arms. 2. The mother feeds the infant every 2 to 3 hours as instructed. 3. The mother points out family traits she sees in the newborn. 4. The mother asks questions about how to properly bathe her infant. Answer: 3 Explanation: 1. This action can be used to assess if the mother is attracted to her newborn and is forming emotional attachments with the newborn. 2. This action can be used to assess the ability of the mother to care for the infant's needs as they arise. 3. This action will help determine if the mother is pleased with her baby's appearance. She may point out both positive and negative traits. 4. This action helps assess the mother's willingness to learn how to care for her infant. Page Ref: 628 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.7 Relate how the nursing assessment of early attachment incorporates factors that influence development of a positive parent-newborn attachment. 10 Copyright © 2022 Pearson Education, Inc.

14) The nurse documents that a postpartum client's volume of lochia is moderate. Which perineal pad did the nurse most likely assess to make this clinical determination? 1.

Answer: 3 Explanation: 1. This would be estimated as a scant amount of lochia. 2. This would be estimated as a light amount of lochia. 3. This would be estimated as a moderate amount of lochia. 4. This would be estimated as a heavy amount of lochia. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.3 Describe the physiologic and psychologic components of a systematic postpartum assessment. 15) A client weighing 80 kg lost 5 kg of body weight immediately after delivery. In 2 days, another 3 kg has been lost. During a 6-week postpartum examination, the client was pleased to learn of returning to her prepregnancy weight of 143 lb. How many kilograms of weight did the client lose during the 6 weeks postpartum? (Calculate to the nearest whole number.) Answer: 7 kg Explanation: First, determine the client's starting weight in pounds by multiplying her weight in kilograms by 2.2, or 80 × 2.2 = 176. Then, subtract the prepregnancy weight from the pregnancy weight, or 176 − 143 = 33 pounds. Then, divide the weight in pounds by 2.2, or 33/2.2 = 15 kg. Then, subtract the total number of kilograms lost after delivery from the total weight of 15 kg. or 15 kg − 5 kg − 3 kg = 7 kg. The client lost 7 kg of weight in 6 weeks. Page Ref: 618 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its prepregnant state.

16) A postpartum client weighing 165 lb is prescribed to take 12 mg/kg/day of lysine to help with afterpains. If the client ingests 375 mg of lysine in food, how many additional milligrams of the supplement should the client take? (Calculate to the nearest whole number.) Answer: 525 mg Explanation: First, determine the client's weight in kilograms by dividing the weight in pounds by 2.2, or 165/2.2 = 75 kg. Then, determine the amount of lysine that should be taken each day by multiplying the client's weight by 12, or 75 × 12 mg = 900 mg. If the client ingests 375 mg of lysine each day in food, then subtract this amount from the total amount of lysine, or 900 - 375 = 525 mg. Page Ref: 619 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Planning Learning Outcome: 28.1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its prepregnant state.

17) During a home visit, the nurse is concerned that a new mother is experiencing postpartum blues. Which finding did the nurse assess to make this clinical determination? Select all that apply. 1. Fear 2. Anger 3. Euphoria 4. Anorexia 5. Weepiness Answer: 1 Explanation: 1. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Fear is not commonly associated with postpartum blues. 2. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anger. 3. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Euphoria is not commonly associated with postpartum blues. 4. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anorexia. 5. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by weepiness. Page Ref: 619 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.2 Identify the psychologic adjustments that normally occur during the postpartum period.

18) The nurse is assessing the episiotomy of a client who is 2 days postpartum. In which order should the nurse complete this assessment? A. Edema B. Redness C. Ecchymosis D. Approximation E. Discharge/drainage 1. B, A, C, E, D 2. A, B, D, E, C 3. B, A, D, E, C 4. D, E, C, B, A Answer: A Explanation: 1. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for redness, the nurse inspects the wound for edema. 2. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, the nurse first inspects the wound for redness. 3. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for edema the nurse inspects the wound for ecchymosis. 4. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for discharge/drainage the nurse inspects the wound for approximation. 5. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for ecchymosis the nurse inspects the wound for discharge/drainage. Page Ref: 625 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.3 Describe the physiologic and psychologic components of a systematic postpartum assessment.

19) The nurse is assessing the abdomen of a client who delivered an infant 1 hour ago. On the diagram, where should the nurse assess the client's uterine level?

Answer:

Explanation: Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus. Page Ref: 614 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its prepregnant state.

20) The nurse decides that a family with a newborn would benefit from a Social Services consultation. Which statements were made by family members that caused the nurse to make this decision? Select all that apply. 1. "I think we're getting along better." 2. "I'm not going to let a baby make me fat." 3. "My mother could care less about this baby." 4. "At least help me if you don't want to get a job." 5. "That's fine. Go to work. Leave me here to do all of the work." Answer: 1 Explanation: 1. The statement about getting along would indicate adapting to the new infant. 2. Preoccupation with physical status or weight could indicate adjustment difficulties. 3. Lack of support systems could indicate adjustment difficulties. 4. Unemployment could indicate adjustment difficulties. 5. Marital problems could indicate adjustment difficulties. Page Ref: 627 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.7 Relate how the nursing assessment of early attachment incorporates factors that influence development of a positive parent-newborn attachment. 21) A client from a non-English speaking culture is recovering from a delivery. Which question should the nurse ask to support this client's cultural needs? 1. "When would you like a bath?" 2. "What is your new baby's name?" 3. "What time will your family be visiting?" 4. "Would you like something warm to drink?" Answer: 4 Explanation: 1. Asking about bathing would not necessarily support the client's cultural needs. 2. Asking about the baby's name does not necessarily support the client's cultural needs. 3. Asking about family does not necessarily support the client's cultural needs. 4. The nurse should determine the client's customs and practices. The client's individual preferences may include warmed fluids as this would take into consideration the client's cultural needs. Page Ref: 629 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.6 Explain the impact of cultural influence during the postpartum period.

22) A client who delivered 12 hours ago is resting in bed while her mother provides care to the newborn. Which assessment should the nurse complete before addressing the client's disinterest in the newborn? 1. History of mental health disorders 2. Expectations of the client's culture 3. Amount of blood lost during the delivery 4. Amount of food eaten during the last meal Answer: 2 Explanation: 1. There is no evidence that disinterest in care during the first 12 hours indicates a mental health disorder. 2. The client's apparent disinterest may be a cultural expectation. In some cultures, extended family provides newborn care so that the client can rest. 3. The client's apparent disinterest in providing newborn care is not related to the amount of blood lost during the delivery. 4. The client's apparent disinterest in providing newborn care is not related to the amount of food ingested during the last meal. Page Ref: 630 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care │ AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. │ NLN Competencies: Context and Environment; Practice; transcultural approaches to health │ Nursing/Integrated Concepts: Assessment Learning Outcome: 28.6 Explain the impact of cultural influence during the postpartum period.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 29 The Postpartum Family: Early Care Needs and Home Care 1) The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago. Assessment finding includes the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB ↓ the uterus; and client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on a scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which problem has the highest priority for this client? 1. Pain 2. Lack of fluid volume 3. Family dynamic changes 4. Need to learn how to care for the newborn Answer: 2 Explanation: 1. Patient can be offered techniques and medications to treat pain, but it is not currently the highest priority for this patient. 2. Adequate fluid volume is a critical physiologic need; therefore, this is the highest problem specifically because the client is at risk for hemorrhage and is breastfeeding. 3. This is not a priority as the partner is present and involved. 4. This is not a high priority at this time as the client is showing she is caring for the baby and is in pain so it is the best time for learning. Page Ref: 658 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 29.1 Formulate nursing care based on the findings of the normal postpartum assessment and teaching needs.

2) During a home care visit, the new breastfeeding mother reports breast engorgement. Which statement by the home care nurse is the most appropriate based on this information? 1. "Apply an ice compress to your breast before nursing." 2. "Encourage your baby to suckle for an average of 5 minutes per feeding." 3. "Apply warm compresses to your breast after you finish feeding your baby." 4. "When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep." Answer: 4 Explanation: 1. Ice is suggested for the non breastfeeding mother to relieve discomfort and discourage milk production. 2. Longer feedings are helpful to relieve breast engorgement. Suggested time is 10-15 min per side at each feeding. 3. Warm compresses should be used before feedings to help soften the breast. 4. The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension. Page Ref: 635 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.13 Delineate interventions to address the common concerns of breastfeeding mothers following discharge.

3) The postpartum client, who delivered 4 hours ago, has a mediolateral episiotomy and large hemorrhoids. The client currently rates her pain at 7 on a scale of 1 to 10. She has a history of anaphylactic reaction to acetaminophen (Tylenol). Which nursing action is the most appropriate? 1. Offering 800 mg ibuprofen (Advil) orally with food 2. Providing two oxycodone with acetaminophen tablets (Percocet) by mouth 3. Encouraging use of the prescribed topical anesthetic spray 4. Running very warm water into the tub and assisting her into the bath Answer: 1 Explanation: 1. This is the best option because the patient is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. 2. The patient is allergic to the Tylenol in the Percocet, so she cannot take this medication. 3. Patients can be prescribed topical spray, but it should not be overused. 4. This is not suggested to the risk of the mother overheating and passing out. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Physiological Adaptation / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.2 Describe appropriate nursing interventions to promote postpartum maternal comfort, rest, and well-being. 4) On the second day postpartum, the client who is bottle-feeding experiences engorgement. Which should the nurse encourage to enhance the client's comfort? 1. Removing her bra 2. Applying heat to her breasts 3. Applying ice packs to her breasts 4. Limiting breastfeeding to twice daily Answer: 3 Explanation: 1. Keeping a well-fitting bra on at all times for the first 7-10 days postpartum is suggested to help with engorgement. 2. Heat can assist with breastfeeding but is not suggested for non breastfeeding support. 3. Applying ice packs to the breasts relieves discomfort through the numbing effect of ice. 4. The patient is not breastfeeding, so this is not the correct answer. Page Ref: 650 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.2 Describe appropriate nursing interventions to promote postpartum maternal comfort, rest, and well-being. 3 Copyright © 2022 Pearson Education, Inc.

5) The nurse is caring for a postpartum client who is 4 hours postoperative following a cesarean birth. Which nursing interventions are appropriate based on these data? Select all that apply. 1. Administering the prescribed analgesics, as needed 2. Encouraging ambulation to the bathroom to void 3. Encouraging leg exercises every 2 hours 4. Encouraging coughing and deep breathing every 2 to 4 hours 5. Encouraging the use of breathing, relaxation, and distraction Answer: 1, 3, 4, 5 Explanation: 1. Administering the prescribed analgesics, as needed, addresses the client's nursing care needs, which are similar to those of other surgical clients. 2. The patient is at risk for falling, so she must be accompanied to the bathroom initially post cesarean section. Post op ambulation usually happens more than 4 hours post surgery. 3. Encouraging leg exercises addresses the client's nursing care needs, which are similar to those of other surgical clients. 4. Encouraging coughing and deep breathing every 2 to 4 hours addresses the client's nursing care needs, which are similar to those of other surgical clients. 5. Encouraging the use of breathing, relaxation, and distraction addresses the client's nursing care needs, which are similar to those of other surgical clients. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.2 Describe appropriate nursing interventions to promote postpartum maternal comfort, rest, and well-being.

6) A new mother wants to stop breastfeeding because of breast pain and nipple cracking. Which recommendation should the nurse make? 1. Begin bottle-feeding. 2. Wear a supportive bra. 3. Apply ice packs to the breasts. 4. Review positions for breastfeeding. Answer: 4 Explanation: 1. Before reviewing alternatives, the cause of the cracked and bleeding nipples should be reviewed and addressed. 2. This is a technique to address breast engorgement. 3. This is a technique to address breast engorgement. 4. Cracking and bleeding nipples are most commonly caused by improper positioning with feeding. There is no need to convert to bottle-feeding the newborn. A supportive bra and ice packs would be appropriate for breast engorgement. Page Ref: 635 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.13 Delineate interventions to address the common concerns of breastfeeding mothers following discharge.

7) The hospital is developing a new maternity unit. Which aspects should be included in the planning of this new unit to best promote family wellness? 1. Normal newborn nursery centrally located to all client rooms 2. A kitchen with refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a client bed and rocking chair 4. A nursing model based on providing couplet care Answer: 4 Explanation: 1. The nursery does not promote family wellness; it separates the mother from the infant. 2. This is a nice to have but will not promote family wellness. 3. The way the room is set up is important but is not the best answer to promote family wellness. 4. Couplet care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered. Page Ref: 641 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Planning/Caring Learning Outcome: 29.3 Explain factors that affect postpartum family wellness in the provision of nursing care and patient teaching.

8) The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." Which response by the nurse is most appropriate? 1. "We'll take good care of you and your baby. You'll be home before you know it." 2. "You'll be wearing sequential compression devices to prevent blood clots from forming in your legs." 3. "You will have a lot of pain, but there are medications that we give when it gets bad." 4. "You won't be able to nurse until the baby is 12 hours old because of your epidural." Answer: 2 Explanation: 1. You need to answer the patient with a concrete answer, not acknowledge that they need concrete answers. 2. Sequential compression devices (SCDs) are used until the client is up and walking to prevent thrombus formation. 3. Reviewing the plan for pain management is appropriate but this is not the best way to state it. 4. Breastfeeding as soon as possible is encouraged for post-cesarean patients to enhance recovery. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 29.4 Compare the postpartum nursing needs of the woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally.

9) The nurse is caring for a client who delivered by cesarean birth and during which she received a general anesthetic. Which will the nurse encourage to prevent or minimize abdominal distention? Select all that apply. 1. Increasing intake of cold beverages 2. Participating in leg exercises every 2 hours 3. Tightening the abdominal muscles 4. Ambulating as often as possible 5. Eating a high-protein general diet Answer: 2, 3, 4 Explanation: 1. Nausea and vomiting can be a side effect of general anesthesia, and warm liquids are encouraged to help relieve those symptoms. 2. Participating in leg exercises every 2 hours serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 3. Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 4. Ambulating as often as possible serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 5. A high protein diet may cause some abdominal distention. bloating, nausea, or vomiting post general anesthesia. A light diet is suggested initially. Page Ref: 642-643 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.4 Compare the postpartum nursing needs of the woman who experienced a cesarean birth with the needs of a woman who gave birth vaginally.

10) The nurse is caring for an adolescent client who gave birth to her first child yesterday. Which nursing action indicates accurate understanding of adolescent parenting concepts? 1. The client's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby during the assessment. 4. A discussion on contraceptive methods is the first topic of teaching. Answer: 3 Explanation: 1. The adolescent mother should be the main learner in all discussions; a nurse can include the mother if the adolescent requests it and they will be caring for the baby also. 2. The father should be included in any learning but may need to be taught how to change a diaper or give a bottle. 3. This helps the client learn about her baby and understand the baby as an individual, and facilitates maternal-infant attachment. This is the highest priority. 4. This is a very important topic and should be reviewed but is not the first thing that should be reviewed as it will be touched upon multiple times. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 29.5 Examine the nursing needs of the childbearing adolescent during the postpartum period.

11) The nurse is providing care to a postpartum client who is relinquishing custody of her newborn through an open adoption. Which nursing action is most important? 1. Assigning the client a room on the GYN surgical floor instead of the postpartum floor 2. Preparing to have teaching done in time for discharging the client at 24 hours postdelivery 3. Making an effort not to bring up the topic of the baby, and discuss the mother's health instead 4. Asking the client if she wants to feed her baby, and how much contact she wants to have Answer: 4 Explanation: 1. The client should be given open access to her infant after birth prior till she decides how much contact is right for her. 2. Some may request to go home early but it is up to the mother ultimately so the nurse should not assume. 3. The client should be allowed to talk about the baby if she wants to so; it is not always best to not address the topic. 4. Assess the client's preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother. Page Ref: 644 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.6 Describe possible approaches to sensitive, holistic nursing care for the woman who relinquishes her newborn.

12) The nurse is caring for a client who plans to relinquish her baby for adoption. Which nursing actions are appropriate based on this information? Select all that apply. 1. Encourage the client to see and hold her infant. 2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow for access to the infant if the client requests it. Answer: 2, 3, 4, 5 Explanation: 1. The nurse should allow for the client to have access to the baby, but it is up to the mother to decide if she will see and hold the infant. 2. Encouraging the client to express emotions is an aspect of providing care for the client who decides to relinquish her infant. 3. Respecting any special request for the birth is an aspect of providing care for the client who decides to relinquish her infant. 4. Acknowledging the grieving process is an aspect of providing care for the client who decides to relinquish her infant. 5. Allowing for access to the infant at the client's request is an aspect of providing care for the client who decides to relinquish her infant. Page Ref: 644 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.6 Describe possible approaches to sensitive, holistic nursing care for the woman who relinquishes her newborn.

13) The nurse, who is orienting a new nurse, discusses maternal psychologic adaptations and stressors after birth. Which statement reflects the correct approach to addressing potential and actual postpartum depression in maternal patients? 1. "Because emotional disorders and imbalances are a very sensitive subject, we try not to offend patients by routinely bringing up the topic of postpartum depression." 2. "For women with a history of depression, we include education about postpartum depression." 3. "Teaching about postpartum depression is a routine part of education for all maternal patients." 4. "If we suspect a woman may have developed postpartum depression; then, we provide specialized education about that topic." Answer: 3 Explanation: 1. All maternal patients should be educated on postpartum depression and the signs and symptoms of it. 2. All maternal patients should be educated on postpartum depression and the signs and symptoms of it. 3. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 4. All maternal patients should be educated on postpartum depression and the signs and symptoms of it, not just clients with the disorder. Page Ref: 665 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation Learning Outcome: 29.3 Explain factors that affect postpartum family wellness in the provision of nursing care and patient teaching.

14) During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? 1. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychologic approach to family bonding. 2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on the stomach." 3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." 4. "Cosleeping is not recommended; however, if you wish to do this, place your baby on a comforter, as opposed to directly on the mattress." Answer: 3 Explanation: 1. This is false and cosleeping is considered a SIDS risk factor. 2. This is false and is considered a SIDS risk factor, and recommended sleeping position for an infant is on the back. 3. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety guidelines. 4. The RN should inform the parents why cosleeping is not recommended then counsel them on the specific safety guidelines. Page Ref: 664 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.14 Describe the assessment and care of the newborn during postpartum home care.

15) A new mother is concerned about spoiling her newborn. Which statement should the home care nurse include in this teaching session with the new mother? 1. "Spoiling occurs when an infant is rocked to sleep every night." 2. "Newborns can be manipulative, so caution is advised." 3. "Crying is good for an infant, and letting them cry it out is advised." 4. "It is important to meet your infant's needs to develop a trusting relationship." Answer: 4 Explanation: 1. Rocking your baby is a form of comfort and is not spoiling them. 2. Newborns need to learn that the adult is going to care for them. They just need their needs met; they are not manipulative. 3. Newborns need to be comforted, so it is not indicated to let them cry it out. 4. Meeting the infant's needs develops a trusting relationship. Picking babies up when they cry teaches them that adults try to meet their needs and are responsive to them. This helps build a sense of trust in humankind. Page Ref: 641 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.10 Identify the main purposes and components of home visits during the postpartum period.

16) Which safety device is most appropriate for the nurse who conducts home care visits to postpartum mothers? 1. Cellular phone 2. Map of the area 3. Personal handgun 4. Can of Mace Answer: 1 Explanation: 1. Cellular phones provide a means of contact, and are advisable for the nurse to carry. 2. A map may be helpful but is not a safety device. 3. A handgun should not be brought into a client's home. 4. Mace is not a device that should be brought into a client's home. Page Ref: 648 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 5.3 Contribute to a culture of provider and work environment safety. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.11 Summarize actions a nurse should take to ensure personal safety as well as fostering a caring relationship during a home visit.

17) The nurse is teaching a postpartum client when light housekeeping can be resumed. Which response by the client indicates accurate understanding of the information provided? 1. "I can resume light housekeeping after the 6-week postpartum checkup." 2. "I can resume light housekeeping during my first week at home." 3. "I can resume light housekeeping during my second day at home." 4. "I can resume light housekeeping as my energy allows." Answer: 4 Explanation: 1. Light activity can be added in slowly over the initial postpartum period as she feels the energy to do so. 2. The transition to light housekeeping should be slow over the initial postpartum period, as energy allows. 3. The transition to light housekeeping should be slow over the initial postpartum period, as energy allows. 4. The postpartum client can resume and add more activity over the next few days and weeks as her energy allows. Page Ref: 647 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 29.10 Identify the main purposes and components of home visits during the postpartum period.

18) Which is the obese postpartum client at a greater risk of experiencing? Select all that apply. 1. Injury 2. Infection 3. Breast engorgement 4. Deep vein thrombosis 5. Respiratory complications Answer: 1, 2, 4, 5 Explanation: 1. The obese postpartum client is at a greater risk for injury. 2. The obese postpartum client is at a greater risk for infection. 3. This is not a greater risk for the obese postpartum client. 4. The obese postpartum client is at a greater risk for thromboembolic disease, such as deep vein thrombosis (DVT). 5. The obese postpartum client is at a greater risk for respiratory complications. Page Ref: 645 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment; Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.7 Explain the specific postpartum needs for women with obesity, developmental disabilities, mental health issues, or history of sexual abuse.

19) The nurse is providing postpartum care to a client who a lesbian and her life partner. Which nursing actions are appropriate when providing care to this couple? Select all that apply. 1. Providing the couple with the same rights and care as those given to heterosexual couples 2. Educating the couple about contraception during the postpartum period 3. Teaching the couple about when it is safe to resume sexual relations 4. Encouraging the couple to join a support group of other postpartum lesbian couples 5. Inviting both the client and the partner to share their parenting concerns Answer: 1, 3, 4, 5 Explanation: 1. Lesbian couples should be given the same rights and care as heterosexual couples in the acute care environment 2. Contraception is not needed for a Lesbian couple as there is not a risk of conception. 3. Lesbian couples require education regarding the safe resumption of sexual relations. 4. Lesbian couples should be encouraged to seek support, including joining a support group with other postpartum lesbian couples. 5. The partner often assumes a comothering role, so it is appropriate to invite both the client and her partner to share their parenting concerns and to provide both of them with patient education related to care of the newborn. Page Ref: 645 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.8 Identify postpartum teaching needs that should be modified to provide sensitive care to meet the needs of lesbian mothers.

20) The nurse is instructing a postpartum client on the use of perineal pads. Which statements should the nurse include in the teaching session? Select all that apply. 1. "Apply the pad from back to front." 2. "Change the pad after each perineal cleansing." 3. "Place the pad so that it applies pressure to the perineum." 4. "Change the pad each time you use the bathroom." 5. "Your pad should be loose to allow the perineum to 'breathe.' " Answer: 2, 4 Explanation: 1. The pad should be applied front to back to avoid contamination. 2. The perineal pad should be changed after each perineal cleansing. 3. The pad should be placed snuggly but not applying pressure to the perineum. 4. The perineal pad should be changed after urination and defecation. 5. A loose pad may cause some chaffing of the perineal area causing contamination. Page Ref: 634 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 29.9 Identify teaching topics related to postpartum discharge.

21) The nurse is conducting discharge teaching for a postpartum client who has an episiotomy. Which client actions indicate correct understanding of the information presented? Select all that apply. 1. Using topical anesthetics regularly 2. Remaining in the sitz bath for 20 minutes 3. Using the peri-bottle to cleanse the site after urination 4. Stating that she will loosen her buttocks prior to sitting down 5. Stating that she will continue to use an ice pack for pain after discharge Answer: 1, 2, 3 Explanation: 1. The use of topical anesthetics regularly after an episiotomy is a client action that indicates correct understanding of episiotomy care. 2. The postpartum client who remains in a sitz bath for 20 minutes is correctly caring for an episiotomy. 3. The use of a peri-bottle each time the postpartum client urinates indicates correct understanding of episiotomy care. 4. Tightening of the buttocks is suggested prior to sitting down 5. Ice packs are suggested in the first 24 hours to reduce swelling but are not usually needed at home. Page Ref: 635 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 29.9 Identify teaching topics related to postpartum discharge.

22) Which will the nurse include in the family assessment for the postpartum client? Select all that apply. 1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 4. Signs and symptoms of infection 5. Level of comfort with newborn care Answer: 1, 2, 3, 5 Explanation: 1. The nurse assesses parental role adjustment during the family assessment for the postpartum client. 2. The nurse assesses bonding behaviors during the family assessment for the postpartum client. 3. The nurse assesses sibling adjustment during the family assessment for the postpartum client. 4. Signs and symptoms of an infection are not part of a family assessment. 5. The nurse assesses level of comfort with newborn care during the family assessment for the postpartum client. Page Ref: 642 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.12 Describe maternal and family assessment and anticipated progress after birth.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 30 The Postpartum Family at Risk 1) The nurse is assisting a multiparous postpartum woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. Which is the priority nursing action? 1. Assist the client to empty her bladder. 2. Help the client back to bed to check her fundus. 3. Assess her blood pressure and pulse. 4. Begin an IV of lactated Ringer infusion. Answer: 2 Explanation: 1. The client might be experiencing a postpartum hemorrhage. Her fundus is not contracting well. Although this might be due to a full bladder, the priority nursing action is to assess and massage the fundus. 2. Massaging the fundus is the priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss. 3. Massaging the fundus is the top priority because of the excessive blood loss. Blood pressure and pulse do not change until 1000 to 2000 mL of blood has been lost. Massaging the fundus will prevent further blood loss. 4. Massaging the fundus is the top priority because of the excessive blood loss. An IV might need to be started if the client becomes symptomatic. Page Ref: 669 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late postpartum hemorrhage.

2) A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse anticipates which prescriptions from the healthcare provider? Select all that apply. 1. Methylergonovine maleate (Methergine) 2. Butorphanol tartrate (Stadol) 3. Misoprostol (Cytotec) 4. Betamethasone (Diprolene) 5. Fentanyl (Duragesic) Answer: 1, 3 Explanation: 1. Methylergonovine maleate is a drug of choice for postpartum hemorrhage. 2. Stadol is an analgesic, and is not used for postpartum hemorrhage. 3. Misoprostol is commonly administered rectally for postpartum hemorrhage. 4. Betamethasone is a glucocorticoid used for preterm labor in an attempt to decrease respiratory distress in the preterm infant. 5. Fentanyl is an analgesic, and is not used for postpartum hemorrhage. Page Ref: 672 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late postpartum hemorrhage.

3) The postpartum client who delivered a newborn 2 days ago develops endometritis. Which entry in the medical record would the nurse expect to find when reviewing the client's history? 1. "Cesarean birth performed secondary to arrest of dilation." 2. "Rupture of membranes occurred 2 hours prior to delivery." 3. "External fetal monitoring used throughout labor." 4. "Client has history of pregnancy-induced hypertension." Answer: 1 Explanation: 1. Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical examinations necessary to assess for arrest of dilation are another risk factor for postpartum infection. 2. Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum endometritis. 3. Internal fetal monitoring (both internal fetal scalp electrode and intrauterine pressure catheter) is risk factors for postpartum endometritis. 4. Pregnancy-induced hypertension is not a risk factor for development of postpartum endometritis. Page Ref: 677 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

4) The postpartum client presents to the maternity clinic with complaints of urinary urgency and dysuria 3 days after hospital discharge. Which statement is the most important for the nurse to make? 1. "Void into this sterile cup without touching the inside of the cup." 2. "Be sure to wipe from back to front after you have a bowel movement." 3. "Call the clinic if you develop nausea and vomiting or constipation." 4. "Decrease your fluid intake for a few days, but eat a lot of vegetables." Answer: 1 Explanation: 1. A clean-catch urine sample will need to be obtained for urinalysis to determine if the client has developed a urinary tract infection. 2. Clients should be taught to wipe from front to back after bowel movements in order to prevent contamination of the urethra and bladder with normal bowel flora. 3. A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever and flank pain. Constipation is not associated with urinary tract infections. 4. Clients should increase their fluid intake but decrease their consumption of carbonated beverages. Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables do not help clear or prevent urinary tract infections. Page Ref: 681 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

5) Which method of initial assessment would best indicate whether a postpartum client is experiencing a urinary complication? 1. Urine pH 2. Calculation of urine output 3. Urine specific gravity 4. Calculation of intake Answer: 2 Explanation: 1. Urine pH and urine specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. 2. Calculation of output would provide a better assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection. 3. Urine pH and urine specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. 4. Monitoring intake is an intervention that may help prevent urinary complications but calculating the intake itself would not indicate a complication. Page Ref: 681 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

6) A postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. Which response by the nurse is the most appropriate? 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it toward the nipple to unblock that duct." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe." Answer: 1 Explanation: 1. A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis. 2. It is not unusual for mothers to develop complications similar to those experienced in prior pregnancies. 3. Warm packs, not cold packs, should be applied to areas that are warm, red, or hardened. 4. The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for detecting early onset of the infection. Massaging the area to unplug the duct and relieve milk stasis is much more effective. Page Ref: 683 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

7) Which assessment data support the nurse's suspicion that a postpartum client has mastitis? Select all that apply. 1. Pain in the nipple during breastfeeding described as "shooting" 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Breast engorgement prior to each feeding Answer: 1, 2 Explanation: 1. The pain associated with mastitis is described as "shooting" pain that occurs during breastfeeding. 2. Mastitis is characterized by late-onset of nipple pain. 3. The skin of the affected breast, not nipple, becomes pink, flaking, and pruritic. 4. Nipple soreness often occurs if the infant is not latching onto the breast correctly. This is not a symptom associated with mastitis. 5. Breast engorgement prior to each feeding is not a clinical manifestation associated with mastitis. Page Ref: 682 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

8) The postpartum client is diagnosed with thrombophlebitis in the right leg. Which assessment finding requires immediate intervention by the nurse? 1. Acute pain 2. Redness 3. Chest pressure 4. Edema Answer: 3 Explanation: 1. Acute pain often accompanies diagnosis of thrombophlebitis. While the pain is important and should be addressed, this finding does not require priority nursing intervention. 2. Redness often accompanies diagnosis of thrombophlebitis. While the redness should be noted and monitored, this does not require priority nursing intervention. 3. A sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a lifethreatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention by the nurse. 4. Edema often accompanies diagnosis of thrombophlebitis. While the swelling should be noted and monitored, this does not require priority nursing intervention. Page Ref: 684 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

9) The nurse is revising the care plan of a postpartum client who develops mastitis. Which problem is the most appropriate for inclusion in this client's updated plan of care? 1. Pain 2. Anxiety 3. Nausea 4. Fever Answer: 1 Explanation: 1. Potential clinical problems include pain due to trauma to the breast and difficulties in breastfeeding due to pain. 2. Anxiety is not a problem associated with mastitis. 3. Nausea is not a problem associated with mastitis. 4. Fever is not a problem associated with mastitis. Page Ref: 683 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

10) The nurse is performing wellness checks for postpartum clients after hospital discharge via the telephone. Which client should be seen immediately? 1. The client who at 4 weeks postpartum describes feeling sad all the time. 2. The client who at 2 weeks postpartum reports hearing voices talking about the baby. 3. The client who at 1 week postpartum states that she has no appetite and feels tired all the time. 4. The client with a history of depression who states she needs a refill on her sertraline (Zoloft) in 1 week. Answer: 2 Explanation: 1. While this may indicate postpartum blues or postpartum depression, this client does not require an immediate appointment to be seen. 2. This is an indication the client is experiencing postpartum psychosis, and is the highest priority, because the voices might tell her to harm her baby. 3. While this may indicate postpartum blues or postpartum, this client does not require an immediate appointment to be seen. 4. A client on medications needs refills on time, but right now she has medication, and therefore is not a high priority. Page Ref: 691 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

11) The maternal nurse educator is conducting a presentation for antepartum clients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in the teaching content? 1. Postpartum depression occurs in as many as 50% to 70% of mothers, and is characterized by mild depression interspersed with happier feelings. 2. Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks. 3. Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum. 4. Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror. Answer: 3 Explanation: 1. As many as 50% to 70% of mothers develop adjustment reaction with depressed mood, which is also known as postpartum blues or as maternal or baby blues. Unlike postpartum depression, this condition is characterized by mild depression interspersed with happier feelings. 2. Postpartum blues typically manifest as mild symptoms that are transient and self-limiting. Postpartum depression is severe and poses major threats to the woman and the infant, as well as to the father/partner. 3. Women with a history of postpartum psychosis or depression or other risk factors should be referred to a mental health professional for counseling and biweekly visits between the second and sixth week postpartum for evaluation. 4. Posttraumatic stress disorder, or PTSD (also called posttraumatic stress syndrome), is associated with exposure to an extremely traumatic event involving direct personal experience with actual or threatened death or serious injury, and evokes a reaction of intense fear, helplessness, or horror. Page Ref: 691 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

12) The charge nurse is reviewing the plan of care for maternal clients currently admitted for postpartum care. During the course of the medical record review, which intervention requires immediate consideration for revision? 1. Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis. 2. Use of the REEDA (redness, edema, ecchymosis, discharge, approximation) scale for assessment every 8 hours in the care of a client diagnosed with puerperal infection. 3. Misoprostol (Cytotec) administration to a client who demonstrates uterine atony and bleeding after receiving oxytocic medications. 4. Inserting a straight catheter to drain the overdistended bladder of a client during the early postpartum period of her care. Answer: 1 Explanation: 1. Prothrombin time (PT) evaluates the anticoagulation effects of warfarin (Coumadin); the effects of heparin are assessed by way of activated partial thromboplastin time (aPTT). 2. The nurse should inspect the woman's perineum every 8 to 12 hours for signs of early infection. The REEDA scale helps the nurse remember to consider redness, edema, ecchymosis, discharge, and approximation. 3. Misoprostol (Cytotec) is used to prevent and treat uterine atony after failed attempts to control bleeding with oxytocics. 4. Overdistention in the early postpartum period is often managed by draining the bladder with a straight catheter as a one-time measure. Page Ref: 685 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

13) The nurse is providing care to a postpartum client 24 hours after delivery who has been diagnosed with metritis. Which response by the nurse is accurate when the client asks what made her sick? 1. "Early infections such as this are often caused by group beta strep (GBS)." 2. "Most infections are often caused by a chlamydial infection. Do you practice safe sex?" 3. "You must have already been sick when you came to deliver your baby." 4. "There is no way to knowing why you got sick. Sometimes, it just happens." Answer: 1 Explanation: 1. Most early metritis infections are caused by group beta strep (GBS). 2. Most late, not early, metritis infections are caused by chlamydia. Also, it is not appropriate to ask her about safe sex practices at this time. 3. Telling the client that she was sick when she came to deliver the baby is often not true and does not specifically address the client's question. 4. This response is inaccurate as most cases of early metritis are attributed to a GBS infection. Page Ref: 677 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 30.2 Explain the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection.

14) The nurse is conducting discharge instruction for a postpartum client. Which client response indicates accurate understanding of when to notify the healthcare provider? 1. "If I am having trouble getting the baby to latch on, I should call my doctor." 2. "If I continue to have pain after taking my prescribed analgesic, I should call my doctor." 3. "If I saturate one pad every 8 hours, I should call my doctor." 4. "If I don't have a bowel movement within 24 hours of going home, I should call my doctor." Answer: 2 Explanation: 1. Issues with getting the baby to latch on during breastfeeding should be reported but not to the doctor. The client would be instructed to contact a lactation consultant. This statement indicates the need for further education. 2. Pain that is not alleviated by the prescribed analgesic is cause for concern and would require healthcare provider notification. This statement indicates accurate understanding of the information presented. 3. Saturation of one peripad every hour, not every 8 hours, would indicate the need to contact the healthcare provider. This statement indicates the need for further education. 4. The return of bowel function varies with every woman after childbirth. Not having a bowel movement within 24 hours of discharge is not an indication of a problem and would not require the client to contact the healthcare provider. This statement indicates the need for further education. Page Ref: 676 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Evaluation/Teaching and Learning Learning Outcome: 30.4 Evaluate the woman's knowledge of health promotion measures and signs of postpartum complications to be reported to the primary care provider.

15) The nurse is assessing a postpartum client's risk for early postpartum hemorrhage. Which findings in the client's health history place this client at an increased risk for early postpartum hemorrhage? Select all that apply. 1. Microsomia 2. Grand multiparity 3. African American heritage 4. Oxytocin induction of labor 5. History of anorexia nervosa Answer: 2, 4 Explanation: 1. Macrosomia, not microsomia, increases the postpartum client's risk for early hemorrhage. 2. Grand multiparity is one risk factor for early postpartum hemorrhage. 3. Asian or Hispanic, not African American, heritage places the postpartum client at an increased risk for hemorrhage. 4. The use of oxytocin to augment, or induce, labor is a risk factor for early postpartum hemorrhage. 5. Obesity, not a history of anorexia nervosa, is a risk factor for early postpartum hemorrhage. Page Ref: 669 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Identify the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for early and late postpartum hemorrhage.

16) The nurse is assessing a postpartum client who is 36 hours post delivery. Which findings cause the nurse to suspect a reproductive tract infection? Select all that apply. 1. Temperature of 38.0°C (100.4°F) or higher 2. Foul-smelling lochia 3. Uterine tenderness 4. Leg edema and erythema 5. Breast engorgement Answer: 1, 2, 3 Explanation: 1. A temperature of 38.0°C (100.4°F) or higher is an indication that the postpartum client is experiencing a reproductive tract infection. 2. Foul-smelling lochia is an indication that the postpartum client is experiencing a reproductive tract infection. 3. Uterine tenderness is an indication that the postpartum client is experiencing a reproductive tract infection. 4. Leg edema and erythema is an indication of thrombophlebitis, not a reproductive tract infection. 5. Breast engorgement is not an indication of a reproductive tract infection. Page Ref: 678 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.2 Explain the causes, contributing factors, signs and symptoms, clinical therapy, and nursing interventions for reproductive tract infection.

17) The nurse is planning care for a postpartum client. Which data in the client's history increase the risk for postpartum depression? Select all that apply. 1. Type 1 diabetes mellitus (DM) 2. Bipolar disorder 3. Premenstural dysphoric disorder (PMDD) 4. Recent relocation to a new city 5. Family history of hypertension Answer: 2, 3, 4 Explanation: 1. A personal or family history of type 1 DM is not a risk factor for postpartum depression. 2. A personal or family history of bipolar disorder is a risk factor for postpartum depression. 3. A personal history of PMDD is a risk factor for postpartum depression. 4. Poor support from family and friends, which can occur due to a recent relocation to a new city, is a risk factor for postpartum depression. 5. A family history of hypertension is not a risk factor for postpartum depression. Page Ref: 690 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

18) The nurse is reviewing the medical record for a postpartum client. Which findings would necessitate the need for the nurse to monitor the client closely for the development of thrombophlebitis? Select all that apply. 1. Vaginal birth 2. 25 years of age 3. History of diabetes mellitus 4. Current smoker 5. Laboratory values indicating anemia Answer: 3, 4, 5 Explanation: 1. A cesarean, not vaginal, birth increases the postpartum client's risk for the development of thrombophlebitis. 2. Advanced maternal age increases the postpartum client's risk for the development of thrombophlebitis. The 25-year-old postpartum client does not have an increased risk for thrombophlebitis. 3. A history of diabetes mellitus is a risk factor for the development of thrombophlebitis during the postpartum period. 4. Cigarette smoking is a risk factor for thrombophlebitis during the postpartum period. 5. Anemia is a risk factor for the development of thrombophlebitis during the postpartum period. Page Ref: 684 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.3 Develop a nursing care plan that reflects knowledge of etiology, pathophysiology, current clinical therapy, and nursing and preventive management for the woman experiencing urinary tract infection, lactation mastitis, thromboembolic disease, or a postpartum psychiatric disorder.

19) The nurse conducts discharge teaching for a postpartum client who is diagnosed with deep vein thrombosis (DVT). Which statements indicate accurate understanding of the information presented? Select all that apply. 1. "I will cross my legs while I sit and watch TV in the evening." 2. "I will wear supportive stockings if I have to stand for long periods of time." 3. "I will only have to continue taking Coumadin for 1 month once I am home." 4. "If I develop bleeding gums, I should contact my healthcare provider." 5. "I should plan to elevate my legs during times of rest." Answer: 2, 4, 5 Explanation: 1. The client would be instructed not to cross the legs while sitting as this can increase venous stasis, which further increases the client's risk for more DVTs. This statement indicates the need for further education. 2. The use of supportive stockings if the client has to stand for long periods of time is recommended when diagnosed with DVT. This statement indicates correct understanding of the information presented. 3. Clients diagnosed with a DVT will require warfarin (Coumadin) therapy for 2 to 6 months, not 1 month, after discharge. This statement indicates the need for further education. 4. Bleeding of the gums while on warfarin (Coumadin) therapy can be an indication of a dose that is too large and would be reported to the healthcare provider. This statement indicates correct understanding of the information presented. 5. The postpartum client who is diagnosed with DVT should plan to elevate the legs during times of rest. This statement indicates correct understanding of the information presented. Page Ref: 685 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 30.4 Evaluate the woman's knowledge of health promotion measures and signs of postpartum complications to be reported to the primary care provider.

20) The nurse is conducting teaching for a postpartum client who is approaching discharge. Which topics will the nurse include in the educational session regarding the prevention of postpartum hemorrhage? Select all that apply. 1. Using the peri-bottle 2. Applying ice to the breasts 3. Wearing cotton underwear 4. Performing fundal massage 5. Inspecting the episiotomy site Answer: 1, 4, 5 Explanation: 1. The nurse includes education on the use of the peri-bottle during discharge instructions regarding the prevention of postpartum hemorrhage. 2. Application of ice is an appropriate topic when teaching the postpartum client to avoid engorgement. This information is not appropriate when teaching methods to prevent postpartum hemorrhage. 3. The use of cotton underwear is an appropriate topic when teaching the postpartum client to avoid a urinary tract infection (UTI), not postpartum hemorrhage. 4. The nurse includes education on performing fundal massage during discharge instructions regarding the prevention of postpartum hemorrhage. 5. The nurse includes education on inspecting the episiotomy site during discharge instructions regarding the prevention of postpartum hemorrhage. Page Ref: 676 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.4 Evaluate the woman's knowledge of health promotion measures and signs of postpartum complications to be reported to the primary care provider.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 31 Growth and Development 1) While being comforted in the emergency department, the 6-year-old male sibling of a pediatric trauma victim blurts out to the nurse, "It's all my fault! When we were fighting yesterday, I told him I wished he was dead!" Which response by the nurse is most therapeutic? 1. Asking the child if he would like to sit down and drink some water 2. Sitting the child down in an empty room with markers and paper so that he can draw a picture 3. Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have no control over whether an accident happens 4. Discussing the catheters, tubes, and equipment that the sibling requires, and explaining why they are needed Answer: 3 Explanation: 1. Ignoring the child's outburst will not help the child understand it really was not his fault. 2. Asking the child to draw a picture might be appropriate later, but the nurse first needs to make sure the child knows the trauma did not occur because of anything he said. 3. Magical thinking is the belief that events occur because of one's thoughts or actions, and the most therapeutic way to respond to this is to correct any misconceptions that the child might have and reassure him that he is not to blame for any accident or illness. 4. Addressing the sibling's needs and equipment reinforces the child's magical thinking that the trauma was his fault. Page Ref: 703 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.C.1. Appreciate strengths and weaknesses of scientific bases for practice | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.1 Describe the major theories of development as formulated by Freud, Erikson, Piaget, Kohlberg, social learning theorists, and behaviorists.

2) The nurse is conducting a physical assessment for a pediatric client. Which part of Bronfenbrenner's ecologic theory of development is the nurse assessing when discussing the parents' work environment in relation to the client? 1. Chronosystem 2. Mesosystem 3. Macrosystem 4. Exosystem Answer: 4 Explanation: 1. The chronosystem involves the perspective of time in the child's life. 2. The relationships of one microsystem to another involve a child's mesosystem. 3. Political and cultural beliefs comprise a child's macrosystem. 4. A child's exosystem is composed of the settings that influence a child even though he or she is not in daily contact with that system. Page Ref: 705 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.C.1. Appreciate strengths and weaknesses of scientific bases for practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.4 Explain contemporary developmental approaches such as temperament theory, ecological theory, and the resilience framework.

3) The parents of a toddler are concerned that their child seems different from their other child, stating, "He just doesn't seem to like new people and wants us with him in these situations." Which response by the nurse is appropriate when using the temperament theory to respond to the toddler's parents? 1. "Your child seems to withdraw from new situations. This is typical with slow-to-warm-up children." 2. "Your child is having an intense reaction to the environment and new people, and we will need to investigate this more closely." 3. "Difficult children often display a negative mood. Does your child often throw temper tantrums?" 4. "Slow-to-warm-up children are often diagnosed with autism spectrum disorder." Answer: 1 Explanation: 1. Slow-to-warm-up children adapt slowly to new situations and initially will withdraw. 2. Having intense reactions to the environment is a characteristic of "difficult" children. The child in this scenario is not displaying this temperament. This response is inaccurate and not appropriate. 3. Displaying a predominately negative mood to the environment is a characteristic of "difficult" children. The child in this scenario is not displaying this temperament. This response is inaccurate and not appropriate. 4. Slow-to-warm-up children are not often diagnosed with autism spectrum disorder. This statement is inaccurate and not appropriate. Page Ref: 706 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.C.1. Appreciate strengths and weaknesses of scientific bases for practice | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 31.4 Explain contemporary developmental approaches such as temperament theory, ecological theory, and the resilience framework.

4) The parents of a 12-month-old client ask the nurse for suggestions regarding age-appropriate toys for their child. Which toys are appropriate for the nurse to recommend for this client? Select all that apply. 1. Soft toys that can be mouthed 2. Toys with black-and-white patterns 3. Toys that can pop apart and go back together 4. Jack-in-the-box toys 5. Push-and-pull toys Answer: 3, 4, 5 Explanation: 1. A 12-month-old client is more mobile and shows less interest in soft toys that can be placed in the mouth. 2. A 12-month-old client will tend to enjoy colorful toys, not toys with black-and-white patterns. 3. A 12-month-old client has gross and fine motor skills that are becoming more developed and enjoys toys that can help them refine these skills. 4. A 12-month-old client enjoys toys that can be manipulated and that grab his or her attention. A jack-in-the-box toy allows both. 5. A 12-month-old client is learning to walk and will enjoy toys that promote mobility. Page Ref: 714 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.5 Identify major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents.

5) While assessing the development of a 9-month-old client, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which is the nurse assessing with this question to the parent? 1. Transductive reasoning 2. Conservation 3. Centration 4. Object permanence Answer: 4 Explanation: 1. Transductive reasoning is when a child connects two events in a cause—effect relationship because the events occurred at the same time. 2. Conservation is when a child knows that matter is not changed when its form is altered. 3. Centration is when a child focuses on only one particular aspect of a situation. 4. A child who has developed object permanence has the ability to understand that even though something is out of sight, it still exists. Page Ref: 716 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.5 Identify major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents.

6) The nurse is assessing language development in all the pediatric clients presenting at the healthcare provider's office for well-child visits. At which age would the nurse further assess language development if the client is unable to verbalize the words "dada" and "mama"? 1. 3 months 2. 6 months 3. 8 months 4. 12 months Answer: 4 Explanation: 1. By 3 months of age, infants vocalize during play and with familiar people. The infant may also begin to laugh. At this time, they do not use these as names for the parents. 2. By 6 months of age, infants will be making the sounds "mamamamam" and "dadadada" because they like to repeat sounds. At this time, they do not use these as names for the parents. 3. By 8 months of age, infants will be making the sounds "mamamamam" and "dadadada" because they like to repeat sounds. At this time, they do not use these as names for the parents. 4. By 12 months of age, children should be able to verbalize "mama" or "dada" to identify their mother or father. This client would require further assessment by the nurse. Page Ref: 713 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.6 Synthesize information from several theoretical approaches to plan assessments of the child's physical growth and developmental milestones.

7) Two 3-year-old clients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play are these children participating in based on this scenario? 1. Cooperative play 2. Solitary play 3. Parallel play 4. Associative play Answer: 3 Explanation: 1. Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole. The school-age child participates in cooperative play. 2. Solitary play is when a child plays alone. Infants' play style is described as solitary. 3. Parallel play is when two or more children play together, each engaging in his or her own activities. 4. Associative play is characterized by children interacting in groups and participating in similar activities. Preschoolers' play style is associative. Page Ref: 716 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.3 Plan nursing interventions for children that are appropriate for each child's developmental state based on theoretical frameworks.

8) The nurse is teaching new parents how to communicate with their infant. Which response by the parents indicates accurate understanding of the information presented? 1. "I will prop the bottle while my baby is in the car seat so that I can cook dinner." 2. "I will use a low-pitched voice while talking to my baby as this is most appropriate." 3. "I will unwrap my baby when she is upset to allow interaction with the environment." 4. "I will talk and sing to my baby while I am providing daily care, including diaper changes." Answer: 4 Explanation: 1. Parents should hold their babies during feedings as a method of communicating with their infants. This parental response indicates the need for further education. 2. Parents should use a high-pitched, not low-pitched, voice when talking with their infant children. This parental response indicates the need for further education. 3. Parents should swaddle and hold their infants when they are upset as a communication method. Unwrapping the baby when the baby is upset indicates the need for further education. 4. Parents should talk and sing to their infants while providing daily care, such as diaper changes. This parental response indicates accurate understanding of the information presented. Page Ref: 714 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 31.3 Plan nursing interventions for children that are appropriate for each child's developmental state based on theoretical frameworks.

9) While trying to inform a 5-year-old child about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. Which response by the nurse is age appropriate? 1. "You must be so excited to have a new puppy! They are so much fun. Now let me tell you again about going downstairs in a wheelchair to a special room." 2. Redirect the child by saying, "Please stop talking about your puppy. I need to tell you about your CT scan." 3. "I'll come back when you are ready to talk with me more about your CT scan." 4. Ignore the information regarding the puppy and state, "I need to teach you about going to the special room later today." Answer: 1 Explanation: 1. When a child becomes engaged in a collective monologue, it is best to respond to the content of her conversation and then attempt to reinsert facts about the content that needs to be covered. 2. Asking the child to stop talking about her puppy and then abruptly talking about the CT scan will alienate the child and possibly make her shut down. 3. Coming back later is not usually an option, as radiologic exams are scheduled for a certain time. The nurse needs to address the inattention but should listen for a few moments before directing the client's attention. 4. Ignoring the child's obvious lack of attention will not help prepare her for the upcoming procedure. Page Ref: 721 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 31.3 Plan nursing interventions for children that are appropriate for each child's developmental state based on theoretical frameworks.

10) The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism will the nurse include when responding to the mother? 1. Repression 2. Rationalization 3. Fantasy 4. Regression Answer: 4 Explanation: 1. Repression is the involuntary forgetting of uncomfortable situations. The child is not exhibiting repression. 2. Rationalization is an attempt to make unacceptable feelings acceptable. The child is not exhibiting rationalization. 3. Fantasy is a creation of the mind to help deal with an unacceptable fear. The child is not exhibiting fantasy. 4. Regression is a return to an earlier behavior and can often occur during a hospital stay. The nurse will include regression in the response to the mother. Page Ref: 699 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.2 Recognize risks to developmental progression and factors that protect against those risks.

11) The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure? 1. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker." 2. "We will give you your shot when your mommy comes back." 3. "I will wipe your skin with a magic wipe and then hold the needle like this and say 'one, two, three, go' and give you your shot. Are you ready?" 4. "This is a magic sword that will give you your medicine and make you all better." Answer: 1 Explanation: 1. The most appropriate response would be to acknowledge the child's feelings, and allow the child to pick out a sticker at the conclusion of the injection. 2. Waiting for the mother to come back would be inappropriate because toddlers do not have an understanding of time. 3. Giving elaborate descriptions and using colorful language are inappropriate because the instructions are unclear and lengthy. 4. The nurse should not make statements that are not true and might confuse the child. Page Ref: 718 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 31.8 Use data collected during developmental assessments to implement activities that promote development of children and adolescents.

12) An adolescent client diagnosed with cystic fibrosis suddenly becomes noncompliant with the medication regimen. Which nursing intervention would most likely improve compliance? 1. Give the client a computer-animated game that presents information on the management of cystic fibrosis. 2. Set up a meeting with other adolescents with the cystic fibrosis who have been managing their disease effectively. 3. Arrange for the primary healthcare provider to sit down and talk to the client about the risks related to noncompliance with medications. 4. Discuss with the client's parents that privileges, such as a cell phone, can be taken away if compliance fails to improve. Answer: 2 Explanation: 1. Interest in games might begin to wane during adolescence. 2. Providing adolescents with positive role models who are in their peer group is the intervention most likely to improve compliance. 3. Adult opinions, even from a primary healthcare provider, could be viewed negatively and challenged. 4. Threatening punishment could further incite rebellion. Page Ref: 726 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.8 Use data collected during developmental assessments to implement activities that promote development of children and adolescents.

13) The home health nurse is conducting a home visit for a family. The toddler-age child, who is potty training, has an "accident." The mother becomes angry with the child and calls him a baby for messing himself. Which is the nurse concerned with regarding the toddler's development, based on the mother's reaction? 1. The child's cognitive development 2. The child's sense of independence 3. The child's conscience 4. The child's superego Answer: 2 Explanation: 1. Erikson's theory is related to psychosocial development. The mother's criticism will not affect the child's ability to think. 2. Erikson's toddler stage is autonomy (independence) versus shame and doubt. The mother's criticism may hinder the child's sense of independence. 3. Conscience is what controls our knowledge of right and wrong and is a component of Kohlberg's theory. The mother's criticism will not affect the child's conscience, according to Kohlberg. 4. In Freudian theory, the superego is the moral and ethical system of the personality. The mother's criticism will not affect the child's superego. Page Ref: 700 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.6 Synthesize information from several theoretical approaches to plan assessments of the child's physical growth and developmental milestones.

14) The clinic administrator has suggested that the nurse teach all children newly diagnosed with diabetes in a single class to save nursing time. The children recently diagnosed range in age from 6 to 15. Which is the rationale for the nursing staff to continue with more than one group session? 1. Freud's theory of psychosexual development, which states that the 6-year-old child's sexual energy is at rest while the adolescent has developed mature sexuality. 2. Erikson's psychosocial theory, which discusses how children learn to relate to others. 3. Piaget's cognitive development theory, which says the 6-year-old child learns by concrete examples, while the 15-year-old adolescent can think abstractly. 4. Kohlberg's theory, which says the young children are conventional in their thinking and will want to learn to please others, while older children can internalize values and will learn for their own principles. Answer: 3 Explanation: 1. This theory would not explain why it would be the best to separate the group by age. 2. Erikson's theory is about relationships, not learning ability. 3. The younger child will need to handle the equipment, and observe demonstrations, while the older child will require more discussion and less demonstration. 4. Kohlberg's theory may explain the reasons the child learns the material but does not discuss the learning style. Page Ref: 702 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Planning/Teaching and Learning Learning Outcome: 31.6 Synthesize information from several theoretical approaches to plan assessments of the child's physical growth and developmental milestones.

15) As children grow and develop, their style of play changes. Place the descriptions of play styles in order from infancy to school age. 1. Plays beside but not with other children 2. Plays games with other children and is able to follow the rules of the game 3. Plays alone with play directed by others 4. Plays with others in loose groups Answer: 3, 1, 4, 2 Explanation: 1. This describes parallel play, seen in toddlers. 2. This describes cooperative play, seen in the school-age child. 3. This describes infant-style play, called solitary play. 4. This describes associative play, which is seen in the preschooler. Page Ref: 714; 717, 718; 721 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: I2.5 Develop a plan of care. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.5 Identify major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents. 16) A 10-year-old client has been struggling with his self-esteem. Which activity would best help this child have a positive resolution of Erikson's industry versus inferiority stage? 1. Playing sports with his older brother and the brother's friends 2. Having his mother compliment him when he completes his homework 3. Encouraging the child to participate in Boy Scouts and earn badges 4. Suggesting to the mother that she allow the child to babysit his younger siblings Answer: 3 Explanation: 1. This would not help the child develop a positive self-esteem because the older boys will be more skilled at the sport than this child. 2. Positive reinforcement is beneficial but does not support the development of industry. 3. The badges will be a visible documentation of his accomplishments. 4. The 10-year-old cannot safely babysit the younger children, and this is unrelated to Erikson's sense of industry. Page Ref: 700 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.3 Plan nursing interventions for children that are appropriate for each child's developmental state based on theoretical frameworks.

17) Two hospitalized pediatric clients are working on a puzzle together in the hospital playroom. Which type of play are the clients exhibiting? 1. Solitary play 2. Associative play 3. Parallel play 4. Cooperative play Answer: 4 Explanation: 1. Solitary play is when a child plays alone. 2. Associative play is characterized by children interacting in groups and participating in similar activities. 3. Parallel play is when two or more children play together, each engaging in his or her own activities. 4. Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole. Page Ref: 722 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.7 Describe the role of play in the growth and development of children.

18) Which nursing actions are developmentally appropriate when caring for a hospitalized school-age child? Select all that apply. 1. Knocking on the school-age child's hospital room door prior to entering 2. Giving clear instructions about details of treatment 3. Providing brochures regarding sexuality 4. Offering medical equipment to play with prior to a procedure 5. Using toys for distraction during a painful procedure Answer: 1, 2 Explanation: 1. It is developmentally appropriate for the nurse to knock on the school-age child's door prior to entering the hospital room to provide care. 2. It is developmentally appropriate for the nurse to give clear instructions to the school-age child regarding details of the treatment. 3. Information regarding sexuality is more appropriate for the adolescent versus the school-age child. 4. Offering medical equipment to play with prior to a procedure is more appropriate for the preschool, not the school-age, child. 5. Using toys for distraction during a painful procedure is more appropriate for the preschool, not the school-age, child. Page Ref: 702 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.3 Plan nursing interventions for children that are appropriate for each child's developmental state based on theoretical frameworks.

19) Which nursing actions are developmentally appropriate when providing care to a hospitalized toddler-age child? Select all that apply. 1. Using a crib mobile for distraction during a procedure 2. Having a potty-chair available 3. Allowing self-feeding opportunities 4. Showing equipment that will be used during the scheduled surgery 5. Assessing drawings to determine concerns Answer: 2, 3 Explanation: 1. A crib mobile would be more developmentally appropriate for the infant, not the toddler-age, child. 2. Many toddlers are potty training; therefore, it is appropriate for the nurse to have a potty-chair available for the child. 3. It is appropriate for the nurse to allow for self-feeding opportunities as this is developmentally appropriate for a toddler-age child. 4. Showing equipment that will be used during a scheduled surgery is not a developmentally appropriate intervention for a toddler-age child. This is more appropriate for the preschool-age child. 5. Assessing drawing to determine concerns is developmentally appropriate for the preschool, not the toddler-age, child. Page Ref: 701 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.3 Plan nursing interventions for children that are appropriate for each child's developmental state based on theoretical frameworks.

20) The nurse is assessing a 6-month-old infant during a scheduled well-baby checkup. Which are expected findings for this infant? Select all that apply. 1. No head lag when pulled for sitting 2. Ability to turn from back to abdomen 3. Manipulates objects. 4. Transfers objects from one hand to the other. 5. A pincer grasp is noted. Answer: 1, 2, 3 Explanation: 1. A 6-month-old infant should not have head lag when pulled for sitting. This is an expected finding. 2. A 6-month-old infant should be able to turn from back to abdomen. This is an expected finding. 3. A 6-month-old infant is able to manipulate objects. This is an expected finding. 4. The nurse would not anticipate that the 6-month-old infant would be able to transfer objects from one hand to the other. This is an unexpected finding. 5. The nurse would not anticipate that the 6-month-old infant would use a pincer grasp. This is an unexpected finding. Page Ref: 712 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.5 Identify major developmental milestones for infants, toddlers, preschoolers, school-age children, and adolescents.

21) The nurse provides education to the parents of a 7-month-old infant regarding play. Which parental responses indicate accurate understanding of the information presented? Select all that apply. 1. "I should offer my baby toys that are black and white." 2. "My baby will prefer stuffed animals during this stage of development." 3. "I should offer my baby a teething ring during this stage of development." 4. "My baby will want to interact with other people." 5. "I should offer my baby large blocks to stack while sitting on the floor." Answer: 3, 4 Explanation: 1. Black and white toys are often preferred by infants from birth to 3 months, not at 7 months. The statement indicates the need for further education. 2. Stuffed animals are often enjoyed by infants between 3 months and 6 months, not at 7 months. The statement indicates the need for further education. 3. Many babies are teething by 7 months of age; therefore, it is appropriate to offer the infant a teething ring. This statement indicates accurate understanding of the information presented. 4. By 6 to 9 months of age, the infant will enjoy interacting with other people. This statement indicates appropriate understanding of the information presented. 5. Stacking blocks is not a skill acquired until 9 to 12 months of age. This statement indicates the need for further education. Page Ref: 714 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching and Learning Learning Outcome: 31.7 Describe the role of play in the growth and development of children.

22) Which activities will the nurse suggest to the parents of a preschool-age child to enhance fine motor skills? Select all that apply. 1. Using scissors 2. Playing with clay 3. Riding a bicycle 4. Throwing a ball 5. Tying shoe laces Answer: 1, 2, 5 Explanation: 1. Using scissors is an activity that will enhance fine motor skills during the preschool years. 2. Playing with clay is an activity that will enhance fine motor skills during the preschool years. 3. Riding a bicycle is an activity that will enhance gross, not fine, motor skills during the preschool years. 4. Throwing a ball is an activity that will enhance gross, not fine, motor skills during the preschool years. 5. Tying shoe laces is an activity that will enhance fine motor skills during the preschool years. Page Ref: 718 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Science: Knowledge: Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.8 Use data collected during developmental assessments to implement activities that promote development of children and adolescents.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 32 Infant, Child, and Adolescent Nutrition 1) Which instruction from the nurse is appropriate when conducting teaching to new parents regarding infant care and feeding? 1. Delay supplemental foods until the infant is 4 to 6 months old. 2. Begin diluted fruit juice at 2 months of age, but wait 3 to 5 days before trying a new food. 3. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age. 4. Delay supplemental foods until the infant reaches 15 pounds or greater. Answer: 1 Explanation: 1. Age 4 to 6 months is the optimal age to begin supplemental feedings. The infant does not need supplemental foods earlier, and introducing supplemental foods earlier does not promote sleep. 2. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age as they lack the digestive enzymes to take in and metabolize many food products. 3. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age as they lack the digestive enzymes to take in and metabolize many food products. Introducing cereal at this stage will not help promote sleep. 4. Earlier feeding of nonformula foods, regardless of the infant's weight, is more likely to cause the development of food allergies. Page Ref: 733 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 32.1 Discuss major nutritional concepts pertaining to the growth and development of children.

2) The nurse is teaching an African American mother of a 3-month-old infant, born in the late fall, who is being exclusively breastfed. Which is the priority nutrient for the nurse to include in the teaching session? 1. Iron 2. Vitamin D 3. Calcium 4. Fluoride Answer: 2 Explanation: 1. An infant's iron stores are usually adequate until about 4 to 6 months of age. 2. This infant will have limited exposure to sunlight due to decreased sun exposure in the fall and winter months. The limited sun exposure combined with the infant's dark skin means the infant may need additional vitamin D. 3. The infant should be receiving sufficient amounts of calcium from breast milk. 4. Fluoride supplementation, if needed, does not begin until the child is approximately 6 months old. Page Ref: 744 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 32.1 Discuss major nutritional concepts pertaining to the growth and development of children.

3) Which statement should the nurse include when teaching parents of an infant about normal growth and development regarding weight gain? 1. "Your baby's weight should triple by 9 months of age." 2. "Your baby's weight should double by 5 months of age." 3. "Your baby's weight should triple by 6 months of age." 4. "Your baby's weight should double by 1 year of age." Answer: 2 Explanation: 1. The normal infant's birth weight triples by 1 year of age. 2. It is expected that the infant would double in weight by 5 months of age. 3. The infant's birth weight should double by 5 months of age. A child whose weight triples by 6 months of age has gained weight too rapidly. 4. The child's birth weight should triple by 1 year of age. This child may not be growing adequately. Page Ref: 738 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 32.1 Discuss major nutritional concepts pertaining to the growth and development of children.

4) The nurse is teaching the parents of a 4-month-old infant about good feeding habits. Which is the rationale for not letting the baby go to sleep with the bottle? 1. To decrease the risk for aspiration 2. To decrease the risk for dental caries 3. To decrease the risk for malocclusion problems 4. To decrease the risk for sleeping disorders Answer: 2 Explanation: 1. There have been limited data to date showing a positive correlation to putting a baby to sleep with a bottle and increased risk of aspiration. 2. Infants should not be put to bed with a bottle as this increases the risk for developing dental caries. 3. The primary concerns related to putting an infant to bed with a bottle are dental caries and otitis media. Poor dental alignment is not a significant problem. 4. Sleeping disorders have not been found to be related to letting an infant go to sleep with a bottle. Page Ref: 731 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 32.1 Discuss major nutritional concepts pertaining to the growth and development of children.

5) A vegetarian adolescent is placed on iron supplementation secondary to a diagnosis of irondeficiency anemia. Which will the nurse encourage the adolescent to drink when taking the daily iron supplement? 1. Orange juice 2. Black or green tea 3. Milk 4. Tomato juice Answer: 1 Explanation: 1. Acidity increases absorption of iron. 2. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron. 3. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron. 4. Foods containing phosphorus, such as in milk; oxalates, such as in tomatoes; and tannins, such as in teas, all decrease absorption of iron. Page Ref: 744 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.2 Describe and plan nursing interventions to meet nutritional needs for all age groups from infancy through adolescence.

6) The nurse is presenting a program on healthy eating habits to the parents of children attending the clinic. Which parental comment indicates the need for more information about safe food preparation? 1. "We always wash our hands well before any food preparation." 2. "We use separate utensils for preparing raw meat and for preparing fruits, vegetables, and other foods." 3. "We take the meat out of the freezer and then allow it to thaw on the counter for 2 to 3 hours before cooking it thoroughly." 4. "If our baby doesn't drink all the formula in his bottle, we throw the rest out." Answer: 3 Explanation: 1. Washing hands removes pathogens from the hands and prevents food contamination. 2. Raw meats are a good source of pathogens. Utensils used on raw meat can transfer the pathogens to other foods if they are not prepared in a manner to destroy these pathogens. 3. Allowing meat to sit out on a counter can cause the bacteria counts to increase quickly, and cooking the meat might not effectively destroy all of the bacteria. Frozen meat should be thawed in the refrigerator prior to cooking. 4. While drinking from a bottle, organisms can be transferred from the baby's mouth to the formula. If this formula is saved, the organisms can multiply in the formula. Page Ref: 743 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 32.4 Identify and explain common nutritional problems of children.

7) During a 4-month-old infant's well-child checkup, the nurse discusses introduction of solid foods into the infant's diet. Although the nurse recommends delaying the introduction of many foods into the diet, which food(s) will the nurse discuss delaying because they increase the risk for food allergy? 1. Honey 2. Carrots, beets, and spinach 3. Pork 4. Cow's milk, eggs, and peanuts Answer: 4 Explanation: 1. Although honey can contain botulism spores that cannot be detoxified by the infant younger than 1 year old, it does not cause an allergic reaction. 2. Carrots, beets, and spinach contain nitrates and should not be given before 4 months of age. 3. The addition of pork is delayed until the infant is 8 to 10 months old because meats are hard to digest. 4. Cow's milk, eggs, and peanuts are foods that have been associated with food allergies. Page Ref: 750 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 32.4 Identify and explain common nutritional problems of children.

8) The parents of a 2.5-year-old boy are concerned about their child's finicky eating habits. While counseling the parents, which statements by the nurse would be accurate? Select all that apply. 1. "Nutritious foods should be made available at all times of the day so that the child is able to 'graze' whenever he is hungry." 2. "The child is experiencing physiologic anorexia, which is normal for this age group." 3. "A general guideline for food quantity at a meal is one quarter cup of each food per year of age." 4. "It is more appropriate to assess a toddler's nutritional demands over a 1-week period rather than a 24-hour one." 5. "The toddler should drink 16 to 24 ounces of milk daily." Answer: 2, 4, 5 Explanation: 1. Food should be offered only at meal and snack times. 2. Physiologic anorexia is caused when the extremely high metabolic demands of infancy slow to keep pace with the slower growth of toddlerhood, and it is a very normal finding at this age. 3. The correct general guideline for food quantity is 1 tablespoon of each food per year of age. 4. It is not unusual for toddlers to have food jags where they only want one or two food items for that day. So it is more helpful to look at what their intake has been over a week instead of a day. 5. Two to three cups of milk per day are sufficient for a toddler; more than that can decrease his desire for other foods and lead to dietary deficiencies. Children should sit at the table while eating to encourage socialization skills. Page Ref: 733 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.4 Identify and explain common nutritional problems of children.

9) The mother of a 6-week-old male infant tells the nurse that her baby has had colic for several days, crying for up to 3 hours and drawing his legs up on his abdomen. The mother says she is at "wits end" and wonders what she can do. The nurse learns that the infant is being formula-fed and gaining weight satisfactorily. Which recommendations will the nurse make based on the current data? Select all that apply. 1. Breastfeeding the infant 2. Switching to a bottle that has a collapsible bag inside 3. Putting the infant in a baby swing after feeding 4. Burping the baby more frequently 5. Giving the baby a suppository once each morning Answer: 2, 3, 4 Explanation: 1. The infant is 6 weeks old. Initiating breastfeeding is not a good option at this time. 2. This would reduce the amount of air that the baby swallows. 3. The motion may reduce the abdominal discomfort. 4. This helps the infant expel gas, which is a factor contributing to colic. 5. Suppositories would not be recommended. Page Ref: 746 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.2 Describe and plan nursing interventions to meet nutritional needs for all age groups from infancy through adolescence.

10) An adolescent is admitted to the eating disorders unit with a 2-year history of anorexia nervosa. Assessment data indicate that the adolescent has recently sustained additional weight loss and electrolyte imbalances. Which is the priority when planning care for this client? 1. Individual counseling 2. Family therapy 3. Regulation of antidepressant drugs 4. Nutritional support Answer: 4 Explanation: 1. This will be an important component of inpatient treatment but is not the priority intervention. 2. Family therapy is usually a component of the treatment of anorexia nervosa but is not the priority intervention. 3. Antidepressant drugs may be used as a component of the treatment, but this is not the priority intervention. 4. Hospitalization usually is in response to the weight loss and electrolyte imbalances, so nutritional support becomes the priority intervention. All other activities can be managed as outpatient therapies. Page Ref: 748 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.5 Develop nursing interventions for children with nutritional disorders.

11) A 2-month-old infant is admitted to the hospital with a diagnosis of avoidant/restrictive food intake disorder. Which possible causes for the condition will the nurse include in the infant's plan of care? Select all that apply. 1. Overdilution of formula concentrate 2. Parental neglect 3. Rumination 4. Malabsorption syndromes 5. Pica Answer: 1, 2, 3, 4 Explanation: 1. Adding too much water to formula concentrate will lead to inadequate caloric intake and could lead to a diagnosis of avoidant/restrictive food intake disorder. 2. Parental neglect should be evaluated in a baby who is not gaining weight adequately. 3. Rumination involves regurgitation of recently ingested food followed by rechewing and reswallowing. It is often associated with sensory deprivation and may result in growth failure. 4. Malabsorption syndromes, such as cystic fibrosis, can cause nutrients to be excreted instead of absorbed. 5. Pica is an eating disorder characterized by ingestion of nonfood items. It would not be an issue in a 2-month-old infant. Page Ref: 746-747 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.4 Identify and explain common nutritional problems of children.

12) A vegetarian adolescent is prescribed iron supplementation secondary to a diagnosis of irondeficiency anemia. Which food will the nurse encourage the adolescent to increase intake of based on the current diagnosis? 1. Black tea 2. Eggs 3. Fresh fruit 4. Milk Answer: 2 Explanation: 1. Black tea contains tannins, which decrease the absorption of iron. 2. Eggs are one type of food rich in iron. 3. Dried fruit, not fresh fruit, is rich in iron. 4. Foods containing phosphorus, such as milk, decrease absorption of iron. Page Ref: 752 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.3 Integrate methods of nutritional assessment into nursing care of infants, children, and adolescents. 13) The nurse is providing nutritional guidance to the parents of a school-age child. Which comment by a parent would prompt the nurse to provide further education? 1. "We use separate utensils for food preparation and for eating." 2. "We allow our child to drink only pasteurized apple cider." 3. "We let our child sample cookie dough while making cookies." 4. "We always wash our hands well before any food preparation." Answer: 3 Explanation: 1. Using separate utensils for preparing raw meat and preparing fruits, vegetables, and other foods helps prevent infection with foodborne pathogens. 2. Not serving unpasteurized apple cider helps prevent infection with foodborne pathogens. 3. Raw cookie dough contains raw eggs, which increases the risk for foodborne illness. 4. Washing hands helps prevent infection with foodborne pathogens. Page Ref: 743 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 32.3 Integrate methods of nutritional assessment into nursing care of infants, children, and adolescents.

14) The nurse collects the weight and height measurements of a child, and calculates the child's body mass index (BMI) to be in the 10th percentile. Previous assessments indicate that the child's BMI was also in the 10th percentile. Which should the nurse include in the discussion of this child's BMI with the parents? 1. Undernutrition 2. Inconsistent growth 3. Consistent growth 4. Overnutrition Answer: 3 Explanation: 1. Body mass index (BMI) is a calculation that falls between the 10th and 90th percentiles. That a child consistently has a BMI in the 10th percentile reveals consistent growth, and does not necessarily indicate undernutrition. 2. Body mass index (BMI) is a calculation that falls between the 10th and 90th percentiles. That a child consistently has a BMI in the 10th percentile reveals consistent growth. 3. Body mass index (BMI) is a calculation that falls between the 10th and 90th percentiles. That a child consistently has a BMI in the 10th percentile reveals consistent growth, and doesn't necessarily indicate undernutrition. 4. Body mass index (BMI) is a calculation that falls between the 10th and 90th percentiles. That a child consistently has a BMI in the 10th percentile reveals consistent growth, and doesn't indicate overnutrition. Page Ref: 737 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.3 Integrate methods of nutritional assessment into nursing care of infants, children, and adolescents.

15) Which concepts will the nurse use when conducting client teaching to a family regarding Dietary Reference Intake (DRI) in the United States (U.S.)? Select all that apply. 1. Estimated Average Requirement (EAR) 2. Recommended Daily Allowance (RDA) 3. Adequate Intake (AI) 4. Upper Intake (UI) 5. Reference Nutrient Intake (RNI) Answer: 1, 2, 3, 4 Explanation: 1. The nurse includes information on EAR when discussing DRI with a U.S. family. 2. The nurse includes RDA when discussing EAR with a U.S. family. 3. The nurse includes AI when discussing EAR with a U.S. family. 4. The nurse includes UI when discussing EAR with a U.S. family. 5. The nurse would not include RNI when discussing EAR with a U.S. family. This is a concept used in other countries, not in the U.S. Page Ref: 730 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 32.1 Discuss major nutritional concepts pertaining to the growth and development of children.

16) The nurse is teaching the parents of a 6-month-old infant about the introduction of solid foods. Which foods will the nurse include in the teaching session? Select all that apply. 1. Rice cereal 2. Fruits 3. Vegetables 4. Meats 5. Nut products Answer: 1, 2, 3 Explanation: 1. Rice cereal is typically the first solid food that is introduced at 6 months of age. It is appropriate to include this food in the teaching session. 2. Fruits are introduced at 6 to 8 months of age. It is appropriate to include this food in the teaching session. 3. Vegetables are introduced at 6 to 8 months of age. It is appropriate to include this food in the teaching session. 4. Meats are not introduced until 8 to 10 months of age. 5. Nut products are not introduced until 2 to 3 years of age. Page Ref: 734 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.2 Describe and plan nursing interventions to meet nutritional needs for all age groups from infancy through adolescence.

17) Which parental statements during the nutrition assessment for a toddler would cause the nurse concern? Select all that apply. 1. "My child drinks 20 ounces of fat-free milk each day." 2. "My child drinks 6 ounces of 100% fruit juice each day." 3. "We eat at fast-food restaurants several times each week." 4. "We only give our child pasteurized fruit juices." 5. "My child likes to drink water with snacks." Answer: 1, 3 Explanation: 1. Toddlers should consume whole milk until the age of 2 years at which time 2% milk should be used. Fat-free milk is not appropriate for the toddler. 2. It is appropriate for the toddler-age child to consume 6 ounces of 100% fruit juice each day. 3. Consumption of fast food should be restricted to only one time per week. 4. It is appropriate for a toddler-age child to drink only pasteurized fruit juices. 5. It is appropriate for the toddler-age child to drink water with snacks. Page Ref: 734 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.3 Integrate methods of nutritional assessment into nursing care of infants, children, and adolescents.

18) Which assessment findings would cause the nurse to believe that a school-age child is not receiving enough vitamin C in the diet? Select all that apply. 1. Dermatitis 2. Bleeding gums 3. Scaling of the skin 4. Muscle weakness 5. Headaches Answer: 1, 2 Explanation: 1. Dermatitis is a clinical manifestation associated with a vitamin C deficiency. 2. Bleeding gums is a clinical manifestation associated with a vitamin C deficiency. 3. Scaling of the skin is a clinical manifestation associated with a vitamin A, not C, deficiency. 4. Muscle weakness is a clinical manifestation associated with a vitamin D, not C, deficiency. 5. Headache is a clinical manifestation associated with an excess of vitamin A, not a deficiency of vitamin C. Page Ref: 738 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.4 Identify and explain common nutritional problems of children.

19) The nurse is providing care to a toddler-age client who is diagnosed with celiac disease. Which interventions will the nurse include in the toddler's plan of care? Select all that apply. 1. Temporary removal of wheat products from the diet 2. Permanent removal of oat products from the diet 3. Fat-soluble vitamin supplements 4. Avoidance of processed foods 5. Obtaining a dietary prescription Answer: 3, 4, 5 Explanation: 1. Wheat products contain gluten; therefore, these products must be removed permanently from the diet. 2. Oat products are often tolerated by clients diagnosed with celiac disease. 3. Fat-soluble vitamin supplements are often needed by clients diagnosed with celiac disease. 4. Processed foods should be avoided because they are often hidden sources of gluten. 5. A dietary prescription is often necessary for clients diagnosed with celiac disease because this allows insurance company coverage for the purchase of specialized foods. Page Ref: 745 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.5 Develop nursing interventions for children with nutritional disorders.

20) The nurse is providing care for an infant who is diagnosed with colic. Which interventions will the nurse include in the infant's plan of care? Select all that apply. 1. Using a front-carrying sling 2. Recommending swaddling 3. Suggesting frequent burping 4. Recording all feedings in an intake journal 5. Removing gluten from the diet Answer: 1, 2, 3 Explanation: 1. A front-carrying sling is often useful for an infant diagnosed with colic. 2. Infant swaddling is often useful for an infant diagnosed with colic. 3. Frequent burping is often useful for an infant diagnosed with colic. 4. Recording all feedings in an intake journal is an appropriate intervention for an infant diagnosed with failure to thrive (FTT), not colic. 5. Removing gluten from the diet is an appropriate intervention for an infant diagnosed with celiac disease, not colic. Page Ref: 746 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.5 Develop nursing interventions for children with nutritional disorders.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 33 Pediatric Assessment 1) During the newborn examination, the nurse assesses for signs of developmental dysplasia of the hip. Which finding would strongly suggest this disorder? 1. Asymmetric knee height 2. A positive Babinski reflex 3. A negative Moro reflex 4. Flat soles with prominent fat pads Answer: 1 Explanation: 1. To check knee height symmetry, flex the infant's hips and knees so the heels are as close to the buttocks as possible. Place the feet flat on the examining table. The knees are usually the same height. A difference in knee height is an indicator of hip dislocation. 2. A positive Babinski reflex is a normal neurologic response in children up to 2 years old. (pg. 797) 3. The Moro reflex should be present in a newborn assessment; it will disappear as the newborn grows 4. This is a foot assessment and is not evaluating the development of dysplasia of the hip. Page Ref: 793 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Discuss the elements of a health history appropriate for infants and children of different ages.

2) The nurse is taking a health history from the family of a 3-year-old child. Which statement or question by the nurse would be most likely to establish rapport, and elicit an accurate response from the family? 1. "Tell me about the concerns that brought you to the clinic today." 2. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 3. "Hello, I would like to talk with you and get some information about you and your child." 4. "You will need to fill out these forms; make sure that the information is as complete as possible." Answer: 1 Explanation: 1. Asking the parents to talk about their concerns is an open-ended question and one that is more likely to establish rapport and an understanding of the parents' perceptions. 2. This is a good historical question to ask after rapport is established. 3. It is important to validate why the child was brought into the clinic before you jump into the interview. 4. It is important to understand that all clients have different literacy levels, so we must allow for flexibility when it comes to the paperwork. Page Ref: 758 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Discuss the elements of a health history appropriate for infants and children of different ages.

3) A newborn has a respiratory rate of 50 breaths per minute. Which action should the nurse take? 1. Continue to observe. 2. Suction the mouth and nares. 3. Prepare for intubation. 4. Turn the newborn to the right side. Answer: 1 Explanation: 1. A respiratory rate of 50 breaths per minute in a newborn is within normal limits. The child does not need suctioned, intubation, or turned onto the right side. 2. The respiratory rate is normal and does not require suctioning of the infant. 3. The respiratory rate is normal and does not require the infant to be intubated. 4. The respiratory rate is normal and the infant does not need to be placed on the right side at this time. Page Ref: 781 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.6 List five normal variations in pediatric physical findings (such as breast budding in a girl) found during a physical assessment.

4) The nurse is completing a physical examination of a 4-year-old girl. Which is the best position to place the child in to assess the genitalia? 1. Supine, with legs at a 50-degree angle 2. Right side-lying 3. In prone position, with knees drawn up under the body 4. Frog-legged position Answer: 4 Explanation: 1. This is not the best position to allow for a genitalia examination and will be hard for the patient to maintain. 2. This will not allow for visualization of the genitalia. 3. This is not a position that will be comfortable for the client or allow for a good visual of the genitalia. 4. Having the child lie supine, flexing her knees and pulling them up to a frog-legged position, allows for accurate assessment of the genitalia and is well tolerated by the majority of children. Page Ref: 788 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.5 Modify physical assessment techniques for the age and developmental stage of the child.

5) Which is the correct order for the nurse to conduct a physical assessment for a toddler-age client? Place in order from first assessment to last assessment. 1. Auscultation of chest 2. Examination of eyes, ears, and throat 3. Palpation of abdomen 4. General appearance Answer: 4, 1, 3, 2 Explanation: 1. Auscultation usually is less threatening to the toddler than is palpation, especially if the nurse first demonstrates using the stethoscope on a parent or a toy. 2. The most uncomfortable, most invasive examination for the toddler is most likely to be the examination of the eyes, ears, and throat; therefore, this assessment should be performed last. 3. Palpation can be more threatening than is observing or listening, so it should be completed after both. 4. The nurse will begin the assessment by looking at the child. This can be done while the mother is holding the child, and the nurse is talking to the mother. This environment will be neutral for the child and will not cause anxiety. Page Ref: 764, 772 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.5 Modify physical assessment techniques for the age and developmental stage of the child.

6) The nurse prepares to conduct a quick evaluation of a 1-month-old infant's hearing. Which action will provide the best information? 1. Examining the child's ear canal with an otoscope 2. Using a vibrating tuning fork placed against the child's skull 3. Using tympanometry to assess the child's hearing 4. Using a noisemaker to evaluate the child's response Answer: 4 Explanation: 1. The otoscope will allow for the visualization of the ear canal but will not allow for the evaluation of the patient's hearing. 2. A tuning fork is not suggested for this age group; its use is for school aged and up.(pg. 774) 3. Tympanometry assess the pressure in the middle ear and tympanic membrane movement. 4. This is a quick, simple evaluation of the child's ability to hear sounds. The child's response can be a stopping of activity, widening of the eyes, or turning toward the sound. Page Ref: 772 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.5 Modify physical assessment techniques for the age and developmental stage of the child. 7) Which action by the nurse is appropriate when assessing blood pressure (BP) on a child? 1. Give an opportunity to play with the equipment. 2. Ask the child to sit quietly for 3 to 5 minutes. 3. Encourage the child to sit on the parent's lap. 4. Ask the parent to leave the examination room. Answer: 2 Explanation: 1. The child does not need to play with the equipment prior to having blood pressure measured. 2. The child should be seated and quiet for 3 to 5 minutes. 3. The child does not need to sit on the parent's lap. 4. The parent does not need to leave the examination room. Page Ref: 786 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.5 Modify physical assessment techniques for the age and developmental stage of the child.

8) While assessing a school-age child, the nurse notices a regular—irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. Which nursing action is appropriate based on these data? 1. Record the finding as normal. 2. Notify the healthcare provider. 3. Schedule an electrocardiogram (ECG) immediately. 4. Ask the mother if a murmur has been detected before. Answer: 1 Explanation: 1. This is sinus arrhythmia and is a normal finding in children but not in adults. 2. This is a normal finding so no need to notify the healthcare provider. 3. This is a normal finding and an ECG is not needed. 4. There is no murmur so no need to ask the mother if one has been identified previously. Page Ref: 784 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.6 List five normal variations in pediatric physical findings (such as breast budding in a girl) found during a physical assessment.

9) While assessing the blood pressure of a school-age child, the nurse notes the blood pressure in the leg is higher than those of the arms. Which action should the nurse take? 1. Document the findings. 2. Notify the healthcare provider. 3. Elevate the child's legs. 4. Elevate the head of the bed. Answer: 1 Explanation: 1. The blood pressure being higher up to 20 mmHg is expected so Documentation of the finding is appropriate 2. The blood pressure in the leg should be the same or up to 20 mmHg higher than the arm reading. The finding should be documented. There is no need to notify the healthcare provider, elevate the legs, or elevate the head of the bed. 3. There is no indication to elevate the child's legs 4. There is no indication to elevate the head of the bed. Page Ref: 786 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 33.5 Modify physical assessment techniques for the age and developmental stage of the child.

10) Which would the nurse consider as normal during a newborn assessment? Select all that apply. 1. Swelling over the occiput that crosses suture lines 2. Tiny white papules located primarily on the nose and chin. 3. Tiny red macules and pustules that come and go, primarily on the trunk and extremities. 4. When the Moro reflex is elicited, the right arm extends and returns to the body. The left arm remains resting against the chest. 5. Greenish discoloration of skin over the entire body that is not removed by the initial bath Answer: 1, 2, 3 Explanation: 1. By crossing suture lines, this finding indicates it is caput succedaneum, a normal finding after vaginal delivery. No further evaluation or treatment is needed. 2. This is a description of milia, a normal finding. No further care is required. 3. This is a description of erythema toxicum, a normal newborn finding that requires no further treatment. 4. The Moro reflex should be equal on each side of the infant. 5. A whole body Greenish discoloration is not a normal assessment finding, so it is important to look into further. Page Ref: 758 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.6 List five normal variations in pediatric physical findings (such as breast budding in a girl) found during a physical assessment.

11) The nurse is conducting an admission assessment for a newborn client. Which physical finding should the nurse expect? Select all that apply. 1. Respiratory rate 20 per minute 2. Heart rate 80 per minute 3. Flaccid extremities 4. Anterior fontanelle palpable 5. Diaphragmatic breathing Answer: 4, 5 Explanation: 1. The respiratory rate is slow and should be reported to the healthcare provider. 2. The heart rate is slow and should be reported to the healthcare provider. 3. The extremities should not be flaccid and should be reported to the healthcare provider. 4. The anterior fontanelle should be palpable. 5. Diaphragmatic breathing should occur. Page Ref: 758 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.4 Describe the differences in sequence of the physical assessment for infants, children, and adolescents.

12) The nurse is conducting a health history for the family of a 3-year-old child. Which statements or questions by the nurse would establish rapport, and elicit an accurate response from the family? Select all that apply. 1. "Hello, I would like to talk with you and get some information on you and your child." 2. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 3. "Tell me about the concerns that brought you to the clinic today." 4. "You will need to fill out these forms; make sure that the information is as complete as possible." 5. Asking the child, "What is your doll's name?" Answer: 3, 5 Explanation: 1. This is not an open-ended question and does not elicit information from the parents or establish rapport. 2. This is a good historical question to ask after rapport is established. 3. Asking the parents to talk about their concerns is an open-ended question, and one that will establish rapport, and give the nurse an understanding of the parents' perceptions. 4. It is important to understand that all clients have different literacy levels, so we must allow for flexibility when it comes to the paperwork. 5. Including the child in the health history process by asking the name of the doll is a question from the nurse that establishes rapport. Page Ref: 758 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.2 Apply communication strategies to improve the quality of historical data collected.

13) Which question from the nurse during a health history and physical assessment for the school-age child would best determine cognitive development? 1. "What grade are you in?" 2. "What is your least favorite class?" 3. "What books have you read lately?" 4. "What classes are you taking, and what are your grades in them?" Answer: 4 Explanation: 1. Grade level may not always match cognitive development in a child. 2. This is a good question to find out what the child is interested in but will not indicate cognitive development. 3. The level of books the child is reading will assist in the cognitive assessment but is not the best answer. 4. Asking about what kind of classes the child is taking and the grades that the child is receiving in those classes would give the nurse an indication of how the child is developing cognitively. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.3 Demonstrate strategies to gain cooperation of a young child for assessment.

14) While assessing a 10-month-old infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would require more in-depth assessment based on this finding? 1. Hepatic 2. Cardiac 3. Genitourinary 4. Respiratory Answer: 1 Explanation: 1. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver or hepatic system. 2. Cardiac conditions do not usually affect the sclerae. 3. Genitourinary conditions do not usually affect the sclerae. 4. Respiratory conditions do not usually affect the sclerae. Page Ref: 769 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Knowledge and Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

15) During a routine physical assessment for a 9-month-old client, the nurse notes swelling in the ankles. The nurse presses against the ankle bone for 5 seconds; then, releases the pressure, noticing a markedly slow disappearance of the indentation. Which system requires a more indepth assessment based on these data? 1. Cardiovascular system 2. Musculoskeletal system 3. Respiratory system 4. Integumentary system Answer: 1 Explanation: 1. Dependent, pitting edema, especially in the lower extremities, can be a symptom of a cardiovascular disorder. The cardiovascular system would be suspected before the respiratory, musculoskeletal, or integumentary system. 2. Musculoskeltal system issues do not usually cause pitting edema in an infant. 3. Respiratory system issues that are associated with pitting edema are usually based in the cardiac system. 4. Integumentary system issues do not usually cause pitting edema in an infant. Page Ref: 762 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

16) Which questions will the nurse include in the health history for an infant when assessing the birth history? Select all that apply. 1. "When did you first receive prenatal care when you learned you were pregnant?" 2. "Where was your baby born?" 3. "Was your baby born vaginally or by cesarean birth?" 4. "Is your baby experiencing vomiting after bottle feedings?" 5. "Does your baby take any medications on a regular basis?" Answer: 1, 2, 3 Explanation: 1. The nurse asks questions related to prenatal care when assessing the infant's birth history during the health history interview. 2. The nurse asks questions to determine a description of the birth when assessing the infant's birth history during the health history interview. 3. The nurse asks questions about the type of birth when assessing the infant's birth history during the health history interview. 4. This piece of information is not related to the birth history. 5. This piece of information is not related to the birth history. Page Ref: 760 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Discuss the elements of a health history appropriate for infants and children of different ages.

17) Which actions by the nurse are appropriate to enhance cooperation when assessing a 10month-old infant? Select all that apply. 1. Placing the infant on the examination table 2. Using toys to distract the infant 3. Touching the infant's feet before moving on to the trunk 4. Keeping the infant's clothing on during the process 5. Observing the infant's interaction with the mother while she is holding the baby Answer: 2, 3, 5 Explanation: 1. Keeping the infant in the mother's lap as to not separate them is best to enhance cooperation for the assessment. 2. It is appropriate for the nurse to use toys to enhance cooperation during the infant assessment. 3. The nurse should first touch the infant's feet before moving onto the trunk to enhance cooperation during the assessment process. 4. The infant should be fine with clothes removal as long as the room is warm and they are not removed from their parent. 5. It is appropriate for the nurse to observe the interaction between infant and mother while the mother holds the infant during the assessment process. Page Ref: 763 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.3 Demonstrate strategies to gain cooperation of a young child for assessment.

18) Which statements are true in regard to the physical assessment the nurse conducts for an infant and a toddler? Select all that apply. 1. An infant client will have all clothing removed during the weight assessment. 2. A toddler client's assessment will include a length assessment instead of a height assessment. 3. An infant client will have a blood pressure assessment at each visit. 4. It is inappropriate to ask the toddler-age client if he or she can perform certain tasks. 5. It is appropriate to allow the toddler-age client to play with equipment prior to use. Answer: 1, 4 Explanation: 1. An infant client will have all clothing removed during the weight assessment. 2. The toddler will have a height assessment not a length assessment. 3. It is not necessary for an infant to have a blood pressure check at every appointment. 4. The nurse would not ask the toddler-age client if they can perform certain tasks, as the answer will typically be "no." 5. This is not a safe way to allow for a physical assessment, all equipment should be used last in the assessment. Page Ref: 763-764 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.4 Describe the differences in sequence of the physical assessment for infants, children, and adolescents.

19) Which techniques would the nurse use when assessing a preschool-age child? Select all that apply. 1. Asking the child to sit on the examination table 2. Having the child undress for the examination leaving on the undergarments 3. Asking the child when he or she would like to have head, eyes, and ears assessed 4. Asking direct questions to the child 5. Having the parent of the child leave the room for the duration of the exam Answer: 1, 2, 3, 4 Explanation: 1. It is appropriate for the nurse to assess the preschool-age child on the examination table. 2. It is appropriate for the nurse to ask the preschool-age child to remove all clothing except for the undergarments. 3. It is appropriate to give the preschool-age child a choice regarding when the nurse will assess a certain system. 4. It is appropriate to ask the preschool-age child questions directly. 5. This is not suggested for the preschool child's exam. They prefer to stay with parents during the exam. Page Ref: 764 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.5 Modify physical assessment techniques for the age and developmental stage of the child.

20) The nurse is assessing a preschool-age child. Which finding indicates a change in the child's eyes? Select all that apply. 1. Blue eye color 2. Red conjunctiva 3. Pupils react to light 4. Left eyelid swelling 5. Squints when reading Answer: 2, 4, 5 Explanation: 1. Eye color is determined by genetics. 2. Red conjunctiva could indicate an infection or an allergic response. 3. Pupils reactive to light would be an expected finding. 4. Eyelid swelling could indicate a change in the client's vision. 5. Squinting when reading could indicate a change in the client's vision. Page Ref: 762 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.7 Evaluate the growth pattern of an infant or child. 21) The nurse is completing an assessment of a school-age child. Which action should the nurse take when assessing the client's abdomen? 1. Use light palpation to locate the spleen. 2. Use percussion to locate the kidney border. 3. Use deep palpation to assess for an umbilical hernia. 4. Use auscultation for 10 to 30 seconds over all quadrants. Answer: 4 Explanation: 1. Deep palpation is used to locate the spleen. 2. Deep palpation is used to locate the kidney border. 3. Light palpation is used to assess for an umbilical hernia. 4. Auscultation should occur for 10 to 30 seconds to listen for bowel sounds. Page Ref: 786-787 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Context and Environment: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.7 Evaluate the growth pattern of an infant or child.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 34 Health Promotion and Maintenance: The Newborn, and the Infant 1) The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which strategies can be classified as health promotion and health maintenance? Select all that apply. 1. Instructing on how to use dental floss 2. Treating a child with a diagnosis of acute otitis media 3. Administering the flu vaccine to infants 6 to 23 months old 4. Working with new parents to create daily feeding schedules for infants 5. Conducting developmental screening examinations for toddlers Answer: 1, 3, 4, 5 Explanation: 1. Administering flu vaccines, discussing feeding schedules, and instructing in oral healthcare are all health promotion and health maintenance topics. 2. Treating a child with an acute ear infection (otitis media) would not be a topic for health promotion or health maintenance because it is an acute illness. 3. Administering flu vaccines, discussing feeding schedules, and instructing adolescents in oral healthcare are all health promotion and health maintenance topics. 4. Administering flu vaccines, discussing feeding schedules, and instructing adolescents in oral healthcare are all health promotion and health maintenance topics. 5. Conducting developmental screening exams for toddler-age clients is an example of strategy that is classified as health promotion and maintenance. Page Ref: 807-808 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Define health promotion and health maintenance.

2) The mother of a newborn asks the nurse what the purpose of the first scheduled health maintenance visit will be. Which are appropriate responses by the nurse to this question? Select all that apply. 1. "To determine if your baby is being abused." 2. "To determine compatibility between you and the provider." 3. "To discuss policies related to provision of care." 4. "To evaluate your understanding of the services offered." 5. "To determine your baby's risk for obesity." Answer: 2, 3, 4 Explanation: 1. Only under very unusual circumstances would the healthcare providers be able to determine whether the parents are potential child abusers. 2. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and healthcare provider will get along well. 3. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and healthcare provider will get along well. 4. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and healthcare provider will get along well. 5. Only under very unusual circumstances would the healthcare providers be able to determine whether the parents will tend to overfeed the infant, and place the infant at risk for obesity. Page Ref: 808 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 34.2 Describe how health promotion and health maintenance are facilitated by partnering with families during health supervision visits.

3) During a health supervision visit, the nurse is attempting to develop a partnering relationship with the child and family. Which is the initial action by the nurse? 1. Telling the family what the child should be doing physically for the age level 2. Telling the family that the healthcare provider will answer any questions they might have related to their child's growth and development 3. Setting goals for the family related to the child's health 4. Discussing a plan with the family to address the child's health needs Answer: 4 Explanation: 1. Not all children develop each skill at the same age. Telling the family what the child should be doing can cause feelings of fear, frustration, and concern for the family if the child is not doing all of the activities listed by the nurse. 2. Telling the family to direct their questions just to the healthcare provider will not allow any teaching opportunities by the nurse, and will not allow for the development of a trusting relationship with the family. 3. The nurse should not set the goals without family involvement. 4. Discussing and developing a plan with the family will actively involve the family members and will build more trust, as they are not just being told what to do. Page Ref: 804 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.2 Describe how health promotion and health maintenance are facilitated by partnering with families during health supervision visits.

4) During a scheduled health maintenance visit for a 6-month-old infant, the nurse asks, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? 1. Health promotion 2. Developmental surveillance 3. Health maintenance 4. Disease surveillance Answer: 2 Explanation: 1. While health promotion activities are related to developmental surveillance, this question is looking specifically at the milestones. 2. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. 3. While health maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones. 4. These questions are not classified as disease surveillance questions. Page Ref: 806 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Describe how health promotion and health maintenance are facilitated by partnering with families during health supervision visits.

5) A parent says to a nurse, "How do you know when my baby needs these screening tests the doctor just mentioned?" Which response by the nurse is most appropriate? 1. "Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first 2 years of life." 2. "Screening tests are done at each office visit." 3. "Screening tests are most often done when the doctor suspects something is wrong with the child." 4. "Screening tests are administered at the ages when a child is most likely to develop a condition." Answer: 4 Explanation: 1. This provides incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. 2. This provides incorrect information to the parent. Screening tests are not done at each office visit. 3. This provides incorrect information to the parent. Screening tests are done to detect the possibility of problems, and are not done when a problem is suspected. 4. "Screening tests are administered at ages when a child is most likely to develop a condition" provides a definition for screening tests. Page Ref: 807 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 34.3 Describe the components of a health supervision visit.

6) The nurse is working with first-time parents. Which activity will the nurse suggest to encourage the development of good muscle tone in their infant? 1. Placing the infant in an infant seat rather than lying down in a crib 2. Surrounding the infant with toys and other stimulating items to encourage motor movement 3. Swaddling the infant 4. Putting the infant to bed each night at 8 p.m., even if the infant protests with crying Answer: 2 Explanation: 1. Placing the infant in an infant seat is more restrictive than lying in a crib, which allows free moment. 2. Encouraging movement best assists the infant to obtain good muscle tone. 3. Swaddling the infant, while calming for a young infant, restricts movement. 4. The bedtime has nothing to do with development of infant muscle tone. Page Ref: 811 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.5 Analyze the nurse's role in providing health promotion and health maintenance for the newborn and infant.

7) A mother who is bottle-feeding her newborn is discharged 48 hours postdelivery. At which time should the nurse schedule the first office visit for the newborn with the pediatrician? 1. Within 5 days of discharge 2. Within 7 days of discharge 3. Within 2 weeks of discharge 4. Within 3 weeks of discharge Answer: 1 Explanation: 1. A newborn who is discharged from the hospital within 48 to 72 hours postdelivery should have the first office visit scheduled with the pediatrician within 5 days of discharge. 2. Newborns who are discharged within 48 to 72 hours postdelivery should be seen by the pediatrician before 7 days of age. 3. Newborns who are discharged within 48 to 72 hours postdelivery should be seen by the pediatrician before 2 weeks of age. 4. Newborns who are discharged within 48 to 72 hours postdelivery should be seen by the pediatrician before 3 weeks of age. Page Ref: 809 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.5 Analyze the nurse's role in providing health promotion and health maintenance for the newborn and infant.

8) While interviewing the parents of a toddler-age client, the nurse notes that the mother is pregnant. At the end of the visit, the nurse decides to give a new pamphlet to the parents about car seat usage for newborns. Which is the purpose of this action by the nurse? 1. Secondary preventative health maintenance 2. Developmental health screening 3. Tertiary preventative health maintenance 4. Primary preventative health maintenance Answer: 4 Explanation: 1. The secondary level of prevention is focused on diagnosis of a problem, usually medical in nature, in order to address it, and make a plan of care. 2. This is education, and not a developmental screening to elicit data. The focus of the teaching is on an unborn child, so developmental level is not a current issue. 3. The tertiary level of preventative care is related to restoring a level of functioning that is below an expected level, such as in a rehabilitation situation. 4. The teaching regarding proper car seat use is an example of an activity that might decrease the opportunity for injury in a newborn; therefore, this is primary preventive health maintenance. Page Ref: 803 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

9) The nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the measurements 2 months ago were at the 25th percentile. Which interpretation of these data by the nurse is accurate? 1. The infant is not gaining enough weight. 2. The infant has gained a significant amount of weight. 3. These measurements most likely are inaccurate. 4. The previous measurements were most likely inaccurate. Answer: 2 Explanation: 1. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. 2. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. 3. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. 4. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. Page Ref: 810 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

10) The mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. Which response by the nurse to the mother is appropriate? 1. "Let's ignore this behavior. It will stop sooner." 2. "What do you usually do or say during a temper tantrum?" 3. "This is definitely a temper tantrum. I know exactly what you are feeling right now." 4. "Pick up and cuddle your child now, please." Answer: 2 Explanation: 1. Ignoring the behavior is not an effective way to problem solve for temper tantrums. 2. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. 3. Sympathizing with the mother may make the mother feel better at that moment but does not help the mother improve her child's behavior. 4. Cuddling the child will provide positive reinforcement to the child to continue that behavior. Providing a direct instruction to the mother in this manner is unlikely to elicit the mother's trust in the nurse. Page Ref: 814 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

11) Parents are in the pediatric clinic with their infant for a 1-month checkup. Which assessment question regarding immunizations should the nurse ask the infant's parents? 1. "Did your baby receive the influenza vaccine prior to hospital discharge?" 2. "Did your baby receive the hepatitis B vaccine prior to hospital discharge?" 3. "Did your baby receive the rubella vaccine prior to hospital discharge?" 4. "Did your baby receive the rotavirus vaccine prior to hospital discharge?" Answer: 2 Explanation: 1. The influenza vaccine is not administered at birth. 2. Hepatitis B is given routinely at birth. 3. The rubella vaccine is not administered at birth. 4. The rotavirus vaccine is not administered at birth. Page Ref: 814 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

12) A nurse is assessing an 11-month-old infant, and notes that the infant's height and weight are at the 5th percentile on the growth chart; the infant was previously plotted at the 25th percentile. Psychosocial history reveals that the parents are separated and are planning to divorce. Which is the priority when planning this infant's care? 1. Parental anxiety 2. Risk for failure to thrive 3. Excessive nutritional intake 4. Risk for injury Answer: 2 Explanation: 1. While parental anxiety due to the situation may be occurring, this is not the priority when planning this infant's care. 2. This infant's growth curve indicates poor growth, which places the infant at risk for failure to thrive. 3. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. 4. While the infant may be at a risk for injury, the priority is risk for failure to thrive. Page Ref: 810 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34.9 Recognize the importance of family in newborn and infant healthcare and include family assessment and collaboration in each health supervision visit.

13) Which observation in a health supervision visit leads the nurse to have concerns about the infant's mental health? 1. A 1-month-old is swaddled by the parent because of crying after an immunization. 2. A 7-month-old infant grabs her mother and cries when the nurse attempts touch. 3. A 9-month-old avoids eye contact with parents and the nurse. 4. A 10-month-old reportedly sleeps about 12 hours total per night. Answer: 3 Explanation: 1. Crying after a painful procedure, such as an immunization, is a normal reaction by the 1-month-old infant. Swaddling the infant for comfort is a normal reaction by the parent. 2. Grabbing for her mother and crying when the nurse attempts touch is a normal reaction for a 7-month-old infant. 3. The nurse should expect the 9-month-old to have eye contact with the parents and the nurse. If no eye contact is made, the nurse should implement a more detailed assessment of the infant's mental health. 4. Sleeping 12 total hours per night is considered normal behavior for a 10-month-old infant. Page Ref: 812 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

14) The nurse is assessing a small-for-gestational-age newborn who had an older sibling who died of sudden infant death syndrome (SIDS). Which should the nurse include in the newborns plan of care based on these data? 1. Encourage the parents to sleep with the newborn for close observation. 2. Encourage the parents to place the newborn on the abdomen to sleep. 3. Encourage the parents to place the newborn in a crib with a tight-fitting, firm mattress. 4. Encourage the parents to place the newborn in a crib with a soft mattress with extra blankets. Answer: 3 Explanation: 1. Cobedding is not encouraged because it is associated with an increased risk for SIDS. 2. A prone sleeping position is not encouraged because it is associated with an increased risk for SIDS. 3. Placing the infant in a crib with a tight-fitting, firm mattress will help keep the infant's mouth free of obstructions. This is the recommended sleeping position and environment for all newborns but is especially important due to the history of SIDS. 4. Quilts, blankets, and other soft items are not recommended as these increase the risk for SIDS. Put the newborn in a blanket sleeper instead. Page Ref: 816 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

15) Which nursing actions are appropriate for the 2-month-old infant during a scheduled health maintenance visit? Select all that apply. 1. Reviewing infant fluid needs with the parents 2. Reinforcing the importance of heating bottles with water versus the microwave 3. Demonstrating proper gum care to the parents 4. Educating the parents to begin introducing solid foods, such as rice cereal 5. Recommending that juice be introduced in a sippy cup Answer: 1, 2, 3 Explanation: 1. It is appropriate for the nurse to review infant fluid needs with the parents during the 2-month health maintenance visit. 2. It is appropriate for the nurse to reinforce the importance of heating bottles with water versus the microwave with the parents during the 2-month health maintenance visit. 3. It is appropriate for the nurse to demonstrate proper gum care to the parents during the 2month health maintenance visit. 4. The nurse would not educate the parents to begin introducing solid foods during the 2-month visit. Solid foods are not introduced until 6 months of age. 5. While juice should only be offered in a sippy cup, the nurse would not recommend this during the 2-month health maintenance visit. This subject is appropriate during the 6-month health maintenance visit. Page Ref: 811 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.4 Apply the preventive care schedule for screenings and health assessment.

16) Which topics are appropriate for the nurse to include when teaching preventive disease strategies during infancy? Select all that apply. 1. Metabolic screenings 2. Hearing screenings 3. Risks of environmental smoke exposure 4. Stranger danger strategies 5. Bike safety Answer: 1, 2, 3 Explanation: 1. It is appropriate for the nurse to include information regarding metabolic screening when teaching preventative disease strategies to the parents of an infant. 2. It is appropriate for the nurse to include information regarding hearing screening when teaching preventative disease strategies to the parents of an infant. 3. It is appropriate for the nurse to include information on the risks of environmental smoke exposure when teaching preventative disease strategies to the parents of an infant. 4. Stranger danger strategies are more appropriate for the parents of a preschool-age child. 5. Bike safety is more appropriate for the parents of preschool-age and school-age children. Page Ref: 814 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.4 Apply the preventive care schedule for screenings and health assessment.

17) Which actions are appropriate when the nurse is performing general observations during the assessment process for an infant? Select all that apply. 1. Asking the family how they are adjusting to having the infant in the home 2. Monitoring the parents for clinical manifestations associated with fatigue 3. Assessing for behaviors that indicate appropriate bonding 4. Placing the infant on the scale for a weight and length assessment 5. Auscultating heart and lung sounds while the infant is asleep Answer: 1, 2, 3 Explanation: 1. When performing general observations during the assessment of an infant, the nurse will ask the parents how they are adjusting to having an infant in the home. 2. When performing general observations during the assessment of an infant, the nurse will monitor the parents for clinical manifestations associated with fatigue. 3. When performing general observations during the assessment of an infant, the nurse will assess for behaviors that indicate appropriate bonding. 4. Placing the infant on the scale to measure height and weight is not an appropriate action when performing general observations during the assessment process. 5. Auscultating heart and lung sounds is not an appropriate action when performing general observations during the assessment process. Page Ref: 809 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.6 Perform the general observations made of infants and their families as they come to the pediatric healthcare home for health supervision visits.

18) What is the purpose of making general observations during the assessment process for an infant during a scheduled health maintenance visit? Select all that apply. 1. Invite discussion with the parents. 2. Validate positive parenting efforts. 3. Promote a partnership between healthcare providers and parents. 4. Decrease the risk of communicable diseases. 5. Meet standards required for The Joint Commission accreditation. Answer: 1, 2, 3 Explanation: 1. One purpose for making general observations during the infant assessment process is to invite discussion with the parents. 2. One purpose for making general observations during the infant assessment process is to validate positive parenting efforts. 3. One purpose for making general observations during the infant assessment process is to promote a partnership between healthcare providers and parents. 4. Decreasing the risk for communicable diseases is not the purpose for making general observations during the assessment process for an infant. 5. Meeting The Joint Commission accreditation standards is not the purpose for making general observations during the assessment process for an infant. Page Ref: 809 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.6 Perform the general observations made of infants and their families as they come to the pediatric healthcare home for health supervision visits.

19) The nurse is preparing for a health maintenance visit for a 9-month-old infant. Which teaching topics are appropriate for the nurse to include during the scheduled visit? Select all that apply. 1. Using iron-fortified formula 2. Encouraging self-feeding of finger foods 3. Increasing the number of daily milk feedings 4. Encouraging cups for all feedings 5. Introducing burping techniques Answer: 1, 2 Explanation: 1. The nurse should teach the parents the importance of continuing to use an ironfortified formula until the infant reaches 12 months of age. 2. The nurse should encourage the parents to allow for self-feeding opportunities with finger foods. 3. The number of daily milk feedings should be decreased, not increased, at this stage of development. 4. While the cup should be introduced by 9 months of age, it is not appropriate for the nurse to encourage the use of a cup for all feedings until 12 months of age. 5. While it may be appropriate for the nurse to reinforce burping techniques through the first year of life, the nurse would not introduce this teaching at 9 months of age. Page Ref: 811 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.8 Plan health promotion and health maintenance strategies employed during health supervision visits of newborns and infants.

20) The nurse is educating the parents of a 2-month-old infant when to contact the healthcare provider. Which statements by the parents indicate the need for further instruction? Select all that apply. 1. "We will contact the doctor if our baby does not have a bowel movement each day." 2. "We will contact the doctor if our baby is vomiting." 3. "We will contact the doctor if our baby has a temperature greater than 99°F." 4. "We will contact the doctor if our baby does finish each bottle." 5. "We will contact the doctor if our baby develops a skin rash." Answer: 1, 3, 4 Explanation: 1. Each infant will develop a pattern for bowel movements; some infants will have several each day, while others may have a bowel movement once every couple of days. This parental statement indicates the need for further education. 2. Infants are prone to dehydration; therefore, it is appropriate for the parents to contact the healthcare provider for vomiting. 3. Parents are instructed to contact the healthcare provider for a temperature greater than or equal to 99.3°F. This parental statement indicates the need for further education. 4. Failure to eat is a reason to contact the healthcare provider; however, failure to finish each bottle is not a reason to contact the healthcare provider. This parental statement indicates the need for further education. 5. A skin rash is a reason to contact the healthcare provider. This statement indicates appropriate understanding of the information presented. Page Ref: 815 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 34.7 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 35 Health Promotion and Maintenance: The Toddler and the Preschooler 1) Which is the priority nursing action when performing a physical assessment on a toddler? 1. Leaving intrusive procedures such as eye and ear examinations until the end 2. Explaining each part of the examination to the child before performing it 3. Performing the assessment from head to toe 4. Asking the mother to tell the child not to be afraid Answer: 1 Explanation: 1. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs. 2. A toddler is too young to understand the medical terminology. 3. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs. 4. Asking the mother to tell the child not to be afraid is an inappropriate response. Page Ref: 821 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

2) At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process? 1. 12 months 2. 18 months 3. 2 years 4. 4 years Answer: 3 Explanation: 1. While the nurse will plot a child's growth at 12 months of age, a BMI is not included in the physical assessment at this time. 2. While the nurse will plot the child's growth at 18 months of age, a BMI is not included in the physical assessment at this time. 3. BMI is first calculated at 2 years of age, and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that can reduce the incidence of obesity. 4. The nurse will not initiate BMI calculation for a 4 year old; this action should be implemented into the nursing assessment prior to 4 years of age. Page Ref: 870 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

3) During a well-child visit with a 4-year-old girl, the nurse notes that the parents speak harshly to the child and used negative remarks when speaking with the nurse. Which statement by the nurse would be beneficial in this situation? 1. "Perhaps you should leave the room so that I can speak with your child privately." 2. "I am going to refer you for counseling since your interactions with your child seem so negative." 3. Addressing the child, the nurse says, "Are you unhappy when mommy talks to you like this?" 4. "Let's talk privately. We should discuss the way you speak with your child and possible ways to be more positive." Answer: 4 Explanation: 1. Since the child is only 4 years old, it would be difficult to ask the parent to leave the room. If the nurse wants to speak alone with the child, it would be best to escort the child to another area, and speak briefly with the child. 2. Referring to counseling without a discussion with the parent is not appropriate. 3. The nurse should not ask the child if she is "unhappy" with the parent. 4. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Page Ref: 826 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.2 State components of self-concept for preschool children.

4) Which action by the nurse is appropriate when teaching the parents of a 2-year-old child during a scheduled health maintenance visit? 1. Encouraging the parents to allow the child to pour liquids using a pitcher 2. Being sure that all major foods group have been introduced to the child 3. Teaching the parents that it is appropriate to switch from whole to 2% milk 4. Educating the child about food groups Answer: 3 Explanation: 1. It is not appropriate to encourage the parents to allow the child to pour liquids using a pitcher until 3 years of age. 2. The nurse should ensure that all major food groups have been introduced to the child at 1 year of age. 3. The nurse will teach the parents that it is appropriate to switch from whole to 2% milk during the 2-year-old's health maintenance visit. 4. The nurse would not educate the child about food groups until the age of 4 years. Page Ref: 824 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.3 Plan health promotion and health maintenance strategies employed during health supervision visits of toddlers and preschoolers.

5) The visiting nurse is evaluating the home environments of several preschool-age children as they relate to child safety. The nurse visits the home of each child and gathers the following data. Which activity noted during the visit places a child at the greatest risk for bodily harm? 1. The parents are in a methadone program. 2. The parents consume alcohol on a daily basis. 3. The child watches television for 2 hours each day. 4. The child is permitted to swim in the family pool unsupervised. Answer: 4 Explanation: 1. Drug and alcohol use or past use places the child at risk; however, this is not the priority risk assessed. 2. Drug and alcohol use or past use also place the child at risk; however, this is not the priority risk assessed. 3. A child who is allowed to watch excessive amounts of television each day is at risk for obesity and other health problems; however, this is not the priority risk assessed. 4. A child should be supervised while swimming at all times. This observation places the child at the greatest risk for bodily harm. Page Ref: 829 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.4 Discuss the importance of family in child healthcare and include family assessment in each health supervision visit.

6) The parents of a 2-year-old girl inquire about information to help their child transition to bed each night. Which response by the nurse is appropriate? 1. Let the child cry self to sleep a few nights to adjust to the transition. 2. Play a favorite video at bedtime on a television in the child's room to enhance relaxation. 3. Read a book to the child just before bedtime each night. 4. Let the child fall asleep while playing and then put the child in bed. Answer: 3 Explanation: 1. A child of this age will not just learn to fall asleep on her own if left alone. Letting the child cry for an extended period of time can affect attachment issues. 2. Having a television in a 2-year-old child's room is not a healthy practice. This can lead to decreased physical activity. 3. Developing a quiet routine just before bedtime can help calm the child and give an expectation to what will happen next: going to bed. 4. Letting the child fall asleep while playing is not healthy, as it allows the child to get to the point of exhaustion without any limits set. Page Ref: 827 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.4 Discuss the importance of family in child healthcare and include family assessment in each health supervision visit.

7) Parents of a preschool-age child report that they find it necessary to spank the child at least once a day. Which response by the nurse is appropriate based on this information? 1. "Can you try spanking the child only every other day for 1 week, and see how that affects your child's behavior?" 2. "Spanking is one form of discipline; however, you want to be sure that you do not leave any marks on the child." 3. "I think you are not parenting properly, so let's talk about ways to improve your parenting skills." 4. "Let's talk about other forms of discipline that have a more positive effect on the child." Answer: 4 Explanation: 1. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 2. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 3. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 4. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. Page Ref: 826 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.5 Integrate pertinent mental healthcare into health supervision visits for toddlers and preschoolers.

8) Which parental statement during a scheduled health maintenance assessment for a preschoolage child would cause the nurse concern? 1. "We have dinner together as a family each evening." 2. "We are so proud that our child is able to recognize letters of the alphabet." 3. "Our child wakes up each night screaming because of nightmares." 4. "Our child attends a daycare program 3 days per week." Answer: 3 Explanation: 1. Parents are encouraged to spend time with their children each day. The statement about eating dinner together each evening as a family would not cause the nurse concern. 2. A preschool-age child should be able to recognize letters of the alphabet. Parents who verbalize pride in their child would not cause the nurse concern. 3. A child who awakens each night due to nightmares may be indicative of a mental illness. This statement would cause the nurse concern. 4. Many children attend daycare due to both parents in the house working. The nurse should further assess the interactions between the parents and the caregivers; however, this statement would not cause the nurse concern. Page Ref: 827 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.6 Examine data about the family and other social relationships to prioritize interventions and to maintain health of toddlers and preschoolers.

9) The nurse is caring for a preschool-age child. Which strategy will the nurse use to prevent disease development in this client? 1. Review immunization schedule. 2. Complete an electrocardiogram. 3. Schedule for serum blood tests. 4. Discuss need for daily activity. Answer: 1 Explanation: 1. Toddlers and preschoolers are prone to many infectious diseases due to immature immune systems. At the end of the preschool period, a complete review of the immunization record is done so that any needed immunizations are administered before school entry. 2. There is no reason for an electrocardiogram. 3. Serum blood tests are not used as a disease prevention strategy. 4. There is no evidence that a discussion about daily activity is needed. Page Ref: 828 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

10) The nurse is teaching the parents of a toddler-age child about injury prevention. Which statement by the parent indicates the need for further education? 1. "I will turn the handles of the pots outward while I am cooking dinner." 2. "We will make sure that our child always wears a life vest when we are out in the boat." 3. "I will keep all our medications out of reach, and ensure child-resistant containers." 4. "We will provide safe climbing toys for our child." Answer: 1 Explanation: 1. Handles of the pots should be turned inward and not outward to prevent toddler injury. This statement indicates the need for further education. 2. A life vest should be worn by the toddler when near water or on a boat. This statement indicates correct understanding of the information presented. 3. All medications should be kept out of reach from the toddler, and the parents should ensure child-resistant containers are used. This statement indicates correct understanding of the information presented. 4. Parents should supervise toddlers closely, and provide safe climbing toys for the child. This statement indicates correct understanding of the information presented. Page Ref: 829 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

11) Which assessment finding for a toddler-age child indicates an increased risk for an unhealthy self-concept? 1. A parent who praises the child for his or her accomplishments 2. A parent who is attempting potty training but who understands that accidents will happen 3. A parent who is observed spanking a child for taking a toy from another child in the waiting room 4. A parent who reads a book to the toddler-age child each night before bed to encourage cooperation Answer: 3 Explanation: 1. Praise from a parent to a toddler-age child for his or her accomplishments does not place the child at risk for an unhealthy self-concept. 2. A parent who attempts potty training for a toddler-age child but expects accidents to happen does not place the child at risk for an unhealthy self-concept. 3. Physical discipline is a risk factor for the toddler to develop an unhealthy self-concept. 4. A parent who reads a book to a toddler-age child each night to encourage cooperation is not at risk for an unhealthy self-concept. Page Ref: 826 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.2 State components of self-concept for preschool children.

12) The nurse is teaching the parents of a toddler-age child information regarding toy and playground safety. Which parental statement indicates the need for further education? 1. "I allow my child to play with the packaging material for new toys." 2. "I will avoid buying my child toys that are battery operated." 3. "I allow my child to play with age-appropriate toys as indicated on the packaging." 4. "I don't let my child play on the playground without supervision." Answer: 1 Explanation: 1. The toddler-age child should not be allowed to play with packaging material for new toys as this increases the risk of injury. This statement indicates the need for further education. 2. The toddler-age child should not be allowed to play with battery-operated toys. This is not appropriate until the child is 8 years of age. This statement indicates appropriate understanding of the information presented. 3. The toddler-age child should be provided with toys that are age-appropriate. A parent who buys the child toys based on the age range on the packaging is appropriate and does not indicate the need for further education. 4. The toddler-age child should not be allowed to play on the playground without supervision. This statement indicates appropriate understanding of the information presented. Page Ref: 833 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

13) The nurse is planning health promotion activities for a toddler-age child during a scheduled health maintenance visit. Which action by the nurse is appropriate during this visit? 1. Connecting developmental skills with risks for injury 2. Recognizing that childcare attendance increases the risk for communicable disease 3. Planning education for treatment of common disease processes 4. Illustrating developmental progression on a screening tool Answer: 4 Explanation: 1. Connecting developmental skills with risks for injury is an action that prevents disease and injury. This is not a health promotion activity. 2. Recognizing that attendance at a daycare center increases the risk for communicable disease is an action that prevents disease and injury. This is not a health promotion activity. 3. Planning treatment for common disease processes is an action that prevents disease and injury. This is not a health promotion activity. 4. Illustrating developmental progression on a screening tool is a health promotion action. Page Ref: 822 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.3 Plan health promotion and health maintenance strategies employed during health supervision visits of toddlers and preschoolers.

14) Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 4-year-old child? 1. Recognizing that food jags are common 2. Involving the child in snack selection and preparation 3. Encouraging the use of a high chair with a safety strap 4. Recommending the child consumes high-fat foods Answer: 2 Explanation: 1. Food jags are not common for a 4-year-old child. This is more common for the 2-year-old child. 2. A 4-year-old child should be involved in snack selection and preparation. 3. The use of a high chair with a safety strap is not information that should be included for a 4year-old child during a health maintenance visit. This is more appropriate for a toddler-age child. 4. Low-fat, not high-fat, foods should be encouraged during the health maintenance visit. Page Ref: 824 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.3 Plan health promotion and health maintenance strategies employed during health supervision visits of toddlers and preschoolers.

15) The nurse is conducting a physical assessment for a preschool-age child. When plotting the child's body mass index (BMI), the nurse notes that the child's BMI is at the 90th percentile. Which action by the nurse is appropriate? 1. Referring the child to a nutritionist 2. Conducting a developmental assessment 3. Assessing the child's level of activity 4. Checking a blood glucose level Answer: 3 Explanation: 1. While the nurse will need to assess a detailed dietary intake for the child, it is not appropriate to refer the child to a nutritionist at this time. 2. There is no reason for the nurse to conduct a developmental assessment based on the current assessment data. 3. A child with a BMI that is 85% or greater should have a detailed dietary intake assessment conducted along with assessing the child's level of activity. 4. The current assessment data do not support the need to check the child's blood glucose level. Page Ref: 821 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

16) Which will the nurse assess in the family of a 3-year-old child during a pediatric clinic visit scheduled due to regressive behavior? Select all that apply. 1. Change in parental marital status 2. Level of education for each parent 3. Health of child's siblings 4. Maternal depression 5. Child's exposure to communicable diseases Answer: 1, 3, 4 Explanation: 1. Changes that occur with the family members of a 3-year-old child could be the source of the regressive behavior being exhibited. It is appropriate for the nurse to assess for a change in parental marital status. 2. The nurse would not need to assess the level of education for each parent for a 3-year-old child exhibiting regressive behavior. This information will already be compiled in the child's medical record. 3. A change in the health of the child's siblings could cause regressive behavior. This is appropriate for the nurse to include in the family assessment. 4. Maternal depression can be associated with poor self-concept and could be a reason for regressive behavior. This is appropriate for the nurse to include in the family assessment. 5. While it is appropriate for the nurse to assess the child's exposure to communicable disease, this is not included in the family assessment for regressive behavior. Page Ref: 827 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.4 Discuss the importance of family in child healthcare and include family assessment in each health supervision visit.

17) Which assessment questions are appropriate when the nurse is assessing the mental health of a preschool-age client? Select all that apply. 1. "Is your child experiencing nightmares?" 2. "Does your child ask questions about the genitalia?" 3. "How do you implement punishment for your child when a rule is broken?" 4. "Is your child up-to-date on recommended immunizations?" 5. "Does your child wear safety equipment when riding a bicycle?" Answer: 1, 2, 3 Explanation: 1. The nurse inquires about nightmares when assessing the mental health of a preschool-age client. 2. The nurse inquires about sexual exploration when assessing the mental health of a preschoolage client. 3. The nurse inquires about implementing punishment for broken rules when assessing the mental health of the preschool-age client. 4. Assessing immunization status is not included in a mental health assessment for a preschoolage client. 5. Assessing the use of safety equipment is not included in a mental health assessment for a preschool-age client. Page Ref: 826 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.5 Integrate pertinent mental healthcare into health supervision visits for toddlers and preschoolers.

18) Which nursing actions are appropriate when conducting a mental health assessment for a toddler-age child? Select all that apply. 1. Observing the child's interaction with family members 2. Asking the caregiver to describe the child's typical day 3. Giving the child a crayon to assess ability to use 4. Determining the number of hours the child sleeps each night 5. Inquiring about recent exposure to communicable diseases Answer: 1, 2, 3, 4 Explanation: 1. When conducting a mental health assessment for a toddler-age child, it is appropriate for the nurse to observe the child's interaction with family members. 2. When conducting a mental health assessment for a toddler-age child, it is appropriate for the nurse to ask the caregiver to describe the child's typical day. 3. When conducting a mental health assessment for a toddler-age child, it is appropriate to determine whether the child is mastering age-appropriate skills, such as the use of a crayon for a toddler-age child. 4. When conducting a mental health assessment for a toddler-age child, it is appropriate to inquire about the number of hours of sleep the child gets each night. 5. The nurse assesses exposure to communicable diseases during a typical health maintenance visit; however, this action is not appropriate when assessing the toddler's mental health. Page Ref: 827-828 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.5 Integrate pertinent mental healthcare into health supervision visits for toddlers and preschoolers.

19) Which interventions will the nurse recommend for a toddler-age client who is biting other children at daycare? Select all that apply. 1. Using a time-out as a form of discipline for the child's behavior 2. Separating the child from the situation 3. Telling the child it is not okay to hurt another person 4. Inquiring whether the child is getting enough sleep 5. Implementing distraction to avert the behavior Answer: 1, 2, 3, 4 Explanation: 1. A time-out is an appropriate intervention for the nurse to suggest when a toddler-age child is exhibiting behaviors that include other people, such as biting. 2. Separation of the child from the situation is an appropriate intervention for the nurse to suggest when a toddler-age child is exhibiting behaviors that include other people, such as biting. 3. It is appropriate to encourage the parents to tell the child that the behavior is unacceptable when the child is exhibiting behaviors that include other people, such as biting. 4. When a child is exhibiting behaviors that include other people, such as biting, it is appropriate to assess the amount of sleep the child is getting each night. Lack of sleep is a common cause for behaviors such as biting. 5. Distraction is appropriate for undesirable behaviors exhibited by the child; however, this is not an appropriate when the child is exhibiting behaviors that include other people, such as biting. Page Ref: 826 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

20) Which recommendations will the nurse make to the parents of a preschool-age child who is experiencing frequent nightmares? Select all that apply. 1. Reassure the child by back rubbing. 2. Repeat a nighttime routine, such a reading a story. 3. Bring the child to the parental bed. 4. Allow the child time to settle back into sleep. 5. Place a television in the child's room for distraction. Answer: 1, 2, 4 Explanation: 1. It is appropriate for the parent to reassure the child by back rubbing when a nightmare occurs. 2. It is appropriate for the parent to repeat a nighttime ritual, such as reading a story. 3. It is not recommended for the parent to bring the child to the parental bed as the child may continue to awaken at night to continue this practice. 4. It is appropriate to allow the child time to settle back into sleep. 5. It is not recommended to place a television in the child's room as a form of distraction for the nightmare. Page Ref: 827 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the areas of assessment and intervention for health supervision visits for toddler and preschool children: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 36 Health Promotion and Maintenance: The School-Age Child and the Adolescent 1) The nurse develops and implements a health promotion plan for an adolescent client. Which information should the nurse include in the evaluation of the plan? 1. Methods to expand and sustain successful approaches 2. Instruction to the client on what is considered healthy behavior 3. Advice for promoting health behaviors that will maintain a healthy lifestyle 4. Information on the client's attitude toward health Answer: 1 Explanation: 1. When establishing youth programs, whether with individual adolescents or with groups, the nurse includes methods to expand and sustain successful approaches. 2. This is part of the plan but is not part of the evaluation of the plan. 3. The nurse will be looking for input into her plan, but this is not part of the evaluation step. 4. Understanding the attitude of the clients is important in the planning of the health promotion activity. Page Ref: 849 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

2) The nurse is assessing an adolescent client to determine relationships with others. Which nursing action is appropriate? 1. Telling the parents that information from the assessment will be shared with them after the examination 2. Providing separate time to communicate with both the adolescent and the parents 3. Avoiding asking the parents their opinions of the adolescent's friends 4. Telling the parents they are not allowed to come into the examination room Answer: 2 Explanation: 1. This is not always the case as teens are allowed a level of privacy in these assessments. 2. Provide time alone with both the adolescent and the parents so that everyone has time to talk freely and ask questions. 3. It is important to understand how the parents feel regarding the teen's friendships. 4. The teen and parents should be allowed time to discuss feelings separately. Page Ref: 842 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.4 Apply assessment skills to plan data-gathering methods for nutrition, physical activity, oral health, and mental health status of youth.

3) Which should the nurse keep in mind when providing care to an adolescent client during the initial visit? 1. The importance of explaining procedures and introducing personnel to adolescents. 2. Adolescents usually are quiet and will offer no opinions. 3. The importance of attending to and discharging the adolescent quickly. 4. Adolescents are comfortable with their surroundings. Answer: 1 Explanation: 1. If the setting is new to the adolescent, explain the procedures and introduce personnel so the adolescent feels more at ease. 2. Adolescents are usually partners in healthcare and will usually engage in the discussions. 3. Taking time with adolescents is important to make them feel welcomed and not like they are a burden. 4. Some are comfortable and some are not, so you may have to work to make them feel comfortable. Page Ref: 850 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

4) Which nursing action is appropriate when providing care to an adolescent client who is accompanied to an appointment by a parent? 1. Instructing the parent to stay in the waiting room with the explanation that the adolescent will provide a report after the examination 2. Telling the parent it is against policy for a parent to accompany the adolescent to the examination room 3. Reassuring the parent that the nurse will discuss any parental concerns or questions after the examination 4. Allowing the parent to come into the examination room with the adolescent Answer: 3 Explanation: 1. Parents may accompany the patient to the examination especially if it is a medical concern, but the patient must always be offered some private time without parents present. 2. Parents may accompany the patient to the examination especially if it is a medical concern, but the patient must always be offered some private time without parents present. 3. If one or both parents come with the adolescent, be alert that you might need to provide some private time by asking the parents to wait outside for a moment. Reassure the parents that you will talk with them about any of their concerns and questions, and provide them with an opportunity to ask questions and get information as well. 4. Parents may accompany the patient to the examination especially if it is a medical concern, but the patient must always be offered some private time without parents present. Page Ref: 850 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

5) A school nurse is performing annual height and weight screening. The nurse notes that three adolescent girls who are close friends each lost 15 pounds over the past year. Which is the priority nursing action? 1. Obtaining a nutritional history for each of these adolescents 2. Referring these adolescents to the school psychologist 3. Calling the respective parents to discuss the eating patterns of each adolescent 4. Speaking with the adolescents in a group to discuss the problems associated with anorexia nervosa Answer: 1 Explanation: 1. The school nurse must evaluate why these three friends have all lost 15 pounds in 1 year. The best way to begin this assessment is to obtain a nutritional history for each client. 2. The situation must first be assessed prior to sending the students off to the psychologist. 3. The adolescents should be talked to first so that the nurse has a better understanding of the history. It will be important to talk with the parents also, but first a history of events needs to be discovered. 4. The adolescents should be given privacy in discussing the situation so that they are not feeling any undue pressure from the group setting. Page Ref: 850 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Identify the major health concerns of the school-age and adolescent years.

6) The following information is collected during the nursing assessment: the adolescent's menses began when she was 12 years old; a current body mass index (BMI) of 27.5; inconsistent school performance over the last several years. Which is the priority area of teaching for this adolescent? 1. Menstrual cycle 2. Nutritional intake 3. School performance 4. Mental health status Answer: 2 Explanation: 1. Menstrual cycle is not a concern for this patient. 2. The BMI for this client is high, placing the adolescent at risk for cardiovascular disease, hypertension, and diabetes mellitus in later life. Therefore, nutritional intake is the most important topic to focus on with this client at this time. 3. School performance should be addressed but is not the priority teaching area for this client. 4. Mental health status should be evaluated for all adolescents but is not the priority for this client. Page Ref: 850 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: I2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.1 Identify the major health concerns of the school-age and adolescent years.

7) The nurse is assessing an adolescent patient during a scheduled health maintenance visit. The adolescent's mother is currently in the examination room with the patient. Which topic should the nurse avoid until the mother has left the examination room? 1. School performance 2. Cigarette smoking 3. School friends 4. Seat belt use Answer: 2 Explanation: 1. The topic of school performance is not one that the nurse needs to maintain confidentiality. 2. The nurse must maintain the nurse-client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse should refrain from asking any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and cigarette smoking. 3. The topic of school friends is not one that needs to be kept confidential between the nurse and the client, so it is ok to review in front of the parent. 4. The topic of seat belts is not one that needs to be kept confidential between the nurse and the client, so it is ok to review in front of the parent. Page Ref: 843 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Practice: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.3 Apply communication skills in interactions with school-age children and adolescents.

8) The nurse is assessing an adolescent client during a scheduled health maintenance appointment. Which issues should the nurse address when the parents are not present? 1. The adolescent's role in the family 2. Teen job responsibilities 3. Possible domestic violence 4. Activities done as a family Answer: 3 Explanation: 1. This topic involves the parents, so it is ok to address while the parents are present. 2. This topic involves the parents, and allowing for both the teen and the parents to talk about it is important. 3. If domestic violence is suspected, it would be appropriate to ask these questions only when the teenager is alone with the nurse or healthcare provider. 4. This topic involves the parents and allowing for both the teen and the parents to talk about it is important. Page Ref: 855 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Practice: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.3 Apply communication skills in interactions with school-age children and adolescents.

9) An adolescent with obesity who adamantly denies sexual activity has a positive pregnancy test. Which response by the nurse is most appropriate? 1. "When was your last menstrual period (LMP)?" 2. "Tell me how you feel about your body image." 3. "Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy." 4. "Why are you denying sexual intercourse?" Answer: 3 Explanation: 1. Obesity can affect the teens menstrual period, so this question may not help the teen come to the realization of the positive pregnancy test. 2. The teens body image may be a problem but is not the priority at this time, so this response is not appropriate when discussing the pregnancy test results. 3. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is to ask a direct question in which the nurse and client search for an answer. 4. Accusing the teen will not allow for therapeutic communication between the nurse and the teen. Page Ref: 853 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.5 Synthesize data from history and examination of the school-age child and adolescent with knowledge of development to plan interventions appropriate during health supervision visits.

10) A mother reports that her adolescent daughter is always late. The mother states, "She was born late and has been late every day of her life." Which response by the nurse is appropriate? 1. "Setting specific alarms and reinforcing the value of being 'on-time' may assist her to be more of an 'on-time' individual." 2. "Just let it go for now. Teachers and, in the future, employers will be the best people to help her be 'on-time.' " 3. "You need to establish specific time frames for your adolescent and be certain she adheres to them." 4. "You have a major problem. There must be a lot of screaming in your home." Answer: 1 Explanation: 1. The best response is to help the mother find a way to help the teen deal with the problem of lateness. 2. This response does not validate how the mother is feeling and doesn't allow for a concrete way to address the situation. 3. This answer is close but doesn't give the parent some real life tips to help the adolescent be more on time. 4. This is not acknowledging the parent's feelings and is not appropriate Page Ref: 843 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.6 Plan with school-age children and adolescents to help them integrate activities to promote health and to prevent disease and injury.

11) Which screening is appropriate for the school nurse to perform on all adolescent students? 1. Respiratory rate 2. Hepatitis B profile 3. Chest x-ray 4. Scoliosis Answer: 4 Explanation: 1. This will be part of a vital sign assessment but is not a screening tool for adolescents. 2. The vaccine records should be reviewed to confirm the patient has received the Hep B profile but is normally received prior to adolescents. 3. An x-ray is not part of a routine screening for adolescents. 4. Routine screening for adolescents includes checking for scoliosis, height, weight, and blood pressure measurements. Page Ref: 855 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Identify the major health concerns of the school-age and adolescent years.

12) During a health maintenance visit, an adolescent states, "I have no friends in my new school and I no longer want to go to college. I know I will be lonely there, too." Which is the priority nursing action? 1. Stressing the importance of remaining in a close parent-child relationship during these stressful times 2. Promoting healthy mental health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school due to adolescent exclusion behaviors 4. Helping the adolescent realize the value of postsecondary education Answer: 2 Explanation: 1. The adolescent is having some feelings and they need to be validated, so this is not the best answer as they are looking for friends not parents. 2. The adolescent is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental health outcomes for the child. 3. The adolescent needs immediate coping skills; telling them to wait it out is not the best answer. 4. The adolescent is in crisis right now, so talking about the future is not the best answer. They need real-time help. Page Ref: 855 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.6 Plan with school-age children and adolescents to help them integrate activities to promote health and to prevent disease and injury.

13) The nurse is planning to teach a group of adolescents about what can happen when having unprotected sex. Which nursing action will allow effective communication with the group? 1. Offering personal opinions on the topic 2. Allowing for discussion among the participants 3. Lecturing on the topic for the allotted time without any discussion 4. Discussing sex education related to religious belief Answer: 2 Explanation: 1. Offering personal options on the topic will not allow for effective communication especially if they disagree with the opinion and now will not talk about it to avoid conflict. 2. Whatever the setting, the nurse partners with the adolescent, the parents, and other persons, such as teachers or school counselors, to plan appropriate goals and related interventions. Appropriate interventions include applying communication skills effective with teens, such as listening to concerns, allowing for discussion, and bringing peers who have had experiences related to the topic being discussed. 3. Just lecturing and not allowing for discussion is not an effective communication tactic. 4. Bringing in religious beliefs will not establish effective communication as the group may have differing religious beliefs. Page Ref: 857 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Practice: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Teaching and Learning Learning Outcome: 36.3 Apply communication skills in interactions with school-age children and adolescents.

14) Which nursing action is the best when teaching adolescent health promotion and health maintenance topics? 1. Contacting the parents and asking what issues they have with their adolescents 2. Having the adolescents identify a personal health goal 3. Asking the advice of the counselors at school 4. Telling the adolescents information that will be included in the lecture Answer: 2 Explanation: 1. The focus should be on the adolescent's needs and not the parents' needs, the input would be helpful but is not the best course of action. 2. Teaching topics will be directed at both health promotion and health maintenance. A good starting point is to have the adolescent identify a personal health goal, and begin teaching there. 3. The input of the counselor is important in the planning but is not the best answer. 4. Allowing for the adolescents to share what they are looking to get out of the lecture is best before starting out saying what will be discussed. Page Ref: 857 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 36.6 Plan with school-age children and adolescents to help them integrate activities to promote health and to prevent disease and injury.

15) Which screenings are appropriate for an adolescent client who admits to being sexually active during a scheduled health maintenance visit? Select all that apply. 1. Herpes simplex virus 2. Gonorrhea 3. Chlamydia 4. Impetigo 5. Mononucleosis Answer: 1, 2, 3 Explanation: 1. Herpes simplex 1 and 2 can be sexually transmitted and should be included in the screening. 2. Some individuals with gonorrhea may display no symptoms. Because it is a sexually transmitted infection, screening for it would be appropriate. 3. Chlamydia is the most common sexually transmitted infection in the United States. Screening is appropriate. 4. This is a skin condition found mostly in young children, not a sexually transmitted disease. 5. This is not a sexually transmitted disease, so no need for screening during a health maintenance visit. Page Ref: 855 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.5 Synthesize data from history and examination of the school-age child and adolescent with knowledge of development to plan interventions appropriate during health supervision visits.

16) Which nursing action maintains confidentiality when performing height and weight measurements during a co-ed physical education class? 1. Having a student worker record the screening findings on the appropriate adolescent's record 2. Having a volunteer weigh and measure the adolescents and verbally give the findings to the nurse to calculate the body mass index and record 3. Providing a privacy screen and having the health aid record the findings directly on the record. The nurse will then calculate body mass index. 4. Using a buddy system with the students, having the students measure each other, and then recording the findings. Answer: 3 Explanation: 1. This action would not provide privacy from other students. 2. The information should not be shared out loud as it will not provide privacy. 3. A privacy screen and written responses will prevent other adolescents from hearing or seeing results. 4. This action would not provide privacy from other students. Page Ref: 837 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.4 Apply assessment skills to plan data-gathering methods for nutrition, physical activity, oral health, and mental health status of youth. 17) The nurse is planning care for an overweight adolescent. Which topic may also be appropriate for the nurse to include in the adolescent's plan of care? 1. Substance abuse 2. School phobia 3. Spiritual distress 4. Negative self-esteem Answer: 4 Explanation: 1. The student is not suffering substance abuse, so this topic is not needed. 2. The student is not having school phobia, so this topic is not needed. 3. The student is not experiencing spiritual distress, so this is not the best answer. 4. Self-esteem is tied closely to body image, a common source of distress among obese adolescents. Therefore, the nurse will monitor the adolescent for issues with self-esteem. Page Ref: 839 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.1 Identify the major health concerns of the school-age and adolescent years. 16 Copyright © 2022 Pearson Education, Inc.

18) The school nurse is assessing an adolescent who reports getting less than 6 hours of sleep at night. Which consequences of inadequate sleep will the nurse include when responding to the adolescent? Select all that apply. 1. Hyperactivity 2. Increased nocturnal emissions 3. Increased risk of automobile accidents when driving 4. Moodiness 5. An inability to perform well at school Answer: 3, 4, 5 Explanation: 1. This is common in school-age children but not in adolescents. 2. This is common in puberty and is not increased by less sleep at night. 3. This is a possibility in the adolescent who is sleep deprived. 4. Parents often report that sleep-deprived adolescents tend to be moody and are difficult to communicate with. 5. Drowsiness will inhibit the performance of the adolescent. Page Ref: 842 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

19) Which teaching topics are appropriate for the nurse to include for an adolescent who admits to the use of chewing tobacco? Select all that apply. 1. Lung cancer 2. Nicotine addiction 3. Mouth cancers 4. Emphysema 5. Mouth ulcers Answer: 2, 3, 5 Explanation: 1. Lung cancer is related to smoking tobacco vs chewing tobacco. 2. Nicotine addiction occurs with chewing tobacco just as it does with smoking cigarettes. 3. Cancer of the mouth is associated with chewing tobacco. 4. This is caused by smoking not chewing tobacco. 5. Mouth ulcers occur in individuals who chew tobacco. Page Ref: 853 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.6 Plan with school-age children and adolescents to help them integrate activities to promote health and to prevent disease and injury. 20) Which question is appropriate for the nurse to include in the assessment for an adolescent client related to developmental tasks? 1. "How are you adapting to the high school setting?" 2. "What type of relationship do you have with your friends? 3. "Have you thought about your future career goals?" 4. "Do you play any team sports?" Answer: 2 Explanation: 1. This question is in the coping category and not developmental. 2. The primary task for the adolescent is to separate from parents, and develop positive peer relationships. 3. This is a thoughts question and not focused on developmental tasks. 4. This is a good question to develop therapeutic communication but not related to developmental tasks. Page Ref: 855 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.4 Apply assessment skills to plan data-gathering methods for nutrition, physical activity, oral health, and mental health status of youth. 18 Copyright © 2022 Pearson Education, Inc.

21) The nurse notes dental issues during the assessment of an adolescent client. Which topics will the nurse explore further to determine the cause of the issues? Select all that apply. 1. Use of fluoridated water 2. Use of a mouth guard when playing physical sports 3. Anorexia nervosa 4. Bulimia nervosa 5. Use of daily vitamins Answer: 2, 3, 4, 5 Explanation: 1. Use of fluoridated water is a concern in young children, not adolescents who are grown. 2. Sports injuries can be the cause of dental issues without proper safety equipment, such as a mouth guard. 3. Dental injuries can be related to eating disorders. 4. Repeated vomiting can destroy enamel due to contact with acidic stomach juices. 5. A lack of certain vitamins can cause dental issues. Page Ref: 853 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.5 Synthesize data from history and examination of the school-age child and adolescent with knowledge of development to plan interventions appropriate during health supervision visits.

22) The nurse is planning care for an adolescent whose parents have both recently been laid off from their jobs. Which is a potential problem for the adolescent and family? 1. Problems in sleeping 2. Possible risky behavior 3. Insufficient food at home 4. Lack of information about growth and development Answer: 3 Explanation: 1. This is not a potential problem to a jobless family unit. 2. This is not a potential problem related to unemployed parents. 3. The family who has a change in finances may have difficulty with having sufficient food at home. This would be the priority problem for the adolescent. Sleeping, risky behavior, and information about growth and development are not as essential to the adolescent if a parent becomes unemployed. 4. This is not a potential problem related to unemployed parents. Page Ref: 851 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 36.5 Synthesize data from history and examination of the school-age child and adolescent with knowledge of development to plan interventions appropriate during health supervision visits.

23) Which is the most appropriate assessment question for the nurse to ask when collecting nutritional data from an adolescent client? 1. "How do you feel about your weight and the way you look?" 2. "What did you have to eat so far today?" 3. "What is your favorite grocery store?" 4. "Do you eat school lunches or pack a lunch from home each day?" Answer: 1 Explanation: 1. The best way to obtain information to include in the plan of care is to use a open ended question. It is also important to ask information about the way the child feels about his or her body image. 2. This is not the best answer and doesn't open the topic up for more discussion initially. 3. This is not the best answer and doesn't open the topic up for more discussion initially. 4. This is not the best answer and doesn't open the topic up for more discussion initially. Page Ref: 853 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

24) A nurse obtains a nutritional health history from a 10-year-old child. Which food increases the risk for dental cavities necessitating education regarding oral hygiene? 1. Sorbet and yogurt 2. Fluoridated water 3. Gummy bears and licorice 4. Peanuts and crackers Answer: 3 Explanation: 1. This food is healthy and doesn't stick to the teeth as much as others. 2. Fluoridated water helps prevent dental cavities. 3. Food items that stick to the teeth lead to dental cavities. Items such as gummy bears and licorice stick to the teeth and lead to dental cavities. 4. This is a healthy snack that will not increase the risk of dental cavities. Page Ref: 840 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

25) The mother of a 12-year-old child informs the nurse that the child's father died from sudden cardiac death at 44 years old. Which laboratory tests does the nurse anticipate will be prescribed by the healthcare provider? 1. Chest x-ray 2. Complete blood count (CBC) with differential 3. Electroencephalogram (EEG) 4. Lipid profile Answer: 4 Explanation: 1. Chest x-ray would not help identify any cardiac risk factors. 2. CBC would not identify any early cardiac risk factors. 3. EEG is used to study the brain's electroconductivity, not the hearts. 4. This child should have a lipid profile completed at 12 years old, and based on the results, further testing might be needed. Page Ref: 851 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

26) Which will the nurse include in the assessment process for a school-age child who is exhibiting poor school performance? Select all that apply. 1. Hearing screen 2. Muscle tone 3. Dental inspection 4. Vision screen 5. Throat culture Answer: 1, 2, 4 Explanation: 1. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance because most school activities involve listening, seeing, and kinetic activity. A hearing screen is appropriate for the nurse to include in the assessment process. 2. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance because most school activities involve listening, seeing, and kinetic activity. A muscle tone assessment is appropriate for the nurse to include in the assessment process. 3. Dental problems are not risk factors for poor school performance. 4. Children with problems with vision, hearing, and muscle tone are at risk for poor school performance because most school activities involve listening, seeing, and kinetic activity. A vision screen is appropriate for the nurse to include in the assessment process. 5. A throat culture is not part of a screening for poor school performance. Page Ref: 851 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the general observations made of school-age children, adolescents, and families as they come to the "pediatric healthcare home" for health supervision visits.

27) The school nurse is planning an education program for fourth-grade children regarding prepubescent changes. Which nursing action will make the educational program successful? 1. Discussing program content with the parents 2. Talking to all of the classes at one time 3. Planning the program for after school 4. Having the parents present during the program Answer: 1 Explanation: 1. At this age, the information might be new to the child. Involving the parents might entail a preprogram discussion by the parents with the child, or giving the parents a guide to discuss and reinforce later. If the parents and child are able to communicate about the changes, this will promote communication throughout the rest of the growth of the child. 2. Smaller group settings are best for this topic to allow. 3. Planning the session during school hours will allow for attendance rates to be high and allow for a successful program. 4. By having the parents not be present, this gives the children time to process the information and ask questions without parents present. Then, when children are with parents at a later time, it will allow for a further discussion and reinforcement of the topic. Page Ref: 842 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.6 Plan with school-age children and adolescents to help them integrate activities to promote health and to prevent disease and injury.

28) During the psychosocial portion of the nursing assessment, a school-age child states, "I know I am not as good as them, so I just play by myself at recess every day." Which conclusion by the nurse is accurate? 1. The child has a good sense of self-worth. 2. The child has a poor body image. 3. The child has decreased self-esteem. 4. The child has a self-determined concept. Answer: 3 Explanation: 1. The child is not interacting with others, so this is concerning that they do not think they are worthy. 2. Body image may be part of it but is not the most accurate reason why the child is not interacting. 3. The child's statement reveals no interaction with other children during play periods; therefore, the child's self-esteem is low. 4. This is not the reason for the child to not play with other children. Page Ref: 841 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36.4 Apply assessment skills to plan data-gathering methods for nutrition, physical activity, oral health, and mental health status of youth.

29) An overweight school-age girl states, "I would like to be more active but my parents won't let me try out for the soccer team." Which is an appropriate nursing action based on this statement? 1. Referring the child to the school psychologist to discuss the weight issue 2. Telling the child to talk to the school nurse each day about the foods eaten 3. Encouraging the parents to investigate the option of ride sharing with a classmate's family 4. Suggesting that the family plan an activity night, and play board games together Answer: 3 Explanation: 1. The child is showing that she wants to be more active, so the psychologist is not warranted. 2. This tactic could cause more harm than good making the girl's relationship with food unhealthy. 3. Sharing rides with another family might allow the girl to get involved with a physical activity after school and still have the parents involved. 4. Board games are not bad but will not help the child increase her physical activity. Page Ref: 852 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.4 Apply assessment skills to plan data-gathering methods for nutrition, physical activity, oral health, and mental health status of youth.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 37 Family Assessment and Concepts of Nursing Care in the Community 1) Which pediatric client will the community health nurse assess first? 1. A 6-year-old who is wheezing and short of breath. 2. A 2-year-old who has been pulling at his ear. 3. A 2-month-old with a 2-day history of diarrhea. 4. A 10-year-old with a sore throat and low-grade fever. Answer: 1 Explanation: 1. A child who has symptoms of respiratory distress should be seen right away. 2. While the 2-year-old is exhibiting symptoms of an ear infection and needs to be seen; however, this is not the priority client for assessment. 3. While the 2-month-old with a 2-day history of diarrhea needs to be seen, this is not the priority client for assessment. 4. While a 10-year-old with a sore throat and low-grade fever need to be seen, this is not the priority client for assessment. Page Ref: 871 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.3 Assemble a list of family support services that might be available in a community.

2) A community assessment conducted by the nurse reveals that the number of serious injuries in children has doubled in the past year. Which problem should the nurse use when planning care to address the increased number of injuries? 1. Family needs when a child is hospitalized 2. Use of bicycle helmets to reduce injuries 3. Incorrect use of child car seats 4. Ways to prevent injuries in children Answer: 4 Explanation: 1. This problem might be appropriate in a specific situation. 2. This problem might be appropriate in a specific situation. 3. This problem might be appropriate in a specific situation. 4. Ways to prevent injuries in children is general to the problem as a whole and is, therefore, the most appropriate to address the community's needs. Page Ref: 862 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 37.3 Assemble a list of family support services that might be available in a community. 3) Which must the nurse realize prior to accepting any assignment as a home health nurse? 1. All decisions will be made by the healthcare provider. 2. Independent decisions regarding emergency care of the child will be made by the nurse. 3. The family will adapt their lifestyle to the needs of the nurse. 4. The family is in charge. Answer: 4 Explanation: 1. The home health nurse must realize that the family is in charge. 2. The family must provide informed consent for emergency care. 3. The nurse must be flexible and adaptable to the lifestyle of the family. 4. The home health nurse must realize that the family is in charge. Page Ref: 871 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.3 Assemble a list of family support services that might be available in a community.

4) The home health nurse is providing care to a 2-week-old newborn, and notes that the baby has a necklace with a charm around the neck. The parents state that they believe the charm will keep the baby healthy. Which nursing action is most appropriate? 1. Report the parent to Social Services for endangering the child. 2. Respect the parents' wishes, and leave the necklace in place. 3. Remove the necklace, and inform the parents that it is dangerous. 4. Ask the parents to remove the necklace. Answer: 2 Explanation: 1. The nurse should honor the practices of the family. To do otherwise would lead to loss of trust from the family. The nurse can provide anticipatory guidance to the family that includes safety principles as the infant grows. 2. Families of different cultural backgrounds might have specific beliefs about healthcare. These beliefs might differ from those of the nurse. The nurse should honor the practices of the family. 3. The nurse should honor the practices of the family. To do otherwise would lead to loss of trust from the family. The nurse can provide anticipatory guidance to the family that includes safety principles as the infant grows. 4. The nurse should honor the practices of the family. To do otherwise would lead to loss of trust from the family. The nurse can provide anticipatory guidance to the family that includes safety principles as the infant grows. Page Ref: 863 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Discuss the community healthcare settings where nurses provide health services to children.

5) A 2-month-old infant with bronchopulmonary dysplasia (BPD) is being prepared for discharge from the neonatal intensive care unit. The infant will continue to receive oxygen via nasal cannula at home. Prior to discharge, the home health nurse assesses the home. Which finding poses the greatest risk to this infant? 1. Paint peeling on the walls 2. A wood stove used for heating 3. A sibling who has an ear infection 4. Small toys strewn on the floor Answer: 2 Explanation: 1. Paint peeling from the wall will pose a choking risk to the older infant who is crawling. 2. Assessment of the home environment is essential prior to discharge of a medically fragile infant. The use of a wood stove poses great risk to the infant who already has fragile lungs and is a fire hazard when using oxygen in the home environment. 3. Ear infections are not contagious. 4. Small toy pieces will pose a choking risk to the older infant who is crawling. Page Ref: 871 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Discuss the community healthcare settings where nurses provide health services to children.

6) An adolescent client has a long leg cast secondary to a fractured femur. Which nursing action is most appropriate in order to effectively facilitate the adolescent's return to school? 1. Develop an individualized health plan (IHP) that focuses on long-term needs of the adolescent. 2. Meet with all of the other students prior to the student's return to school to emphasize the special needs of the injured teen. 3. Meet with teachers and administrators at the school to make sure entrances and classrooms are wheelchair accessible. 4. Meet with parents of the injured student to encourage homebound schooling until a short leg cast is applied. Answer: 3 Explanation: 1. While an IHP might be developed, short-term needs would be the focus. 2. It is not necessary to meet with all of the students to discuss the adolescent's needs. 3. An adolescent with a long leg cast secondary to a fractured femur will be dependent on a wheelchair for mobility. It is essential that the environment be wheelchair accessible prior to the adolescent's return to school. 4. There is no reason to encourage the adolescent to stay at home for schooling if the child is ready to return. Page Ref: 868 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Discuss the community healthcare settings where nurses provide health services to children.

7) Which is the priority topic the nurse will include when teaching newly hired teachers at a child care center within the community? 1. How to take a temperature 2. The schedule for immunizations 3. How to interpret healthcare records 4. Principles of infection control Answer: 4 Explanation: 1. While the teachers may need to monitor a child's temperature while working at the center, this is not the priority topic for the nurse to include in the teaching session. 2. While the teachers may need to review immunization records for the children, this is not the priority topic for the nurse to include in the teaching session. 3. While the teachers may need to review and interpret the children's healthcare records, this is not the priority topic for the nurse to include in the teaching session. 4. It is essential that teachers know principles of infection control to decrease the spread of germs that can cause disease in young children; therefore, this is the priority topic for the nurse to include in the teaching session. Page Ref: 868 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Knowledge: Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.5 Compare the roles of the nurse in each identified community healthcare setting.

8) In which situation will the school nurse collaborate with the family and other members of the healthcare team in order to develop an individualized health plan (IHP)? 1. For a child who recently developed a penicillin allergy 2. For a child who has been treated for head lice 3. For a child who has missed 2 weeks of school due to mononucleosis 4. For a child who is newly diagnosed with insulin-dependent diabetes mellitus. Answer: 4 Explanation: 1. A child who is allergic to penicillin will not receive this medication anymore and, therefore, should not encounter any problems related to it at school. 2. A child who has been treated for head lice can return to school, and does not need an IHP. 3. While a child who has missed 2 weeks of school will need to make arrangements for makeup work, an IHP is not needed. 4. An IHP that ensures appropriate management of the child's healthcare needs must be developed for a child newly diagnosed with a chronic illness, such as diabetes. Page Ref: 867 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Knowledge: Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.5 Compare the roles of the nurse in each identified community healthcare setting.

9) The telephone triage nurse receives a call from a parent who describes a crowing sound when the 18-month-old breathes, and the child is hard to wake up. Which is the appropriate nursing action? 1. Making an appointment for the child to see the healthcare provider 2. Obtaining the history of the illness from the parent 3. Advising the parent to hang up and call 911 4. Reassuring the parent and providing instructions on home care for the child Answer: 3 Explanation: 1. This action would be appropriate only in nonemergency situations. 2. This action would be appropriate only in nonemergency situations. 3. The nurse should immediately recognize the symptoms of severe upper respiratory distress, and advise the parent to call 911. 4. This action would be appropriate only in nonemergency situations. Page Ref: 871 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Knowledge: Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.5 Compare the roles of the nurse in each identified community healthcare setting.

10) Which actions are expected for a nurse who works in the school environment? Select all that apply. 1. Developing a plan for emergency care of injured children 2. Teaching a class on wellness to teachers and staff 3. Prescribing antibiotics for streptococcal pharyngitis 4. Diagnosing an ear infection 5. Screening for head lice Answer: 1, 2, 5 Explanation: 1. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. 2. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. 3. Prescribing medication for a new illness is beyond the scope of practice for the school nurse unless the nurse is licensed as an advanced practice nurse. 4. Diagnosing acute illness is beyond the scope of practice for the school nurse unless the nurse is licensed as an advanced practice nurse. 5. Screening of students for certain conditions; educating students, teachers, and staff; and developing emergency plans are all roles of the school nurse. Page Ref: 865, 867 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Knowledge: Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.5 Compare the roles of the nurse in each identified community healthcare setting.

11) A child who has had a tracheostomy for several years is scheduled to begin kindergarten in the fall. The teacher is concerned about this child being in the class, and consults the school nurse. Which nursing action is appropriate? 1. Making arrangements for the child to go to a special school 2. Recommending that the child be home schooled 3. Asking the parents of the child to provide a caregiver during school hour 4. Teaching the teacher how to care for the child in the classroom Answer: 4 Explanation: 1. Laws have been implemented to ensure that children with disabilities will receive a free education. 2. Laws have been implemented to ensure that all children with disabilities will receive a free education. While the parents may wish to home school their child, it is not appropriate for the nurse to recommend this to the parents. 3. Since the child has had a tracheostomy for several years, the child might need a little extra attention while in the school setting. If needed, a health aide may be assigned to the child, but this is not the responsibility of the parents. 4. Since the child has had a tracheostomy for several years, the child might need a little extra attention while in the school setting. The teacher should be taught how to care for the child, if needed, and taught the signs of distress. Page Ref: 868 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Knowledge: Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.5 Compare the roles of the nurse in each identified community healthcare setting.

12) A child who is dependent on a ventilator is being discharged from the hospital. Which will the nurse recommend for the emergency plan of care for this family during the discharge instruction process? 1. Designating an emergency shelter site 2. Notifying the power company that the child is on life support 3. Acquiring a backup generator 4. Having an alternate heating source if power is lost Answer: 3 Explanation: 1. While this action is very important, it is most essential that the ventilator must have power to continue to function at all times. 2. While this action is very important, it is most essential that the ventilator must have power to continue to function at all times. 3. Prior to discharge to home, it is essential that the family acquire a generator so that the child's life support will continue to function effectively should power be lost. 4. While this action is very important, it is most essential that the ventilator must have power to continue to function at all times. Page Ref: 872 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: V.C.4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Practice: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.6 Review the special developmental needs of children to consider in disaster preparedness planning.

13) Which aspect of an emergency medical services system (EMS) indicates the providers are prepared to provide emergency care to children? 1. Listing hospitals in the area that treat children 2. Having pediatric-sized equipment and supplies 3. Placing small stretchers in emergency vehicles 4. Educating staff related to assessment and treatment of children of all ages Answer: 4 Explanation: 1. While a list of hospitals that treat children is an essential part of an EMS system, the aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. 2. While size-appropriate equipment is an essential part of an EMS system, the aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. 3. While size-appropriate equipment is an essential part of an EMS system, the aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. 4. The aspect that is most indicative that EMS providers actually are prepared to take care of children is evidence of education related to assessment and emergency treatment. Page Ref: 873 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: V.C.4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Teamwork: Practice: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 37.6 Review the special developmental needs of children to consider in disaster preparedness planning.

14) The nurse is planning care for a pediatric client who has a fractured femur and requires a spica cast after being involved in a motor vehicle accident. The client's adolescent brother was driving the car, which was a total loss. The client's father lost his job 3 weeks ago, and the mother has just accepted a temporary waitress job. Which is an appropriate problem for this child, and family, based on the current data? 1. Change in family functioning 2. Caregiver burden 3. Change in social interactions 4. Compromised family coping Answer: 4 Explanation: 1. The spica cast might require alteration in family functioning; however, the situation describes no signs and symptoms to indicate this. In addition, fractures generally are not considered a significant long-term disability. 2. The need for a spica cast is not considered a newly acquired disability. Nothing about the situation describes caregiver role strain. 3. Lack of family members and lack of respite support were not mentioned in the scenario. 4. The situation describes multiple changes, or stressors, in the family's situation that compromise family coping skills. Page Ref: 862 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 37.1 Contrast the categories of family strengths that help families cope with stressors.

15) The nurse is developing an ecomap for a pediatric client and family. Which explanation should the nurse provide prior to beginning this task? 1. "It provides information about your family structure including family life events, health, and illness." 2. "It illustrates your family relationships and interactions with community activities including school, parental jobs, and children's activities." 3. "It is a short questionnaire of five questions that measures your family's growth, affection, and resolve." 4. "It is an assessment that consists of three categories of information about your family's strengths and problems." Answer: 2 Explanation: 1. Information of this type is called a genogram. 2. This is the description of the ecomap. 3. The five-item questionnaire measuring family growth, affection, resolve, adaptability, and partnership is a Family Apgar. 4. This describes a Calgary Family Assessment Model. Page Ref: 863 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.2 Summarize the advantages of using a family assessment tool.

16) Which are resources that enable families to develop and adapt to stressors? Select all that apply. 1. Education 2. Communication 3. Prior experiences 4. Problem solving 5. Adequate finances Answer: 1, 3, 5 Explanation: 1. Education is a resource that enables families to develop and adapt to stressors. 2. While effective communication does enable families to develop and adapt to stressors, it is not considered a resource. 3. Prior experiences are a resource that enables families to develop and adapt to stressors. 4. While problem solving does enable families to develop and adapt to stressors, it is not considered a resource. 5. Adequate finances are a resource that enables families to develop and adapt to stressors. Page Ref: 862 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.1 Contrast the categories of family strengths that help families cope with stressors.

17) Which nursing actions will allow a family to further develop resilience when faced with an illness of a child? Select all that apply. 1. Teaching skills to provide care 2. Suggesting adaptations related to discipline 3. Providing positive reinforcement 4. Recommending the use of defensive coping strategies 5. Focusing on the weaknesses Answer: 1, 2, 3 Explanation: 1. Most families have the capacity to develop resilience. One nursing action that can support the development of resilience to helping family members learn new skills. This occurs by teaching the family the skills they need to provide care. 2. Most families have the capacity to develop resilience. One nursing action that can support the development of resilience is to suggestion adaptations. This occurs by providing education related to alternative methods for discipline. 3. Most families have the capacity to develop resilience. One nursing action that can support the development of resilience is to provide positive reinforcement. This allows the family to gain confidence in their ability to manage the challenges of the child's health condition. 4. Defensive coping strategies promote dysfunction and not resilience. 5. While it is important to assess for family weaknesses, it is not appropriate to focus on these weakness when the goal is to develop resilience. Page Ref: 862 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.1 Contrast the categories of family strengths that help families cope with stressors.

18) The nurse is preparing to collect data for a family assessment. Which nursing actions are appropriate? Select all that apply. 1. Conducting interviews 2. Observing interactions 3. Reviewing reports from the healthcare provider 4. Monitoring daily living patterns 5. Asking a family friend his or her opinion of the family Answer: 1, 2, 3, 4 Explanation: 1. The nurse collects data when conducting a family assessment by conducting interviews with the members of the family. 2. The nurse collects data when conducting a family assessment by observing interactions between the members of the family. 3. The nurse collects data when conducting a family assessment by reviewing reports from the healthcare provider. 4. The nurse collects data when conducting a family assessment by monitoring daily living patterns among the family members. 5. Interviewing a family friend without first getting permission from the family is a confidentiality violation. Page Ref: 863 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Teamwork: Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.2 Summarize the advantages of using a family assessment tool.

19) The nurse is constructing a genogram as part of the family assessment process. Which will the nurse include in the genogram? Select all that apply. 1. Social class 2. Occupation 3. Place of residence 4. Social networks 5. Ethnicity Answer: 1, 2, 3, 5 Explanation: 1. Social class is included when constructing a family genogram. 2. Occupation is included when constructing a family genogram. 3. Place of residence is included when constructing a family genogram. 4. Social networks are explored through the use of a family ecomap, not a genogram. 5. Ethnicity is included when constructing a family genogram. Page Ref: 863 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Teamwork: Knowledge: Effective strategies for communicating with different members of the health team, including patients and families, nurses, and other health professionals | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.2 Summarize the advantages of using a family assessment tool.

20) The pediatric nurse is working as a first responder within the community after a tornado. Which nursing actions are appropriate? Select all that apply. 1. Providing first aid to the walking wounded 2. Assessing for panic reactions 3. Allowing a child to leave the scene unaccompanied by an adult 4. Administering immunizations 5. Discussing the situation with the local media Answer: 1, 2, 4 Explanation: 1. A nurse who is functioning as a first responder after a natural disaster such as a tornado will provide first aid to the walking wounded. 2. A nurse who is functioning as a first responder after a natural disaster such as a tornado will assess for panic reactions. 3. It is not appropriate for the nurse to allow a child to leave the scene unaccompanied by an adult. 4. A nurse who is functioning as a first responder after a natural disaster such as a tornado will provide immunizations, if necessary. 5. It is not appropriate for the nurse to discuss the situation with the local media. A hospital representative is someone who can discuss the situation with the local media. Page Ref: 873 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: V.C.4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Practice: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.6 Review the special developmental needs of children to consider in disaster preparedness planning.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 38 Nursing Considerations for the Child and Family with a Chronic Condition 1) The nurse is providing care to several pediatric clients in the hospital setting. Which client diagnosis is capable of producing chronic limitations for the child? 1. Pneumonia from the bacillus Haemophilus influenzae 2. Respiratory syncytial virus 3. Streptococcus pneumoniae, a gram-positive diplococcus 4. Congenital heart defect Answer: 4 Explanation: 1. Pneumonia is not a chronic limitation. 2. Respiratory syncytial virus is a serious infection caused by a virus that affects infants. It does not result in permanent disability. 3. Streptococcus pneumoniae, a gram-positive diplococcus, is treatable and will not cause chronic limitation. 4. A congenital heart defect can leave a child with a permanent chronic condition. Page Ref: 877 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.1 Explain the causes of chronic conditions in children.

2) The nurse is providing care to several hospitalized pediatric clients. Which child has the greatest risk for a developmental disability? 1. An 18-month-old admitted with a diagnosis of drowning 2. A school-age child newly diagnosed with type 1 diabetes mellitus 3. A toddler with sepsis 4. A 2-year-old child with a fractured femur Answer: 1 Explanation: 1. Drowning indicates a period of time when the child was underwater and not breathing; near drowning can leave a child with a permanent chronic condition. 2. Diabetes is a chronic disease but does not lead to developmental disabilities. 3. Sepsis is treatable and will not result in a developmental disability. 4. A fractured femur is limiting to a child but will not leave the child with a chronic, limiting condition. Page Ref: 877 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.1 Explain the causes of chronic conditions in children.

3) The nurse is planning care for a school-age child who requires oxygen, enteral tube feedings, and IV medications during the school day. To which category of chronic illness does this child belong? 1. Dependent on special diet 2. Dependent on medical technology 3. Increased use of healthcare services 4. Functional limitations Answer: 2 Explanation: 1. While this child does have a special diet, this category is not comprehensive enough to describe the child's needs. 2. This child requires oxygen, enteral tube feedings, and IV medications, which indicates the child is dependent on medical technology. 3. While this child does have increased use of healthcare services, this category is not comprehensive enough to describe the child's needs. 4. While this child may have functional limitations, this category is not comprehensive enough to describe the child's needs. Page Ref: 878 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Identify the categories of chronic conditions in children.

4) The nurse is partnering with the family of a hospitalized premature neonate who suffered an intraventricular hemorrhage (IVH). After 3 months in the neonatal intensive care unit (NICU), the infant is being discharged. Which activities will the nurse suggest to the family to help stimulate the infant's development? Select all that apply. 1. Using a day care for stimulation 2. Discouraging sibling interaction 3. Holding and rocking the infant 4. Interacting face to face 5. Talking softly and singing to the infant Answer: 3, 4, 5 Explanation: 1. A premature infant might not have a mature immune system; therefore, day care might present an infection issue. The needs of this child might not be met in a day care setting with many children. 2. Sibling interaction is important and should be encouraged. 3. Holding and rocking the infant stimulates the infant's sense of motion, facilitating parentinfant bonding. 4. Interacting face to face stimulates the infant's sense of vision, facilitating parent-infant bonding. 5. Talking softly and singing to the infant are activities that stimulate the infant's senses of hearing, touch, and motion, facilitating parent-infant bonding. Page Ref: 881 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.3 Describe the nurse's role in caring for a child with a chronic condition.

5) The nurse is providing care to a pediatric client who is newly diagnosed with a chronic condition. The parents ask, "When will our child be able to assume more responsibility for managing the disease?" Which age group will the nurse include in the response to the parents? 1. Preschooler 2. School-age 3. Adolescent 4. Toddler Answer: 2 Explanation: 1. Preschoolers do not have the cognitive and psychomotor skills for these tasks. 2. School-age children are developing a sense of industry and can begin assuming responsibility for self-care. 3. Adolescents should already be well accomplished at self-care. 4. Toddlers do not have the cognitive and psychomotor skills for these tasks. Page Ref: 881 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.3 Describe the nurse's role in caring for a child with a chronic condition. 6) Which intervention should the nurse include in the plan of care for an adolescent with a chronic condition? 1. Being more concerned for parents 2. Exhibiting less concern about appearance 3. Having an altered body image 4. Portraying a higher self-esteem Answer: 3 Explanation: 1. As adolescents develop a sense of identity, they are focused on themselves and the present. 2. Adolescents with chronic conditions will have a heightened concern about their appearance. 3. Adolescents with chronic conditions might have inaccurate assessments of their body image. 4. Adolescents with chronic conditions have low self-esteem when comparing their bodies with those of their peers. Page Ref: 881 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.3 Describe the nurse's role in caring for a child with a chronic condition.

7) The nurse is working with the parents of a child with a chronic condition. Which statement made by the child's parents indicates the need for intervention related to overwhelming caregiver burden? 1. "My mother moved in and helps us with the care of our family." 2. "I chose to quit my job to be home with my child, and my husband helps in the evening when he can." 3. "I have to care for my child day and night, which leaves little time for me." 4. "Our health insurer sent us a rejection letter for my child's brand-name medication, and we must fill out forms to get the generic." Answer: 3 Explanation: 1. The family's pitching in to help indicates family support. 2. The mother chose to care for the child, and receives help from the husband. 3. No respite time from caregiving responsibilities could lead to overwhelming caregiver burden. 4. Substituting generic for brand-name medications will not result in caregiver burden. Page Ref: 887 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.4 Assess the family of a child with a chronic condition.

8) The nurse is planning care for the family of a child with a chronic illness. Which activities will the nurse recommend to decrease the risk for caregiver burden? Select all that apply. 1. Fostering social relationships 2. Exercising 3. Developing a hobby 4. Moving away 5. Sleeping more than 9 hours per 24-hour period Answer: 1, 2, 3 Explanation: 1. Fostering social relationships contributes to social and mental rest and restoration. 2. Exercising contributes to physical restoration. 3. Developing a hobby contributes to physical, spiritual, social, and mental rest and restoration. 4. Moving away is an avoidance behavior that does not address exhaustion from overwhelming caregiving responsibilities. 5. Sleeping more than the body requires is an avoidance behavior. Page Ref: 887 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.5 Prepare the family of a child with a chronic condition to effectively care for the child in the home. 9) The nurse is conducting a nursing assessment of the parent and child with severe cerebral palsy during a routine clinic visit. Which nursing action is appropriate based on the current data? 1. Measuring the urine output 2. Measuring the child's head circumference 3. Observing the parent-child relationship 4. Observing how the child interacts during play Answer: 3 Explanation: 1. Measuring urine output is not important unless there are problems with the bladder. 2. Measuring the child's head circumference is not an important assessment at this time. 3. Observing the parent-child relationship is important to the success of health supervision for both the child and parents. 4. Playtime is not important during this time. Page Ref: 880 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.4 Assess the family of a child with a chronic condition. 7 Copyright © 2022 Pearson Education, Inc.

10) The nurse is conducting an educational program for parents of children with chronic conditions. Which parental statement indicates the need for further instruction? 1. "I know my child will get better and not have to take any more medication." 2. "I know my child will need assistance with activities of daily living." 3. "I know my child may need specialized education." 4. "I know my child will have to stay on a special diet." Answer: 1 Explanation: 1. Chronic conditions might require lifetime dependence on medication. 2. Children with chronic conditions typically need assistance with daily living activities. 3. A child with a chronic condition may require specialized education. 4. Depending on the diagnosis, children with chronic conditions might require a special diet. Page Ref: 877 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 38.4 Assess the family of a child with a chronic condition. 11) An adolescent diagnosed with type 1 diabetes mellitus (DM) is prescribed dietary restrictions and daily insulin injections. Which behavior does the nurse anticipate from the adolescent upon return to school? 1. Administering medication in front of peers 2. Teaching peers about the diagnosis 3. Acknowledging the condition to classmates 4. Exhibiting poor adherence to the prescribed treatment plan Answer: 4 Explanation: 1. Most adolescents do not want to be seen as "different" by their peers; therefore, it is unlikely that the adolescent will administer the prescribed insulin in front of the peer group. 2. Most adolescents do not want to be seen as "different" by their peers; therefore, it is unlikely that the adolescent will teach his or her peers about the disease process. 3. Adolescents will attempt to hide their health conditions from their classmates. 4. Adolescents have poorer eating habits than all other age groups, and adolescents with diabetes may not adhere to necessary dietary restrictions. Page Ref: 881 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.6 Summarize nursing management for the child with a chronic condition to support transition to school and adult living.

12) The nurse is caring for a 17-year-old client with a chronic condition who will be transitioning into adulthood. When planning care for this client, which should the nurse consider? Select all that apply. 1. Ability to work 2. Ability to live independently 3. Psychosocial needs 4. Parental needs 5. Sibling needs Answer: 1, 2, 3 Explanation: 1. The nurse must consider the client's ability to live independently when planning care for a client with a chronic condition who is transitioning into adulthood. 2. The nurse must consider the client's ability to live independently when planning care for a client with a chronic condition who is transitioning into adulthood. 3. The nurse must consider the client's ability to live independently when planning care for a client with a chronic condition who is transitioning into adulthood. 4. The parent's needs are not considered when planning care for a client with a chronic condition who is transitioning into adulthood. 5. The needs of the client's siblings are not considered when planning care for a client with a chronic condition who is transitioning into adulthood. Page Ref: 887 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.6 Summarize nursing management for the child with a chronic condition to support transition to school and adult living.

13) The nurse is providing care to a toddler-age client newly diagnosed with a chronic condition. Which nursing action will prepare the family for providing care to the toddler once discharged from the hospital setting? 1. Suggesting that the parents use a mobile to provide sensory stimulation 2. Helping the parents recognize their child's capabilities 3. Allowing the child to choose the color of the gown during hospitalization 4. Suggesting the child be enrolled in a special camp to learn about the diagnosis Answer: 2 Explanation: 1. A mobile is not an appropriate toy to provide sensory stimulation to the toddler. This suggestion is appropriate for an infant. 2. It is important for the nurse to help the parents recognize their child's capabilities and to encourage the parents to allow enough time to practice, and learn a new skill. 3. This is an appropriate nursing action when the child is hospitalized; however, this is not a nursing action that will prepare the family for providing care to the toddler with a chronic condition after discharge. 4. Enrollment in a special camp would be appropriate for a school-age child, not the toddler. Page Ref: 878 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.5 Prepare the family of a child with a chronic condition to effectively care for the child in the home.

14) After the infant is diagnosed with a chronic health condition, the family is assigned a nurse case manager. Which will the nurse include in the explanation to the infant's parents regarding this role? 1. Limiting the number of visits to the healthcare facility 2. Preventing duplication of services 3. Improving the quality of life for the child and parents 4. Recognizing the equipment needs of the child and providing assistance with equipment acquisition 5. Visiting the child in the home to assist with physical care Answer: 2, 3, 4 Explanation: 1. Although well-managed care may reduce illnesses and thus visits to the healthcare facility, limiting visits is not a function of the case manager. 2. Because many children who are chronically ill are seen by many healthcare providers and clinics, there is often a duplication of services. Case managing coordinates between the various clinics and healthcare providers to prevent duplication. 3. Case managing has many modes of improving the quality of life for children and parents. By coordinating care, the child can often be seen by several healthcare providers during the same visit, thus, improving the quality of life. 4. The case manager will assist the family in meeting the needs of the child, including helping with identifying and acquiring equipment necessary for caring for the child. 5. The case manager does not provide direct client care. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.3 Describe the nurse's role in caring for a child with a chronic condition.

15) The nurse works in a clinic for medically fragile children who require home care. The nurse has noticed that a high percentage of the families parents divorce. In an attempt to reduce the divorce rate among the parents, the nurse creates an educational session for parents of medically fragile children. Which should be the focus of this session? 1. Communication 2. Financial stability 3. Ways to meet the child's physical needs 4. The state laws that have relevance to the medically fragile child. Answer: 1 Explanation: 1. Both partners need to be able to communicate honestly and frequently to maintain the marriage relationship. 2. Finances will be a problem for the family as the cost of care of medically fragile child can be high. Nurses may refer to community resources but cannot solve all financial problems. 3. The nurse will teach parents how to meet the child's physical needs on a one-to-one basis, not in a group session. 4. This will not reduce the divorce rate. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.4 Assess the family of a child with a chronic condition.

16) The school nurse is reviewing the records of all incoming kindergarten students. Which students will require an individualized education plan (IEP)? 1. The child with diabetes controlled with insulin 2. The child with a casted arm due to a fracture 3. The child with a hearing deficit 4. The child with autism spectrum disorder 5. The child with an IQ of 60 Answer: 3, 4, 5 Explanation: 1. This child may need an individual health plan but does not require an IEP. 2. This is not a chronic problem and does not require an IEP. 3. This child will need modification of the educational plan in order to be successful. 4. The child diagnosed on the autism spectrum will have special educational needs that will be determined by the IEP. 5. The child with an IQ of 60 is intellectually disabled, and will require an IEP. Page Ref: 885 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 38.6 Summarize nursing management for the child with a chronic condition to support transition to school and adult living.

17) Which nursing action is appropriate when preparing the family of a school-age child with a chronic illness to provide care in the home setting? 1. Teaching the family about appropriate sensory stimuli, such as a mobile 2. Educating the family to allow the child choices, such as which food to eat first 3. Preparing the family for the transition of care into adulthood 4. Encouraging interaction between the child and others with the same diagnosis Answer: 4 Explanation: 1. Teaching age-appropriate interventions is important; however, a mobile is an age appropriate toy for the infant, not the school-age child. 2. Providing choices is important for the preschool-age child, not the school-age child. 3. Preparing the family for the transition of care into adulthood is important for the adolescent, not school-age, patient. 4. School-age children should be encouraged to interact with other child who has the same diagnosis. Page Ref: 887 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.5 Prepare the family of a child with a chronic condition to effectively care for the child in the home.

18) The mother of an adolescent with multiple medical and developmental issues says to the nurse: "There are times that I think about just walking out of the house and not coming back." Which problem is the mother demonstrating? 1. Fear 2. Anxiety 3. Lack of finances 4. Caregiver burden Answer: 4 Explanation: 1. There is no evidence that the mother is experiencing fear. 2. There is no evidence that the mother is experiencing anxiety. 3. There is no evidence that the mother is experiencing lack of finances. 4. The mother is experiencing caregiver burden, which is the unrelenting pressure and anxiety related to providing daily care to a child with disabilities while meeting other family obligations. Page Ref: 936 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 38.6 Summarize nursing management for the child with a chronic condition to support transition to school and adult living.

19) A 3-year-old child, recently hospitalized for the exacerbation of a chronic illness, presents for a follow-up appointment at the pediatric clinic. The child's mother states, "He was potty trained before the hospital stay but now he is having daily accidents." Which response by the nurse is most appropriate? 1. "This is probably a reaction to the antibiotics and will disappear when the antibiotics are finished." 2. "Urinary incontinence is a common symptom of progression of cystic fibrosis. Be sure to notify the healthcare provider of this change." 3. "The child may have a urinary tract infection and needs to be evaluated." 4. "Children often regress after hospitalization. Be patient and remind him to go to the bathroom frequently." Answer: 4 Explanation: 1. Antibiotic therapy does not cause incontinence. 2. Urinary incontinence is not a symptom of cystic fibrosis. 3. There are no symptoms of a urinary tract infection (UTI). 4. Regression is a common response to hospitalization. Page Ref: 881 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.3 Describe the nurse's role in caring for a child with a chronic condition.

20) The nurse learns that a newborn is diagnosed with phenylketonuria (PKU). Which is the most appropriate way to inform the newborn's parents about this diagnosis? 1. Calling the parents to provide the diagnosis over the phone 2. Mailing a certified letter explaining the diagnosis and requesting the parents make a pediatric office appointment 3. Planning a group meeting for all parents whose children received the diagnosis in the last two months 4. Scheduling an appointment for the parents to see the healthcare provider in person to discuss the diagnosis Answer: 4 Explanation: 1. Providing the parents information of a chronic health problem of their newborn should not be done over the phone. 2. This information should be provided to the parents in person. 3. This information should be shared on a one-to-one basis. 4. The appropriate environment allows for privacy and freedom from interruptions. The parents should be allowed other support people to be present as they request. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.4 Assess the family of a child with a chronic condition.

21) The parents of a 4-month-old child learn that there will be long-term consequences due to the head injury sustained in a motor vehicle accident, including intellectual disability and cerebral palsy. The parents express anger at the diagnosis and project that anger on the nursing staff. Which responses by the nursing staff are appropriate? Select all that apply. 1. Referring the family to the hospital administrator 2. Recognizing that the parents' anger is a normal response to the news 3. Continuing to provide physical and emotional care to the child and family 4. Offering hospital resources to the parents in addition to continued nursing support 5. Explaining to the family that you are sorry about their child's injury but suggest they transfer the child to another hospital for their own comfort Answer: 2, 3, 4 Explanation: 1. The hospital administrator will be unable to meet their needs or to calm their anger. 2. Parents grieve for the loss of the perfect child. This is a normal reaction. 3. The nursing staff will continue to provide physical and emotional care to the child and family. 4. It is appropriate to offer the hospital chaplain and other mental health workers in addition to continued support from the nursing staff. 5. This option is a resolution for the nursing staff but not for the parents. Page Ref: 882 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.5 Prepare the family of a child with a chronic condition to effectively care for the child in the home.

22) The nurse is assigned as the care coordinator for a child with special healthcare needs. Which actions by the nurse enhance the family's ability to participate in their child's care coordination? Select all that apply. 1. Coordinating the healthcare team 2. Arranging the needed healthcare services 3. Modifying the home for care 4. Helping with decision making for meeting goals of care 5. Educating the family about the diagnosis Answer: 4, 5 Explanation: 1. Coordinating the healthcare team is one of the responsibilities of the nurse case coordinator. This is not an action that will enhance the family's ability to coordinate care for their child. 2. Arranging needed healthcare services is one of the responsibilities of the nurse case coordinator. This is not an action that will enhance the family ability to coordinate care for their child. 3. Modifying the home for care is one of the responsibilities of the nurse case coordinator. This is not an action that will enhance the family ability to coordinate care for their child. 4. The nurse case coordinator helps the family with decision making related to meeting the goals of care. This action enhances the family's ability to coordinate care for their child. 5. The nurse case coordinator educates the family about the child's diagnosis. This action enhances the family's ability to coordinate care for their child. Page Ref: 882 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.7 Discuss the family's role in care coordination.

23) The nurse care coordinator is supporting a family who wishes to become their child's care coordinator. Which statements will the nurse include in the teaching session to prepare the family for this task? Select all that apply. 1. "You won't need to set aside much time to properly coordinate your child's care." 2. "Care coordination requires ongoing assessment of your child's needs." 3. "Since you are the parent, you will not be required to use cost-efficient strategies when coordinating your child's care." 4. "Care coordination requires you to be educated regarding your child's diagnosis." 5. "There is a care coordination workshop provided by hospital educators that will help you to learn this role." Answer: 2, 4, 5 Explanation: 1. Care coordination is time consuming. This statement is not appropriate for the nurse to include in the teaching session. 2. Care coordination requires ongoing assessment of the child's needs. This statement is appropriate to include in the teaching session. 3. All care coordination efforts should include the implementation of cost-efficient strategies for care. This statement is not appropriate for the nurse to include in the teaching session. 4. In order to be a successful care coordinator, it is essential to have an adequate knowledge base regarding the diagnosis. This statement is appropriate to include in the teaching session. 5. When parents wish to assume the role of care coordinator is often necessary that they receive extensive training, which is often provided by hospital educators. This statement is appropriate to include in the teaching session. Page Ref: 883 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.7 Discuss the family's role in care coordination.

24) The nurse of the family who is assuming the role of care coordinator is providing education regarding the use of a healthcare log. Which will the nurse encourage the family to include on this log? Select all that apply. 1. Role of each provider 2. Date of each appointment 3. Prescribed interventions 4. Future treatments 5. Out-of-pocket cost Answer: 1, 2, 3, 4 Explanation: 1. The nurse will encourage the family to include the role of each provider on the healthcare log. 2. The nurse will encourage the family to include the date of each appointment on the healthcare log. 3. The nurse will encourage the family to include the prescribed interventions on the healthcare log. 4. The nurse will encourage the family to include future treatments on the healthcare log. 5. Out-of-pocket cost is not something the nurse encourages the family to keep on the healthcare log. Page Ref: 883 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.7 Discuss the family's role in care coordination.

25) The nurse provides care to pediatric clients with chronic disease process. Which diagnoses does the nurse categorize as dependent on medications or special diets? Select all that apply. 1. Diabetes mellitus 2. Epilepsy 3. Celiac disease 4. Down syndrome 5. Traumatic brain injury Answer: 1, 2, 3 Explanation: 1. A child who is diagnosed with diabetes mellitus is categorized as dependent on medications or special diets. 2. A child who is diagnosed with epilepsy is categorized as dependent on medications or special diets. 3. A child who is diagnosed with celiac disease is categorized as dependent on medications or special diets. 4. A child who is diagnosed with Down syndrome is categorized as having functional limitations. 5. A child who is diagnosed with a traumatic brain injury is categorized as having functional limitations. Page Ref: 878 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Identify the categories of chronic conditions in children.

26) The nurse provides care to pediatric clients with chronic disease process. Which diagnoses does the nurse categorize as needing increased use of healthcare services? Select all that apply. 1. Cancer 2. Sickle cell disease 3. Renal failure 4. Cystic fibrosis 5. Autism spectrum disorder Answer: 1, 2, 4 Explanation: 1. A child who is diagnosed with cancer is categorized as needing increased use of healthcare services. 2. A child who is diagnosed with sickle cell disease is categorized as needing increased use of healthcare services. 3. A child who is diagnosed with renal failure is categorized as being dependent on medical technology. 4. A child who is diagnosed with cystic fibrosis is categorized as needing increased use of healthcare services. 5. A child who is diagnosed with autism spectrum disorder is categorized as having functional limitations. Page Ref: 878 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Identify the categories of chronic conditions in children.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 39 Nursing Considerations for the Hospitalized Child 1) The nurse is providing care to a pediatric client who is experiencing separation anxiety. Which data would support the documentation of the "despair" phase? 1. Lies quietly in bed. 2. Does not cry if his parents return and leave again. 3. Appears to be happy and content with staff. 4. Screams and cries when his parents leave. Answer: 1 Explanation: 1. Children in the "despair" stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. 2. The young child who appears to be happy and content with everyone is in the "denial" stage, as is the child who does not cry if his parents return and leave again. 3. The young child who appears to be happy and content with everyone is in the "denial" stage, as is the child who does not cry if his parents return and leave again. 4. Screaming and crying are components of the "protest" stage. Page Ref: 893 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.3 Describe the child's and family's adaption to hospitalization.

2) Which is a common fear, in addition to separation anxiety, for the hospitalized pediatric client between the ages of 6 and 18 months? 1. Disfigurement 2. Death 3. Stranger anxiety 4. Bodily injury Answer: 3 Explanation: 1. Infants do not fear disfigurement. 2. Infants and toddlers do not fear death. 3. In addition to separation anxiety, infants between 6 and 18 months of age might display stranger anxiety when confronted with strangers such as healthcare providers. 4. Infants and toddlers do not fear bodily injury. Page Ref: 893 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.3 Describe the child's and family's adaption to hospitalization.

3) The parents of a child who is critically injured wish to stay in the room while the child is receiving emergency care. Which nursing action is most appropriate in this situation? 1. Asking the healthcare provider if the parents can stay with the child 2. Allowing the parents to stay with the child 3. Escorting the parents to the waiting room and assuring them that they can see their child soon 4. Telling the parents that they do not need to stay with the child Answer: 2 Explanation: 1. The physician does not make the decision whether the parents stay with the child; the parents make the decision. 2. Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care. 3. Parents should be allowed to stay with their child if they wish instead of going to the waiting room where they lack privacy. 4. The parents need to make the decision about staying with their child without input from the nurse. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.4 Apply family-centered care principles to the hospital setting.

4) The pediatric group is providing care to a group of hospitalized clients. Which client is at the greatest risk for developing separation anxiety if the parents are unable to stay with the child at all times? 1. 6-month-old 2. 18-month-old 3. 4-year-old 4. 6-year-old Answer: 2 Explanation: 1. The 6-month-old child does not experience separation anxiety, which usually begins at around 1 year of age. 2. The young toddler is at the greatest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly. 3. The 4-year-old child is past the age when separation anxiety would be most prevalent. 4. The 6-year-old child is attending school and is used to short periods of separation from parents. Page Ref: 892 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.3 Describe the child's and family's adaption to hospitalization.

5) A preschool-age boy presents to the outpatient clinic for a sore throat. In the child's mind, which is the most likely causative agent of the sore throat? 1. Being exposed to a classmate with strep throat 2. Yelling at sibling for being annoying 3. Not eating the right foods 4. Not taking daily vitamins Answer: 2 Explanation: 1. At this age, the child does not yet understand that he can become sick from exposure to someone else who is sick. 2. Preschoolers understand some aspects of being sick, but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They frequently will view illness as punishment. 3. Not eating the right foods can be a factor in some illnesses, but this thinking is beyond the level of a 4-year-old boy. 4. While not taking his vitamins can be a factor in some illnesses, this thinking is beyond the capabilities of a 4-year-old boy. Page Ref: 894 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.1 Compare and contrast the child's understanding of health and illness according to the child's developmental level.

6) A school-age client is in the playroom when the respiratory therapist arrives to give a scheduled breathing treatment. Which is the most appropriate nursing action? 1. Escorting the child to his room and asking the child-life specialist to bring toys to the bedside 2. Rescheduling the treatment for a later time 3. Assisting the child back to his room for the treatment but reassuring him that he may return when the procedure is completed 4. Showing the respiratory therapist to the playroom so the treatment can be performed Answer: 3 Explanation: 1. The child should be allowed to return to the playroom as soon as the procedure is completed; bringing toys to the bedside is unnecessary. 2. Scheduled respiratory treatments should be performed on time. 3. It is important for scheduled treatments to occur on time, so the child should go back to his room. He can return to the playroom as soon as the treatment is completed. 4. Procedures should not be performed in the playroom. Page Ref: 902 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

7) A preschool-age child is admitted to the pediatric unit for surgery. The parents request to stay with their child. Which is the best response by the nurse? 1. Tell the parents they can stay in the hospital but not on the unit. 2. Read the rules and regulations of rooming-in with the child. 3. Let the parents know they are allowed to stay with the child. 4. Explain to the parents why they cannot stay with the child. Answer: 3 Explanation: 1. The parents should be allowed to stay with their child on the unit. 2. The parents should be aware of the rules about rooming-in, but they should know first that they can stay. 3. The practice of rooming-in involves a parent's staying in the child's hospital room during the course of the child's hospitalization. Some hospitals provide cots, while others have special builtin beds on pediatric units. 4. The parents should be allowed to stay with their child. Page Ref: 892 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.4 Apply family-centered care principles to the hospital setting.

8) A child is being prepared for surgery. The parents request to be present during anesthesia induction. Which response by the nurse is most appropriate? 1. Telling the parents the names of all the medications that will be administered 2. Explaining what the parents will see and hear during induction 3. Telling the parents they will be upset to see the child under anesthesia 4. Ignoring the request and focusing on the child Answer: 2 Explanation: 1. Parents do not need to know the names of the medications the child will receive. 2. The nurse explains visual and auditory experiences, such as a surgical gown, cap, shoe covers, and the parents' role during induction. The nurse offers the parents an opportunity to ask questions and voice concerns. 3. The nurse should tell the parents what to expect but not how they will feel while they watch their child. 4. The nurse should never ignore a request made by parents. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.4 Apply family-centered care principles to the hospital setting.

9) The mother of a child admitted to the intensive care unit (ICU) appears very angry, and tells the nurse no one is providing information about the child. Which response by the nurse is most appropriate? 1. Asking the mother to leave if the behavior continues 2. Apologizing for the mother's perception and assure the mother that the staff will keep her informed. 3. Offering to ask the healthcare provider to come and talk with her 4. Telling the mother her behavior will upset the child Answer: 2 Explanation: 1. Telling the mother she will be asked to leave will only worsen the situation. 2. Nursing techniques include informing the family of potential problems that could occur. If the child's condition changes, make every effort to inform the family immediately. 3. The mother is already angry because of the lack of information sharing. The nurse should not "pass the buck" to the healthcare provider. 4. The mother is already angry, and informing her that her behavior will upset the child will only anger her more. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 39.4 Apply family-centered care principles to the hospital setting.

10) The nurse is caring for a child in the pediatric intensive care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing action is most appropriate? 1. Explaining to the parents that their anger is affecting their child, and they will not be allowed to visit the child until they calm down 2. Asking the healthcare provider to talk with the family 3. Acknowledging the parents' concerns and collaborating with them regarding the care of their child 4. Calling the hospital chaplain to sit with the family Answer: 3 Explanation: 1. Telling the parents that they cannot visit their child will only increase their anger. 2. Calling the healthcare provider might be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. 3. Hospitalization of the child in a PICU is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they might become angry and upset. 4. Calling the chaplain could be appropriate at some point, but the nurse needs to collaborate with the parents about the care the child receives. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

11) Which nursing action is most appropriate when performing a procedure on a toddler-age child? 1. Allowing the child to cry or scream 2. Performing the procedure in the child's hospital bed 3. Asking the child if it is okay to start the procedure 4. Asking the mother to restrain the child during the procedure Answer: 1 Explanation: 1. The child should be allowed to cry or scream during the procedure. 2. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place. 3. The nurse should avoid giving the child a choice if there is no choice. 4. While the toddler will need to be restrained, the parent should not be the one to do this. Page Ref: 902 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

12) A child has a planned hospitalization in a few weeks, and the client and family appear very stressed. Which nursing action will minimize the stress for the client and family? 1. Telling the client and family that everything will be fine 2. Explaining to the client and family how the child will benefit from the surgery 3. Telling the client and family that the surgeon is very good 4. Giving a tour of the hospital unit or surgical area to the client and family Answer: 4 Explanation: 1. The nurse cannot know for certain that everything will be fine. 2. The pros and cons of the surgery would have been explained to the family prior to the decision to have the surgery. Restating the benefits will not reduce the stress of the client and family. 3. Telling them the surgeon is very good is not going to minimize stress for long. They need to be more familiar with what to expect in a familiar environment. 4. A variety of approaches can be used to provide information and allay fears. Tours of the hospital unit or surgical area are helpful. This activity assists the child and family to become familiar with the environment they will encounter. Page Ref: 897 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

13) Which is the rationale for why parents should be allowed to be present with their children during a medical procedure? 1. Parents want to support their child before, during, and immediately after the procedure. 2. Parents want to ensure that nothing goes wrong with the child. 3. Parents are interested because they are also in the medical field. 4. Parents want to ensure that the correct medication is being used. Answer: 1 Explanation: 1. Many hospitals now allow parents to be present with their child during and after procedures. Parents often want to support their child, and their presence offers reassurance and comfort to the child. 2. When parents ask to be present for a procedure, they are doing so to be available to comfort the child, not to control the procedural outcome. 3. Parents might be in the medical field, but their primary concern is to comfort their child during the procedure. 4. The parents' first concern is to comfort their child, not supervising the nursing staff. Page Ref: 898 Cognitive Level: Understanding Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.6 Integrate the concept of family presence during procedures and nursing strategies used to prepare the family.

14) The parents have requested to be present during their child's procedure. In which way should the nurse plan for this request? 1. Explain in detail, using medical terms, what will occur. 2. Explain to the family that it is not permitted for family members to be present. 3. Prepare family members for what they should anticipate, and what is expected of them. 4. Prepare the family to speak with the healthcare provider. Answer: 3 Explanation: 1. The nurse should not use medical terms to discuss the child's procedure. 2. In most circumstances, it is not only permitted but also desired to have the parents presence during a procedure. 3. Parents often want to support their child before and after procedures, and their presence offers reassurance and comfort to the child. Prepare family members for what to anticipate, and what is expected of them. 4. The nurse can speak to the family to prepare them and does not need to wait for the healthcare provider. Page Ref: 898 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.6 Integrate the concept of family presence during procedures and nursing strategies used to prepare the family.

15) The mother of a child admitted after a motor vehicle accident expresses concern about caring for the child's wounds at home. The mother has demonstrated appropriate technique with medication administration and wound care. Which is the main problem for this situation? 1. Parent anxiety 2. Prevent infection 3. Ineffective coping 4. Change in role expectation Answer: 1 Explanation: 1. While all of the problems might have been appropriate at some point, the current focus is the mother's anxiety about caring for the child at home. The priority of the nurse is relieving this anxiety. 2. The mother has demonstrated the ability to care for the wounds. 3. There is no evidence that the mother is having issues with coping. 4. There is no evidence that there is a change in role expectation. Page Ref: 910 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 39.7 Summarize strategies for preparing children and families for discharge from the hospital setting.

16) A child is being discharged from the hospital requiring complex, long-term care with medication administration through a central line and maintenance of oxygen administration by nasal cannula. A home health nurse will be visiting each day. Which information should the nurse teach the family members prior to hospital discharge? 1. How to insert an IV line 2. Nothing, the family is familiar with the care 3. Instruction on oxygen administration 4. How to remove a central line Answer: 3 Explanation: 1. Starting an IV line is not within the family's responsibilities for home care. 2. The nurse can never assume the family members are familiar with the care required, even if they have been participating during the hospital stay. 3. Prior to discharge, the parents will need to learn about oxygen administration. 4. Removing a central line is not within the realm of what family members need to do at home. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.7 Summarize strategies for preparing children and families for discharge from the hospital setting.

17) Prior to discharging the child from the hospital, what routine discharge instructions should the nurse discuss with the family? 1. Monitoring signs and symptoms specific to condition 2. Instruction on performing a medical examination on the child 3. No instructions are needed; the family is familiar with the child. 4. A list of all diagnostic tests obtained during the hospitalization and their results Answer: 1 Explanation: 1. Families need support and education as they continue to be anxious or stressed over their child's hospitalization. Standard discharge plans for routine hospital discharge include monitoring signs and symptoms specific to the condition and care at home. 2. The family does not need to know how to complete a medical examination on the child. 3. The family knows the child but needs teaching regarding the signs and symptoms to watch for in case of recurrence or complications arise. 4. This information was shared with the family as the tests were performed, and results received. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.7 Summarize strategies for preparing children and families for discharge from the hospital setting.

18) Which age groups can best tolerate separation from parents during hospitalization? Select all that apply. 1. Infants birth to 5 months 2. Infants 5 months to 1 year 3. Toddlers and preschoolers 4. School-age children 5. Adolescents Answer: 1, 4, 5 Explanation: 1. Infants in this age group do not recognize parents as separate from themselves so will not feel abandoned when parents do not stay. 2. Infants in this age group recognize object permanence and will be aware of the absence of their parents. 3. Both groups suffer from separation anxiety and fear of abandonment. 4. School-age children are accustomed to dealing with adults other than parents and can better tolerate separation. 5. Adolescents are able to understand separation and time and thus will not suffer from separation from parents. Page Ref: 893 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.3 Describe the child's and family's adaption to hospitalization.

19) A hospitalized preschool-age child will be left alone for short periods of time for the mother to return home to care for the child's siblings. The mother asks the nurse what is the best way to leave. Which response by the nurse is appropriate? Select all that apply. 1. "Leave after your child falls asleep so he won't know you are going." 2. "Tell your child you are leaving, and identify when you will return after dinner." 3. "Leave an article of clothing behind to comfort your child." 4. "Tell the nurse on duty when you are leaving so that the nurse can stay with your child while you are gone." 5. "Plan to leave when your child is having procedures performed as the child will be busy and less aware of the parent's absence." Answer: 2, 3 Explanation: 1. The child will awaken and feel mom has disappeared. When mom returns, the child may be unwilling to fall asleep again for fear she will disappear again. 2. The child cannot tell time, so it is appropriate to associate time of return with an event that the child recognizes rather than give a specific time. It is appropriate for the mother to tell the child she is leaving and promise to return. 3. The child recognizes that mother will return for her clothing, and this may provide comfort. 4. The nurses need to know that the child is alone, but staffing demands will not allow a nurse to sit with the child during the parent's absence. 5. Whenever possible, the parents should be present when procedures are being performed. Page Ref: 894 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

20) A 6-year-old child is hospitalized for a surgical procedure. The parents ask if the child's four siblings can visit. Which response by the nurse is the most appropriate? 1. "Let's plan their visit for a time when the child has received pain medication." 2. "Only those siblings over 16 will be allowed to visit." 3. "I don't think the other children should visit because it might scare them to see their sibling so sick." 4. "Very young children shouldn't visit as they may carry germs." Answer: 1 Explanation: 1. Planning a time to visit when the child is most comfortable will be the best for the client and the siblings. 2. Unless hospital policy prevents visitation by younger children, they should be allowed to visit. 3. Children should be prepared for a visit, but visits should be allowed. Children who cannot visit often imagine the situation is worse than it is. 4. All children may carry germs. Children should be assessed for signs of infection, but if they are free of symptoms, they should be allowed to visit. Page Ref: 896 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.4 Apply family-centered care principles to the hospital setting.

21) The 4-year-old child is undergoing cardiac surgery. Which nursing action will reduce the child's stress in the preoperative period? Select all that apply. 1. Explain the procedure to the child in simple terms of what the child will see, hear, and feel while awake. 2. Explain to the child that the surgery will fix her "broken" heart. 3. Allow the parents to accompany the child to the surgical holding room, and wait with the child. 4. Allow the child to hold onto their special "teddy bear" while awake. 5. Wait until the child is in the holding room to insert the Foley catheter. Answer: 1, 3, 4 Explanation: 1. The child does not need to understand the surgical activity while asleep. 2. Care must be utilized in selecting terminology for the child. To the child, the heart is not just a muscle, but the center of the child's love. A "broken" heart may be discarded. 3. This is appropriate as parents are the child's main source of support. 4. Children of this age often have security objects; the child should be allowed to hold the object for comfort. Care must be taken that the teddy bear be labeled and returned to the child after the surgical procedure. 5. The child is awake in the holding room. It is better to wait until the child is under anesthesia to insert the catheter. Page Ref: 904 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

22) An adolescent tells the nurse that the new diagnosis of diabetes has him "stressed out." Which stress-reduction activities will the nurse recommend to this adolescent? Select all that apply. 1. Daily exercise, such as walking 2. Learning more about his illness 3. Practicing deep breathing and other relaxation techniques 4. Not thinking about his diagnosis 5. Allowing the parents control of his disease Answer: 1, 2, 3 Explanation: 1. Exercise is an effective stress reducer. 2. Fully understanding his condition will reduce his stress. 3. Relaxation techniques can help reduce stress. 4. Keeping feelings and emotions in will increase stress in the adolescent. 5. Adolescents like to be in control of themselves and are working on separation from the parents, so it would be inappropriate to encourage the child to give control to others. Page Ref: 902 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

23) The healthcare provider has prescribed the toddler an oral medication. The toddler has fought medication administration in the past. Which strategies may be helpful when administering the medication to this toddler? Select all that apply. 1. Request the medication in liquid form, and draw the medication in an oral syringe. 2. Put the medication in a favorite drink in the child's sippy cup. 3. Allow the mother to administer the medication to the child. 4. Notify the healthcare provider to change the route to intravenous. 5. Hold the child down, and squirt the medication in the corner of his mouth. Answer: 1, 3 Explanation: 1. These activities will make the administration easier. 2. This would not be appropriate as it increases the volume that must be administered and may unfavorably change the taste of the drink. 3. The child is more willing to take the medication from the mother. 4. This would not be appropriate. 5. This could cause the child to choke on the medication and is inappropriate. Page Ref: 901 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

24) Which changes can a nurse manager implement to reduce the stress experienced by hospitalized pediatric clients? 1. Having only female nurses on the unit 2. Assigning nurses one-on-one with clients 3. Use scrubs for the clients to play dress-up 4. Having the nurses avoid entering the client's room unless a procedure is to be performed Answer: 3 Explanation: 1. The sex of the nurse has not been shown to be a source of stress. 2. Staffing patterns will not allow a one-to-one nurse to client ratio on the regular pediatric unit. 3. Providing scrubs and uniforms for dress-up encourages dramatic play, which provides an outlet for anxiety in children dealing with stressful situations. 4. Nurses should visit when not performing procedures to allow the children to become familiar and comfortable with the nurses. Page Ref: 907 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.5 Identify nursing strategies to minimize the stressors related to hospitalization.

25) Which nursing actions are important when providing care to a pediatric client who is on contact precautions due to a communicable disease? Select all that apply. 1. Encouraging frequent family visits 2. Scheduling physical therapy (PT) for the child 3. Providing age-appropriate stimulation and activities 4. Allowing the parents to have physical contact with the child 5. Educating the family about personal protective equipment (PPE) Answer: 1, 3, 4, 5 Explanation: 1. It is important for the nurse to encourage frequent family visits to decrease the sense of isolation that can occur for the pediatric client who is on contact precautions. 2. This nursing action is more appropriate for a client who is receiving rehabilitative care versus a client who is on contact precautions. 3. It is important for the nurse to provide age-appropriate stimulation and activities due to limited contact with other children and family members while on contact precautions. 4. It is important to allow parents to have physical contact with their child when the child is on contact precautions. PPE should be limited to only what is needed to protect the parent from being exposed to the communicable disease. 5. It is important for the nurse to educate the family regarding which PPE to use, and how to properly wear it when providing care to a child on contact precautions. Page Ref: 899 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.2 Explain the effect of hospitalization on the child and family.

26) The nurse is providing care to an infant who is hospitalized for bronchiolitis. Which infant stressors should the nurse plan for when providing care for this infant? Select all that apply. 1. Separation anxiety 2. Stanger anxiety 3. Disrupted sleep-wake cycle 4. Loss of self-control 5. Fear of the dark Answer: 1, 2, 3 Explanation: 1. Separation anxiety is an infant stressor that the nurse should plan for when providing care to the hospitalized infant. 2. Stranger anxiety is an infant stressor that the nurse should plan for when providing care to the hospitalized infant. 3. A disrupted sleep-wake cycle is an infant stressor that the nurse should plan for when providing care to the hospitalized infant. 4. Loss of the control is a stressor for the hospitalized toddler, not the infant. 5. Fear of the dark is a stressor for the hospitalized toddler, not the infant. Page Ref: 893 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Explain the effect of hospitalization on the child and family.

27) The nurse is providing care to a hospitalized adolescent client. Which should the nurse include in the adolescent's plan of care related to stressors? Select all that apply. 1. Loss of privacy 2. Fear of the dark 3. Loss of identity 4. Fear of altered body image 5. Separation anxiety Answer: 1, 3, 4 Explanation: 1. Loss of privacy is a stressor the nurse should plan for when providing care to a hospitalized adolescent client. 2. Fear of the dark is a stressor for the hospitalized toddler and preschool-age client not the adolescent client. 3. Loss of identity is a stressor the nurse should plan for when providing care to a hospitalized adolescent client. 4. A fear of altered body image is a stressor the nurse should plan for when providing care to a hospitalized adolescent client. 5. Separation anxiety is a stressor for the hospitalized infant, toddler, and preschool-age child not the adolescent. Page Ref: 893 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Explain the effect of hospitalization on the child and family.

28) Which are barriers to successful discharge planning that the nurse may need to plan for when providing care to a pediatric client who is approaching discharge? Select all that apply. 1. Financial concerns 2. Parental unavailability for teaching 3. Lack of equipment 4. Poor teamwork 5. Insurance payment for services Answer: 1, 2, 3, 4 Explanation: 1. Financial concerns related to the cost associated with care that is needed after discharge is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 2. Parents who are not available for discharge instruction is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 3. Not having the equipment the family will use after discharge is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 4. Poor teamwork is one barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. 5. Insurance payment for services is not a known barrier to successful discharge planning when providing care to the pediatric client who is approaching discharge. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.7 Summarize strategies for preparing children and families for discharge from the hospital setting.

29) Which nursing actions are appropriate for teaching the family of a pediatric client requiring skilled care prior to discharge? 1. Teaching how to use home equipment 2. Educating on symptoms that indicate distress 3. Encouraging participation in a cardiopulmonary resuscitation course 4. Recommending that one parent take a leave of absence from work 5. Discouraging participation in case coordination activities Answer: 1, 2, 3 Explanation: 1. The nurse will educate the family regarding equipment that will be used after discharge. It is essential that the family perform a successful return demonstration. 2. The nurse will teach the family symptoms that indicate the client is experiencing distress, and include information on who to contact if these symptoms should occur. 3. The nurse will encourage the family to participate in a cardiopulmonary resuscitation course prior to discharge. 4. While it is appropriate for the nurse to educate the family on the Family Medical Leave Act (FMLA), it is not appropriate for the nurse to recommend that one parent take a leave of absence from work. 5. The nurse should encourage the family to participate in care coordination for their child if they indicate they would like to learn about this portion of the child's healthcare management. Page Ref: 910 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Teamwork: Ethical Comportment: Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.7 Summarize strategies for preparing children and families for discharge from the hospital setting.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 40 Pain Assessment and Management in Children 1) While making rounds, the nurse observes all of the following client behaviors. Which child should the nurse further evaluate for postoperative pain? 1. The 6-month-old in deep sleep. 2. The 2-year-old who is cooperative when the nurse takes vital signs. 3. The 4-year-old who is actively watching cartoons. 4. The 14-month-old who is thrashing his arms and legs. Answer: 4 Explanation: 1. Children are unable to obtain deep sleep when experiencing acute pain. 2. When experiencing acute pain, children are less likely to cooperate with treatments. 3. It is difficult for children to concentrate when experiencing acute pain. 4. Young children in acute pain display a variety of behaviors, including loud crying, screaming, thrashing their arms and legs, lack of cooperation, clinging behavior, and restlessness and irritability. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.2 Analyze the behaviors of an infant or a child to assess for pain.

2) The nurse is taking care of a postoperative school-age child. The child's mother requests that the child not receive narcotics because she is afraid the child will become addicted. The nurse should explain that children who do not receive adequate pain control will be at risk for which complication? 1. Respiratory 2. Urinary 3. Cardiac 4. Bowel Answer: 1 Explanation: 1. The child with acute postoperative pain takes shallow breaths and suppresses coughing to avoid more pain. These self-protective actions increase the potential for respiratory complications. 2. Uncontrolled pain does not usually lead to urinary complications. 3. Uncontrolled pain does not lead to cardiac complications. 4. Uncontrolled pain does not frequently lead to bowel complications. Page Ref: 915 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.2 Analyze the behaviors of an infant or a child to assess for pain.

3) The nurse is caring for a postoperative toddler-age child. Which pain assessment tool should the nurse use to assess this child's pain? 1. Poker Chip Tool 2. Oucher Scale 3. Faces Pain Rating Scale 4. FLACC Behavioral Pain Assessment Scale Answer: 4 Explanation: 1. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 2. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 3. The Faces Scale, Oucher Scale, and Poker Chip Tool are all self-report scales and can usually be used with children 3 years and older. 4. The FLACC scale is an appropriate tool for infants, and young children who cannot report pain. Page Ref: 917 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.3 Assess a young child's readiness to use a self-report pain scale. 4) A 5-year-old child is hospitalized with a fractured femur. Which tool should the nurse use to assess this child's pain? 1. CRIES Scale 2. Faces Pain Rating Scale 3. SUN Scale 4. PIPP Scale Answer: 2 Explanation: 1. The CRIES Scale was developed for preterm and full-term neonates. 2. A 5-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level. 3. The SUN Scale was developed for use in newborns. 4. The PIPP Scale was developed for premature infants. Page Ref: 918 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.3 Assess a young child's readiness to use a self-report pain scale.

5) During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which nursing action is appropriate? 1. Reassess the child in 15 minutes to see if the pain rating has changed. 2. Administer the prescribed analgesic. 3. Do nothing, since the child appears to be resting. 4. Ask the child's parents if they think the child is hurting. Answer: 2 Explanation: 1. There is no need to reassess, as the child needs pain medication now. 2. School-age children are old enough to report their pain level accurately. A pain score of 6 is an indication for prompt administration of pain medication. The child might be trying to be brave or might be lying still because movement is painful. 3. The child might be lying quietly because movement increases the pain. 4. School-age children can answer for themselves, and do not need the parents to answer for them. Page Ref: 920 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.2 Analyze the behaviors of an infant or a child to assess for pain.

6) A hospitalized 3-year-old child needs to have an IV restarted. The child begins to cry when carried into the treatment room by the mother. Which problem would address this situation? 1. Insufficient information about the procedure 2. Fear 3. Anxiety 4. Problems with coping Answer: 3 Explanation: 1. The scenario indicates that the child has been through this before, so insufficient information is not the most appropriate problem. 2. The child's fear is related not to the unfamiliar environment but to the anticipated pain of the IV stick. 3. This child is not old enough to understand the need for an IV infusion. The scenario indicates that the child has been through this painful procedure before, and the child's reaction to entering the treatment room is based on anticipation of repeat discomfort. 4. The child's behavior is appropriate for coping in this age child. Page Ref: 914 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 40.6 Plan nursing care for a child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

7) The nurse is providing care for a pediatric client in the intensive care unit (ICU) who has been on opioids for an extended period of time. Which assessment finding indicates to the nurse that the child is experiencing withdrawal symptoms related to the opioid weaning process? 1. Vomiting and abdominal cramps. 2. Bradycardia and pallor. 3. Decreased blood pressure and drowsiness. 4. Voracious appetite and hypotonicity. Answer: 1 Explanation: 1. These are symptoms of withdrawal resulting from reducing the dose too quickly. 2. A child who is being withdrawn from opioids too quickly will be tachycardic and have hot flashes and sweating. 3. The child who is being withdrawn from opioids too quickly will be hypertensive and wakeful. 4. Nausea, abdominal pain, diarrhea, and hypertonicity would be symptoms of withdrawal. Page Ref: 922 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.4 Plan the nursing care for a child receiving an opioid analgesic. 8) An analgesic is prescribed for a postsurgical pediatric client to be administered every 3 to 4 hours. Which outcome can occur if the nurse is delayed in administering the prescribed analgesic? 1. Decrease in the chance of withdrawal symptoms 2. Decrease in the chance of addiction 3. Increase in the chance of breakthrough pain 4. Increase in the child's pain tolerance Answer: 3 Explanation: 1. A delay in giving pain medication will not decrease the chance of withdrawal symptoms if the medication is stopped without weaning. 2. Delaying the pain medication will not decrease the chance of addiction. 3. Analgesics may be given on a scheduled basis. Delays in giving analgesics increase the chance of breakthrough pain and the subsequent anticipation of pain. 4. Delaying the pain medication will not increase the child's pain tolerance. Page Ref: 922 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 40.4 Plan the nursing care for a child receiving an opioid analgesic. 6 Copyright © 2022 Pearson Education, Inc.

9) The nurse is preparing to perform a heel stick on a neonate. Which complementary therapy should the nurse implement to decrease pain during this quick but painful procedure? 1. Holding the newborn 2. Providing a sucrose pacifier to the newborn 3. Massaging the newborn 4. Swaddling the newborn Answer: 2 Explanation: 1. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. 2. Sucrose provides short-term, natural pain relief, and is most appropriate for use in neonates to decrease pain associated with a quick procedure. 3. Massage and holding the infant are more appropriate following the procedure, or as an adjunct to pain medication for ongoing pain or distress. 4. Swaddling for a neonate undergoing a quick painful procedure will not decrease the pain. Page Ref: 924 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.5 Examine the role of nonpharmacologic (complementary) interventions in effective pain management.

10) A 6-year-old postoperative client's IV infiltrates and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. Which complementary therapy would be helpful when placing this IV? 1. Restraints 2. Moderate sedation 3. Anesthesia 4. Distraction Answer: 4 Explanation: 1. Restraints are used only as a last resort and are not appropriate for an IV start. 2. Moderate sedation has its own side effects and possible complications and should not be used for quick procedures. 3. Drugs may not be used for quick procedures, such as a dressing change or an unexpected intravenous insertion, injection, or venipuncture. 4. Complementary therapies–especially guided imagery, relaxation techniques, and distraction– can reduce the anxiety associated with the anticipation of the procedure. Page Ref: 923 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.6 Plan nursing care for a child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

11) The pediatric nurse would expect that patient-controlled analgesia (PCA) would be most appropriate for which client? 1. 12-year-old client who is postoperative for spinal fusion for scoliosis 2. 10-year-old client who has a fractured femur and concussion from a bike accident 3. 5-year-old client who is postoperative for tonsillectomy 4. Developmentally delayed 16-year-old client who is postoperative for bone surgery. Answer: 1 Explanation: 1. PCA is most appropriate in children 5 years old and older. Children must be able to press the button and understand that they will receive pain medicine by pushing the button. 2. Children who have suffered head trauma would not be candidates for PCA. 3. PCA generally is prescribed for clients who will be hospitalized for at least 48 hours. 4. Children who are developmentally delayed would not be candidates for PCA. Page Ref: 923 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.4 Plan the nursing care for a child receiving an opioid analgesic.

12) Which statement by the parent of a preschool-age child would indicate the need for further teaching regarding pain management? 1. "I will call the office tomorrow if the pain medicine is not relieving the pain." 2. "I can expect my child to have some pain for the next few days." 3. "Because my child just had surgery today, I can expect the pain level to be higher tomorrow." 4. "I will plan to give my child pain medicine around the clock for the next day or so." Answer: 3 Explanation: 1. If prescribed medication is not relieving the pain to a satisfactory level, the healthcare provider should be notified. This statement indicates the parent understands and does not need additional teaching. 2. The child is expected to have some pain for a few days after surgery. This statement indicates the parent understands the teaching. 3. Increasing pain can be a sign of complication and should be reported to the healthcare provider; therefore, the nurse should clarify expectations for pain control. 4. The child should receive pain medication on a scheduled basis. This statement indicates the parent understands the teaching. Page Ref: 915 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 40.6 Plan nursing care for a child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

13) The nurse is caring for a child who has been sedated for a painful procedure. Which is the priority nursing action? 1. Placing the child on a cardiac monitor 2. Allowing parents to stay with the child 3. Monitoring pulse oximetry 4. Assessing the child's respiratory effort Answer: 4 Explanation: 1. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. 2. Parents may be allowed to stay with the child, but assessment of breathing effort must take priority. 3. Although equipment is important and is used routinely during sedation, it does not replace the need for visual assessment. 4. When the child is sedated for a procedure, it is very important for the nurse to actually visualize the child and the child's effort of breathing. Page Ref: 922 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.7 Develop a nursing care plan for the child with a chronic painful condition.

14) The nurse is planning care for a preschool-age child who is intellectually disabled and is scheduled for surgery the next day. Which should the nurse consider when choosing a pain assessment tool? Select all that apply. 1. The child's language skills 2. The child's ability to understand the concept of more and less 3. The child's ability to sit for a 10-minute evaluation 4. The child's ability to perceive pain 5. The child's ability to understand pain Answer: 1, 2 Explanation: 1. In order to report pain, the child needs adequate verbalization skills to communicate to the nurse. 2. The child who understands more or less can be given a three-option pain scale. The child who cannot understand more or less may need a behavioral pain scale. 3. The assessment does not require the child to sit still. 4. Children perceive pain. The issue is if the nurse can recognize the child's pain. 5. Children do not need to understand pain in order to feel pain. Page Ref: 916 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.3 Assess a young child's readiness to use a self-report pain scale.

15) The nurse administers IV morphine to a 4-year-old postoperative client. Which assessment finding requires further evaluation by the nurse? 1. Pulse decreased from 136 to 104 2. Blood pressure dropped from 110/72 to 90/55 3. Respiratory rate went from 42 to 16 4. Child pulls away from nurse who wants to assess surgical site Answer: 3 Explanation: 1. The normal pulse rate for children 2 to 5 years of age is between 70 and 120. 2. 90/55 is a normal finding for this age group. 3. This respiratory rate is on the low side for the age group and requires further evaluation to determine if the child's respirations are being depressed. 4. This is normal behavior for a 4-year-old child. Page Ref: 922 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.6 Plan nursing care for a child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies. 16) The healthcare provider prescribes hydromorphine (Dilaudid) intravenously for the postoperative 4-year-old child. The therapeutic range for Dilaudid has been determined to be 0.01 to 0.015 mg/kg/dose every 3 to 4 hours. What is the maximum therapeutic dose of Dilaudid if the child weighs 30 pounds? Round your answer to the nearest hundredth. Answer: 0.2 mg Explanation: 30 pounds divided by 2.2 pounds/kg = 13.64 kg 13.64 kg × 0.015 mg/kg = 0.2045, which rounds to 0.2 Your answer should have a 0 in front of the decimal and no 0 after the 2. Otherwise, you may contribute to a medication error. Page Ref: 921 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.4 Plan the nursing care for a child receiving an opioid analgesic.

17) During shift report, the night nurse reports that a terminally ill child has developed tolerance to the prescribed morphine. Which concept should the nurse use when planning care for this child? 1. The child is physically dependent on morphine. 2. The child is addicted to morphine. 3. The child is showing physical signs of withdrawal. 4. The child will need more medication to achieve the same effect. Answer: 4 Explanation: 1. While the child may be physically dependent, this is not the meaning of tolerance. 2. Addiction refers to a compulsive use of a substance despite harm. This is not the definition of tolerance. 3. Withdrawal occurs when the opioid is stopped suddenly. This is not the meaning of tolerance. 4. Tolerance occurs when the body has become accustomed to the presence of the drug in the system. When this happens, the child will need more of a drug or a stronger drug to get the same effect. Page Ref: 922 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.1 Summarize the physiologic and behavioral consequences of pain in infants and children.

18) The 17-month-old toddler, diagnosed with terminal cancer, is experiencing constant pain. Which prescription does the nurse anticipate from the healthcare provider for this toddler? 1. Patient-controlled analgesia (PCA) with the parents controlling the button that administers the dosage 2. Intravenously administered opioids on a scheduled basis 3. Intravenously administered opioids on a prn basis 4. Orally administered opioids on a prn basis Answer: 2 Explanation: 1. PCA should always be controlled by the individual receiving the medication. It is inappropriate to have the parents control the medication administration. 2. This provides continuous blood levels of the opioid. 3. By waiting until symptoms are present, the child's blood level will drop, making it more difficult to control the pain. 4. Parenteral administration controls pain more effectively than oral medication as oral absorption may be modified by stomach activities. In addition, providing analgesics on a scheduled basis is preferred over prn. Page Ref: 922 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.4 Plan the nursing care for a child receiving an opioid analgesic.

19) Which distraction techniques should the nurse to use for a school-age child during a painful procedure? Select all that apply. 1. Blowing bubbles 2. Music therapy 3. Guided imagery 4. Hypnosis 5. Sucrose solution Answer: 1, 2, 3 Explanation: 1. Blowing bubbles or popping bubbles can be a distraction for a young schoolage child. 2. Listening to music or singing can be used as distraction for this age group. 3. Guided imagery is a means of encouraging relaxation and mental images to manage pain. 4. Under hypnosis, the child is an altered state of awareness; this is not a form of distraction. 5. Sucrose solution is used for infants up to 12 months of age. This is a complementary therapy but not a method of distraction. Page Ref: 928 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.6 Plan nursing care for a child in acute pain that integrates pharmacologic interventions and developmentally appropriate nonpharmacologic (complementary) therapies.

20) Which nonpharmacologic interventions are appropriate for the nurse to use when treating pediatric clients in pain? Select all that apply. 1. Regional nerve block 2. Cutaneous stimulation 3. Application of heat 4. Electroanalgesia 5. Use of EMLA cream Answer: 2, 3, 4 Explanation: 1. A regional nerve block involves injecting medications in an area that controls pain for a region of the body. It does not provide nonpharmacologic relief. 2. Massage and rubbing of the skin as well as swaddling and kangaroo care are nonpharmacologic means of relieving pain. 3. The use of heat (and cold) may help reduce pain sensations, and utilizes no pharmacologic agents. 4. Electrical stimulation to the skin uses the gate control theory to relieve pain. 5. EMLA cream is a mixture of lidocaine and prilocaine that is applied to the intact skin. It is a pharmacologic pain relief method. Page Ref: 924 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.5 Examine the role of nonpharmacologic (complementary) interventions in effective pain management.

21) The nurse is providing care to a pediatric client who is receiving sedation for a painful procedure. Which are the priority nursing actions? Select all that apply. 1. Monitoring respirations 2. Assessing for manifestations of deep sedation 3. Ensuring a crash cart is available 4. Administering the prescribed opioid 5. Administering the prescribed benzodiazepine Answer: 1, 2, 3 Explanation: 1. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to monitor the child's respirations. 2. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to assess for manifestations associated with deep sedation. 3. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is ensuring a crash cart is available. 4. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to have an opioid antagonist available, if respiratory depression occurs. 5. A priority nursing action for a pediatric client who is receiving sedation for a painful procedure is to have a benzodiazepine antagonist available, if needed. Page Ref: 931 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.8 Develop a nursing care plan for the child to be given sedation and analgesia for a medical procedure.

22) Which are the priority nursing assessments when providing care to a pediatric client who is receiving sedation? Select all that apply. 1. Respiratory effort 2. Chest wall movement 3. Skin color 4. Level of consciousness 5. Pain Answer: 1, 2, 3, 4 Explanation: 1. A respiratory effort assessment is a nursing priority for the pediatric client who is receiving sedation. 2. Assessing chest wall movement is a nursing priority for the pediatric client who is receiving sedation. 3. Assessing skin color is a nursing priority for the pediatric client who is receiving sedation. 4. Assessing level of consciousness is a nursing priority for the pediatric client who is receiving sedation. 5. Assessing the client's pain is not a priority when providing care to a pediatric client who is receiving sedation. Page Ref: 931-932 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.8 Develop a nursing care plan for the child to be given sedation and analgesia for a medical procedure.

23) Which are discharge criteria the nurse includes in the plan of care for a client who has received sedation? Select all that apply. 1. Stable vital signs 2. Patent airway 3. Ability to sit up without assistance 4. Adequate fluid intake 5. Ability to urinate Answer: 1, 2, 3 Explanation: 1. Stable vital signs are a criterion for discharge for a pediatric client who has received sedation. 2. A patent airway is one criterion for discharge for the pediatric client who has received sedation. 3. The ability to sit up without assistance is one criterion for discharge for the pediatric client who has received sedation. 4. Fluid intake is not essential as some sedation medications stimulate vomiting. 5. Ability to urinate is not an essential criterion for discharge for the pediatric client who has received sedation. Page Ref: 932 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.8 Develop a nursing care plan for the child to be given sedation and analgesia for a medical procedure.

24) Which pediatric diagnoses require the nurse to include interventions to treat chronic pediatric client pain in the plan of care? Select all that apply. 1. Juvenile idiopathic arthritis 2. Sickle cell disease 3. Attention deficit hyperactivity disorder (ADHD) 4. Cancer 5. Human immunodeficiency virus (HIV) Answer: 1, 2, 4 Explanation: 1. Juvenile idiopathic arthritis is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 2. Sickle cell disease arthritis is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 3. ADHD is not a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 4. Cancer is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. 5. HIV is a condition that necessitates the inclusion of interventions to treat chronic pain in the plan of care. Page Ref: 930 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.7 Develop a nursing care plan for the child with a chronic painful condition.

25) Which complementary pain management interventions should the nurse include in the plan of care for a pediatric client who is experiencing chronic pain? Select all that apply. 1. Hypnosis 2. Guided imagery 3. Patient-controlled analgesia (PCA) 4. Fentanyl patch 5. EMLA cream Answer: 1, 2 Explanation: 1. Hypnosis is a complementary intervention that is appropriate for the nurse to include in the plan of care for a pediatric client who is experiencing chronic pain. 2. Guided imagery is a complementary intervention that is appropriate for the nurse to include in the plan of care for a pediatric client who is experiencing chronic pain. 3. PCA is not a complementary pain management therapy. 4. Fentanyl patch is not a complementary pain management therapy. 5. EMLA cream is not a complementary pain management therapy. Page Ref: 930 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: I.C.8. Appreciate the role of the nurse in relief of all types and sources of pain or suffering | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.7 Develop a nursing care plan for the child with a chronic painful condition.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 41 The Child With a Life-Threatening Condition and End-of-Life Care 1) Which problem would be a priority for an adolescent diagnosed with cystic fibrosis who is intubated with an endotracheal tube? 1. Fear 2. Anxiety 3. Loss of control 4. Potential for weight gain Answer: 3 Explanation: 1. The adolescent might be fearful however would not be able to articulate fears. Addressing communication would help reduce the fear. 2. The adolescent might be anxious however cannot talk about it because of being intubated. Addressing communication would help reduce the anxiety. 3. The adolescent values communication with peers, and might feel frustrated that she cannot speak to them while intubated. 4. The adolescent with cystic fibrosis is likely to be underweight, and is unlikely to take in more calories than needed while intubated. Page Ref: 937 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 41.1 Summarize the effects of a life-threatening illness or injury on children.

2) The emergency department (ED) nurse is talking with a preschooler about the death of the child's parents in a motor vehicle crash. Which aspect of the child's growth and development should the nurse take into consideration when formulating the client's plan of care? 1. Preschool-age children often believe that death is their fault. 2. Preschool-age children believe death is permanent. 3. Preschool-age children engage in reality-based thinking. 4. Preschool-age children may believe the parents will not come back home. Answer: 1 Explanation: 1. Preschoolers engage in magical thinking, and might believe they wished or caused the death of their parents. 2. Preschoolers do not have a concept of death as permanent; therefore, they might expect their parents to return home. 3. Preschoolers engage in magical thinking, and might believe they wished or caused the death of their parents. 4. Preschoolers do not have a concept of death as permanent; therefore, they might expect their parents to return home. Page Ref: 951 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.1 Summarize the effects of a life-threatening illness or injury on children.

3) A 16-year-old has a stiff neck, headache, fever of 103°F, and the nurse notes purpuric lesions on the child's legs. Although the adolescent's physical needs take priority at the present time, the nurse can expect which psychologic stressor to be the most significant for this adolescent? 1. Fear of getting behind in schoolwork 2. Separation from friends and permanent changes in appearance 3. Separation from parents and home 4. Fear of painful procedures and bodily mutilation Answer: 2 Explanation: 1. School-age children are developing a sense of industry, and fear getting behind in schoolwork. 2. Adolescents are developing their identity, and rely mostly on their friends. They are concerned about their appearance and how they look compared with their peers. 3. Separation from parents and home is the main psychological stressor for infants and toddlers. 4. Preschoolers fear pain and bodily mutilation. Page Ref: 946 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Summarize the effects of a life-threatening illness or injury on children.

4) A school bus carrying children in grades K-12 crashed into a ravine. The critically injured children are transported by ambulance and admitted to the pediatric intensive care unit (PICU). Which action should the nurse take to calm the frightened children? 1. Explain that the equipment being used is state-of-the-art. 2. Tell the children that the providers are competent. 3. Call the children's parents to come to the unit. 4. Assure the children that the nurses are caring. Answer: 3 Explanation: 1. Children often cannot recognize or care about state-of-the-art equipment. 2. Healthcare providers, no matter how competent or caring, cannot substitute for parents. 3. A sense of physical and psychologic security is best achieved by the presence of parents. Children at all developmental levels look first to their parents or whoever acts as their parents for safety and security. 4. Healthcare providers, no matter how competent or caring, cannot substitute for parents. Page Ref: 937 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.1 Summarize the effects of a life-threatening illness or injury on children.

5) The nurse is working with children in hospice care. The mother of a young child with cancer is frustrated with "waiting" for things to happen or change. Which feeling is the mother experiencing? 1. Actual loss 2. Perceived loss 3. Anticipatory waiting 4. Loss Answer: 3 Explanation: 1. Actual loss is a real loss objectively confirmed by others. 2. A perceived loss is subjectively experienced by a person, but cannot be confirmed by others. 3. Anticipatory waiting is a feeling that life is suspended in time. A great deal of time is waiting for test results, a change in condition, or decisions about treatment. 4. Loss is a general term for something of value being changed, no longer available, or no longer able to be experienced by an individual. Page Ref: 940 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: RelationshipCentered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Examine the family's experience and reactions to having a child with a life-threatening illness or injury.

6) A school-age child is admitted to the hospital with a fractured femur and head trauma. The child was not wearing a helmet while riding a new bicycle on the highway, and collided with a car. Which problems should the nurse include in the plan of care with regard to the child's parents? Select all that apply. 1. Coping with changes 2. Possible role changes 3. Guilt 4. Lack of knowledge 5. Anger Answer: 1, 2, 3, 5 Explanation: 1. This problem is appropriate for the child's parents in this situation. 2. This problem is appropriate for the child's parents in this situation. 3. This problem is appropriate for the child's parents in this situation. 4. The problem of lack of knowledge is not possible in this situation. Although planning for discharge begins with admission, it is too early to begin teaching the parents about home care. The astute and experienced nurse is prepared to recognize current problems, and intervene appropriately. 5. This problem is appropriate for the child's parents in this situation. Page Ref: 940 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 41.2 Examine the family's experience and reactions to having a child with a life-threatening illness or injury.

7) The parents of a 2-year-old child who sustained severe head trauma from falling out of a second-story window are arguing in the pediatric intensive care unit (PICU), and are blaming each other for the child's accident. Which problem explains the family's reaction? 1. Conflict with parental role 2. Anxiety 3. Hopelessness 4. Problems with coping Answer: 4 Explanation: 1. Conflict with the parental role focuses on the parent and not on the family as a whole. 2. Parents might be experiencing anxiety, but they are not coping well as a family unit. 3. Parents might be experiencing hopelessness, but they are not coping well as a family unit. 4. The parents are displaying ineffective coping behaviors as a family. Page Ref: 942 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.C.1. Value seeing healthcare situations "through patients' eyes" | AACN 2021 Domains and Competencies: 2.4. Diagnose actual or potential health problems and needs. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 41.3 Identify the coping mechanisms used by the child and family in response to stress. 8) Which nursing intervention should the nurse include in the plan of care for a child who is sedated, unconscious, and on a mechanical ventilator? 1. Out-of-bed transfer to wheelchair 2. Whirlpool baths 3. Maintenance of intravenous (IV) hydration 4. Active range-of-motion (ROM) exercises Answer: 3 Explanation: 1. The child would not be permitted to be transferred to a wheelchair. 2. The child would not be permitted to be transferred to take whirlpool baths. 3. The child who is unconscious is unable to take anything by mouth, and will need IV therapy for hydration. 4. The nurse may perform passive ROM exercises on the child, but the child is incapable of doing active ROM exercises. Page Ref: 938 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.C.1. Value seeing healthcare situations "through patients' eyes" | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.3 Identify the coping mechanisms used by the child and family in response to stress. 7 Copyright © 2022 Pearson Education, Inc.

9) A 10-year-old child is transported to the emergency department (ED) by ambulance from the scene of a motor vehicle crash. The child is alert and oriented ×3; pulse, respirations, and blood pressure are stable; neck and back are immobilized on a backboard. The nurse sees no obvious bleeding. The child states," I can't move or feel my legs." Which injury does the nurse suspect based on the current data? 1. Spinal cord injury 2. Traumatic shock 3. Traumatic brain injury 4. Ruptured spleen Answer: 1 Explanation: 1. Spinal cord injury results in paralysis and anesthesia of the affected body parts below the level of the lesion. 2. Traumatic shock results in initially increasing then decreasing pulse and respirations and falling blood pressure. 3. Altered levels of consciousness could indicate traumatic brain injury. 4. The child might have a ruptured spleen, but it is not evident from the data given in this scenario. Page Ref: 936 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Relationship-Centered Care: Ethical Comportment: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

10) A preschool-age child with severe head trauma is intubated and on a respirator. The child has three flat electroencephalograms (EEGs) completed 24 hours apart. The electrocardiogram (ECG) shows a rate of 90 beats per minute in a normal sinus rhythm. Which term should the nurse use when documenting these findings? 1. Imminent death 2. Brain death 3. Natural death 4. Heart—lung death Answer: 2 Explanation: 1. Imminent death means physical death is inevitable within a period of time. 2. Cerebral death, or brain death, is the irreversible cessation of all brain functions, including those of the cerebral cortex and brainstem, manifested by the absence of brain waves on EEG. 3. Natural death is allowing cessation of all body functions without extraordinary medical interventions. 4. Heart-lung death, the irreversible cessation of cardiorespiratory functions, has not occurred because the child is being mechanically ventilated. Page Ref: 944 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity Standards: QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 41.5 Apply assessment skills to identify the physiologic changes that occur in the dying child.

11) A female client arrived by life flight to the hospital after experiencing multiple traumas in a motor vehicle crash involving a suspected drunk driver. Which statement is the most important for the nurse to make to the parents before they see their child? 1. "You should press charges against the drunk driver." 2. "Your child's condition is very critical; her face is swollen, and she might not look like herself." 3. "Your child's leg was crushed, and might have to be amputated." 4. "Don't worry, everything will be okay. We will take excellent care of your child." Answer: 2 Explanation: 1. The nurse supports the family, but remains nonjudgmental about accident details. 2. The priority is to prepare the parents for the child's changed appearance. 3. The priority is to prepare the parents for the child's changed appearance. Truthful statements about the child's condition can be introduced after the parents have seen the child and grasped the situation. 4. The priority is to prepare the parents for the child's changed appearance. The nurse must not offer false reassurance or project future stressful events. Page Ref: 940 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 41.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

12) A school-age child diagnosed with congenital heart block codes in the emergency department. The parents witness this and stare at the resuscitation scene unfolding before them. Which is the best nursing intervention in this situation? 1. Asking the parents to help bag the child 2. Asking the parents to sit near the child's face and touch their child 3. Asking the parents to stand at the foot of the cart to watch 4. Asking the parents to leave the room Answer: 2 Explanation: 1. Parents never should be asked to take part in emergency efforts unless absolutely necessary. 2. Parents should be helped to support their child through emergency procedures, if they are able. 3. Merely watching the resuscitation serves no purpose for the child. 4. If the parents interfere with resuscitation efforts, or are unable to tolerate the situation, they can be asked to leave later. Page Ref: 942 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

13) An adolescent experiencing status asthmaticus is rushed to the emergency department by ambulance. The parents arrive and ask to see their child. The triage nurse at the reception desk knows that the adolescent was pronounced dead on arrival. Which is the best action by the triage nurse at this time? 1. Ask the parents to please take a seat in the waiting room. 2. Immediately escort the parents to a quiet, private room. 3. Tell the parents that they must wait because only the healthcare provider can talk with them. 4. Immediately tell the parents, "I'm sorry, but your child didn't make it." Answer: 2 Explanation: 1. Asking parents to wait is uncaring and insensitive. 2. The best nursing intervention is to give the parents an appropriate environment before they are told the news, so that they can begin grieving privately. 3. Nurses as well as other healthcare providers are capable of breaking bad news to families with caring and empathy. 4. Telling the parents the news in public is uncaring and insensitive. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 41.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

14) Which strategies would be helpful for nurses who work with terminally ill children to avoid burnout? Select all that apply. 1. Participating in a mentoring relationship with experienced hospice nurses 2. Participating in support groups with mental health professionals 3. Participating in team decisions regarding the dying child's plan of care 4. Declining the family's invitation to attend the child's funeral 5. Planning the child and family's care alone as the primary nurse Answer: 1, 2, 3 Explanation: 1. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 2. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 3. Team decisions, mentorship, and support groups all alleviate the responsibility of providing nursing care and coping with the death of a child alone. 4. Distancing oneself from the family can result in unresolved grief. 5. Planning the child's care alone might result in an excessive burden of guilt. Page Ref: 952 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II.C.1. Acknowledge own potential to contribute to effective team functioning | AACN 2021 Domains and Competencies: 10.1 Demonstrate a commitment to personal health and well‐being. | NLN Competencies: Relationship-Centered Care: Practice: respond to moral and ethical challenges. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.8 Evaluate strategies to support nurses who care for children who die.

15) Which topics should the nurse include in a discussion with parents of a terminally ill child regarding parental feelings that may occur upon the child's death? Select all that apply. 1. Loneliness 2. Guilt 3. Anger 4. High energy 5. Depression Answer: 1, 2, 3, 5 Explanation: 1. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 2. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 3. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. 4. High energy is not felt during the mourning period. 5. The intense pain and shock initially felt by parents gradually give way to feelings of anger, guilt, depression, and loneliness. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Ethical Comportment: Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.7 Plan bereavement support for the parents and siblings after the death of a child.

16) The nurse is speaking with a preschool-age child whose sibling recently died. Which feelings should the nurse anticipate from the preschool-age child? 1. The child may feel that his or her bad behavior caused the sibling's death as a punishment. 2. The child may feel that the sibling died as a result of a fight. 3. The child may feel that having bad thoughts about the sibling caused the death. 4. The child may feel that the sibling died because the parents did not like that sibling. Answer: 3 Explanation: 1. Preschool-age children do not have a fear of being bad and the sibling's subsequently being punished. 2. Fighting is normal, and preschool-age children do not have those thoughts. 3. Preschool-age children might fear that they caused their brother or sister to be injured or become ill, or they may worry that bad thoughts on their part brought on the illness. 4. Preschool-age children are more likely to believe that they somehow were the cause of their sibling's death, not their parents. Page Ref: 943 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Ethical Compartment: Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.7 Plan bereavement support for the parents and siblings after the death of a child.

17) The mother of a dying 3-year-old child posts on Facebook: "Family and friends. Michael's heart is giving out. Looks like it will be tonight. He is surrounded by family and not in pain. I treasure every minute of being his mother. Pray for us." Which reaction to a life-threatening illness is the mother experiencing? 1. Shock and disbelief 2. Anticipatory waiting 3. Anger and guilt 4. Readjustment or mourning Answer: 2 Explanation: 1. The mother is not demonstrating shock or disbelief. 2. The mother is demonstrating waiting for her child to be at peace. 3. The mother is not demonstrating anger or guilt. 4. The mother is not demonstrating readjustment or mourning since her child is still alive. Page Ref: 940 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Ethical Compartment: Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.7 Plan bereavement support for the parents and siblings after the death of a child.

18) The nurse is leading a recovery group of parents who have lost a child. As the opening topic for the night's discussion, the nurse reviews information about the grief process to the parents and talks about how different people grieve. Which parental statement indicates the need for more education regarding the grieving process? 1. "I understand that everyone grieves differently." 2. "Looking back, I realize why I became so angry when the doctors didn't cure my daughter." 3. "It's been 6 months since my son died, so why isn't my wife ready to move on with our lives?" 4. "I'm glad you described some common grief reactions. I thought I was going crazy for a while." Answer: 3 Explanation: 1. This statement is accurate. This father understands this concept correctly. 2. Anger is a part of the grief process. This father has been able to look at his own behavior and recognize it as normal. 3. There is no standard period of grief. It is individual. This father has not heard the nurse's discussion. 4. This father has applied the knowledge of grief behaviors to his own behavior. He understands the discussion. Page Ref: 950 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Ethical Compartment: Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.7 Plan bereavement support for the parents and siblings after the death of a child.

19) The nurse is providing care to a child who is nearing death. Which nursing actions may offer the family support? 1. Using active listening techniques 2. Looking the parents in the eye when talking 3. Refusing to cry while in the child's room 4. Offering to call and notify family 5. Avoiding being in the room to allow the family to grief Answer: 1, 2, 4 Explanation: 1. Active listening encourages the parents to talk if they feel the need. 2. This behavior indicates willingness to listen. 3. This is no longer considered inappropriate, and allows the parents to know that the nurse feels sadness at the loss. 4. This would be appropriate and helpful to the parents. 5. The nurse should provide support to the parents. Often just sitting in the room quietly is an appropriate intervention. Page Ref: 945 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Ethical Compartment: Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.7 Plan bereavement support for the parents and siblings after the death of a child.

20) The nurse is having difficulty coping with the impending death of a child. With which person should the nurse consult during this difficult situation? 1. Other staff nurses 2. Hospice nurses 3. Unit nurse manager 4. Nurse's spouse Answer: 2 Explanation: 1. Coworkers will also have a difficult time with the death. 2. Mentorship with experienced hospice nurses as well as additional educational experiences could help promote professional nursing care. 3. The unit manager also might have a difficult time with the impending death. 4. The spouse might not fully understand why this is affecting the nurse. Page Ref: 952 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: II.C.1. Acknowledge own potential to contribute to effective team functioning | AACN 2021 Domains and Competencies: 10.1 Demonstrate a commitment to personal health and well‐being. | NLN Competencies: Relationship-Centered Care: Practice: respond to moral and ethical challenges. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.8 Evaluate strategies to support nurses who care for children who die. 21) The nurse is taking care of a child who is showing signs of imminent death. Which manifestations should the nurse expect to assess related to the cardiovascular system? 1. An increase in the volume of Korotkoff sounds 2. Cool and clammy skin, mottling 3. Peripheral pulses will remain when the heartbeat is not heard on auscultation. 4. An increase in cardiac output Answer: 2 Explanation: 1. A change in pulse pressure and a decrease in the volume of Korotkoff sounds indicate imminent death. 2. Peripheral circulation decreases, leading to diaphoresis, clammy and cool skin, and changes in skin coloring such as mottling or cyanosis. 3. The heart rate might initially increase as hypoxia develops, then the heart rate and blood pressure decrease, resulting in decreased cardiac output. 4. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death. Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.5 Apply assessment skills to identify the physiologic changes that occur in the dying child. 19 Copyright © 2022 Pearson Education, Inc.

22) The nurse is doing a follow-up home visit to a family who lost their 3-month-old infant to SIDS 8 weeks ago. The mother answers the door in her nightgown, with hair uncombed. During the interview, the mother states: "I don't see the point of getting dressed each day." Which stage of grief will the nurse document based on the current data? 1. Return to life 2. Guilt 3. Anger 4. Depression Answer: 4 Explanation: 1. The mother's behavior does not indicate returning to life. 2. In this stage of grief behavior, the mother would be making statements such as, "If only…" or "what if …." 3. The mother is not expressing any anger. 4. The mother is demonstrating depression as daily activities seem pointless during this stage. Page Ref: 950 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 41.6 Develop a nursing care plan to provide family-centered care for the dying child and family.

23) The nurse is providing care to a child who was admitted to the pediatric intensive care unit (PICU) after a motor vehicle crash. Which interventions should the nurse include in the plan of care to allow the parents to participate in their child's care? Select all that apply. 1. Encouraging the parents to brush the child's hair 2. Teaching the parents how to perform range of motion exercises with their child 3. Allowing the parents to read to their child 4. Explaining the child's condition to the parents 5. Providing permission for the parents to remain at the child's bedside Answer: 1, 2, 3 Explanation: 1. Encouraging the parents to brush the child's hair is an intervention that allows the parents to participate in their child's care. 2. Teaching the parents how to perform range of motion exercises with their child is an intervention that allows the parents to participate in their child's care. 3. Allowing the parents to read to their child is an intervention that allows the parents to participate in their child's care. 4. Explaining the child's condition to the parents is an intervention that provides information; however, it does not allow the parents to participate in their child's care. 5. Providing permission for the parents to remain at the child's besides allow the parents to be close to their child; however, it does not allow the parents to participate in their child's care. Page Ref: 941-942 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Relationship-Centered Care: Ethical Comportment: Appreciate the patient as a whole person, with his or her own life story and ideas about the meaning of health or illness | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.4 Develop a nursing care plan for the child with a life-threatening illness or injury.

24) Which defense mechanisms should the nurse include in the parental teaching session regarding common pediatric responses to a life-threatening illness? Select all that apply. 1. Regression 2. Anticipating 3. Denial 4. Repression 5. Bargaining Answer: 1, 3, 4, 5 Explanation: 1. Regression is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 2. Anticipating is a coping mechanism, not a defense mechanism, that may be portrayed by the pediatric client in response to a life-threatening illness. 3. Denial is a common defense mechanism portrayed by the pediatric client in response to a lifethreatening illness. 4. Repression is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. 5. Bargaining is a common defense mechanism portrayed by the pediatric client in response to a life-threatening illness. Page Ref: 936 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.C.1. Value seeing healthcare situations "through patients' eyes" | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Relationship-Centered Care: Practice: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.3 Identify the coping mechanisms used by the child and family in response to stress.

25) Which respiratory findings assessed by the nurse indicate that a child is close to death? Select all that apply. 1. Tachypnea 2. Dyspnea 3. Diaphoresis 4. Confusion 5. Accumulation of secretions in the throat Answer: 1, 2, 5 Explanation: 1. Tachypnea is a respiratory finding that may indicate the child is close to death. 2. Dyspnea is a respiratory finding that may indicate the child is close to death. 3. Diaphoresis is a cardiovascular, not respiratory, finding indicating the child is close to death. 4. Confusion is a neurologic, not respiratory, finding indicate the child is close to death. 5. As the child approaches death, the muscles relax and secretions accumulate in the oropharynx and bronchi, causing noisy breathing as air passes through the secretions. Page Ref: 947 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.5 Apply assessment skills to identify the physiologic changes that occur in the dying child.

26) Which assessment findings may indicate to the nurse that the child is experiencing renal failure and is close to death? Select all that apply. 1. Decreased oral fluid intake 2. Decreased urine production 3. Increased urinary incontinence 4. Urinary stones noted 5. Increased diaphoresis Answer: 2, 3 Explanation: 1. Decreased oral intake is a gastrointestinal, not urinary, manifestation associated with impending death. 2. Decreased urine output is a clinical manifestation associated with renal failure that occurs with impending death. 3. Increased urinary incontinence is a clinical manifestation associated with renal failure that occurs with impending death. 4. Urinary stones are not a clinical manifestation associated with renal failure that occurs with impending death. 5. Increased diaphoresis is a cardiovascular, not renal, manifestation associated with impending death. Page Ref: 947 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.5. Assess levels of physical and emotional comfort | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.5 Apply assessment skills to identify the physiologic changes that occur in the dying child.

27) Which support groups should the nurse include in a bereavement package for a family who suddenly lost an adolescent in a motor vehicle crash? Select all that apply. 1. Compassionate Friends 2. First Candle 3. Al Anon 4. Infant Loss Support 5. Rachel's Vineyard Answer: 1, 2 Explanation: 1. Compassionate Friends is a support group the nurse should include in a bereavement package for a family who suddenly lost a child in a motor vehicle crash. 2. First Candle is a support group the nurse should include in a bereavement package for a family who suddenly lost a child in a motor vehicle crash. 3. Al Anon is a support group appropriate for the family of an alcoholic client. 4. Infant Loss Support is an appropriate support group to provide to a family who has suffered the loss of a newborn or infant. 5. Rachel's Vineyard is a support group that assists those grieving due to loss via abortion. Page Ref: 950 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Ethical Comportment: Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.7 Plan bereavement support for the parents and siblings after the death of a child.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 42 Social and Environmental Influences on the Child 1) Which adolescent behavior, reported by a parent, would cause the nurse to suspect possible substance abuse? 1. Becoming very involved with friends and in activities related to basketball 2. Becoming moody, crying, and weeping one minute and then cheerful and excited the next 3. Receiving numerous detentions for sleeping in class 4. Wearing baggy, oversized clothing and dyeing hair black Answer: 3 Explanation: 1. Periodically, distancing themselves from their parents and preferring involvement with their peers are normal adolescent behaviors. 2. Mood swings are normal adolescent behaviors. 3. Even though most teens do prefer staying up late, they are not usually so tired that they fall asleep during the day, especially while engaged in classroom activities. This behavior is abnormal and could indicate involvement with substance abuse or an underlying pathology. 4. Experimentation with different clothes and hair is a normal adolescent behavior. Page Ref: 976 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.3 Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

2) During a well-child examination, the parents of a 4-year-old client inform the nurse that they are thinking of buying a television for their child's bedroom and ask for advice as to whether this is appropriate. Which response by the nurse is most appropriate? 1. "It is okay for children to have a television in their room as long as you limit the amount of time they watch it to less than 2 hours per day." 2. "Research has shown that watching educational television shows improves a child's performance in school." 3. "Don't buy a television for your child's room; he is much too young for that." 4. "Research has shown that children with a television in their bedroom spend significantly less time playing outside than other children." Answer: 4 Explanation: 1. This information is correct in that limiting television viewing to less than 2 hours per day is appropriate, but the probability of this occurring with a television in the child's room is low; the child will most likely be watching much more than 2 hours per day. 2. This statement might encourage the parents to allow the child to watch more television, and the child's developmental need for physical activity is greater than the benefit that he might obtain by watching educational programs. 3. This statement does not give parents a rationale, and it might seem opinionated to them. 4. Young children need to be physically active at this age. Research has shown that children with a television in their bedroom spend significantly less time playing outside than do other children, and physical inactivity in children has been linked to many chronic diseases, such as obesity and type 2 diabetes. Telling parents this is the best response because it gives the parents an evidencebased reason for not placing a television in the child's room. Page Ref: 965 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.1 Identify major social and environmental factors that influence the health and development of children and adolescents.

3) A mother of two children, an 8-year-old and a 10-year-old, tells you that her husband has recently been deployed to the Middle East. The mother is concerned about the children's constant interest in watching TV news coverage of activities in the Middle East. Which suggestion by the nurse to the mother is most appropriate? 1. "Spend time with your children, and take cues from them about how much they want to discuss." 2. "Allow the children to watch as much television as they want. This is how they are coping with their father's absence." 3. "The less that you discuss this, the quicker the children will adjust to their father's absence. Try to keep them busy, and use distractions to keep their mind off of it." 4. "It will just take some time to adjust to their father's absence and then everything will return to normal." Answer: 1 Explanation: 1. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase. 2. Constant viewing of the TV coverage of the war might increase the children's anxiety and fear for their father's safety. 3. Children need to be able to discuss their feelings and concerns with an adult; otherwise, their emotional distress could increase. 4. The mother should be aware that even though the children might appear to have adjusted, there could be delayed reactions or regressions in behavior. Page Ref: 956 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.1 Identify major social and environmental factors that influence the health and development of children and adolescents.

4) A 7-year-old child is seen in the pediatric clinic 3 times in the last 2 months for complaints of abdominal pain. On each occasion, the physical examination and all ordered laboratory work have been normal. Which is the priority nursing assessment at this time? 1. The child's normal eating habits 2. Recent viral illnesses or other infectious symptoms 3. Review of the child's immunization history 4. Changes in school or home life Answer: 4 Explanation: 1. Because of the abdominal complaints, the child's eating habits would have already been discussed. 2. With normal blood work and tests, the chance of any illness over the last few months is unlikely. 3. The immunization history would have been reviewed on the previous visits. 4. With a normal examination and laboratory work, there is a high probability that this child's abdominal pain is stress related, and it is the most important to identify the possible stressors in this child's life to aid in diagnosis and treatment. Asking about changes in home or school life is most likely to get to information about recent stresses in the child's life. Page Ref: 973 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.1 Identify major social and environmental factors that influence the health and development of children and adolescents.

5) The nurse is providing care to homeless adolescents at an outreach clinic. Which concept is important for the nurse to consider when providing care to this population? 1. Teens who are homeless will get a job and somewhere to live. 2. Teens who are homeless will seek help when needed. 3. Teens who are homeless will not be fearful of authority figures. 4. Teens who are homeless are most likely to have unprotected sex. Answer: 4 Explanation: 1. Homeless teens are less likely to obtain employment and a place to live, as often these teens do not have the skills to be able to accomplish such tasks. 2. Homeless teens are less likely to seek help when needed, frequently because of mistrust of others. 3. Homeless teens are generally fearful and distrustful of authority figures. 4. Teens who are homeless are more likely to engage in risky behaviors, such as unprotected sex with multiple partners and substance abuse. They are more likely to need emergency care, to be depressed, and to become pregnant than are other teens. Page Ref: 957 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.3 Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

6) A parent is concerned about her 8-year-old child's recent behavior and calls the nurse for advice. According to the parent, her child is constantly crying, is not sleeping well, has withdrawn from activities, and does not want to attend school. Which should the nurse explore in more detail with the parent? 1. Bullying 2. Sexual abuse 3. Lead poisoning 4. Drug abuse Answer: 1 Explanation: 1. Physical complaints, suicidal thoughts, and other problems can result from bullying. 2. Sexual abuse should be suspected if the child is experiencing vaginal discharge or excessive sexual curiosity for age. 3. Lead poisoning can lead to physical symptoms, including neurologic deficits, but would not include the signs of emotional distress that the child is exhibiting. 4. Drug abuse is more likely to occur in an adolescent than a child of this age. Page Ref: 970 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

7) A high school student calls to ask the nurse for advice on how to care for a new navel piercing. Which response by the nurse is appropriate? 1. "Avoid contact with another person's bodily fluids until the area is well healed." 2. "Do not move or turn the jewelry for the first 3 days." 3. "Apply lotion to the area, rubbing gently, to prevent skin from becoming dry and irritated." 4. "Apply warm soaks to the area for the first 2 days to minimize swelling." Answer: 1 Explanation: 1. Until the piercing has healed, it is a nonintact area of skin that has potential for infection, especially from contact with bodily fluids from someone else. 2. The jewelry needs to be gently rotated several times per day to aid with healing. 3. Lotion can provide a medium for bacteria, and rubbing at the site can cause irritation to the area. 4. Ice, not warm soaks, should be applied to the area for the first two days to minimize the swelling. Page Ref: 967 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.2 Apply the ecological model and resiliency theory to assessment of the social and environmental factors in children's lives.

8) The school nurse is planning a smoking prevention program for middle school students. Which is most likely to be effective in preventing this population from smoking? 1. A demonstration of the pathophysiology of the effects of smoking tobacco on the body given by the school's biology teacher 2. A talk on the importance of not smoking given by a local high school basketball star 3. Colorful posters with catchy slogans displayed throughout the school 4. A pledge campaign during which students sign contracts saying that they will not use tobacco products Answer: 2 Explanation: 1. A physical demonstration may help the children recognize the long-term effects of smoking, but information from adults is not likely to influence children of this age more than the pressure of their peers will. 2. While all of the strategies are good, the most effective would be to have a local high school basketball star come to talk to the students about the importance of not smoking because students at this age are more likely to listen to and attempt to emulate someone of their own peer group. 3. Information from posters is not likely to influence children of this age more than the pressure of their peers will. 4. Information from signed contracts is not likely to influence children of this age more than the pressure of their peers will. Page Ref: 969 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.3 Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

9) Which is the priority nursing action when working with a parent who is suspected of Munchausen syndrome by proxy? 1. Try to keep the parent separated from the child as much as possible. 2. Explain to the child that the parent is causing the illness and that the healthcare team will prevent the child from being harmed. 3. Carefully document parent—child interactions. 4. Confront the parent with concerns of possible abuse. Answer: 3 Explanation: 1. Separating the parent from the child might alienate the parent and cause her to leave with the child. 2. Talking to the child about the healthcare team's suspicions could be confusing and frightening for the child. 3. Munchausen syndrome by proxy is very difficult to prove, and evidence provided by the careful documentation of the nursing staff can be very influential. Care must be taken not to make the parent suspicious and to keep the child in the hospital until enough evidence is collected. 4. Confronting the parent might alienate the parent and cause her to leave with the child. Page Ref: 979 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

10) An infant presents to the emergency department (ED) with physical injuries. The nurse is taking the child's history. Which parental statement would cause the nurse to be suspicious of abuse? 1. "I was walking up the steps and slipped on the ice and fell while carrying my baby." 2. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." 3. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." 4. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor." Answer: 2 Explanation: 1. This statement is plausible from a developmental perspective; therefore, the nurse would not be suspicious of abuse. 2. Developmentally, it would be very difficult for an 18-month-old child to pull an infant out of a crib. 3. This statement is plausible from a developmental prospective; therefore, the nurse would not be suspicious of abuse. 4. This statement is plausible from a developmental prospective; therefore, the nurse would not be suspicious of abuse. Page Ref: 977 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

11) While taking the history of a 10-year-old child, the parents admit to owning firearms. Which information should the nurse suggest to enhance the child's safety based on this information? 1. Keeping all the guns put away and out of the child's reach 2. Taking the child to a shooting range for lessons on how to use a gun properly 3. Storing the guns and ammunition in the same place 4. Using a gun lock on all firearms in the house Answer: 4 Explanation: 1. A 10-year-old child is able to reach any area of the house; more precautions need to be taken. 2. Teaching gun safety is appropriate to a family that has guns; however, it is not sufficient to protect the child. The guns must be secured at all times the adults are not supervising the guns. 3. It is recommended that guns and ammunitions be stored separately. 4. Statistics show that about 75% of unintentional deaths and suicides are committed with firearms found in the home. The safety measures of using a gun lock, keeping the gun and ammunition separate, and putting the guns in a locked cabinet will at least make the guns less accessible. Page Ref: 969 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

12) The nurse is providing care to a 3-year-old client whose mother states, "I am not sure that I have enough money to buy both food for the rest of the month and the antibiotic for my child's ear infection." Which nursing intervention would be beneficial for the child and this family? 1. Talking with the mother about keeping the child's ear clean by using a Q-tip 2. Putting the mother in contact with a local agency that provides food on a regular basis to needy families and helps them access other resources in the community 3. Providing the mother with samples of food and food stamps for the child 4. Giving the mother free samples of an antibiotic Answer: 2 Explanation: 1. Cleaning the ear with a Q-tip will not clear the ear infection. 2. Putting the mother in contact with a local agency is most likely to meet the family's basic need for food and possibly connect the mother to a resource that could supply her with the antibiotic for her child. 3. The nurse will have neither food samples nor food stamps at her disposal. 4. The course of treatment is usually 10 days. Free samples may not be for the appropriate antibiotic or be sufficient to treat the infection. A better intervention will be to provide help that will extend beyond the immediate period. Page Ref: 958 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.7 Plan nursing interventions for children related to social and environmental situations.

13) The mother of an infant reports picking up the baby from day care and notices marks on the baby's body. Which action should the nurse take when the mother asks what should be done? 1. Report the facility to child protective services. 2. Ask the mother to talk with the director of the day care facility. 3. Ask the mother if anyone else could have caused the marks. 4. Suggest the baby be taken for a full examination. Answer: 1 Explanation: 1. Any professional who works with children and reasonably suspects that a child has been abused is required to report suspicions of abuse or neglect to the local agency for child protective services. Reports made in good faith are not liable to countersuits. 2. Professionals who suspect abuse and do not report it may be held responsible by the judicial system. In some states, all citizens are mandated to report suspected abuse. 3. The mother is reporting the marks. It is unlikely someone else in the home caused the marks. 4. There is no evidence that the child has been harmed. A full examination may be suggested after the baby's marks are reported. Page Ref: 977 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; transition and continuity | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.2 Apply the ecological model and resiliency theory to assessment of the social and environmental factors in children's lives.

14) The pediatric public health nurse visits a facility for the homeless. Which types of medical issues will the nurse assess these children for based on the current data? Select all that apply. 1. Dental caries 2. Infections secondary to tattoos 3. Lack of immunizations 4. Nutritional deficits 5. Munchausen syndrome by proxy Answer: 1, 3, 4 Explanation: 1. Children who are homeless do not have the facilities or the supplies to care for their teeth, and do not see a dentist on a regular basis. 2. This is not a specific problem related to homelessness, and many states prohibit tattooing of children. 3. Homelessness often leads to lack of medical care, and some of the children may not be current on their immunizations. 4. The family that is homeless often has difficulty with maintaining adequate nutrition. 5. This is not a common problem for the homeless child. Page Ref: 958 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.7 Plan nursing interventions for children related to social and environmental situations.

15) A child is brought to the emergency department in a coma. The mother thinks the child may have ingested a poison. Which will the nurse assess based on this information? Select all that apply. 1. For oral burns 2. The child's breath 3. The child's vomitus 4. Hair samples 5. Blood and urine toxicology screens Answer: 1, 2, 3, 5 Explanation: 1. Corrosives often leave evidence of burns on the mouth and gums. 2. The breath may have characteristic odors that may help identify the poison. 3. The vomitus may contain leaves, indicating the child has eaten a plant or other items that may provide information on the toxin. 4. Hair samples can be used to test drug use over a period of time. It would not contain any valuable information for this child. 5. These tests will look for a wide variety of toxins. Page Ref: 981 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: V.C.4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.5 Evaluate the environment for hazards to children, such as exposure to harmful substances and potential for poisoning.

16) A child is admitted to the hospital with a diagnosis of lead poisoning. Which should be included in the home assessment to determine the probable source of the lead poisoning? 1. The home's foundation for a possible radon leak 2. The home's water pipes 3. The dirt surrounding the house 4. The presence of imported toys or antique baby furniture 5. Gas stored in cans in the garage. Answer: 2, 3, 4 Explanation: 1. Radon is not a source of lead. 2. Older water pipes were made from lead, which leaches out into the water. 3. Children who eat dirt may acquire lead poisoning due to contamination with fumes from lead gas. 4. Toys imported from other countries and old furniture may have lead paint. The child can be exposed if the child puts these objects in the mouth. 5. Most gas is now not lead based. If the child were to drink the gas from the cans, the problem would be the hydrocarbons, not the lead. Page Ref: 984 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.7 Plan nursing interventions for children related to social and environmental situations.

17) A child is admitted to the hospital unit for physical injuries. The mother's boyfriend is suspected of child abuse. Which is the primary role of the nurse in addition to reporting the information to the proper authorities? 1. Gathering information about how the injuries occurred. 2. Collecting evidence against the suspected abuser. 3. Encouraging the child to talk about his experience. 4. Protecting the child from further injury. Answer: 4 Explanation: 1. This is not a priority role for the nurse. 2. This would be a police function, not the nurse's responsibility. 3. The nurse and the psychologist will be meeting with the child to help the child work through the experience, but this is not the priority action for the nurse. 4. The nurse will monitor the child while in the presence of visitors. In addition, the nurse will talk with the social worker to assist in providing for the child's safety in the future. This is a priority. Page Ref: 978 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

18) The school nurse recognizes that many adolescents who are currently pregnant are hiding their pregnancies from adults, both at school and at home. Which should the nurse educate the adolescents about based on the current data? 1. Safe haven laws 2. Birth control available to all teenagers 3. Domestic abuse protection 4. The father's financial responsibility for the infant Answer: 1 Explanation: 1. Safe haven laws provide for unwanted babies to be left in certain locations without legal repercussions to the mother. 2. A pregnant teenager does not need to know about birth control at this time. 3. This is not the primary information that needs to be given to pregnant teenagers. 4. Most teenagers are aware that the fathers are financially responsible. This is not information that is needed now. Page Ref: 974 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.7 Plan nursing interventions for children related to social and environmental situations.

19) A child is admitted to the emergency department (ED) for scald burns to the buttocks and thighs. According to the mother, she was preparing the child's bath and before she could test the water, the child fell in and was scalded. Which would cause the nurse to suspect abuse? 1. The burns are uneven, with some burns deeper than others. 2. The child's hands and feet are free of burns. 3. In addition to the main burn site, there are splash burns surrounding the area. 4. The mother was home alone with the child. Answer: 2 Explanation: 1. This might occur in an accidental scald burn. 2. Someone who falls in hot water would immediately try to get out by using the hands and feet. 3. This would be a logical finding. 4. It is not unusual for a mother to be home alone with a child. Page Ref: 975 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

20) Which characteristics of abusers should the nurse include in the teaching session for elementary school teachers regarding child abuse? Select all that apply. 1. Physical illness 2. Alcoholism 3. Many friends and families nearby 4. Unrealistic expectations for their child 5. The abuser has no relationship to the child. Answer: 2, 4 Explanation: 1. This is not a common finding in abusers. 2. Drug addiction and alcoholism are common findings in the abuser. 3. The child abuser is often socially isolated. 4. Abusive parents often feel the child is misbehaving for activities, such as soiling their diapers. 5. Most abusers are parents or people who have contact with the child on a regular basis. Page Ref: 975 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.6 Explore the nursing role in prevention and treatment of child abuse and neglect and other forms of violence.

21) A recently divorced mother who must return to work is concerned about the effects of placing her child in day care full time. In counseling the mother, the nurse knows that which factor is the most influential in determining whether day care has a positive or negative effect on the child? 1. The amount of time that the children spend playing outside 2. The closeness of the parent-child relationship 3. The ratio of day care workers to children 4. The cleanliness of the day care facility Answer: 2 Explanation: 1. While the amount of time children are able to spend playing outdoors can contribute to whether child care is a positive or negative experience, the closeness of the parent—child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. 2. The closeness of the parent-child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. 3. While the ratio of day care workers to children can contribute to whether child care is a positive or negative experience, the closeness of the parent-child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. 4. While the cleanliness of the facility can contribute to whether child care is a positive or negative experience, the closeness of the parent-child relationship is more likely to impact how resilient the child is, and this has a greater impact on the effects of the child care experience. Page Ref: 956 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.3 Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

22) Which clinical manifestations should the nurse anticipate when providing care to a pediatric client who huffing glue? Select all that apply. 1. Impaired coordination 2. Elevated liver enzymes 3. Delirium 4. Dementia 5. Giddiness Answer: 1, 2, 3 Explanation: 1. Impaired coordination is a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 2. Elevated liver enzymes are a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 3. Delirium is a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 4. Dementia is not a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. 5. Giddiness is not a clinical manifestation that the nurse anticipates for a client who abuses volatile inhalants, such as glue. Page Ref: 964 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.3 Examine the effects of substance use, physical activity, and other lifestyle patterns on health.

23) Which nursing interventions should the nurse implement for a school-age child who is the victim of physical abuse by a parent? Select all that apply. 1. Referring members of the family for appropriate counseling 2. Protecting the child from further injury 3. Allowing the child to wear clothing during the examination process 4. Discouraging parental participation in the plan of care 5. Documenting the child's response to parental interaction Answer: 1, 2, 3, 5 Explanation: 1. It is appropriate for the nurse to refer members of the family for appropriate counseling. 2. It is appropriate for the nurse to protect the child from further injury. 3. It is appropriate for the nurse to allow the child to wear clothing during the examination process. 4. The nurse should encourage the parents to participate in the child's plan of care; however, the nurse should closely monitor interactions between the child and parent. 5. It is appropriate for the nurse to document the child's response to parental interaction. Page Ref: 977-978 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.4 Plan nursing interventions for children who experience violence.

24) The nurse is providing care to a child who is admitted to the hospital due to environmental exposure to a toxic agent. Which questions should the nurse ask the child and the parent during the assessment process? 1. "Do you work around harmful substances that could have been brought to the home environment?" 2. "What year was your home built?" 3. "Does your child have a hobby that includes working with glue?" 4. "Does your home have a smoke detector?" 5. "Does your home have a carbon monoxide detector?" Answer: 1, 2, 3, 5 Explanation: 1. It is appropriate for the nurse to ask the parents if any harmful substances could be brought home from the job. 2. Many homes built before the 1970s were painted with lead paint. This is an appropriate question for the nurse to ask during the assessment process. 3. It is appropriate for the nurse to assess the use of glue to determine environmental exposure to a toxic agent. 4. Asking the family about a smoke detector is important to determine if there are safety features in the house. This question will not assess the child's risk for environmental exposure to a toxic agent. 5. Carbon monoxide could lead to environmental exposure to the child leading to toxicity. This question is appropriate for the nurse to include in the assessment process. Page Ref: 980 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment Standards: QSEN Competencies: V.C.4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.5 Evaluate the environment for hazards to children, such as exposure to harmful substances and potential for poisoning.

25) The nurse is providing care to a pediatric client who is homeless. Which nursing actions will decrease the risk for the child developing an infectious disease? Select all that apply. 1. Teaching hygienic methods 2. Arranging for medications, as needed 3. Evaluating the family for food security 4. Performing a nutritional assessment 5. Teaching oral hygiene Answer: 1, 2 Explanation: 1. Teaching hygienic measures is an appropriate nursing action to decrease the child's risk for developing an infectious disease. 2. Arranging for medications, as needed, is an appropriate nursing action to decrease the child's risk for developing an infectious disease. 3. Evaluating the family for food security is an appropriate nursing action to assess nutritional deficits. 4. Performing a nutritional assessment is an appropriate nursing action to assess nutritional deficits. 5. Teaching oral hygiene is an appropriate nursing action to address dental care problems. Page Ref: 958 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Personal and Professional Development: Ethical Compartment: Demonstrate respect for all persons, and for human dignity, equality, and justice | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.7 Plan nursing interventions for children related to social and environmental situations.

26) The nurse is assessing a child and suspects the child's mother is abusing an opiate. Which clinical manifestations exhibited by the child's mother lead the nurse to this conclusion? 1. Constricted pupils 2. Mood swings 3. Impaired memory 4. Tremors 5. Psychosis Answer: 1, 2, 3 Explanation: 1. Constricted pupils are a clinical manifestation associated with opiate abuse. 2. Mood swings are a clinical manifestation associated with opiate abuse. 3. Impaired memory is a clinical manifestation associated with opiate abuse. 4. Tremors are a clinical manifestation associated with alcohol, not opiate, abuse. 5. Psychosis is a clinical manifestation associated with hallucinogen, not opiate, abuse. Page Ref: 964 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: V.C.4. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the healthcare team | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Knowledge and Science: Knowledge: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.5 Evaluate the environment for hazards to children, such as exposure to harmful substances and potential for poisoning.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 43 Immunizations and Communicable Diseases 1) The nurse is providing information to a group of new mothers. Which rationale, indicating increased susceptibility for infant infection, should the nurse include in the teaching session? 1. Low levels of antibodies 2. High levels of maternal antibodies to diseases to which the mother has been exposed 3. Passive transplacental immunity from maternal immunoglobulin G 4. Exposure to microorganisms during the birth process Answer: 1 Explanation: 1. The infant's immune system is not fully developed at birth, and the infant has low levels of antibodies due to lack of exposure to antigens. 2. Newborns and young infants do have high levels of maternal antibodies, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 3. Newborns and young infants do have passive transplacental immunity, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. 4. Newborns and young infants do have exposure to microorganisms during the birth process, but this answer is incorrect because it does not explain the susceptibility of newborns and young infants to infection. Page Ref: 990 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Compare the vulnerability of young children and adults to communicable diseases.

2) The nurse is providing education to a group of new mothers regarding immunity and infection. Which information regarding the development of immunity should the nurse include in the teaching session? 1. Acquired through immunization or exposure to the natural disease 2. Acquired through exposure to diseases from family members 3. Acquired through diseases from other children 4. Newborns being born with diseases already in their systems Answer: 1 Explanation: 1. As children grow, they develop immunity through immunization or exposure to the natural disease. As children mature and become more active, they interact more frequently with other children and adults and increase their exposure to infectious agents. 2. Children cannot acquire diseases from family members who have had the disease 3. Acquiring disease from other children would not give children immunity. 4. Newborns are not born with diseases in their systems. Page Ref: 990 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Compare the vulnerability of young children and adults to communicable diseases.

3) The nurse is teaching the mother of a newborn how the immune system functions. Which statement regarding the process that occurs when healthy children are exposed to infection indicates accurate understanding of the information presented? 1. "Children who are exposed to infection naturally develop antibodies." 2. "Children who are exposed to infection are found to be healthier." 3. "Children who are exposed to infection will acquire terminal illnesses." 4. "Children who are exposed to infection will have weakened immune systems." Answer: 1 Explanation: 1. As healthy children are exposed to more infections, they naturally develop antibodies. 2. Being exposed to infections will not lead to healthy children. 3. Exposure to infections will not lead children to acquire terminal illnesses. 4. Exposure to infectious disease will not weaken children's immune systems. Page Ref: 990 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 43.1 Compare the vulnerability of young children and adults to communicable diseases. 4) Which common mode of infectious disease should the nurse include in a teaching session with parents within the community? 1. Playing with the same toy 2. Coughing without covering the mouth 3. Sitting together eating meals 4. Playing board games Answer: 2 Explanation: 1. Microorganisms might be left on toys that children share, but this is not the most common mode of transmission of infectious diseases. 2. The fecal-oral and respiratory routes are the most common sources of transmission in children. 3. Eating together will not transmit infectious disease. 4. Playing with board games will not transmit infectious disease. Page Ref: 991 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.2 Propose strategies to control the spread of infection in healthcare and community settings. 3 Copyright © 2022 Pearson Education, Inc.

5) The nurse is teaching a preschool-age child and parents the importance of hand washing after using the toilet. Which rationale for this practice should the nurse include in the teaching session? 1. Children's immune systems are not fully developed. 2. It is the main way to limit the transmission of disease. 3. Not all bathrooms are clean. 4. Children do not like to have dirty hands. Answer: 2 Explanation: 1. Underdeveloped immune systems will not transmit disease. 2. The fecal-oral and respiratory routes are the most common sources of transmission in children. 3. Children usually do not wash their hands after toileting unless they are closely supervised. 4. This is not a reason for washing hands after using the toilet. Page Ref: 991 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.2 Propose strategies to control the spread of infection in healthcare and community settings. 6) The nurse is teaching parents how to prevent the spread of infectious disease. Which health promotion strategy the nurse should recommend for all age groups of children? 1. Decreasing environmental exposure to pathogens 2. Performing hand hygiene 3. Ensuring all toys are clean and free from germs 4. Keeping child away from sick adults Answer: 2 Explanation: 1. It is not possible to keep children free from colds. 2. Proper hand hygiene is one of the most important health promotion strategies for all age groups of children as well as child care providers. 3. Keeping all toys clean and free from germs is not possible. 4. It is not always possible to keep children away from sick adults. Page Ref: 991 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.2 Propose strategies to control the spread of infection in healthcare and community settings.

7) A child who has not had a tetanus immunization steps on a rusty nail. Which term should the nurse use to identify the tetanus immunization when teaching the parents about the vaccine? 1. Toxoid 2. Live virus 3. Killed virus 4. Recombinant Answer: 1 Explanation: 1. Toxoids are chemicals normally associated with a disease that stimulate the production of immunity. A tetanus immunization is an example of a toxoid vaccine. 2. A live virus vaccine contains a microorganism that is live but attenuated, or in a weakened form. A varicella immunization is an example of a live virus vaccine. 3. A killed virus vaccine contains a microorganism that has been killed but is still capable of causing the human body to produce antibodies. This term is used to describe an inactivated poliovirus vaccine. 4. A recombinant vaccine used a genetically altered organism. A hepatitis B immunization is an example of this type vaccine. Page Ref: 991 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

8) The nurse prepares a DTaP (diphtheria, tetanus toxoid, and acellular pertussis) immunization for a 6-month-old infant. Which nursing action is accurate to safely administer this vaccine to the infant? 1. Administering the vaccine by ID (intradermal) injection 2. Administering the vaccine by SQ (subcutaneous) injection 3. Administering the vaccine by IM (intramuscular) injection 4. Administering the vaccine via a nasal spray Answer: 3 Explanation: 1. DTaP is not administered by an ID injection. 2. DTaP is not administered by a SQ injection. 3. DTaP is administered by an IM injection. 4. DTaP is not administered via a nasal spray. Page Ref: 1047 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

9) A mother refuses to have her child immunized with the measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which is an appropriate response by the nurse? 1. Telling the mother that by not immunizing the child, she may be exposing pregnant women to the virus, which could cause fetal harm 2. Honoring the mother's request because she is the parent 3. Telling the mother that she is wrong and should have her child immunized 4. Explaining the potential complications of measles, mumps, and rubella infections Answer: 4 Explanation: 1. This mother is not concerned about other women; she is concerned about what is the best for her child. 2. Nurses are responsible for helping parents make informed decisions. It is important that the mother has all the facts before she makes a decision. 3. The mother has the right to make the decisions for her child. The nurse's role is not to tell the parents what to do but to give them the information they need to make decisions. 4. Explaining that if her child contracts measles, mumps, or rubella, the child could have very serious and permanent complications from these diseases is correct; measles, mumps, and rubella all have potentially serious sequelae, such as encephalitis, brain damage, and deafness. Page Ref: 1008,1010,1013 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

10) The pediatric clinic has set a goal that 95% or more of the children attending the clinic will be fully immunized. Which should the clinic nurses teach the families to meet this goal? 1. The benefits of immunizations outweigh the risks of communicable diseases. 2. Immunizations should be completed by the time the child starts school. 3. Once a child receives a vaccination, that individual has lifelong immunity against that disease. 4. Vaccinations are 100% safe. Answer: 1 Explanation: 1. The risks and benefits of vaccines far outweigh the risks from communicable diseases and resulting complications. 2. The immunization schedule is not completed by the time the child starts school. Immunizations continue throughout the life of the individual. 3. It is important that the families realize that to be fully protected, many vaccinations will need to be repeated at specified times. 4. Vaccinations can cause illness or injury. No medication is 100% safe. Page Ref: 1001 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching/Learning Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations. 11) A mother brings in her 4-month-old infant for a routine checkup and vaccinations. The mother reports that her child was exposed to the flu. Which nursing action is accurate based on the current data? 1. Withhold the DTaP vaccination but give the others as scheduled. 2. Give the infant the flu vaccination but withhold the others. 3. Give the vaccinations as scheduled. 4. Withhold the vaccinations. Answer: 3 Explanation: 1. There is no reason to withhold any of the vaccinations due at this time. 2. The flu vaccination would not routinely be given to a 4-month-old infant. 3. Giving the vaccine as scheduled will keep the infant properly immunized. 4. Recent exposure to an infectious disease is not a reason to defer a vaccine. Page Ref: 992 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations. 8 Copyright © 2022 Pearson Education, Inc.

12) Which should the nurse use when reconstituting vaccines? 1. The diluents provided 2. Normal saline 3. Any solution available 4. Sterile water Answer: 1 Explanation: 1. When reconstituting vaccines, it is important to use the solution provided, and follow the manufacturer's directions. 2. Not all medications are compatible with normal saline. 3. Only use what is suggested by the manufacturer. 4. Unless otherwise suggested, use what is suggested by the manufacturer. Page Ref: 1003 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.5 Design a plan to maintain the potency of vaccines.

13) A parent reports that her 5-year-old child, who has had all recommended immunizations, had a mild fever 1 week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which diagnosis does the nurse anticipate based on the current data? 1. Rubeola (measles) 2. German measles (rubella) 3. Chickenpox (varicella) 4. Fifth disease (erythema infectiosum) Answer: 4 Explanation: 1. Children with rubeola have a high temperature and a blotchy maculopapular rash. Because there is a vaccination for rubeola, it is unlikely the child has it. 2. The rash of rubella is a pink, maculopapular rash that begins on the face and progresses downward to the trunk and extremities. The child is fully vaccinated, making this unlikely. 3. Varicella (chickenpox) and rubella (German measles) are unlikely if the child has had all recommended immunizations. 4. Fifth disease manifests first with a flu-like illness, followed by a red "slapped-cheek" sign. Then, a lacy maculopapular erythematous rash spreads symmetrically from the trunk to the extremities, sparing the soles and palms. Page Ref: 1007 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.7 Describe the medical and nursing management of common communicable diseases.

14) The nurse is providing care to a child who is diagnosed with Lyme disease. The mother wants to know how to protect her other children from contracting this disease from the infected child. Which should the nurse include in the teaching session regarding the transmission of this disease process? 1. Lyme disease is passed from person to person. 2. Lyme disease is passed from animals to person. 3. Lyme disease is passed from adults to children. 4. Lyme disease is passed from person to insects. Answer: 2 Explanation: 1. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from person to person. 2. Zoonosis describes infectious diseases that are transmitted by animals and are not communicable from person to person. Lyme disease is an example of this type of infectious disease. 3. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not communicable from adults to children. 4. Some infectious diseases are transmitted by insects or animals and are not communicable from person to person. Lyme disease is not passed from people to insects. Page Ref: 1015 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.6 Differentiate between common communicable diseases and vectorborne diseases.

15) A 2-year-old child with a fever is prescribed amoxicillin clavulanate 250 mg/5 mL 3 times daily by mouth for 10 days for otitis media. Which is the priority teaching instruction for the parents of this child? 1. Giving the antibiotic for the full 10 days 2. Measuring the prescribed dose in a household teaspoon 3. Spreading the dose evenly during daylight hours 4. Stopping the antibiotic when the child is afebrile Answer: 1 Explanation: 1. Antibiotics must be administered for the full number of days ordered to prevent mutation of resistant strains of bacteria. 2. A household teaspoon could contain less than 5 mL, and the full dose must be given. 3. The antibiotic should be administered around the clock to maintain a blood level. 4. Stopping the antibiotic before the prescribed time will permit remaining bacteria to reproduce, and the otitis media will return, possibly with antibiotic-resistant organisms. Page Ref: 1014 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.7 Describe the medical and nursing management of common communicable diseases.

16) Which is the priority nursing action when it is suspected that an infectious agent has been used as a weapon by terrorists? 1. Separating clients according to age 2. Initiating airborne and contacts precautions 3. Separating clients according to level of development 4. Disposing of blood-contaminated needles in the lead-lined container Answer: 2 Explanation: 1. Separating clients according to age will do nothing to stop terrorism. 2. When clients present with the same type of infectious symptoms, the priority nursing action is to initiate airborne and contact precautions prior to diagnosis. 3. Separating clients according to level of development will do nothing to stop terrorism. 4. Proper disposal of blood-contaminated needles in the sharps container is appropriate nursing actions but does not relate to terrorism. Page Ref: 1021 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.7 Describe the medical and nursing management of common communicable diseases. 17) Which parental action indicates accurate understanding of information presented by the nurse to treat a fever related to otitis media? 1. Putting the child in a tub of cold water to reduce the fever 2. Alternating acetaminophen with ibuprofen every 2 hours 3. Offering generous amounts of fluids frequently 4. Using aspirin every 4 hours to reduce the fever Answer: 3 Explanation: 1. Putting the child in a tub of cold water will chill the child and cause shivering, a response that will increase body temperature. 2. Alternating acetaminophen with ibuprofen every 2 hours could result in an overdose. 3. The body's need for fluids increases during a febrile illness. 4. Aspirin has been associated with Reye syndrome and should not be given to children with a febrile illness unless prescribed by the healthcare provider. Page Ref: 1018 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 43.8 Create a parent teaching plan that includes important considerations in administering antipyretics to infants and children with a fever. 13 Copyright © 2022 Pearson Education, Inc.

18) Which nursing action is most appropriate to decrease the risk of transmitting viral infections by clients and family members at a local clinic? 1. Sanitizing toys, telephones, and doorknobs to kill pathogens 2. Teaching parents safe food preparation and storage 3. Withholding immunizations for children with compromised immune systems 4. Allowing all children to congregate in the same waiting room Answer: 1 Explanation: 1. Sanitizing toys and all contact surfaces, separating children with infections, and teaching children to wash their hands all control the growth and spread of microorganisms. 2. Teaching parents safe food preparation and storage is another tool to prevent the spread of microorganisms, but it is not related to the flu virus. 3. Immunizations should not be withheld from immunocompromised children, and this is not an infection-control strategy. 4. Children should be separated in different waiting rooms when seeking care at a pediatric clinic. Page Ref: 991 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.7 Describe the medical and nursing management of common communicable diseases.

19) The mother of an immunocompromised child expresses concern that her child will "catch" a disease from the scheduled vaccination. Which vaccines should be administered to this child as they carry no risk for acquiring the infection? 1. Toxoid 2. Killed virus vaccine 3. Live virus vaccine 4. Attenuated vaccine 5. Immunoglobulins Answer: 1, 2, 5 Explanation: 1. A toxoid is not an organism but a chemical produced by the organism. The toxoid has been treated to weaken its toxic effect. 2. The immunization contains organisms that are dead and incapable of reproducing. 3. This immunization contains live but weakened organisms. These organisms can mutate and reproduce and may cause disease in a weakened immune system. 4. An attenuated vaccine is the same as a live virus vaccine. 5. Immunoglobulins are the antibodies produced by others against a disease. They do not contain the live or killed virus. Page Ref: 991-992 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

20) Which nursing actions allow a child to acquire active immunity against a disease? 1. Administering a dose of immunoglobulins 2. Administering a killed virus vaccine 3. Administering a toxoid vaccine 4. Administering antibiotic therapy 5. Administering antiviral therapy Answer: 2, 3 Explanation: 1. Immunoglobulins provide passive immunity. No active immunity is acquired. 2. A killed virus vaccine will stimulate antibody production in the child, which is active immunity. 3. A toxoid vaccine will also stimulate antibody production in the child. 4. Antibiotic therapy provides no immunity. 5. Antiviral therapy provides no immunity. Page Ref: 991-992 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

21) The nurse is preparing to administer a vaccine to a 14-month-old toddler. Which assessment factor would warrant a delay in the scheduled vaccination during the well-child visit? 1. The child is allergic to a substance in the vaccine. 2. The child has a low-grade fever and a runny nose. 3. The child received a dose of immune globulin 2 months ago. 4. The child is on antibiotics. Answer: 3 Explanation: 1. A vaccine allergy contradicts the administration of the vaccine for life. This factor does not warrant a delay. The child should not receive the vaccine at the next well-child visit or at any other time. 2. A mild upper respiratory infection would not be a contraindication for vaccine administration. 3. The antibodies in the immune globulin will prevent the child from developing immunity to the vaccination. By the next well-child visit, the immune globulins will not prevent immunity from developing. 4. Antibiotic administration will not prevent the development of active immunity. Page Ref: 1000 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

22) Which statement regarding what was found during the nurse's daily check of the vaccine refrigerator would cause concern about the potency of the vaccines? 1. The vaccine was frozen as labeled. 2. The vaccines have been stored in a refrigerator where the temperature has been maintained between 35 and 46° F. 3. The vaccine's expiration date expires within the next month. 4. The vaccine is stored in the door of the refrigerator. Answer: 4 Explanation: 1. Some vaccines are stored in the freezer. 2. This is appropriate to maintain potency. 3. The vaccine is still effective until the expiration day. 4. The door will not maintain the temperature of the vaccine. Vaccines should be stored in the middle of the refrigerator. Page Ref: 1001 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.5 Design a plan to maintain the potency of vaccines. 23) Which vaccine reaction, noted by the mother during a telephone conversation with a nurse, would require activation of emergency medical services? 1. A few hives are noted around the injection site. 2. The child is running a slight temperature. 3. The child has swelling of the face. 4. Fever and joint pains occurring within hours of the vaccination. Answer: 3 Explanation: 1. This is a mild allergic reaction and does not require calling 911. 2. A slight temperature does not require calling 911. 3. This could be the onset of anaphylaxis, and immediate response is essential to the survival of the child. The mother should call 911. 4. This is a common reaction to immunizations and does not indicate anaphylaxis. Page Ref: 995 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

24) The nurse administers the flu vaccine to a school-age child. Which should the nurse include in the documentation for the administration of this vaccine? Select all that apply. 1. The date of the last flu vaccine 2. The site of the vaccination 3. The lot number of the vaccine 4. The date and time of administration. 5. Who assisted in restraining the child Answer: 2, 3, 4 Explanation: 1. This information is not pertinent. 2. The site should be recorded. 3. This information should be recorded in case a problem develops. 4. This should be recorded. 5. This information is not pertinent. Page Ref: 1002 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

25) There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about disease at the school's Parent Teacher Association meeting. Which vectorborne diseases, not communicable from person to person, should the nurse include in the teaching session? Select all that apply. 1. Measles 2. Whooping cough 3. Rocky Mountain spotted fever 4. Malaria 5. Lyme disease Answer: 3, 4, 5 Explanation: 1. Rubeola, or measles, is caused by a virus and is transmitted person to person. 2. Pertussis, or whooping cough, is caused by a gram-positive coccobacillus called Bordetella pertussis and is spread person to person. 3. Rocky mountain spotted fever is a vectorborne disease spread by a tick. 4. Malaria is transmitted by a female infected female mosquito. 5. Lyme disease is a vectorborne disease spread by a tick. Page Ref: 1015-1017 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

26) Which medication should the nurse include in a pamphlet to educate parents about methods to reduce the risk of children developing Reye syndrome? 1. Antibiotics 2. Acetaminophen 3. Ibuprofen 4. Aspirin Answer: 4 Explanation: 1. Antibiotics are not associated with Reye syndrome. 2. Acetaminophen is not associated with Reye syndrome. 3. Ibuprofen use is not associated with Reye syndrome. 4. Administering aspirin to a child with a viral illness has been found to be associated with Reye syndrome. Page Ref: 1004 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.8 Create a parent teaching plan that includes important considerations in administering antipyretics to infants and children with a fever.

27) Which communicable diseases, preventable through childhood immunization, should the nurse include in a presentation to families at a local community center wellness fair? (Select all that apply.) 1. Measles 2. Chickenpox 3. Fifth disease 4. Mononucleosis 5. Whooping cough Answer: 1, 2, 5 Explanation: 1. Measles is a communicable disease that can be prevented through childhood immunization. 2. Chickenpox is a communicable disease that can be prevented through childhood immunization. 3. Fifth disease, while a communicable disease, is not preventable through childhood immunization. 4. Mononucleosis, while a communicable disease, is not preventable through childhood immunization. 5. Whooping cough, or pertussis, is a communicable disease that can be prevented through childhood immunization. Page Ref: 992, 994-995 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.3 Examine the role that vaccines play in reducing and eliminating communicable diseases.

28) Which live virus vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Varicella 5. Hepatitis B Answer: 3, 4 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 4. Varicella is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases. Page Ref: 994-995 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.3 Examine the role that vaccines play in reducing and eliminating communicable diseases.

29) Which recombinant vaccines should the nurse teach to parents as being used to decrease the risk of communicable diseases? Select all that apply. 1. Poliovirus 2. Tetanus 3. Measles 4. Acellular pertussis 5. Hepatitis B Answer: 4, 5 Explanation: 1. Poliovirus is an example of a killed virus vaccine that is used to decrease the risk of communicable diseases. 2. Tetanus is an example of a toxoid vaccine that is used to decrease the risk of communicable diseases. 3. Measles is an example of a live virus vaccine that is used to decrease the risk of communicable diseases. 4. Acellular pertussis is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases. 5. Hepatitis B is an example of a recombinant vaccine that is used to decrease the risk of communicable diseases. Page Ref: 992 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.3 Examine the role that vaccines play in reducing and eliminating communicable diseases.

30) Which vaccines should the nurse prepare to administer to a 6-month-old infant during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. PCV13 vaccine Answer: 1, 2, 5 Explanation: 1. The DTaP vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. 2. The Hib vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. 3. The HPV4 vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 11 to 12 years of age. 4. The MMR vaccine is not appropriate to administer to a 6-month-old infant during a scheduled well-child visit. This vaccine is not administered until a child is 12 to 15 months of age. 5. The PCV13 vaccine is appropriate for the nurse to administer to a 6-month-old infant during a scheduled well-child visit. Page Ref: 996 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

31) Which vaccines should the nurse prepare to administer to an 11-year-old child during a scheduled well-child visit? Select all that apply. 1. DTaP vaccine 2. Hib vaccine 3. HPV4 vaccine 4. MMR vaccine 5. MenACWY-D Answer: 3, 5 Explanation: 1. The DTaP vaccine is not appropriate for the nurse to administer to an 11-yearold child during a scheduled well-child visit. 2. The Hib vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 3. The HPV4 vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit. 4. The MMR vaccine is not appropriate for the nurse to administer to an 11-year-old child during a scheduled well-child visit. 5. The MenACWY-D vaccine is appropriate to administer to an 11-year-old child during a scheduled well-child visit. Page Ref: 996 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.4 Develop a nursing care plan for children in each age group needing immunizations.

32) The parent of a child with sepsis asks how the condition developed. Which response should the nurse make? 1. "It is considered a genetic illness." 2. "It is unknown how sepsis develops in a child." 3. "Your child had an illness for a long time that was treated." 4. "There are several reasons, but it is caused by a response to an infection." Answer: 4 Explanation: 1. Sepsis is not a genetic condition. 2. There are specific reasons for sepsis to develop. 3. There is not enough evidence that the child had a long-standing untreated infection. 4. Sepsis is caused by the effects of the infectious agent and its toxins. Significant events that lead to the development of sepsis include: an infectious agent causes severe tissue injuries that result in multiple system organ failure, the child's excessive inflammatory response triggers a secondary response, or counterregulatory mechanisms are ineffective. Page Ref: 1020 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.9 Analyze the pathophysiology of sepsis to guide the nursing management of infants and children with this disorder.

33) The nurse is caring for a school-age child with a high fever. Which additional symptom indicates to the nurse that the client may have septic shock? 1. Tachypnea 2. Tachycardia 3. Mottle extremities 4. Increased urine output 5. Prolonged capillary refill time Answer: 1, 2, 3, 5 Explanation: 1. Tachypnea is a sign of septic shock. 2. Tachycardia is a sign of septic shock. 3. Mottled extremities is a sign of septic shock. 4. Decreased and not increased urine output is a sign of septic shock. 5. Prolonged capillary refill time is a sign of septic shock. Page Ref: 1020 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.C.5. Value relationship between national safety campaigns and implementation in local practices and practice settings | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.9 Analyze the pathophysiology of sepsis to guide the nursing management of infants and children with this disorder.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 44 The Child with Alterations in Fluid, Electrolyte, and Acid-Base Balance 1) A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data? 1. Hypernatremia 2. Metabolic acidosis 3. Hypotonic dehydration 4. Isotonic dehydration Answer: 3 Explanation: 1. Hypernatremia is a condition where the body fluids are too concentrated, and there is an excess of sodium. 2. Metabolic acidosis refers to a condition where the pH of the blood is acidic. 3. This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water. Serum sodium is below normal levels. Hemoglobin and hematocrit will be high due to the loss of serum water. 4. This occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Page Ref: 1027 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.3 Interpret threats to fluid and electrolyte balance in children.

2) The nurse is taking care of four different pediatric clients. Which child is at greatest risk for dehydration? 1. 7-year-old child with migraine headaches 2. 4-year-old child with a broken arm 3. 2-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea Answer: 4 Explanation: 1. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system is at a lower risk than is a toddler with a condition that increases insensible water loss. 2. The pediatric client with an acute condition that does not directly affect electrolytes is at a lower risk than is a client with a condition that increases insensible water loss. 3. The pediatric client with an acute condition, such as a client with cellulitis that does not affect the GI or electrolyte system, is at a lower risk than is a toddler with a condition that increases insensible water loss. 4. The pediatric client with the greatest risk is under 2 years of age and with a condition that increases insensible fluid loss. Page Ref: 1026 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children.

3) Which parental statement indicates correct understanding of preventive techniques for heatrelated illnesses when children exercise? 1. "Wearing dark clothing during exercise is recommended." 2. "Water is the fluid of choice to replenish fluids." 3. "During activity, stop for fluids every 15 to 20 minutes." 4. "Hydration should occur at the end of an exercise session." Answer: 3 Explanation: 1. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. 2. A combination of water and sports drinks is the best to replace fluids during exercise. 3. During activity, stopping for fluids every 15 to 20 minutes is recommended. 4. Hydration should occur before and during the activity, not just at the end. Page Ref: 1031 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance. 4) The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the nurse that the infant is experiencing an early to moderate stage of dehydration? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels Answer: 2 Explanation: 1. Bradycardia is not a sign of dehydration. 2. Tachycardia is a sign that indicates moderate dehydration. 3. In dehydration, the blood pressure is hypotensive. 4. Fontanels would be sunken in moderate dehydration. Page Ref: 1029 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children.

5) In the morning, a nurse receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which child should the nurse see first? 1. The child with tachypnea and pulmonary congestion 2. The child with hepatomegaly and normal respiratory rate 3. The child with dependent and sacral edema and regular pulse 4. The child with periorbital edema and normal respiratory rate Answer: 1 Explanation: 1. A child with respiratory distress should be the first client the nurse checks after receiving a report. 2. The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion. 3. The child with dependent and sacral edema and regular pulse is more stable than the child with tachypnea and pulmonary congestion. 4. The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion. Page Ref: 1034 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance. 6) The nurse is caring for a child on bed rest who has severe edema in a left lower extremity due to blocked lymphatic drainage. Which problem would take priority? 1. Possible change in skin integrity 2. Change in self-perception of body 3. Not enough intake of calories 4. Inability to complete activities Answer: 1 Explanation: 1. The highest priority problem is skin integrity. 2. Body image would not take priority over the integrity of the skin for this scenario. 3. Nutrition would not take priority over the integrity of the skin for this scenario. 4. Activity intolerance would not take priority over the integrity of the skin for this scenario. Page Ref: 1036 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children. 4 Copyright © 2022 Pearson Education, Inc.

7) The nurse is planning care for a child with hyponatremia. For which potential finding should the nurse monitor this client? 1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia Answer: 1 Explanation: 1. A child with hyponatremia is at risk for seizures. 2. Respiratory distress is not a risk of hyponatremia. 3. Hyperthermia is not a risk of hyponatremia. 4. Bradycardia is not a risk of hyponatremia. Page Ref: 1093-1094 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children. 8) The nurse is planning care for a child with hyperkalemia. Which manifestation requires immediate intervention by the nurse? 1. Hyperthermia 2. Respiratory distress 3. Seizures 4. Cardiac arrhythmias Answer: 4 Explanation: 1. Excessive potassium is unrelated to the body temperature. 2. Potassium is needed for contractility of heart and skeletal muscles but not for the muscles of respiration. 3. Seizures are not an adverse outcome of hyperkalemia. 4. A child with hyperkalemia is at risk for cardiac problems that can be life threatening, such as arrhythmias. Page Ref: 1040 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children.

9) A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which condition should the nurse report to the healthcare provider based on these data? 1. Uncompensated metabolic alkalosis 2. Uncompensated metabolic acidosis 3. Uncompensated respiratory acidosis 4. Uncompensated respiratory alkalosis Answer: 3 Explanation: 1. Uncompensated metabolic alkalosis has an increased pH, normal PCO2, and increased HCO3. 2. Uncompensated metabolic acidosis has a decreased pH, normal PCO2, and normal HCO3. 3. If the pH is decreased and the PCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. 4. Uncompensated respiratory alkalosis has an increased pH, decreased PCO2, and normal HCO3. Page Ref: 1050 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Assessment/Communication and Documentation Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children.

10) The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child? 1. 0.9% normal saline (NS) 2. D5 0.2% (1/4) normal saline 3. D5W 4. Albumin Answer: 1 Explanation: 1. 0.9% normal saline (NS) is an isotonic fluid and maintains Na and chloride at present levels. 2. D5 0.2% (1/4) normal saline would not be used initially but later, as maintenance fluids. 3. D5W can lower sodium levels, and so it would not be used to replace fluids in severe isotonic dehydration. 4. Albumin is used to restore plasma proteins. Page Ref: 1030 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance. 11) A 6-year-old child is diagnosed with hypokalemia. Which menu choice should the nurse encourage for this child? 1. Pizza with a fruit plate 2. Chicken strips with chips 3. Fajita with rice 4. A hamburger with French fries Answer: 1 Explanation: 1. Pizza with a fruit plate should be encouraged because fruits (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination. 2. Chicken strips and chips are not good sources of potassium. 3. The nurse is looking for potassium-rich foods that are attractive to children. This choice does not meet the requirement. 4. A hamburger and French fries do not provide potassium. Page Ref: 1042 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance. 7 Copyright © 2022 Pearson Education, Inc.

12) A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give? 1. Furosemide (Lasix) 2. Hydrochlorothiazide (Aquazide) 3. Spironolactone (Aldactone) 4. Mannitol (Osmitrol) Answer: 1 Explanation: 1. Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. 2. Thiazide diuretics (like hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. 3. Spironolactone (Aldactone) is a potassium-sparing diuretic. While there is a net increase in calcium in the urine, it is not as effective an option as furosemide. 4. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium. Page Ref: 1044 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance.

13) The nurse is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: Intake: 4 oz of Pedialyte One-half of an 8-oz cup of clear orange Jell-O Two graham crackers 200 mL of D51/2 sodium chloride IV Output: 345 mL of urine 50 mL of loose stool How many milliliters should the nurse document as the client's total intake? Give the numerical answer only. Do not include any units of measurement. Answer: 440 mL Explanation: The child takes in 120 mL of Pedialyte and 120 mL of Jell-O for a total of 240 mL. With 200 mL of IV fluids, the total intake is 440 mL. Page Ref: 1030 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance.

14) A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg and is estimated to have lost 7% of his normal body weight. The nurse is double-checking the IV rate the healthcare provider prescribed. The formula the healthcare provider used was for maintenance fluids: 1000 mL for 10 kg of body weight plus 50 mL for every kilogram over 10 for 24 hours. Replacement fluid is the percentage of lost body weight × 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, which hourly IV rate will the nurse implement for 24 hours? 1. 88 mL/hr 2. 86 mL/hr 3. 81 mL/hr 4. 83 mL/hr Answer: 2 Explanation: 1. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this, the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1,150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. 2. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this, the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. 3. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this, the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. 4. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this, the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. Page Ref: 1030 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.6 Plan appropriate nursing interventions for children experiencing fluidelectrolyte problems and acid-base imbalance.

15) A 9-month-old infant is hospitalized with vomiting and diarrhea. The mother questions why her child needed hospitalization since her school-age nephew had the same symptoms and was treated at home. Which should the nurse include in the explanation to the infant's mother? Select all that apply. 1. Infants have a lower proportion of their body weight as water. 2. The percentage of extracellular fluid is higher in the infant than the school-age child. 3. School-age children have a larger body surface area. 4. The school-age child's kidneys are more mature and better able to conserve water. 5. The metabolic rate of the school-age child is higher. Answer: 2, 4 Explanation: 1. Infants have a higher percentage of body weight as water. 2. This statement is accurate. 3. Body surface area (BSA) is an assessment of skin surface. BSA compares the height and weight of the child and is greatest in infancy. 4. This statement is accurate. 5. Infants have a higher metabolic rate than a school-age child. Page Ref: 1026 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.1 Describe normal fluid and electrolyte status for children at various ages.

16) As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas? 1. Increased PCO2 and respiratory acidosis 2. Decreased PCO2 and respiratory alkalosis 3. Low pH and low PCO2 4. High pH and high PCO2 Answer: 1 Explanation: 1. Due to inadequate respirations, the child retains CO2, and develops respiratory acidosis. 2. This statement is incorrect as the child retains carbon dioxide. 3. The pH would be acidic, but the pH would be high. 4. The child would have a low pH (acidosis) and high PCO2. Page Ref: 1050 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children. 17) Which rationale will the nurse provide when asked why the specific gravity for infants is lower than for older children? 1. The infant has a greater body surface area. 2. The infant has a higher basal metabolic rate. 3. The infant has a greater percentage of body weight that is water. 4. The infant's kidneys are less able to concentrate urine. Answer: 4 Explanation: 1. Although this is true, it does not explain the lower specific gravity. 2. This statement is true but does not explain the specific gravity differences. 3. Although the statement is true, it does not explain the specific gravity differences. 4. This statement is accurate, and explains why the specific gravity of the infant's urine is closer to water than an older child's urine specific gravity. Page Ref: 1027 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 44.2 Identify regulatory mechanisms for fluid and electrolyte balance.

18) Which is the priority nursing assessment when providing care for an infant at risk for dehydration? 1. Urine output 2. Urine specific gravity 3. Vital signs 4. Daily weight Answer: 4 Explanation: 1. The infant is unable to concentrate urine, and will continue to void dilute urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 2. The infant's kidney is immature and unable to concentrate urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 3. Pulse will elevate and blood pressure may drop, but the other vital sign findings will remain unchanged. However, this is not the best assessment of dehydration. 4. Daily weights on an infant provide the most accurate assessment of fluid balance. Page Ref: 1030 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.5 Analyze assessment findings to recognize fluid-electrolyte problems and acid-base imbalance in children.

19) Which health problem increases a child's risk of developing respiratory acidosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis Answer: 1, 2, 5 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis. Page Ref: 1051 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.4 Describe acid-base balance, and recognize disruptions common in children. 20) Which health problem increases a child's risk for respiratory alkalosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis Answer: 3, 4 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis. Page Ref: 1052 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.4 Describe acid-base balance, and recognize disruptions common in children. 14 Copyright © 2022 Pearson Education, Inc.

21) The nurse is assessing a pediatric client who is experiencing metabolic acidosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?" Answer: 1, 2, 3 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis. Page Ref: 1053 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.4 Describe acid-base balance, and recognize disruptions common in children.

22) The nurse is assessing a pediatric client who is experiencing metabolic alkalosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?" Answer: 4, 5 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis. Page Ref: 1054 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.4 Describe acid-base balance, and recognize disruptions common in children.

23) Which age-appropriate techniques should the nurse implement in order to encourage a young child to participate in deep breathing exercises? Select all that apply. 1. Showing the child how to use the "blow bottle" 2. Using a pinwheel that the child plays with and asking the child to blow until it turns 3. Asking the child to blow bubbles in a glass of water using a straw 4. Having the child blow scraps of paper across the bedside table with a straw 5. Telling the child that a "shot" will be needed if the child does not follow the nurse's directions Answer: 2, 3, 4 Explanation: 1. A blow bottle is appropriate for an older pediatric client, not a young child. 2. Asking the young child to blow on a pinwheel is an age-appropriate intervention to facilitate deep breathing. 3. Asking the child to blow bubbles into a glass of water is an age-appropriate intervention to facilitate deep breathing. 4. Having the child blow scraps of paper across the bedside table with a straw is an ageappropriate intervention to facilitate deep breathing. 5. Telling the child that an injection will be administered if the nurse's directions are not followed is not therapeutic nor age appropriate. Page Ref: 1052 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.4 Describe acid-base balance, and recognize disruptions common in children.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 45 The Child with Alterations in Eye, Ear, Nose, and Throat Function 1) Which rationale explains why young children are more prone to otitis media that the nurse should include in the teaching session with a parent? 1. The eustachian tube is shorter, wider, and horizontal in younger children. 2. The eustachian tube is shorter, more narrow, and horizontal in younger children. 3. The eustachian tube is longer, wider, and vertical in younger children. 4. The eustachian tube is longer, more narrow, and vertical in younger children. Answer: 1 Explanation: 1. The eustachian tube, which connects the nasopharynx to the middle ear, is proportionately shorter, wider, and more horizontal in infants and young children than in older children or adults. This promotes an increase in the incidence of ear infections. 2. Although the eustachian tube is shorter and horizontal in younger children, it is wider, not more narrow in younger children. 3. The eustachian tube is shorter, not longer, more narrow, not wider and is horizontal not vertical in younger children. 4. The eustachian tube is shorter, wider, and horizontal, not longer, more narrow, or vertical in younger children. Page Ref: 1058 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 45.1 Identify anatomy, physiology, and pediatric differences in the eye, ear, nose, and throat of children and adolescents.

2) Which neonate requires a close nursing assessment for the development of retinopathy of prematurity (ROP)? 1. 28-weeks'-gestation infant who has been on long-term oxygen and weighed 1400 g 2. 32-weeks'-gestation infant of African heritage with a congenital heart defect who needed no oxygen and weighed 1850 g 3. 28-weeks'-gestation female infant who was on short-term oxygen, weighed 1420 g, and was treated with phototherapy 4. 36-weeks'-gestation, small-for-gestational-age infant who was in an oxyhood for 12 hours, and weighed 1800 g Answer: 1 Explanation: 1. The 28-weeks'-gestation infant on oxygen weighing 1400 g has the greatest risk of retinopathy of prematurity because of gestational age (28 weeks or less), weight (less than 1600 g), and oxygen therapy. 2. This infant is 32 weeks'- gestation and is not the most at risk for retinopathy of prematurity because of gestational age (greater than the 31 weeks), weight (greater than 1600 grams), and no needed oxygen. 3. This infant is 28 weeks'- gestation and is not the most at risk for retinopathy of prematurity because of weight (greater than 1600 grams). 4. This infant is 36 weeks'- gestation and is not the most at risk for retinopathy of prematurity because of gestational age (greater than 31 weeks) and weight (greater than 1600 grams). Page Ref: 1064 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

3) Which is the priority nursing assessment for a pediatric client who is postoperative for tonsillectomy? 1. Arrhythmias 2. Dehydration 3. Increased blood sugar 4. Increased urinary output Answer: 2 Explanation: 1. Arrhythmias are not common after a tonsillectomy. 2. The child is at risk for dehydration due to deficient fluid volume related to inadequate intake after surgery. The child will anticipate having pain if she tries to swallow. 3. Blood sugar changes are not common after a tonsillectomy. 4. Urinary output will not be increased after a tonsillectomy. Page Ref: 1084 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Describe abnormalities of the eyes, ears, nose, throat, and mouth in children. 4) A neonate is diagnosed with a herpes simplex viral infection of the eye. Which medication should the nurse prepare to administer? 1. Oral erythromycin 2. Fluoroquinolone eyedrops or ointment 3. Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment 4. Intravenous penicillin Answer: 3 Explanation: 1. Oral erythromycin is not an option for a neonate with herpes simplex infection of the eye. Chlamydial infections are treated with oral erythromycin. 2. Fluoroquinolones are used to treat bacterial conjunctivitis. 3. Neonatal herpes simplex virus is treated vigorously with parenteral acyclovir for 14 days or longer and topical ophthalmic medication (trifluridine, iododeoxyuridine, or vidarabine). 4. Intravenous penicillin is not used to treat neonatal herpes simplex virus. Page Ref: 1060 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 45.4 Plan nursing care for children with vision or hearing impairments.

5) A nurse is caring for a visually impaired 20-month-old client who has not begun to walk. Which problem would be appropriate for this child? 1. Problems with dressing 2. Poor muscle development 3. Change in appetite 4. Problem with development Answer: 4 Explanation: 1. This child should be taught specific techniques for dressing. This is not associated with not walking. 2. This child should have no concern with muscle development. 3. This child should have no change in appetite. 4. A 20-month-old child who is not walking is experiencing delayed development. Toddlers generally walk by 15 months of age. Page Ref: 1068 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 45.4 Plan nursing care for children with vision or hearing impairments. 6) A nurse is caring for a visually impaired school-age child. Which is the priority nursing intervention during the admission process to the hospital? 1. Explaining playroom policies 2. Orienting the child to where furniture is placed in the room 3. Taking the child on a tour of the unit 4. Letting the child touch equipment that will be used during the child's hospitalization Answer: 2 Explanation: 1. Playroom policies are not the priority because the child's safety in their room is more important. 2. The priority intervention is to orient the child to furniture placement in the room. This is priority because it addresses basic safety for a visually impaired client. 3. The child will spend the most time in their room therefore orienting them to where the furniture is in their room is more important than the unit. 4. Touching the equipment is not a safety issue, making it not the priority. Page Ref: 1069 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.4 Plan nursing care for children with vision or hearing impairments. 4 Copyright © 2022 Pearson Education, Inc.

7) Which should the nurse include in the discharge instructions for the parents of an infant who is diagnosed with acute otitis media? 1. Keep the baby in a flat position during sleep. 2. Administer a decongestant. 3. Place the baby to sleep with a pacifier. 4. Administer acetaminophen (Tylenol) to relieve discomfort. Answer: 4 Explanation: 1. No certain position is necessary to care for an infant who is diagnosed with acute otitis media. 2. Neither decongestants nor antihistamines have been shown to be effective in the treatment of otitis media with or without effusion. 3. A pacifier is not needed to help care for an infant who is diagnosed with acute otitis media, and placing infants or toddlers to sleep with a pacifier may increase the incidence of otitis media. 4. An infant with a bulging tympanic membrane because of acute otitis media will have pain. Parents are taught to administer acetaminophen (Tylenol) to relieve the discomfort associated with acute otitis media. Page Ref: 1072 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.5 Apply current recommendations when implementing care and teaching for children with abnormalities of eyes, ears, nose, throat, and mouth.

8) Which parental statements indicate correct understanding of the care that is needed for a pediatric client after the insertion of tympanostomy tubes? Select all that apply. 1. "It is important to limit my child's diet after surgery and only allow soft, bland foods." 2. "I should restrict my child to quiet activities after surgery." 3. "I should plan to administer a decongestant to my child for 1 to 2 weeks following surgery." 4. "It is important for my child to drink plenty of fluids after the procedure." 5. "I will remind my child to use ear plugs prior to showering and swimming." Answer: 2, 4, 5 Explanation: 1. The child should drink generous amounts of fluids and reestablish a regular diet as tolerated. 2. The correct responses include encouraging the children to drink generous amounts of water, restricting the children to quiet activities after surgery, and avoiding water in the children's ears at bath time. 3. Decongestants are not prescribed for the child after the insertion of tympanostomy tubes. 4. The correct responses include encouraging the children to drink generous amounts of water, restricting the children to quiet activities after surgery, and avoiding water in the children's ears at bath time. 5. The correct responses include encouraging the children to drink generous amounts of water, restricting the children to quiet activities after surgery, and avoiding water in the children's ears at bath time. Page Ref: 1073 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 45.5 Apply current recommendations when implementing care and teaching for children with abnormalities of eyes, ears, nose, throat, and mouth.

9) Which nursing action is appropriate when providing care to a child with a mild hearing loss who reads lips to enhance adaptation during hospitalization? 1. Touching the child lightly before speaking 2. Using a picture board as the main means of communication 3. Speaking in a loud voice while facing the child 4. Speaking directly to the parents for communication Answer: 1 Explanation: 1. The nurse can facilitate hospital adaptation of a child who has a hearing loss and can lip-read by obtaining the child's visual attention by lightly touching the child before communicating. 2. A picture board may be helpful but should not be the primary form of communication. 3. The nurse should speak to the child at a normal rate and tone. 4. The nurse should speak to the patient, not the parents when providing care to the child. Page Ref: 1077 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.5 Apply current recommendations when implementing care and teaching for children with abnormalities of eyes, ears, nose, throat, and mouth.

10) Which is an appropriate nursing intervention for a child who experiences epistaxis? 1. Laying the child down and applying a warm pack. 2. Tilting the child's head back, squeezing the bridge of the nose, and applying a warm moist pack to the nose. 3. Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose. 4. Immediately packing the nares with a cotton ball soaked with phenylephrine (NeoSynephrine). Answer: 3 Explanation: 1. The nurse should sit the child upright with head tilted slightly forward so blood does not run down the nasopharynx and apply an ice pack or cold compress to the bridge of the nose or the back of the neck. 2. The nurse should apply steady pressure to both nostrils just below the nasal bone with the thumb and forefinger for 15 to 20 minutes and apply an ice pack or cold compress to the bridge of the nose or the back of the neck. 3. The correct initial treatment for a nosebleed is to tilt the head forward, squeeze the nares below the nasal bone for 10 to 15 minutes, and apply ice to the nose or back of the head. 4. The nurse should press a roll of cotton under the upper lip to compress the labial artery and avoid any anticoagulant medications. Page Ref: 1080 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.5 Apply current recommendations when implementing care and teaching for children with abnormalities of eyes, ears, nose, throat, and mouth.

11) Which parental statement indicates correct understanding of discharge instructions for a pediatric client after a tonsillectomy? 1. "We will call the healthcare provider for any indication of ear pain." 2. "We will be sure to give our child adequate amounts of citrus juices." 3. "We will plan on administering acetaminophen (Tylenol) for pain." 4. "We will keep our child on bed rest for 10 days after the surgery." Answer: 3 Explanation: 1. Children may experience ear pain, especially when swallowing, between 4 and 8 days after tonsillectomy. 2. Citrus juices should be avoided as they may produce a burning sensation in the throat. 3. Acetaminophen (Tylenol) is recommended for pain after a tonsillectomy. 4. Children do not need to be confined to bed, but they should avoid vigorous exercise for the first week after surgery. Page Ref: 1084 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 45.5 Apply current recommendations when implementing care and teaching for children with abnormalities of eyes, ears, nose, throat, and mouth. 12) Which information should the nurse include in a teaching session regarding treatment for the common cold in the pediatric population? 1. Aspirin should be taken for alleviation of fever if the common cold is contracted. 2. Antibiotics will eliminate the nasopharyngitis virus. 3. Vaccinations can prevent contraction of a nasopharyngitis virus. 4. Proper hand washing can prevent the spread of the common cold. Answer: 4 Explanation: 1. Aspirin is not recommended because of its association with Reye syndrome in the pediatric population. 2. For viral pharyngitis, symptomatic treatment alone is used. 3. There is no vaccination that can prevent contraction of a nasopharyngitis virus. 4. Proper hand washing should be taught to school-age children to reduce the spread of the "common cold" virus. Page Ref: 1082 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.6 Integrate preventive and treatment principles when implementing health promotion for children related to eyes, ears, nose, and throat. 9 Copyright © 2022 Pearson Education, Inc.

13) Which assessment finding is considered normal for a school-age client? 1. Tonsils are large and seem to fill the throat. 2. Child is complaining of sore throat and drooling. 3. White patches are observed on the tonsils. 4. Throat appears red, and child has a low-grade fever. Answer: 1 Explanation: 1. This is a normal finding as the tonsillar material grows faster than the child, and reaches adult size in this age group. It is not a reason to refer the child for follow-up. 2. Pain such as a sore throat or drooling is not normal for a school-age child. 3. White patches on the tonsils is not a normal assessment finding for a school-age child. 4. A school-age child whose throat appears red and has a low grade fever has symptoms of acute pharyngitis which is not considered normal. Page Ref: 1083 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.1 Identify anatomy, physiology, and pediatric differences in the eye, ear, nose, and throat of children and adolescents. 14) Which topics should the nurse include in a teaching session to the parents of a 10-month-old infant who experiences frequent ear infections? Select all that apply. 1. Prohibiting tobacco smoke in the home 2. Avoiding use of a pacifier while the child is sleeping 3. Breastfeeding the infant 4. Cleaning the child's ears nightly with peroxide 5. Avoiding use of wood-burning stoves Answer: 1, 2, 3, 5 Explanation: 1. This has been shown to decrease the incidence of otitis media. 2. The use of a pacifier for the sleeping baby has been associated with otitis media. 3. Breastfeeding appears to be a protective factor for preventing ear infections. 4. This is not a recommended intervention for an infant. 5. Wood-burning stoves are associated with higher rates of otitis media. Page Ref: 1073 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.6 Integrate preventive and treatment principles when implementing health promotion for children related to eyes, ears, nose, and throat. 10 Copyright © 2022 Pearson Education, Inc.

15) For which reason should a healthcare provider recommend to a preschool-age male client with a documented hearing loss attend preschool at least 2 days per week? 1. Help the child recognize his hearing deficit. 2. Increase the child's socialization skills. 3. Improve the child's immunity by increased exposure to organisms. 4. Teach other children that children are different. Answer: 2 Explanation: 1. Attending preschool will not help the child recognize his hearing deficit. 2. By increasing the interaction with other children, the hearing-impaired child will improve his socialization skills. 3. The healthcare provider should encourage disease prevention not exposure to organisms. 4. This is not the job of a preschooler. Page Ref: 1079 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 45.4 Plan nursing care for children with vision or hearing impairments. 16) Which screening tool should the nurse use to screen a pediatric client for esotropia? 1. Examine the eye with an otoscope. 2. Check for the "red reflex" in the eyes. 3. Perform the cover-uncover test. 4. Use a tonometer to evaluate the eyes. Answer: 3 Explanation: 1. An otoscope would not detect strabismus. 2. The "red reflex" does not indicate the client has or does not have esotropia. 3. When one eye is covered while the child is looking at an object, the uncovered eye will deviate from the location; this tool is used to detect strabismus 4. A tonometer is not a tool to diagnose esotropia. Page Ref: 1062 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.3 Implement screening programs to identify children with vision and hearing abnormalities.

17) Which is a priority nursing assessment the nurse includes in the plan of care for a pediatric client who has received a cochlear implant? 1. Ringing in the ears 2. Pharyngitis 3. Hearing loss 4. Measles Answer: 4 Explanation: 1. This is a common problem for patients who have received a cochlear implant. 2. Pharyngitis is not a common after a cochlear implant. 3. A cochlear implant should help with hearing loss; therefore, the nurse should not expect hearing loss in their patient. 4. All children with cochlear implants should have pneumococcal vaccine (PCV7 for under 5 years of age or PPV23 for over 5 years). The immunization should be completed 2 weeks before surgery for cochlear implant. Children should be current on all immunizations, but rubella, mumps, and measles are especially important, as infections with these diseases could cause further hearing loss. Page Ref: 1078 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Plan nursing care for children with vision or hearing impairments.

18) Which nursing actions are appropriate when providing care to a 12-year-old client who has lost several teeth as a result of a facial injury? Select all that apply. 1. Not worrying about the tooth loss, as children this age still have their "baby " teeth 2. Only handling the lost tooth by the roots and avoiding touching the crown of the tooth 3. Rinsing the lost tooth with sterile saline 4. Placing the tooth back into its socket and taking the child to an emergency dental facility 5. Keeping the tooth clean and dry during transport to an emergency dental facility Answer: 3, 4 Explanation: 1. The nurse should provide immediate care to ensure best possibility of survival for the tooth. A 12 year old will have permanent teeth, not baby teeth. 2. The nurse should handle the tooth only by the crown (its top) rather than the root to avoid further damage. 3. This is appropriate, as there is hope that the tooth can be reimplanted. 4. This is an appropriate way to manage the tooth. 5. The nurse should insert the tooth back into the socket if possible or keep moist rather than dry. Page Ref: 1085 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 45.6 Integrate preventive and treatment principles when implementing health promotion for children related to eyes, ears, nose, and throat.

19) Which parental statements indicate correct understanding of the anatomy and physiology of the infant's mouth, nose, and throat? Select all that apply. 1. "My baby will breathe through her mouth during the first 3 months of life." 2. "When my baby has a cold, she may have trouble with bottle feedings." 3. "My baby's tonsils will be largest during infancy." 4. "I should expect my baby's first tooth to erupt during the first 6 months of life." 5. "I should expect my baby to lose her first tooth during the first year of life." Answer: 2, 4 Explanation: 1. Up to 6 months of age (not 3 months), infants breathe primarily through the nose and not through the mouth. 2. Infants often have difficulty with oral feedings when the nasal passage is blocked. This statement indicates correct understanding. 3. Tonsils are normally large during school age, not infancy. 4. First teeth often erupt during the first 6 months of life. This statement indicates correct understanding. 5. The first loss of tooth begins at about 6 years of age. Page Ref: 1059, 1080 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 45.1 Identify anatomy, physiology, and pediatric differences in the eye, ear, nose, and throat of children and adolescents.

20) Which common eye disorders should the nurse include in a teaching session for the parents of pediatric clients? Select all that apply. 1. Hyperopia 2. Myopia 3. Astigmatism 4. Strabismus 5. Cataracts Answer: 1, 2, 3 Explanation: 1. Hyperopia, or farsightedness, is a common eye disorder seen in the pediatric population. 2. Myopia, or nearsightedness, is a common eye disorder seen in the pediatric population. 3. Astigmatism, or blurred vision, is a common eye disorder seen in the pediatric population. 4. Strabismus is only seen in up to 4% of children. 5. Cataracts are seen in 1-2/10,000 newborns and are not a common eye disorder in children. Page Ref: 1061 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 45.2 Describe abnormalities of the eyes, ears, nose, throat, and mouth in children.

21) Which visual screenings should the school nurse conduct when conducting annual assessments for school-age children? Select all that apply. 1. Light reflex assessment 2. Cover-uncover test 3. Acuity testing 4. Visualization of the tympanic membrane 5. Cranial nerve VIII testing Answer: 1, 2, 3 Explanation: 1. An annual light reflex assessment is an appropriate visual screening for the school-age child. 2. An annual cover-uncover test is an appropriate visual screening for the school-age child. 3. An annual acuity test is an appropriate visual screening for the school-age child. 4. The tympanic membrane is in the ear therefore would not be part of a visual screen. 5. Cranial nerve testing is not part of a visual screen. Page Ref: 1062 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.3 Implement screening programs to identify children with vision and hearing abnormalities.

22) Which should the nurse include in the plan of care for a pediatric client who is diagnosed with periorbital ecchymosis? Select all that apply. 1. Apply ice to the site for 5 to 15 minutes every hour for the first 1 to 2 days. 2. Apply warm compresses beginning on day 3. 3. Apply antibiotic ointment to the conjunctiva for 7 to 10 days. 4. Apply a patch to the affected eye for 5 to 7 days. 5. Apply antibiotic drops to the conjunctiva for 7 to 10 days. Answer: 1, 2 Explanation: 1. Ice should be applied to the injured eye for 5 to 15 minutes every hour for the first 1 to 2 days. 2. Warm compresses should be applied to the injured eye beginning on day 3. 3. Antibiotic ointment is not indicated for a client diagnosed with periorbital ecchymosis. 4. A patch is not needed to care for a patient diagnosed with periorbital ecchymosis. 5. Antibiotic drops are not indicated for a client diagnosed with periorbital ecchymosis. Page Ref: 1070 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 45.4 Plan nursing care for children with vision or hearing impairments. 23) Which should the nurse include in the plan of care for a pediatric client diagnosed with otitis media with effusion? Select all that apply. 1. Administration of antibiotic drops per order 2. Administration of pain relief measures 3. Assessment of hearing acuity over several months 4. Assessment of speech 5. Assessment of development Answer: 2, 3, 4, 5 Explanation: 1. The clinical therapy for a client diagnosed with otitis media with effusion is symptomatic treatment and pain relief not antibiotic drops. 2. Measures to address comfort should be included in the child's plan of care. 3. Hearing acuity assessments should be included in the child's plan of care. 4. Speech assessment should be included in the child's plan of care. 5. Assessment of development should be included in the child's plan of care. Page Ref: 1072 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: Practice: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 45.5 Apply current recommendations when implementing care and teaching for children with abnormalities of eyes, ears, nose, throat, and mouth. 17 Copyright © 2022 Pearson Education, Inc.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 46 The Child with Alterations in Respiratory Function 1) The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate? 1. "You are incorrect in your assessment." 2. "The younger child's airways are smaller and more easily occluded." 3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." 4. "Toddlers do not breathe as deeply as do older children." Answer: 2 Explanation: 1. The mother is correct in her statement. 2. Airways are smaller in the younger child and are more easily occluded when mucus is produced. 3. Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent. 4. Depth of breathing is not age dependent. Page Ref: 1089 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.1 Describe unique characteristics of the pediatric respiratory system anatomy and physiology and apply that information to the care of children with respiratory conditions.

2) Which problem should the nurse include in the plan of care for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Intolerance of activity 2. Poor tissue perfusion 3. Pain 4. Reduced cardiac output Answer: 1 Explanation: 1. Intolerance of activity is a problem because of the imbalance between oxygen supply and demand. 2. Tissue perfusion is not affected by this respiratory disease process. 3. Pain is not usually associated with acute bronchiolitis. 4. Cardiac function is not compromised during an acute phase of bronchiolitis. Page Ref: 1103 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 46.5 Distinguish between conditions of the lower respiratory tract that cause illness in children. 3) A toddler-age client presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data? 1. Throat culture 2. Medical history 3. Vital signs 4. Auscultation of breath sounds Answer: 1 Explanation: 1. Throat cultures should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and can cause complete occlusion of the airway. 2. Medical history should be obtained, which assists in diagnosis. 3. Vital signs should always be taken when assessment is done. 4. Assessment of breath sounds is essential for diagnosis. Page Ref: 1099 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.6 Create a nursing care plan for a child with a common acute respiratory condition. 2 Copyright © 2022 Pearson Education, Inc.

4) Which nursing action is appropriate for the family of a 4-month-old infant who died due to sudden infant death syndrome (SIDS)? 1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints 2. Reassure other children that it will not happen to them 3. Advising parents that an autopsy is not necessary 4. Interviewing parents to determine the cause of the incident Answer: 2 Explanation: 1. Parents will want any personal items available. 2. Older children may need reassurance that SIDS will not happen to them. They may also believe that bad thoughts or wishes about their baby brother or sister caused the death. 3. The death of an infant without a known medical condition is an indication for an autopsy. 4. The parents need to know that SIDS is not their fault. Page Ref: 1097 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.6 Create a nursing care plan for a child with a common acute respiratory condition.

5) Which immunization should the nurse include in a teaching session for parents of a toddlerage client to decrease the risk for epiglottitis? 1. Hepatitis B 2. Polio 3. Measles, mumps, and rubella (MMR) 4. Haemophilus influenzae type B (HIB) Answer: 4 Explanation: 1. Hepatitis B, measles, mumps, rubella, and the poliovirus are not causative agents for epiglottitis. 2. Hepatitis B, measles, mumps, rubella, and the poliovirus are not causative agents for epiglottitis. 3. Hepatitis B, measles, mumps, rubella, and the poliovirus are not causative agents for epiglottitis. 4. The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Page Ref: 1099 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.2 Contrast different respiratory medical conditions that can cause respiratory distress in infants and children. 6) A 10 year-old child is diagnosed with tuberculosis. In which way should this client receive prescribed doses of rifampin? 1. At bedtime 2. With morning cereal 3. Before going to school 4. Twice a week by a healthcare provider Answer: 4 Explanation: 1. The medication does not need to be taken at bedtime. 2. The medication does not need to be taking with cereal. 3. There is no specific time for the medication to be taken. 4. Direct-observed drug therapy administered by a healthcare provider two times a week for the duration of treatment is recommended for children with active TB. Page Ref: 1107 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.6 Create a nursing care plan for a child with a common acute respiratory condition. 4 Copyright © 2022 Pearson Education, Inc.

7) Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented? 1. "We're glad the dog can continue to sleep in our child's room." 2. "We'll keep the plants in our child's room dusted." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We will replace the carpet in our child's bedroom with tile." Answer: 4 Explanation: 1. When possible, pets and plants should not be kept in the home. 2. When possible, pets and plants should not be kept in the home. 3. Smoke from fireplaces should be eliminated. 4. Control of dust in the child's bedroom is an important aspect of environmental control for asthma management. Page Ref: 1118 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 46.7 Develop a school-based nursing care plan for the child with asthma. 8) Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis? 1. Rectal prolapse 2. Constipation 3. Steatorrheic stools 4. Meconium ileus Answer: 4 Explanation: 1. Rectal prolapse is a complication of the large, bulky fatty stools. 2. Constipation is not a symptom of cystic fibrosis. 3. Steatorrhea and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child. 4. Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus. Page Ref: 1120 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.7 Develop a school-based nursing care plan for the child with asthma.

9) Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis? 1. "I will administer this medication 4 times each day." 2. "I will administer this medication twice each day." 3. "I will administer this medication with meals and snacks." 4. "I will administer this medication every 6 hours around the clock." Answer: 3 Explanation: 1. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 2. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 3. Pancreatic enzymes are administered with meals and large snacks. 4. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. Page Ref: 1123 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 46.7 Develop a school-based nursing care plan for the child with asthma. 10) Which should the nurse include in a teaching session for the mother of a 3-year-old client who is concerned about her child choking? 1. Show the mother how to do cardiac compressions and rescue breathing. 2. Recommend the mother perform back blows and chest thrusts. 3. Teach the mother how to perform abdominal thrusts. 4. Tell the mother to do nothing until the child loses consciousness. Answer: 3 Explanation: 1. The method of cardiac compressions and rescue breathing is not the first thing that the mother needs to know. 2. This is the treatment for a choking infant, not a child. 3. Giving abdominal thrusts is the correct intervention for a choking child. 4. The mother should respond to the choking child before the child loses consciousness. Page Ref: 1094 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.2 Contrast different respiratory medical conditions that can cause respiratory distress in infants and children. 6 Copyright © 2022 Pearson Education, Inc.

11) Which positions are appropriate for the nurse to include in a plan of care for a child who is experiencing an acute asthma attack? Select all that apply. 1. Sitting 2. Semi-Fowler 3. Prone 4. With the head hyperextended 5. Supine Answer: 2, 5 Explanation: 1. A sitting position promotes the ease of respiratory effort. 2. The semi-Fowler position promotes the ease of respiratory effort. 3. Prone positioning will not promote respirations. 4. The head should not be hyperextended as that position does not open the airway. 5. The supine position will not promote respirations.. Page Ref: 1115 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.6 Create a nursing care plan for a child with a common acute respiratory condition. 12) Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation? 1. Administering the bath to the neonate in the nursery 2. Transferring to the neonatal intensive care unit for further observation 3. Allowing the neonate to room-in to promote bonding 4. Providing the first feeding in the nursery Answer: 2 Explanation: 1. The newborn is tachypneic. Bathing will only add to the respiratory distress and should be avoided. 2. This newborn needs to remain under constant observation due to the respiratory rate. 3. The newborn needs to be monitored. 4. With a respiratory rate this high, aspiration is likely so feeding should be avoided. Page Ref: 1094 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.4 Assess the child's respiratory status and analyze the need for oxygen supplementation.

13) Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of brief resolved unexplained event (BRUE)? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation. Answer: 1 Explanation: 1. This is appropriate monitoring of the infant. 2. Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen. 3. Laboratory tests are not an independent action. 4. There is no indication of a respiratory infection. At this time, contact isolation is not indicated. Page Ref: 1096 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.4 Assess the child's respiratory status and analyze the need for oxygen supplementation. 14) Which is the priority nursing action for a premature neonate who is experiencing apnea? 1. Administering oxygen 2. Performing back blows and chest thrusts 3. Calling a code blue 4. Providing stimulation by stroking the back Answer: 4 Explanation: 1. If the infant is not breathing, oxygen will not help. 2. This is intervention for choking, not apnea. 3. A code is not the initial response. If the nurse is unable to restart breathing, then a code should be initiated. 4. Tactile stimulation is often sufficient to restart the infant's respirations. Page Ref: 1097 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.2 Contrast different respiratory medical conditions that can cause respiratory distress in infants and children.

15) Which statements should the nurse include in the discharge medication teaching for a child diagnosed with asthma who is prescribed cromolyn sodium (a mast cell stabilizer)? Select all that apply. 1. "The medication works to prevent exacerbations." 2. "The medication should be administered at the first symptom of an asthmatic attack." 3. "The medication should be taken on a daily basis." 4. "The medication should not be administered if the child has a cold." 5. "The medication desensitizes the child against specific allergens." Answer: 1, 3 Explanation: 1. This statement is true. Cromolyn sodium is used to inhibit an asthmatic response to allergens. 2. This is incorrect. This medication does not improve the child's condition during an asthmatic attack. 3. This is a preventative medication so doses should not be missed. 4. The medication should be taken daily. 5. This medication does not desensitize the child against allergens. Page Ref: 1113 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.7 Develop a school-based nursing care plan for the child with asthma. 16) Which is the priority nursing action for a child who presents in the emergency department after a motor vehicle accident with a sucking wound of the chest? 1. Placing the child in a Trendelenburg position 2. Beginning rescue breathing for the child 3. Beginning cardiac resuscitation for the child 4. Covering the child's wound with an air occlusive dressing Answer: 4 Explanation: 1. This would not be the appropriate response to a sucking chest wound. 2. The child is conscious. Rescue breathing is not appropriate at this time. 3. There is no need for cardiac resuscitation at this time. 4. This prevents more air from entering the chest and is appropriate. Page Ref: 1127 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.9 Contrast the signs of different injuries to the respiratory system. 9 Copyright © 2022 Pearson Education, Inc.

17) Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply. 1. Lung sounds clear to auscultation 2. Stridor 3. Substernal retractions 4. Nasal flaring 5. Strong cry Answer: 2, 3, 4 Explanation: 1. Lung sounds that are clear to auscultation do not indicate respiratory compromise. 2. Stridor is an adventitious breath sound that may indicate respiratory compromise. 3. Substernal retractions may indicate respiratory compromise. 4. Nasal flaring may indicate respiratory compromise. 5. A weak, not strong, cry may indicate respiratory compromise. Page Ref: 1093 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.3 Explain the visual and auditory observations made to assess a child's respiratory effort or work of breathing.

18) Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply. 1. Mucous membranes 2. Nail beds 3. Skin 4. Sclerae 5. Corneas Answer: 1, 2, 3 Explanation: 1. The nurse assesses the mucous membranes to determine oxygenation during the respiratory assessment for a pediatric client. 2. The nurse assesses the nail beds to determine oxygenation during the respiratory assessment for a pediatric client. 3. The nurse assesses the skin to determine oxygenation during the respiratory assessment for a pediatric client. 4. The sclerae are not assessed to determine oxygenation during the respiratory assessment for a pediatric client. 5. The corneas are not assessed to determine oxygenation during the respiratory assessment for a pediatric client. Page Ref: 1093 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.3 Explain the visual and auditory observations made to assess a child's respiratory effort or work of breathing.

19) Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply. 1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 3. Prescribing oxygen for low saturations 4. Administering prescribed prophylactic antibiotic therapy 5. Providing support to the family Answer: 1, 2, 5 Explanation: 1. A pediatric client who sustained a smoke-inhalation injury is at risk for respiratory distress; therefore, it is appropriate for the nurse to assess this patient for clinical manifestations associated with the phenomenon. 2. Crackles and wheezing are both complications associated with a smoke-inhalation injury. This nursing action is appropriate. 3. It is outside the scope of nursing practice to prescribe oxygen therapy for a pediatric client. The nurse would, however, administer prescribed oxygen for this client. 4. Prophylactic antibiotic therapy is not included in the treatment plan for a pediatric client who sustained a smoke-inhalation injury. 5. The nurse should provide support to the family of a pediatric client who sustained a smokeinhalation injury. Page Ref: 1126 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.9 Contrast the signs of different injuries to the respiratory system.

20) Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply. 1. A preschool-age client who is admitted after a house fire 2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident 3. A school-age client who is admitted for observation after a skateboarding accident 4. An adolescent client admitted for an asthma exacerbation 5. An infant admitted to rule out cystic fibrosis Answer: 2, 3 Explanation: 1. A preschool-age client admitted after a house fire would require assessment for smoke-inhalation injury not blunt chest trauma. 2. A toddler-age client admitted for injuries sustained in a motor vehicle accident would require assessment to determine blunt chest trauma. 3. A school-age client admitted for observation after a skateboarding accident would require assessment to determine blunt chest trauma. 4. An asthma exacerbation would not necessitate a nursing assessment for blunt chest trauma. 5. An infant admitted to rule out cystic fibrosis would not necessitate a nursing assessment for blunt chest trauma. Page Ref: 1126 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.9 Contrast the signs of different injuries to the respiratory system.

21) Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply. 1. Eupnea 2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles Answer: 2, 3, 4, 5 Explanation: 1. Eupnea, or a normal respiratory rate, is not assessment data the nurse expects for a pediatric client who sustained a large pulmonary contusion in a motor vehicle crash. 2. Dyspnea is a clinical manifestation associated with respiratory distress, which can occur for the pediatric client who sustained a large pulmonary contusion in a motor vehicle crash. 3. Hemoptysis is a clinical manifestation associated with a large pulmonary contusion. 4. Fever is a clinical manifestation associated with a large pulmonary contusion. 5. Crackles are a clinical manifestation associated with a large pulmonary contusion. Page Ref: 1126 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.9 Contrast the signs of different injuries to the respiratory system.

22) A preschool-age child with cystic fibrosis receives care from a grandparent during the day. Which suggestion should the nurse make to ensure the child receives the needed chest physiotherapy until the parents return home from work? Select all that apply. 1. Use an oscillating vest. 2. Instruct on the huffing technique. 3. Place the child in the prone position. 4. Restrict fluids until the parents come home. 5. Use an oscillating positive expiration pressure device. Answer: 1, 2, 5 Explanation: 1. An oscillating vest will help mobilize secretions. 2. The huffing technique will help mobilize secretions. 3. The prone position is not a recommendation to mobilize secretions. 4. Restricting fluids will thicken secretions, making them harder to expectorate. 5. An oscillating positive expiration pressure device will help mobilize secretions. Page Ref: 1125 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.8 Develop a home nursing care plan for the child with cystic fibrosis. 23) A school-age child with cystic fibrosis is playing baseball during physical education class in school. Which action should the school nurse take when the child is sitting between innings? 1. Provide a salty snack. 2. Count respiratory rate. 3. Measure peripheral pulse. 4. Provide chest physiotherapy. Answer: 1 Explanation: 1. Children with CF lose more than normal amounts of salt in their sweat, especially during strenuous exercise. During periods of exercise and increased sweating, encourage the child to increase salt intake. Allow the child to eat salty snacks. 2. The child's respiratory rate does not need to be assessed. 3. The child's pulse does not need to be assessed. 4. Physiotherapy is not needed while exercise is in progress. Page Ref: 1125 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.8 Develop a home nursing care plan for the child with cystic fibrosis. 15 Copyright © 2022 Pearson Education, Inc.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 47 The Child with Alterations in Cardiovascular Function 1) Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization? 1. Capillary refill is greater than 3 seconds. 2. Lower extremities are warm, with a capillary refill of less than 3 seconds. 3. Sensation is decreased with a weakened dorsalis pedis pulse. 4. Dorsalis pedis pulse is palpable but posterior tibial pulse is weak. Answer: 2 Explanation: 1. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. 2. The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than 3 seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color. 3. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. 4. If the capillary refill is over 3 seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate. Page Ref: 1135 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

2) Which initial laboratory data does the nurse anticipate for a child who is admitted to the hospital with a cyanotic heart defect? 1. A low platelet count 2. A high white blood cell count 3. A high hemoglobin 4. A low hematocrit Answer: 3 Explanation: 1. The platelets would be normal. 2. The white blood cell count would not be high unless an infection was present. 3. The child's bone marrow responds to chronic hypoxemia by producing more red blood cells to increase the amount of hemoglobin available to carry oxygen to the tissues. This occurs in cases of cyanotic heart defects. 4. The hematocrit would not be low. Page Ref: 1143 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

3) The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. On which problem should the nurse focus for this child? 1. Hypothermia 2. Pain 3. Muscle dysfunction 4. Problems with gas exchange Answer: 4 Explanation: 1. Ventricular septal defects do not cause pain, fever, or deficient fluid volume. 2. Ventricular septal defects do not cause pain, fever, or deficient fluid volume. 3. Ventral septal defects do not cause problems with muscle function. 4. Because of the increased pulmonary congestion, problems with gas exchange would be the focus problem. Page Ref: 1139 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 47.2 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

4) Which heart defect should the nurse suspect for an infant whose upper extremities have stronger pulses than the lower extremities, and blood pressure is higher in the arms than in the legs? 1. Transposition of the great vessels 2. Patent ductus arteriosus 3. Coarctation of the aorta 4. Atrial septal defect Answer: 3 Explanation: 1. These defects are not associated with blood pressures that are different in upper and lower extremities. 2. These defects are not associated with blood pressures that are different in upper and lower extremities. 3. Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. 4. These defects are not associated with blood pressures that are different in upper and lower extremities. Page Ref: 1151 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

5) An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. 1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered. 4. Draw blood for serum hemoglobin. 5. Administer diphenhydramine (Benadryl) as ordered. Answer: 1, 2, 3 Explanation: 1. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities), and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 2. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and, administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 3. When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in kneechest position (to decrease venous blood return from the lower extremities) and, administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). 4. The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed. 5. Benadryl is not appropriate for this child. Page Ref: 1145 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.2 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

6) An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment? 1. "Your child will have a low-grade fever until the defect is repaired." 2. "It is important for your child to maintain normal activity." 3. "Your child is not at risk for congestive heart failure." 4. "It is important to avoid antipyretics for the treatment of fever." Answer: 2 Explanation: 1. Low-grade fever is not a normal finding in a child with a mild cyanotic heart defect and could be a sign of infective endocarditis. 2. A child with a mild cyanotic heart defect should be treated as normally as possible without activity adjustment. 3. Any child with a heart defect could develop congestive heart failure. 4. Fevers are treated with antipyretics so that dehydration is avoided. Page Ref: 1150 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.3 Develop a nursing care plan for the infant with a congenital heart defect cared for at home prior to corrective surgery. 7) A 2-month-old infant with a congenital heart defect is admitted to the pediatric intensive care unit with congestive heart failure. Which intervention should the nurse include in the infant's plan of care? 1. Monitor respirations during active periods. 2. Give larger feedings less often to conserve energy. 3. Organize activities to allow for uninterrupted sleep. 4. Force fluids appropriate for age. Answer: 3 Explanation: 1. Respirations are difficult to monitor during active periods, making this an unrealistic goal. 2. Feedings should be small-volume, high-calorie. 3. It is important to allow for uninterrupted sleep to decrease metabolic demands on the heart. 4. Fluids should be restricted to high-calorie and low-volume in order to avoid overloading the lungs with fluid. Page Ref: 1156 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.6 Develop a nursing care plan for a child with congestive heart failure. 6 Copyright © 2022 Pearson Education, Inc.

8) A toddler is prescribed digoxin (Lanoxin) for cardiac failure. Which should the nurse instruct the toddler's parents to monitor for as a manifestation associated with digoxin toxicity? 1. Bradycardia 2. Tinnitus 3. Ataxia 4. Hypotension Answer: 1 Explanation: 1. Early signs of digoxin (Lanoxin) toxicity are bradycardia and arrhythmias. 2. Digoxin (Lanoxin) toxicity does not cause tinnitus (ringing in the ears). 3. Digoxin (Lanoxin) toxicity does not cause ataxia (unsteady gait). 4. Digoxin (Lanoxin) toxicity does not cause hypotension (low blood pressure). Page Ref: 1157 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.3 Develop a nursing care plan for the infant with a congenital heart defect cared for at home prior to corrective surgery. 9) Which teaching point should the nurse include in the discharge instructions for a pediatric client who has undergone cardiac surgery? 1. Should not receive routine immunizations. 2. Should be restricted from most play activities. 3. Fever is expected for several weeks following the surgery. 4. Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures. Answer: 4 Explanation: 1. Immunizations should be provided according to the schedule. 2. The child should live a normal and active life following repair of a cardiac defect. 3. Fever is not expected for a prolonged period after surgery, and any unexplained fever should be reported. 4. Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis. Page Ref: 1161 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.4 Create a nursing care plan for the child undergoing open heart surgery.

10) Which parental statement regarding the use of cyclosporin A after a heart transplant indicates correct understanding of the information presented by the nurse? 1. "This medication is used to treat hypertension." 2. "This medication is used to reduce serum cholesterol level." 3. "This medication is used to prevent rejection." 4. "This medication is used to treat infections." Answer: 3 Explanation: 1. Calcium channel blockers may be used to treat hypertension. 2. Lovastatin is given to reduce serum cholesterol level. 3. Cyclosporin A is given to prevent rejection. 4. An antibiotic may be given to treat an infection. Page Ref: 1159 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 47.4 Create a nursing care plan for the child undergoing open heart surgery. 11) Which clinical manifestation does the nurse anticipate for a pediatric client who is admitted with congestive heart failure (CHF)? 1. Tachycardia 2. Weight loss 3. Hypertension 4. Bradycardia Answer: 1 Explanation: 1. Tachycardia is a sign of congestive heart failure because the heart attempts to improve cardiac output by beating faster. 2. The weight, instead of decreasing, increases, because of retention of fluids. 3. Blood pressure does not increase in CHF. 4. Bradycardia is a serious sign and can indicate impending cardiac arrest. Page Ref: 1154 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.5 Recognize the signs and symptoms of congestive heart failure in an infant and child.

12) Which is the rationale the nurse provides to the parents of an infant diagnosed with congestive heart failure (CHF) for the prescribed spironolactone? 1. Produces rapid diuresis. 2. Blocks reabsorption of sodium and water in renal tubules. 3. Spares potassium. 4. Promotes vascular relaxation. Answer: 3 Explanation: 1. Furosemide (Lasix) produces rapid diuresis, and blocks reabsorption of sodium and water in renal tubules. 2. Furosemide (Lasix) produces rapid diuresis, and blocks reabsorption of sodium and water in renal tubules. 3. Spironolactone (Aldactone) is a maintenance diuretic that is potassium-sparing. Hypokalemia would increase the risk of Lanoxin toxicity. 4. Angiotensin-converting enzyme (ACE) inhibitors promote vascular relaxation. Page Ref: 1155 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.6 Develop a nursing care plan for a child with congestive heart failure. 13) Which laboratory test does the nurse anticipate for a child who is admitted to the hospital with suspected rheumatic fever? 1. Erythrocyte sedimentation rate 2. Throat culture 3. C-reactive protein 4. Antistreptolysin-O (ASO) titer Answer: 4 Explanation: 1. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation. 2. A culture can indicate a current streptococcal infection. 3. An erythrocyte sedimentation rate and a C-reactive protein can indicate inflammation. 4. The laboratory test for antistreptococcal antibodies is an antistreptolysin-O (ASO) titer. Page Ref: 1162 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.7 Differentiate among the heart diseases that are acquired or begin development during childhood.

14) Which athletic activity should the nurse recommend for a school-age child who is diagnosed with pulmonary artery hypertension? 1. Golf 2. Basketball 3. Cross-country running 4. Soccer Answer: 1 Explanation: 1. A child with pulmonary artery hypertension should have exercise tailored to avoid dyspnea, such as golf. 2. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. 3. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. 4. Soccer, basketball, and cross-country running are all aerobic activities requiring heavy exertion. Page Ref: 1160 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.7 Differentiate among the heart diseases that are acquired or begin development during childhood.

15) Which treatment options should the nurse anticipate for a 10-month-old infant admitted to the emergency department with supraventricular tachycardia? Select all that apply. 1. Administering intravenous adenosine (Adenocard) 2. Administering intravenous amiodarone (Cardarone) 3. Preparing for cardioversion 4. Applying ice to the face 5. Having the child perform a Valsalva maneuver Answer: 1, 2, 3, 4 Explanation: 1. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 2. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 3. Adenosine or amiodarone may be given when vagal maneuvers are unsuccessful. Cardioversion is used in an urgent situation. 4. Supraventricular tachycardia episodes are initially treated with vagal maneuvers to slow the heart rate including the application of ice or iced saline solution to the face to reduce the heart rate. 5. A 10-month-old child cannot be instructed to hold her breath and bear down as with a bowel movement. Page Ref: 1164 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.7 Differentiate among the heart diseases that are acquired or begin development during childhood.

16) Which assessment data would cause the nurse to suspect that a pediatric client is experiencing hypovolemic shock? Select all that apply. 1. Dyspnea 2. Bradycardia 3. Tachycardia 4. Capillary refill time greater than 3 seconds 5. Blood pressure 72/42 mmHg Answer: 1, 3, 4 Explanation: 1. Increased work of breathing is an early sign of shock, indicating compensation for decreased cardiac output and volume. 2. Bradycardia is a late and ominous sign of shock indicating that the child is no longer able to compensate. 3. Tachycardia is an early compensatory mechanism for hypovolemia in a child. 4. Decreased capillary refill time would be an early indicator of decreased fluid volume and compensation. 5. Decreased blood pressure is a later finding and would not occur until other compensatory mechanisms were exhausted. Page Ref: 1167 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.10 Plan the nursing management of hypovolemic shock.

17) Which is the priority nursing action when providing care to a pediatric client who is diagnosed with hypovolemic shock? 1. Assessing the cause of bleeding 2. Establishing an open airway and administering oxygen 3. Administering analgesics for pain control 4. Providing replacement of volume Answer: 2 Explanation: 1. Airway patency and replacement of volume are priorities before assessing the cause of the bleeding. 2. Airway patency and oxygen delivery (breathing) are always first in the treatment for a client with health concerns. 3. Pain would be a consideration but would not be attended to as a first priority. 4. Replacement of volume is vital but would follow establishing airway and breathing. Page Ref: 1167 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.10 Plan the nursing management of hypovolemic shock. 18) The nurse is teaching a pregnant client about fetal circulation. Which is the correct sequence of blood flow that indicates the pregnant client understands the information presented? 1. Ductus arteriosus 2. Ductus venosus 3. Foramen ovale Answer: 3, 1, 2 Explanation: 1. The ductus arteriosus connects the pulmonary artery to the aorta and is the last structure that blood reaches. 2. The ductus venosus connects the umbilical vein to the inferior vena cava bypassing the liver. It is the first structure that blood reaches. 3. The foramen ovale connects the right atrium to the left ventricle and bypasses the lungs. It is the second structure that blood reaches. Page Ref: 1132 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 47.1 Describe the anatomy and physiology of the cardiovascular system, focusing on the flow of blood and the action of heart valves.

19) Which parental statement indicates correct understanding for the reason a cardiac catheterization is needed for a child who is diagnosed with a congenital heart defect? 1. "This procedure will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed." 2. "This procedure is used to close the ductus arteriosus to prevent mixing of arterial and venous blood." 3. "This procedure will redirect the blood so that blood bypasses the right ventricle." 4. "This procedure connects the ventricle to the atrium." Answer: 1 Explanation: 1. This statement is accurate. 2. A stent maintains an opening; it does not close an opening. 3. A stent maintains the ductus as patent. It does not bypass the ventricle. 4. This is not the purpose of the stent. Page Ref: 1134 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 47.2 Contrast the pathophysiology associated with congenital heart defects having increased pulmonary circulation, decreased pulmonary circulation, mixed defects, and obstructed systemic blood flow.

20) Which feeding techniques should the nurse include in the teaching session for the parents of an infant who is being discharged in order to gain weight for the corrective surgery needed for a congenital heart defect? Select all that apply. 1. Breastfeed if possible. 2. Complete each feeding within 30 minutes. 3. Position the infant flat to promote swallowing. 4. Dilute the formula with extra water to ensure adequate fluid intake. 5. Burp the infant frequently. Answer: 1, 2, 5 Explanation: 1. Breastfeeding is recommended because it provides antibodies to help protect the infant from infection. 2. Allowing the infant to nurse for more than 30 minutes will burn more calories than calories are gained. 3. The infant should be positioned at a 45-degree angle to reduce the workload of the heart. 4. The formula should not be diluted beyond the label recommendations, as it would lower the caloric count. 5. This is appropriate for the infant with a congenital heart defect as well as the normal infant. Page Ref: 1140 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.3 Develop a nursing care plan for the infant with a congenital heart defect cared for at home prior to corrective surgery.

21) Which age-appropriate information should the nurse provide to an 8-year-old girl who is being emotionally prepared for open heart surgery? 1. The name of the surgeon who will be performing the procedure 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine used during the procedure 4. What the environment will look and sound like when the child wakes up Answer: 4 Explanation: 1. The parents know the name of the surgeon. It will mean nothing to a 4-year-old child. 2. The child will be asleep during surgery and therefore does not need to know about the procedure. 3. This is beyond the understanding of a 4-year-old. 4. The child should be prepared in terms of what she will see, hear, smell, or feel. Page Ref: 1140 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.4 Create a nursing care plan for the child undergoing open heart surgery. 22) A child is admitted to the pediatric medical unit with a diagnosis of Kawasaki disease. Which provider prescription should the nurse question? 1. Contact isolation 2. Oral aspirin every 8 hours 3. Echocardiogram 4. Vital signs every 4 hours Answer: 1 Explanation: 1. The child is not contagious so contact isolation is not appropriate. 2. Aspirin is used as an anti-inflammatory and is prescribed around the clock. This is appropriate. 3. This examination will be used as a baseline to compare against as the child recovers to assist in monitoring for cardiac lesions. 4. The child will need close monitoring during the early period of the disease. Page Ref: 1163 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.7 Differentiate among the heart diseases that are acquired or begin development during childhood.

23) A school-age client is diagnosed with rheumatic fever. Which parental statement indicates the need for further education by the nurse? 1. "I understand rheumatic fever is a strep infection of the heart." 2. "My child will be on bed rest for several weeks." 3. "My child will be treated with aspirin and/or corticosteroids." 4. "Once my child has recovered, she will still need to be monitored for sequelae to the disease." Answer: 1 Explanation: 1. Rheumatic fever is not a strep infection of the heart but an autoimmune connective tissue disease in response to a previous strep infection. This statement requires clarification. 2. This statement is correct. No further clarification is needed. 3. This statement is correct and needs no clarification. 4. Children who have had one episode of rheumatic fever are at greater risk for future episodes. In addition, long-term valve damage may occur. This statement needs no further clarification. Page Ref: 1161 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 47.7 Differentiate among the heart diseases that are acquired or begin development during childhood. 24) Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game? 1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4. Assessing for hemorrhage Answer: 1 Explanation: 1. This situation is an example of cardiac concussion. Survival chances improve if CPR is initiated immediately. 2. Other people can call 911. Cardiac resuscitation must be initiated immediately. 3. This is an appropriate action but not a priority. 4. This type of injury often has no external symptoms of injury. Page Ref: 1170 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.7 Differentiate among the heart diseases that are acquired or begin development during childhood. 17 Copyright © 2022 Pearson Education, Inc.

25) Which is an appropriate statement for the nurse to include in the discharge instructions to the parents of a child who is recovering from cardiac surgery? 1. "The child will have a fever for several weeks following the surgery." 2. "The child will be restricted from most play activities." 3. "The child will not receive routine immunizations." 4. "The child will receive prophylactic antibiotics prior to any dental procedures." Answer: 4 Explanation: 1. Any unexplained fever should be reported. 2. The child should live a normal and active life following repair of a cardiac defect. 3. Immunizations should be provided according to the schedule. 4. Parents should be taught that the child should receive prophylactic antibiotics to prevent endocarditis, according to the American Heart Association. Page Ref: 1145 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.8 Develop a nursing care plan for a child with Kawasaki syndrome.

26) Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with early compensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure Answer: 1, 2, 4 Explanation: 1. Tachycardia is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 2. Weak distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 3. Thready distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. 4. Normal blood pressure for age is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 5. A decrease in systolic blood pressure is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. Page Ref: 1170 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.10 Plan the nursing management of hypovolemic shock.

27) Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with moderate uncompensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure Answer: 3, 5 Explanation: 1. Tachycardia is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 2. Weak distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 3. Thready distal pulses are cardiovascular manifestations the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. 4. Normal blood pressure for age is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with early compensated hypovolemic shock. 5. A decrease in systolic blood pressure is a cardiovascular manifestation the nurse anticipates for the pediatric client who is diagnosed with moderate uncompensated hypovolemic shock. Page Ref: 1167 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.10 Plan the nursing management of hypovolemic shock.

28) Which strategies should the nurse recommend for a school-age client who is at risk for developing hypertension as an adult? Select all that apply. 1. Using seasoning substitutes for salt 2. Providing a list of foods high in sodium 3. Decreasing television time 4. Increasing physical activity 5. Monitoring blood pressure daily Answer: 1, 2, 3, 4 Explanation: 1. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend the use of seasoning substitutes to replace added salt. 2. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should provide a list of foods that are high in sodium. 3. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend a decrease in television screen time. 4. Habits that are implemented during childhood will decrease the likelihood of developing hypertension as an adult. The nurse should recommend an increase in physical activity. 5. Monitoring blood pressure daily is not an activity that reduces the child's likelihood of developing hypertension as an adult. Page Ref: 1164 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.9 List strategies to reduce a child's risk of adult onset cardiovascular disease.

29) Which clinical manifestations does the nurse anticipate for a pediatric client who is diagnosed with the subacute stage of Kawasaki disease? Select all that apply. 1. High fever 2. Diarrhea 3. Thrombocytosis 4. Joint pain 5. Beau lines Answer: 3, 4 Explanation: 1. High fever is a clinical manifestation anticipated for a pediatric client diagnosed with the acute stage of Kawasaki disease. 2. Diarrhea is a clinical manifestation anticipated for a pediatric client diagnosed with the acute stage of Kawasaki disease. 3. Thrombocytosis is a clinical manifestation anticipated for a pediatric client diagnosed with the subacute stage of Kawasaki disease. 4. Joint pain is a clinical manifestation anticipated for a pediatric client diagnosed with the subacute stage of Kawasaki disease. 5. Beau lines are a clinical manifestation anticipated for a pediatric client diagnosed with the convalescent stage of Kawasaki disease. Page Ref: 1162 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Context and Environment: apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.8 Develop a nursing care plan for a child with Kawasaki syndrome.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 48 The Child with Alterations in Immune Function 1) A parent of a newborn asks the nurse why young children seem to become ill so often when compared with older children and adults. Which is the best response by the nurse? 1. "Newborns have lower numbers of natural killer cells." 2. "Newborns have high levels of IgA in their systems." 3. "Newborns are lacking lymphoid tissue." 4. "Newborns have an immature thymus gland." Answer: 1 Explanation: 1. Newborns have lower numbers of natural killer cells than do older children and adults, decreasing their ability to respond to certain antigens. 2. IgA is not present at birth. Development of IgA begins at 2 weeks of age but does not reach adult levels until the age of 6. 3. Lymphoid tissue, such as the spleen and tonsils, is present at birth. 4. The thymus is large at birth and grows during childhood, decreasing by adulthood. Page Ref: 1175 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders.

2) A premature neonate is at greater risk for infection than a full-term newborn because of a reduced number of which immunoglobulin? 1. IgE 2. IgG 3. IgA 4. IgM Answer: 2 Explanation: 1. IgE does not cross the placenta and is not present at birth in either preterm or full-term infants. 2. Maternal IgG crosses the placenta. Newborns' levels are similar to their mothers'. Premature infants have lower levels of IgG obtained from their mothers and are at greater risk for infection. 3. IgA does not cross the placenta and is not present at birth in either preterm or full-term infants. 4. IgM does not cross the placenta. The levels are low at birth in both preterm and full-term infants. Page Ref: 1175 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders. 3) The nurse is planning care for a child with acquired immune deficiency syndrome (AIDS). Which vaccines should be avoided in the child with AIDS? 1. Inactivated polio vaccine 2. Tetanus toxoid vaccination 3. Varicella vaccine 4. Acellular pertussis vaccine Answer: 3 Explanation: 1. Killed virus vaccines are safe to administer to the child with AIDS as there is no risk of acquiring an infection. 2. A toxoid vaccination is made of a toxin that has been produced by the organism but does not include living organisms. 3. A child with an immune disorder should not be immunized with a live varicella vaccine because of the risk of contracting the disease. 4. Acellular pertussis vaccine contains a protein from pertussis rather than the whole cell. Page Ref: 1181 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders. 2 Copyright © 2022 Pearson Education, Inc.

4) An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which action by the client indicates acceptance of the body changes that occur because of SLE? 1. Attends school but does not stay for after-school activities. 2. Discusses the body changes with healthcare providers only. 3. Discusses the body changes with her best friend. 4. Only attends small parties at friends' homes. Answer: 3 Explanation: 1. Avoiding social activities does not show acceptance of body changes. 2. Discussing changes only with healthcare providers does not indicate the teen has adjusted to the body image changes. 3. Peer interaction is important to the teen. Being able to discuss the changes to her body with a peer indicates acceptance of the changes in her body image. 4. Avoiding social activities other than those involving immediate friends indicates the teen is still concerned with body image. Page Ref: 1187 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 48.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis. 5) A school-age client diagnosed with rheumatoid arthritis (RA) wants to participate in the school sports programs. The client asks the nurse to recommend a sporting activity that is appropriate. Which activity would be the most appropriate for the nurse to recommend? 1. Baseball 2. Basketball 3. Football 4. Swimming Answer: 4 Explanation: 1. Baseball places stress on the knee joints. 2. Basketball involves running, which will stress the joints. 3. All positions in football will cause stress to the joints. 4. Swimming helps to exercise all the extremities without putting undue stress on joints. Page Ref: 1189 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis.

6) The nurse is caring for a child with rheumatoid arthritis. Which nonpharmacologic intervention should the nurse include in the plan of care for joint pain? 1. Elevation of the extremity 2. Immobilization 3. Massage 4. Application of moist heat Answer: 4 Explanation: 1. Elevation of the extremity would not have an effect on reducing pain in rheumatoid arthritis. 2. Immobilization can lead to contractures. Range of motion to the involved joint should be maintained. 3. Massage of extremities should be avoided because of potential risk for emboli. 4. Moist heat can promote relief of pain and decrease joint stiffness. Page Ref: 1190 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis. 7) Which action should the nurse take if a hospitalized pediatric client has a history of an anaphylactic reaction to a medication? 1. Review actions for the client to take if the medication is taken. 2. Label the chart, the bed, and apply a red armband. 3. Instruct the mother to obtain a medical alert bracelet for the child. 4. Ask the healthcare provider to prescribe an epinephrine pen for the child. Answer: 2 Explanation: 1. The child has an allergy to the medication and should never take it. 2. When the child is hospitalized, be sure to label the child's chart and bed, and apply a red armband to alert others to allergies. 3. The child may not need a medical alert bracelet if the medication is not one that is routinely used. 4. An epinephrine pen would not be applicable. Page Ref: 1192 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.6 Determine nursing interventions and prevention measures for the child experiencing hypersensitivity reactions.

8) A child is prescribed oral corticosteroid for a rash caused by graft-versus-host disease. Which should the nurse monitor the child for after administering the drug? 1. Infection 2. Hepatic toxicity 3. Seizures 4. Renal toxicity Answer: 1 Explanation: 1. Corticosteroids suppress the immune system, and increase the risk of infections. 2. Hepatic toxicity is not a side effect associated with steroid therapy. 3. Seizures are not a side effect associated with steroid therapy. 4. Renal toxicity is not a side effect associated with steroid therapy. Page Ref: 1193 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.6 Determine nursing interventions and prevention measures for the child experiencing hypersensitivity reactions. 9) After a severe allergic reaction, an EpiPen is prescribed for the school-age child. Which instructions should the nurse provide to this child's parents based on the current data? Select all that apply. 1. "It is important that your child always has access to this medication." 2. "Your child is too young to self-administer this medication." 3. "If you are able to administer the medication, there is no need for follow-up care." 4. "It is important to check the expiration date on the medication and replace, if expired." 5. "Your child should wear a Medic Alert bracelet at all times." Answer: 1, 4, 5 Explanation: 1. This is appropriate care. 2. Both the child and family members should be taught administration of the EpiPen. 3. The EpiPen effect is good for approximately 20 minutes. The child should be transported to the hospital immediately after administering the EpiPen. 4. An expired EpiPen may have less than desired effects. 5. If the child is unable to speak due to anaphylaxis, it is important that rescuers have information about the child's allergies. Page Ref: 1192 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.6 Determine nursing interventions and prevention measures for the child experiencing hypersensitivity reactions. 5 Copyright © 2022 Pearson Education, Inc.

10) An adolescent female client is diagnosed with systemic lupus erythematosus (SLE). Which should the nurse include in the teaching session regarding an activity that should be avoided? 1. Receiving a manicure and a pedicure 2. Washing the hair with shampoo daily 3. Using a tanning bed 4. Attending late night parties and dances Answer: 3 Explanation: 1. Manicures and pedicures do not place the teenager at any risk. 2. Although one symptom of SLE can be alopecia, gentle shampooing is not a cause of this symptom. 3. Individuals with SLE have photosensitivity, and tanning beds can lead to exacerbations as well as skin damage from sunburns. 4. Although adequate rest is important for the teenager with SLE, the teenager can "catch up" on her sleep the next day. Page Ref: 1188 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis. 11) Which is the priority nursing action when providing care to a pediatric client who has documented allergies to cow's milk, peanuts, and latex? 1. Evaluating the hospital room for equipment containing latex 2. Ordering an EpiPen for the child 3. Notifying dietary of the milk and peanut allergy 4. Placing a sign on the door, which identifies all allergies Answer: 1 Explanation: 1. This is appropriate as latex allergies can be life threatening. Many pieces of medical equipment may contain latex. 2. Nurses do not prescribe or dispense medication, so this is inappropriate. 3. This action should be taken but is not the priority. 4. Depending on hospital policy, there may be some sign to indicate allergies, but this is not the priority. Page Ref: 1193 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.A.4. Delineate general categories of errors and hazards in care | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.5 Identify exposure prevention measures for the child with latex allergy.

12) Which is the rationale for ensuring a pediatric client with severe combined immune deficiency (SCID) receives blood that has been irradiated? 1. Transfusion reaction from lymphocytes and platelets in the donor blood 2. Transfusion reaction and infection from lymphocytes in the donor blood 3. Infection and graft-versus-host disease from lymphocytes in the donor blood 4. Infection and graft-versus-host disease from erythrocytes in the donor blood Answer: 3 Explanation: 1. Lymphocytes in the donor blood are responsible for infection and graft-versushost disease. 2. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 3. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. 4. Lymphocytes in the donor blood are responsible for infection and graft-versus-host disease. Page Ref: 1176 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: V.A.4. Delineate general categories of errors and hazards in care | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.2 Summarize infection control measures needed for children with an immunodeficiency.

13) A nurse is planning care for a child with human immunodeficiency virus (HIV). Which is the priority problem for this child? 1. Insufficient blood circulation 2. Fever 3. Lack of sufficient fluid volume 4. Potential for infection Answer: 4 Explanation: 1. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Insufficient blood circulation would not be a priority problem with this disease process. 2. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Fever would not be a priority problem with this disease process. 3. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Lack of sufficient fluid volume would not be a priority problem with this disease process. 4. A child with HIV is at risk for a myriad of bacterial, viral, fungal, and opportunistic infections because of the effect of the virus on the immune system. Page Ref: 1180 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 48.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

14) A child is receiving a nucleoside reverse transcriptase inhibitor for human immunodeficiency virus (HIV). Which mechanism of action should the nurse review with the child's parent? 1. Inhibits the action of an enzyme. 2. Blocks the virus from replicating. 3. Kills the virus. 4. Boosts the production of white blood cells. Answer: 1 Explanation: 1. A nucleoside reverse transcriptase inhibitor inhibits the action of an enzyme in the conversion of RNA to DNA. 2. A nucleoside reverse transcriptase inhibitor does not block the virus from replicating. 3. A nucleoside reverse transcriptase inhibitor does not kill the virus. 4. A nucleoside transcriptase inhibitor does not boost the production of white blood cells. Page Ref: 1180 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection). 15) A child with human immunodeficiency virus (HIV) is diagnosed with oral candidiasis. Which should the nurse include in the plan of care related to oral care based on this information? 1. Listerine 2. Normal saline 3. Viscous lidocaine 4. Scope Answer: 2 Explanation: 1. Listerine is a commercial mouth rinse that can have an alcohol base and cause drying of the membranes. 2. The mouth care should be with a nonalcohol base. Normal saline can keep the child's lips and mouth moist. 3. Viscous lidocaine causes numbing, and could depress the gag reflex in a younger child. 4. Scope is a commercial mouth rinse that can have an alcohol base and cause drying of the membranes. Page Ref: 1183 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

16) The nurse is providing care for the family of a child who is diagnosed with acquired immunodeficiency syndrome (AIDS). Which problem should the nurse include in the plan of care? 1. Stress 2. Role conflict 3. Anger 4. Financial problems Answer: 1 Explanation: 1. Family support systems and coping mechanisms should be addressed because the stress of caring for a child with AIDS infection may overwhelm the parents. 2. There is no evidence of role conflict when caring for a child with AIDS. 3. There is no evidence of anger when caring for a child with AIDS. 4. There is no evidence of financial problems when caring for a child with AIDS. Page Ref: 1180 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 48.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

17) The nurse is providing discharge instructions to the family of a child who experienced an anaphylactic reaction. Which parental statements indicate accurate understanding of the action that histamine plays during this type of reaction? Select all that apply. 1. "Histamine releases IgE antibodies, which help to stop the reaction." 2. "Histamine causes smooth muscle contraction, which causes the wheezing." 3. "Histamine causes increased capillary permeability, which is what causes difficulty breathing." 4. "Histamine causes vasoconstriction leading to respiratory issues." 5. "Histamine causes the destruction of red blood cells, which is why we administer the EpiPen." Answer: 2, 3 Explanation: 1. IgE antibodies cause the release of histamine, not the other way around. 2. Smooth muscle contraction causes the constriction of the bronchioles, which causes the wheezing and respiratory distress. 3. Increased capillary permeability causes the plasma to leak into surrounding tissues, including the lungs, leading to pulmonary edema. 4. Anaphylaxis causes vasodilation, not vasoconstriction. 5. Histamine does not cause red cell destruction. Page Ref: 1190 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 48.6 Determine nursing interventions and prevention measures for the child experiencing hypersensitivity reactions.

18) When teaching a pregnant client about antibodies that are passed from mother to newborn, which antibody should the nurse include? 1. IgM 2. IgA 3. IgD 4. IgG Answer: 4 Explanation: 1. IgM is the first antibody produced with primary immune response. It does not cross the placenta. 2. IgA does not cross the placenta. 3. Although the function of IgD is not fully understood, it is not thought to cross the placenta. 4. IgG crosses the placenta, and provides the newborn with passive immunity. Page Ref: 1174 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.1 Describe the structure and function of the immune system and apply that knowledge to the care of children with immunologic disorders.

19) Which infection control measures should the nurse include in the discharge instructions for the family of a child who is immunodeficient? Select all that apply. 1. "It is important that your child does not share cups with other members of the family." 2. "You should avoid washing your child's utensils in the dishwasher." 3. "You should allow your child to eat fresh fruit with the skin intact." 4. "It is important that everyone practices hand hygiene before touching your child." 5. "You should use alcohol wipes to cleanse your child's diaper area." Answer: 1, 4 Explanation: 1. Children who are immunodeficient should not share cups with other members of the family, as this increases the child's risk for developing an infection. 2. Utensils should be washed in warm water or placed in the dishwasher to ensure that contaminates are properly cleansed. 3. Fresh fruit should be washed and peeled prior to allowing the child who is immunocompromised to eat it. 4. Hand hygiene before handling the child, after changing diapers, and prior to feeding the child is essential to decrease the risk for infection. 5. The diaper area should be cleaned with mild soap and allowed to dry. The use of alcohol will increase the risk for skin breakdown and infection. Page Ref: 1176 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.A.4. Delineate general categories of errors and hazards in care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.2 Summarize infection control measures needed for children with an immunodeficiency.

20) Which interventions should the nurse include in the plan of care to address nutrition for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Encourage three large meals each day. 2. Eliminate unpleasant odors from the environment during meals. 3. Weigh the child each day, using the same scale. 4. Assess skin turgor every 4 hours. 5. Include favorite foods in the meal plan. Answer: 2, 3, 5 Explanation: 1. Children diagnosed with AIDS who are experiencing impaired nutrition should be offered small frequent meals to meet nutritional needs. 2. Unpleasant stimuli and odors often decrease the desire for food. 3. Taking daily weights, using the same scale, is an appropriate intervention to monitor the child's nutritional status. 4. Skin turgor should be assessed each shift, not every 4 hours, in order to monitor hydration status. 5. Allowing children to eat their favorite foods encourages intake. Page Ref: 1181 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.3 Develop a nursing care plan in partnership with the family for a child with human immunodeficiency virus (HIV infection).

21) Which interventions should the nurse include in the plan of care for a hospitalized child who is diagnosed with rheumatoid arthritis (RA)? Select all that apply. 1. Performing passive range-of-motion (ROM) exercises with the child 2. Discouraging the child from completing activities of daily living (ADLs) 3. Encouraging periods of rest for the child 4. Placing cool compresses on the child's joints 5. Measure daily weights Answer: 1, 3, 5 Explanation: 1. Active and passive ROM is encouraged as this decreases joint stiffness and inflammation. 2. The child should be encouraged, not discouraged, to be as independent as possible with ADLs. 3. Exacerbations of RA often cause fatigue; therefore, it is appropriate for the nurse to encourage rest periods. 4. Warm, not cool, compresses should be placed on the joints. 5. Daily weights are needed, as it is not uncommon for the child with RA to experience reduced activity and metabolic needs yet maintain the same diet, which places the child at risk for overweight and obesity. Page Ref: 1189-1190 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.4 Plan nursing care for the child with an autoimmune condition such as systemic lupus erythematosus or juvenile arthritis.

22) The nurse is providing education to a family whose child experiences anaphylaxis when exposed to any amount of latex. Which items, often found in the home or school environment, should the nurse include in the teaching session? Select all that apply. 1. Art supplies 2. Toothpaste 3. Balloons 4. Perfumes 5. Chewing gum Answer: 1, 3, 5 Explanation: 1. Art supplies often contain latex; therefore, the nurse should include this item in the teaching session. 2. Toothbrushes, not toothpaste, are known to contain latex. The nurse should not include this item in the teaching session. 3. Balloons often contain latex; therefore, the nurse should include this item in the teaching session. 4. Perfumes are not known to contain latex. The nurse should not include this item in the teaching session. 5. Chewing gum often contains latex; therefore, the nurse should include this item in the teaching session. Page Ref: 1193 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: V.A.4. Delineate general categories of errors and hazards in care | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.5 Identify exposure prevention measures for the child with latex allergy.

23) The nurse is providing care to a child who experienced an anaphylactic reaction to an unknown allergen. Which high-risk foods should the nurse question the family about regarding recent consumption? 1. Peanut butter 2. Shrimp 3. Eggs 4. Milk 5. Soda Answer: 1, 2, 3 Explanation: 1. Peanut products, such as peanut butter, are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 2. Shellfish, such as shrimp, is considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 3. Egg whites are considered a high-risk food allergen. The nurse should question the family about the consumption of this product. 4. While milk allergies are common, they rarely cause anaphylaxis. 5. Soda is not a high risk for the nurse to include in the assessment process. Page Ref: 1190 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.6 Determine nursing interventions and prevention measures for the child experiencing hypersensitivity reactions.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 49 The Child with Alterations in Hematologic Function 1) The nurse prepares to administer a vitamin K injection during the admission assessment for a newborn. The father asks, "Why does my baby need a shot?" Which rationale for administering this injection should the nurse include in the response? 1. Activates clotting factors. 2. Dissolves blood clots. 3. Promotes gas exchange. 4. Promotes the production of hemoglobin. Answer: 1 Explanation: 1. Levels of clotting factors are lower in infants, so vitamin K is given prophylactically to activate essential clotting factors. 2. Vitamin K promotes clotting; it is not administered to dissolve blood clots. 3. Vitamin K does not promote gas exchange. 4. Vitamin K has no effect on the production of hemoglobin. Page Ref: 1199 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.3 Explain similarities and differences in the major bleeding disorders affecting the pediatric population.

2) Which parental statement indicates correct understanding of information presented regarding the treatment for infant anemia? 1. "We will add green leafy vegetables to our child's low-iron formula." 2. "We will discontinue the use of vitamin C supplements by 6 months of age." 3. "We will begin an iron-fortified infant cereal at 4 to 6 months of age." 4. "We will introduce cow's milk by 6 months of age." Answer: 3 Explanation: 1. The infant's maternal iron stores are depleted by 6 months. Infants who are not breastfed should get iron-fortified formula. Green leafy vegetables, while iron fortified, are not appropriate for the infant. 2. Vitamin C should be started at 6 to 9 months of age and continued because foods rich in vitamin C improve iron absorption. 3. Starting iron-fortified infant cereal at 4 to 6 months of age is recommended for prevention of iron deficiency in children. 4. Cow's milk should not be introduced until 12 months of age. Page Ref: 1200 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

3) The parents of an infant diagnosed with sickle-cell disease ask, "How did our child get this disease? Neither one of us has it." Which should the nurse consider when responding to the parents? 1. The father is not the biologic father of the infant. 2. The mother of the child has the trait, but the father does not. 3. The father of the child has the trait, but the mother does not. 4. The mother and the father of the child have the sickle-cell trait. Answer: 4 Explanation: 1. There is no indication that the father is not the actual parent. Both parents could be carriers of the disorder but unaware of their status. 2. Both parents must have the trait for the child to have a 25% chance of having this disease. 3. Both parents must have the trait for the child to have a 25% chance of having this disease. 4. Sickle-cell disease is an autosomal recessive disorder; both parents must have the trait in order for a child to have a 25% chance of having this disease. Page Ref: 1201 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

4) Which parental statements regarding precipitating factors for sickle-cell disease indicate correct understanding of the discharge information presented by the nurse? Select all that apply. 1. "My child should avoid regular exercise." 2. "We should provide acetaminophen or ibuprofen to treat fever." 3. "Our child needs to drink lots of fluid to avoid dehydration when playing sports." 4. "High altitudes can cause exacerbation and should be avoided." 5. "Fluid restriction is necessary to avoid exacerbations from occurring." Answer: 2, 3, 4 Explanation: 1. Regular exercise and increased fluid intake are recommended activities for a child with sickle-cell disease and will not contribute to a sickle-cell crisis. 2. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis. 3. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis. 4. Fever, dehydration, and altitude are all precipitating factors contributing to a sickle-cell crisis. 5. Regular exercise and increased fluid intake are recommended activities for a child with sicklecell disease and will not contribute to a sickle-cell crisis. Page Ref: 1201, 12.3 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 5) The nurse is administering packed red blood cells to a child with sickle-cell disease (SCD). When should the nurse monitor the child closely due to the risk of reaction? 1. Six hours after the transfusion is given. 2. At the end of the administration of the transfusion. 3. The first 20 mL of blood administered. 4. Never; children with SCD do not have reactions. Answer: 3 Explanation: 1. Transfusion reaction does not occur this long after the transfusion. 2. Reactions generally occur at the onset or during the first 20 minutes of transfusion. 3. Blood reactions can occur as soon as the blood transfusion begins. The nurse should administer the first 20 mL of blood slowly, and monitor for a reaction during this time frame. 4. Anyone can have a transfusion reaction during any transfusion. Page Ref: 1207 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 4 Copyright © 2022 Pearson Education, Inc.

6) A child who has beta-thalassemia is receiving numerous blood transfusions and deferoxamine (Desferal) therapy. The parents ask how the deferoxamine will help their child. Which response by the nurse is accurate? 1. "It stimulates red blood cell production." 2. "It prevents iron overload." 3. "It provides vitamin supplementation." 4. "It decreases the risk of transfusion reactions." Answer: 2 Explanation: 1. Desferal does not stimulate red blood cell production. 2. Iron overload can be a side effect of a hypertransfusion therapy. Desferal is an iron-chelating drug that binds excess iron so it can be excreted by the kidneys. It does not prevent blood transfusion reactions, stimulate red blood cell production, or provide vitamin supplementation. 3. Desferal does not provide vitamin supplementation. 4. Desferal does not prevent blood transfusion reactions. Page Ref: 1209 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 7) A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate? 1. "Aplastic anemia causes a proliferation of white blood cells." 2. "Aplastic anemia is characterized by abnormally shaped red blood cells." 3. "Aplastic anemia is caused the bone marrow producing inadequate cells." 4. "Aplastic anemia is a disorder that occurs after a viral illness." Answer: 3 Explanation: 1. All blood cells, not just white blood cells, are affected by aplastic anemia. 2. Aplastic anemia does not cause abnormally shaped red blood cells; this is a description of sickle-cell disease. 3. In aplastic anemia, the bone marrow does not produce sufficient numbers of circulating blood cells. 4. There is no known association between aplastic anemia and viral illness. Page Ref: 1209 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 5 Copyright © 2022 Pearson Education, Inc.

8) Which symptoms should the nurse include in the teaching plan for the family of a recently child diagnosed with aplastic anemia? 1. Fatigue and fever 2. Runny nose and cough 3. Nausea and vomiting 4. Cyanosis and bradycardia Answer: 1 Explanation: 1. Fatigue secondary to anemia and fever related to infection secondary to neutropenia are common symptoms. 2. Aplastic anemia is not associated with upper respiratory infections. 3. Nausea and vomiting are not symptoms of aplastic anemia. 4. The child would exhibit tachycardia rather than bradycardia, and there is no reason for cyanosis. Page Ref: 1210 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder. 9) A child diagnosed with hemophilia presents to the emergency department (ED) with multiple injuries following a motor vehicle crash. Which injury is the priority when conducting the nursing assessment? 1. Occipital hematoma 2. Radial fracture 3. Dislocated shoulder 4. Abdominal abrasions Answer: 1 Explanation: 1. A potential intracranial bleed would receive highest priority because of the danger of increased intracranial pressure and potential neurologic damage. 2. Although at risk for bleeding, this would not take priority over a head injury. 3. A dislocation is not at high risk for bleeding or tissue ischemia. 4. Although at risk for bleeding, this would not take priority over a head injury. Page Ref: 1211 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder.

10) Which nursing action is appropriate when treating a school-age child, diagnosed with hemophilia, for a superficial wound above the knee? 1. Applying pressure to the area 2. Applying a warm, moist pack to the area 3. Performing some passive range-of-motion to the affected leg 4. Keeping the affected extremity in a dependent position Answer: 1 Explanation: 1. If a child with hemophilia experiences a bleeding episode, superficial bleeding should be controlled by applying pressure to the wound. 2. Heat would increase the bleeding by dilating the superficial blood vessels. A cool compress should be applied. 3. The extremity should be immobilized to prevent further bleeding; passive range-of-motion could cause further bleeding at the site. 4. The extremity should be elevated, if possible, to prevent swelling at the site. Page Ref: 1211 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder.

11) The nurse is providing care to a child diagnosed with hemophilia who states, "I am going to join a bike club at school." Which recommendation should the nurse give to the child? 1. Wear kneepads, elbow pads, and a helmet while bicycling. 2. Consider a swim club instead of the bicycling club. 3. Do not join the club. 4. Participate only in the social activities of the club. Answer: 1 Explanation: 1. Children with hemophilia should be encouraged to participate in noncontact sports activities. Bicycling is an excellent option, and is recommended, along with swimming. However, the child should always use kneepads, elbow pads, and a helmet when participating in any physical sport. 2. Biking is an acceptable sport as long as protective equipment is worn, and the child should be encouraged to make choices when possible. 3. Discouraging a child from joining a club would not foster growth and development. 4. Participating only in the social aspects of the club would not encourage physical activity. Page Ref: 1211 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder.

12) Which is the priority nursing intervention when providing care to a pediatric client who is experiencing disseminated intravascular coagulation (DIC)? 1. Preparing the child for radiographic procedures 2. Implementing the prescribed fluid restriction for the child 3. Encouraging the child to frequently ambulate 4. Monitoring the child's oxygen saturation and vital signs Answer: 4 Explanation: 1. DIC is not diagnosed with a radiographic examination but by serum laboratory studies. 2. Fluids need to be monitored but will not be restricted. 3. Ambulation places stress on joints and can promote bleeding. The child with DIC should be placed on bed rest. 4. In a child who has a bleeding and clotting disorder, the priority nursing intervention would be monitoring for life-threatening complications. Page Ref: 1212 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder. 13) Which is the priority problem for the child diagnosed with idiopathic thrombocytopenic purpura (ITP)? 1. Pain 2. Anxiety 3. Increased fluid 4. Risk for bleeding Answer: 4 Explanation: 1. Pain is not a major problem with ITP. 2. Anxiety is not a problem with ITP. 3. Excess fluid is not a problem with ITP. 4. ITP is a common bleeding disorder in children, which increases the risk for bleeding. Page Ref: 1213 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 49.3 Explain similarities and differences in the major bleeding disorders affecting the pediatric population.

14) Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a child who was admitted in a sickle-cell crisis? 1. Rapid weaning of pain medications 2. A diet high in protein 3. Adequate hydration 4. Restriction of activities Answer: 3 Explanation: 1. Rapid weaning is not necessary; reduction of pain medication should proceed at a rate dictated by the child's pain. 2. A high-protein diet is not necessary; a well-balanced diet should be promoted. 3. Adequate hydration will help prevent further sequestration and crisis. 4. Normal activities are not restricted. Page Ref: 1204 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder. 15) Which teaching topic should the nurse include in the discharge instructions for the family of child diagnoses with sickle-cell disease to prevent crisis? 1. Respiratory infection and dehydration 2. Midrange altitudes 3. Weight loss without dehydration 4. Overhydration Answer: 1 Explanation: 1. The child with sickle-cell disease is at risk for infection, and dehydration can precipitate crisis. 2. High altitudes with lower oxygen concentrations pose a risk; mid-altitude is not a risk factor. 3. Weight loss is acceptable as long as hydration is maintained. 4. Hydration should be encouraged; risk of overhydration is minimal. Page Ref: 1206 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder.

16) Which risks should the nurse closely assess a pediatric client for during the posttransplant phase of hematopoietic stem cell transplantation (HSCT)? 1. Hemorrhage 2. Thrombosis 3. Pancytopenia 4. Infection 5. Fluid volume overload Answer: 1, 3, 4 Explanation: 1. Suppression of platelets increases the risk for bleeding. 2. There is no increased risk for thrombosis. 3. It takes 2 to 4 weeks for the bone marrow to begin producing cells; the client will show evidence of suppression until that time. 4. Suppression of white blood cells increases the client's risk for infection. 5. There is no increased risk of excess fluid; the client is at greater risk for dehydration. Page Ref: 1213 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder. 17) During a natural disaster, a child diagnosed with hemophilia is injured and bleeding internally. Which blood product should the nurse plan to administer if the appropriate factor is not available? 1. Platelets 2. Whole blood 3. Packed cells 4. Fresh or fresh frozen plasma Answer: 4 Explanation: 1. The child has adequate platelets, and administration of platelets will not promote clotting. 2. Whole blood will increase the blood volume without promoting clotting. 3. A unit of packed cells will provide red blood cells (RBCs) but not the factor needed to clot. 4. Factors are located in the plasma. Fresh or fresh frozen plasma will provide the best source of factor available. Page Ref: 1210 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.3 Explain similarities and differences in the major bleeding disorders affecting the pediatric population. 11 Copyright © 2022 Pearson Education, Inc.

18) A school-age child diagnosed with classic hemophilia is admitted to the hospital for hemorrhage into the knee joint. Which problem should the nurse use to plan care for this child? 1. Anxiety 2. Reduced self-esteem 3. Reduced hemoglobin level 4. Possible impaired physical mobility Answer: 4 Explanation: 1. A bleed into the joint will not cause a high amount of anxiety. 2. Although the knee will be swollen, self-esteem is not the priority diagnosis at this time. 3. The bleeding into the joint will not most likely affect total circulating hemoglobin level. 4. A bleed into the joint can lead to permanent contracture of the joint. Bone changes can result from the immobility associated with the bleed. Page Ref: 1211 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder. 19) Which rationale should the nurse include in the teaching session, related to infant iron deficiency anemia, when a parent asks why it is inappropriate to switch from formula to cow's milk prior to 1 year of age? Select all that apply. 1. Cow's milk is a poor source of iron. 2. The child may be exposed to an antibiotic in processed milk. 3. Cow's milk has a high fat content. 4. In young children, cow's milk can lead to bleeding from the gastrointestinal tract. 5. Cow's milk contains no vitamin C, which is necessary for iron absorption. Answer: 1, 4 Explanation: 1. This information is correct. 2. This would not be a reason for delaying the entry of milk into the diet. 3. Because there are low-fat varieties of cow's milk, this would not be a reason to delay introducing it. 4. This information is correct. 5. While the amount of vitamin C in milk is limited, this is not the reason for delaying introducing cow's milk into the child's diet. Page Ref: 1200 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 12 Copyright © 2022 Pearson Education, Inc.

20) The nurse is preparing to administer a blood transfusion to a child with a severe anemia. Which type of transfusion reaction can be avoided by the nurse's assessment? 1. Allergic 2. Hemolytic 3. Febrile 4. Septic Answer: 2 Explanation: 1. Allergic reactions are due to a protein in the donated blood to which the child reacts. The nurse cannot prevent this type of reaction. 2. A hemolytic reaction results from mismatched blood, a preventable error. This error is most likely to occur at the bedside if the nurse does not carefully identify the unit of blood and the patient. 3. A febrile reaction is related to contamination of blood. The nurse has no control over this type of reaction. 4. Septic is another name for a febrile reaction and is not preventable by the nurse. Page Ref: 1207 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 21) The healthcare provider prescribes a unit of packed red blood cells for a pediatric client. Which intravenous fluid should the nurse infuse during the blood transfusion? 1. D5W 2. D5LR 3. D5 1/4NS 4. NS Answer: 4 Explanation: 1. Dextrose should not be used, as it will cause packed cells to clot. 2. D5 lactated Ringer solution also contains dextrose and should not be used with packed cells. 3. Dextrose is inappropriate no matter what is the other component of the intravenous fluids. 4. Normal saline is appropriate to use prior to initiating blood. Page Ref: 1207 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.4 Plan the nursing management and collaborative care of a child with a hematologic disorder.

22) A school-age child is admitted to the hospital in a sickle-cell crisis. Which actions should the nurse include in the plan of care to address the child's pain? 1. Administering opioid analgesics, per order 2. Administering nonsteroidal anti-inflammatory drugs (NSAIDs), per order 3. Applying cold packs to affected joints, prn 4. Encouraging oral fluid intake 5. Maintaining bed rest Answer: 1, 2, 4, 5 Explanation: 1. Narcotics, such as morphine, are used to control the pain and reduce sickling. 2. NSAIDs may be used in combination with narcotics to control the pain. 3. Cold application is inappropriate in this situation as it would increase the sickling. 4. Oral fluids will help "thin" the blood and reduce sickling. 5. Bed rest will reduce the oxygen requirements of the body and prevent further sickling. Page Ref: 1203-1204 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population. 23) The healthcare provider orders laboratory tests following the initiation of treatment for a child diagnosed with iron deficiency anemia. Which laboratory result should the nurse share with the child's family as an indication of improvement? 1. Low hemoglobin 2. Normal platelet count 3. High reticulocyte count 4. Low hematocrit Answer: 3 Explanation: 1. Low hemoglobin is a typical finding in iron deficiency anemia. 2. Platelet count is unrelated to iron deficiency anemia. 3. Reticulocytes are immature red blood cells, and indicate new cells are being produced. 4. This would be a typical finding in iron deficiency anemia. Page Ref: 1200 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.2 Discuss the pathophysiology and clinical manifestations of the major disorders of red blood cells affecting the pediatric population.

24) Which topic should the nurse include in the discharge instructions for the family of a child who has undergone hematopoietic stem cell transplantation (HSCT)? 1. Avoiding influenza vaccination 2. Returning to school within 6 weeks 3. Maintaining a low-calcium diet 4. Practicing diligent hand hygiene Answer: 4 Explanation: 1. The child and the family should be encouraged to get yearly influenza vaccinations. 2. The child cannot return to school for 6 to 12 months after an HSCT. In-hospital or in-home schooling is required. 3. The child should be placed on calcium supplements to reduce the risk of osteopenia. 4. Handwashing is essential to prevent the spread of infection. Page Ref: 1213 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.5 Prioritize nursing interventions for a child receiving hematopoietic stem cell transplantation (HSCT). 25) Which functions of red blood cells (RBCs) should the nurse include in a teaching session for the family of a pediatric client who is diagnosed with anemia? Select all that apply. 1. Carry oxygen from the lungs to the tissues. 2. Return carbon dioxide from the tissues to the lungs. 3. Assist the body to fight infection. 4. Assist the body to fight allergens. 5. Form hemostatic plugs to stop bleeding. Answer: 1, 2 Explanation: 1. A function of RBCs is to carry oxygen from the lungs to the tissues. 2. A function of RBCs is to return carbon dioxide from the tissues to the lungs. 3. A function of the white blood cells, not the RBCs, is to fight infection. 4. A function of the white blood cells, not the RBCs, is to fight allergens. 5. A function of platelets, not RBCs, is to form hemostatic plugs to stop bleeding. Page Ref: 1199 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.1 Describe the function of red blood cells, white blood cells, and platelets.

26) Which functions of white blood cells (WBCs) should the nurse include in a teaching session for the family of a pediatric client who is diagnosed with human immunodeficiency virus (HIV)? Select all that apply. 1. Carry oxygen from the lungs to the tissues. 2. Return carbon dioxide from the tissues to the lungs. 3. Assist the body to fight infection. 4. Assist the body to fight allergens. 5. Form hemostatic plugs to stop bleeding. Answer: 3, 4 Explanation: 1. A function of red blood cells, not WBCs, is to carry oxygen from the lungs to the tissues. 2. A function of red blood cells, not WBCs, is to return carbon dioxide from the tissues to the lungs. 3. A function of the WBCs is to fight infection. 4. A function of the WBCs is to fight allergens. 5. A function of platelets, not WBCs, is to form hemostatic plugs to stop bleeding. Page Ref: 1199 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.1 Describe the function of red blood cells, white blood cells, and platelets.

27) The nurse is providing care to a pediatric client who is diagnosed with leukopenia. Which disorders should the nurse suspect based on this information? Select all that apply. 1. Cardiovascular 2. Immune 3. Bone marrow 4. Respiratory 5. Neurologic Answer: 2, 3 Explanation: 1. Cardiovascular disorders are not associated with leukopenia. 2. Immune disorders are associated with leukopenia. 3. Bone marrow disorders are associated with leukopenia. 4. Respiratory disorders are not associated with leukopenia. 5. Neurologic disorders are not associated with leukopenia. Page Ref: 1199 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Assessment Learning Outcome: 49.3 Explain similarities and differences in the major bleeding disorders affecting the pediatric population.

28) Which injury prevention topics should the nurse include in the plan of care for a pediatric client who has received hematopoietic stem cell transplantation (HSCT)? Select all that apply. 1. Medication storage strategies 2. Needle and syringe disposal 3. Immunization schedule 4. Yearly influenza vaccination 5. Routine dental appointments Answer: 1, 2 Explanation: 1. Medication storage strategies is a topic the nurse should include in the plan of care related to injury prevention strategies. 2. Needle and syringe disposal is an area the nurse should include in the plan of care related to injury prevention strategies. 3. An altered immunization schedule is a topic related to infection, not injury, prevention. 4. Yearly influenza vaccination is a topic related to infection, not injury, prevention. 5. Routine dental appointments are an important topic to include regarding oral health, not injury prevention. Page Ref: 1213 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.5 Prioritize nursing interventions for a child receiving hematopoietic stem cell transplantation (HSCT).

Maternal & Child Nursing Care, 6e (London et al.) Chapter 50 The Child with Cancer 1) The nurse is providing care for a pediatric client who is diagnosed with a Wilms tumor. Which laboratory test result should the nurse monitor prior to administering the prescribed chemotherapy dose? 1. Hemoglobin 2. Red blood cell count 3. Platelets 4. Absolute neutrophil count (ANC) Answer: 4 Explanation: 1. Hemoglobin indicates oxygen-carrying capacity, not immune response. 2. Red blood cell count has no correlation with immune function. 3. Platelets are associated with clotting, not immune function. 4. The absolute neutrophil count uses both the segmented (mature) and bands (immature) neutrophils as a measure of the body's infection-fighting capability. Page Ref: 1221 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

2) Which general manifestations should the nurse monitor for when conducting a physical assessment for a pediatric client who is diagnosed with cancer? Select all that apply. 1. Infection 2. Polycythemia 3. Petechiae 4. Pain 5. Cachexia Answer: 1, 3, 4, 5 Explanation: 1. Infection is often a general manifestation associated with cancer caused by altered immune function. 2. Anemia, not polycythemia, is a general manifestation associated with cancer. 3. Hemorrhagic spots, or petechiae, are general manifestations associated with cancer. 4. Pain is often a general manifestation of cancer resulting from neoplasms directly or indirectly affecting nerve receptors. 5. Cachexia is a state that is often associated with cancer. Specific symptoms include anorexia, nausea, and vomiting. Page Ref: 1220 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.1 Describe the incidence, known etiologies, and common clinical manifestations of cancer.

3) Which is a therapeutic nursing response when the mother of a pediatric client diagnosed with cancer states, "I regret not seeking medical attention earlier for my child"? 1. "You may feel guilty, but you should not blame yourself." 2. "Most cancers can be treated easily." 3. "Many types of cancer are difficult to diagnose and might not show early symptoms." 4. "Early diagnosis is not significant in the diagnosis and management of cancer." Answer: 3 Explanation: 1. This is not a therapeutic response. It is not appropriate for the nurse to tell the family how they should feel. 2. This answer is not accurate, as cancer is generally prolonged and difficult for both the child and family. 3. Many cancers do not present significant findings until late and can progress rapidly. Giving such information is a communication tool. 4. Outcomes for many cancers are improved with early diagnosis. Page Ref: 1238 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.1 Describe the incidence, known etiologies, and common clinical manifestations of cancer. 4) A child diagnosed with cancer is prescribed chemotherapy. Recent laboratory data show a low white blood cell (WBC) count. Which prescription should the nurse anticipate based on the current data? 1. Epoetin alfa (Epogen) 2. Ondansetron (Zofran) 3. Oprelvekin (Neumega) 4. Filgrastim (Neupogen) Answer: 4 Explanation: 1. Epoetin alfa (human recombinant erythropoietin) stimulates red blood cell (RBC) production. 2. Ondansetron (Zofran) is an antiemetic. 3. Oprelvekin (Neumega) increases platelets. 4. Filgrastim (Neupogen) increases production of neutrophils, a specific WBC, by the bone marrow. Page Ref: 1226 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures. 3 Copyright © 2022 Pearson Education, Inc.

5) Which urine specific gravity, and corresponding pH, should the nurse include in a goal statement for a pediatric client receiving chemotherapy in the treatment of cancer? 1. Specific gravity 1.030 and pH 7.5 2. Specific gravity 1.005 and pH 6 3. Specific gravity 1.030 and pH 6 4. Specific gravity 1.005 and pH 7.5 Answer: 4 Explanation: 1. A specific gravity higher than 1.010 can mean fluid intake is not high enough. 2. A pH of less than 7 means acidosis. 3. A specific gravity higher than 1.010 can mean fluid intake is not high enough, and a pH of less than 7 means acidosis. 4. Because the breakdown of malignant cells releases intracellular components into the blood and electrolyte imbalance causes metabolic acidosis, the patient should remain well hydrated, with the urine specific gravity at less than 1.010 and the pH at 7.0 to 7.5. Page Ref: 1228 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

6) The nurse is preparing to administer a prescribed, as needed, antiemetic drug for a child who is diagnosed with cancer. Which action by the nurse is most appropriate? 1. Administering the drug only if the child is nauseated 2. Administering the drug prophylactically prior to the next dose of chemotherapy 3. Administering the drug after the next dose of chemotherapy 4. Administering the drug only if the child is experiencing diarrhea Answer: 2 Explanation: 1. Administering the prn dose of the antiemetic drug only if the child is nausea is not the best use of this medication. 2. The antiemetic should be administered before chemotherapy and every 4 hours during the administration of chemotherapy, as a prophylactic measure. 3. Administering the prn dose of the antiemetic drug after the next dose of chemotherapy may not provide adequate coverage for nausea. 4. Antiemetic drugs are not administered to treat diarrhea. They are administered to treat nausea and vomiting. Page Ref: 1236 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

7) Which nursing intervention is contraindicated for a pediatric client who is experiencing thrombocytopenia secondary to chemotherapy treatments? 1. Administering intramuscular injections 2. Monitoring intake and output 3. Palpating during the assessment 4. Providing oral hygiene Answer: 1 Explanation: 1. When the child is thrombocytopenic (decreased platelets) from chemotherapy, the nurse should not administer intramuscular injections because of the risk of bleeding. 2. Monitoring intake and output is not contraindicated for a pediatric client who is experiencing thrombocytopenia as a result of chemotherapy treatments. 3. Palpation during the assessment is not contraindicated due to thrombocytopenia. This action is contraindicated for a child who is diagnosed with Wilms tumor. 4. Providing oral hygiene is not contraindicated for a pediatric client who is experiencing thrombocytopenia as a result of chemotherapy treatments. Page Ref: 1236 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

8) The child is receiving chemotherapy for acute lymphocytic leukemia (ALL). Which assessment data should the nurse immediately report to the healthcare provider due to a metabolic emergency? 1. Thrombocytopenia 2. Leukocytosis 3. Oliguria 4. Edema Answer: 3 Explanation: 1. Thrombocytopenia is a clinical manifestation associated with a hematologic, not metabolic, emergency. 2. Leukocytosis is a clinical manifestation associated with a hematologic, not metabolic, emergency. 3. Tumor lysis causes a metabolic emergency caused by an electrolyte imbalance. Clinical manifestations associated with this include altered renal function and altered levels of consciousness. 4. Edema is not indicative of a metabolic emergency. Page Ref: 1228 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

9) The adolescent client is receiving methotrexate chemotherapy after undergoing limb-salvage surgery for osteogenic sarcoma. The healthcare provider also prescribes leucovorin therapy. Which adolescent statement indicates correct understanding for the administration schedule for this newly prescribed drug? 1. "I do not have any pain, so I will not need to take the leucovorin this time." 2. "I do not have any nausea, so I will not need the leucovorin." 3. "I am glad I only need one dose of the leucovorin." 4. "It is important that I receive my leucovorin on time, as it protects my body from the methotrexate." Answer: 4 Explanation: 1. Leucovorin is not administered for pain. 2. Leucovorin is administered for nausea. 3. One dose is not the recommended therapy. 4. Leucovorin (citrovorum factor) is a form of folic acid that helps to protect normal cells from the destructive action of methotrexate. It is started within 24 hours of methotrexate administration and is given along with hydration therapy. Usual administration is every 6 hours times 72 hours or until serum methotrexate is at the desired level. Page Ref: 1236 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 50.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care.

10) The sibling of a pediatric client diagnosed with leukemia expresses feelings of anger and guilt to the nurse. Which explanation should the nurse provide to the client's parents regarding the reaction of the sibling? 1. Abnormal; the sibling should be referred to a psychologist. 2. Unexpected; the cancer is easily treated. 3. Unusual; the illness does not affect the sibling. 4. Normal; the sibling is affected, too, and anger and guilt are expected feelings. Answer: 4 Explanation: 1. Siblings are generally affected to some degree, but this is a normal reaction. 2. Cancer is not easily treated, and will affect the entire family. 3. A diagnosis of cancer affects the entire family; siblings will be affected to some degree. 4. A diagnosis of cancer affects the whole family, and initial feelings experienced by the sibling might be anger and guilt. Page Ref: 1238 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

11) The nurse is providing care to a pediatric client who is receiving chemotherapy to treat acute lymphocytic leukemia (ALL). For which potential problems should the nurse plan care for this client? Select all that apply. 1. Potential injury 2. Change in skin status 3. Electrolyte imbalances 4. Potential for an infection 5. Change in sleep pattern Answer: 1, 2, 3, 4 Explanation: 1. A pediatric client can sustain an injury due to the potential hemorrhagic cystitis, a common side effect for chemotherapy. 2. A pediatric client is at risk to a change in skin status due to mouth sores, a common early side effect of chemotherapy. 3. The client could experience nausea and vomiting, which would affect the balance of electrolytes. 4. The chemotherapy can suppress the bone marrow, which increases the client's risk for an infection. 5. There is no expected change in sleep pattern for this client. Page Ref: 1232 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 50.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia.

12) Which is the priority nursing intervention for a pediatric client, diagnosed with leukemia, who has a granulocyte count of 250/mm3 and a platelet count of 150,000/mm3? 1. Fluid restriction 2. Mouth care 3. Neutropenic precautions 4. Hand hygiene Answer: 4 Explanation: 1. A fluid restriction is not a priority nursing intervention based on the current data. Fluids should continue to be encouraged. 2. Platelet count is normal; mouth care should include brushing with a soft toothbrush and frequent rinsing. 3. The child should be isolated from anyone infectious, but neutropenic isolation is not necessary. 4. Hand hygiene is vital for preventing the spread of infection. Page Ref: 1233 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.5 Plan care for children and adolescents of all ages who have a diagnosis of leukemia. 13) A child with rhabdomyosarcoma is prescribed radiation therapy after surgical removal of the tumor. Which intervention should the nurse include in the child's plan of care? 1. Apply lotion to the area before radiation therapy. 2. Apply sunscreen to the area when the child is exposed to sunlight. 3. Remove any markings left after each radiation treatment. 4. Vigorously scrub the area when bathing the child. Answer: 2 Explanation: 1. Lotion can increase the chance of a radiation burn when applied before the treatment. 2. Radiation therapy causes the skin in that area to be sensitive. Sunscreen should be applied so that sunburns are avoided. 3. Radiation markings are to guide the radiologist and should not be removed. 4. Vigorous scrubbing is not recommended. Page Ref: 1229 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 50.6 Prioritize elements of comprehensive care planning for children with soft-tissue tumors. 11 Copyright © 2022 Pearson Education, Inc.

14) The child is admitted to the hospital unit newly diagnosed with retinoblastoma. Which clinical manifestation does the nurse anticipate upon assessment? 1. A white reflection 2. Blue-tinged sclerae 3. A red reflex 4. Yellow-tinged sclerae Answer: 1 Explanation: 1. The first sign of retinoblastoma is a white pupil. The red reflex is absent. This is known as leukocoria, or "cat's eye" reflex. 2. Blue-tinged sclerae are a sign of osteogenesis imperfecta, not retinoblastoma. 3. Red reflex is absent in retinoblastoma. 4. Yellow sclerae are a sign of jaundice, not retinoblastoma. Page Ref: 1253 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.6 Prioritize elements of comprehensive care planning for children with soft-tissue tumors. 15) A preschool-age child is being seen in the oncology clinic. Which reaction should the nurse anticipate based on the child's stage of development? 1. Unawareness of the illness and its severity 2. Acceptance, especially if able to discuss the disease with children their own age 3. Understanding of what cancer is, and how it is treated 4. Thoughts that they caused their illness, and are being punished Answer: 4 Explanation: 1. Infants and toddlers are unaware of the severity of the disease. 2. Immediate acceptance will not occur with children of any age. Adolescents find contact with others who have gone through their experience helpful. 3. School-age children can understand a diagnosis of cancer. 4. Preschool-age children are egocentric and have magical thinking, and thus, they might believe they caused their own illness. Page Ref: 1229 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 50.7 Analyze the impact of cancer survival on children and use this information to plan for ongoing physiologic and psychosocial care in the children's futures.

16) A pediatric client diagnosed with cancer is to receive 2 months of chemotherapy that is separated by a 6-week period. The mother asks why the child cannot receive the medication for 2 months straight. Which rationale should the nurse include when responding to the client's mother? 1. Prevention of nausea and vomiting from the drugs 2. Schedule requirement of the infusion center 3. Decrease incidence of heart failure 4. Allows normal cells to repair themselves while the cancer cells die Answer: 4 Explanation: 1. The 6-week break will not decrease the side effects of nausea and vomiting. 2. Necessary treatment should never be delayed for the convenience of the medical personnel. 3. The 6-week break is not to decrease the incidence of heart failure, as this is not an adverse effect to chemotherapy. 4. Cancer cells have lost the ability to repair themselves, so medications allow the normal cells to repair while the cancer cells die. Page Ref: 1222 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures. 17) The parent of a child diagnosed with Ewing sarcoma asks why multiple drugs are needed to treat this cancer. Which rationale should the nurse use when responding to the client's mother? 1. The prescribed drug protocol is needed due to the aggressive nature of the cancer. 2. The prescribed drug protocol decreases side effects. 3. The prescribed drug protocol is used in specifically in children. 4. The prescribed drug protocol involves a group of drugs that work in different modes. Answer: 4 Explanation: 1. A multiple drug protocol is not prescribed due to aggressive nature of Ewing sarcoma. 2. A multiple drug protocol is not prescribed to decrease side effects. 3. A multiple drug protocol is used in both children and adults. 4. A multiple drug protocol is used to attack the cancer cells from all angles. Page Ref: 1236 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.4 Recognize the most common solid tumors in children, describe their treatment, and plan comprehensive nursing care. 13 Copyright © 2022 Pearson Education, Inc.

18) An adolescent female client, diagnosed with osteosarcoma, has a below-the-knee amputation as part of the treatment regimen. Which behavior, assessed by the nurse, indicates the client is beginning to accept the amputation? 1. Complaints of pain in the missing leg. 2. Insists that a prosthetic be applied prior to participating in physical therapy. 3. Insists on covering the lower portion of the body prior to peer visitation. 4. Watches the dressing change. Answer: 4 Explanation: 1. Phantom pain is an expected finding after an amputation; however, this does not indicate acceptance. 2. This indicates she wants to return to mobility but has not yet accepted the stump. 3. Being in a wheelchair with a blanket cover indicates she doesn't want her friends to be aware of her amputation. 4. This indicates the girl is willing to look at the stump, which is a step toward acceptance. Page Ref: 1248 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.6 Prioritize elements of comprehensive care planning for children with soft-tissue tumors.

19) A school-age child, diagnosed with rhabdomyosarcoma, is experiencing nausea and vomiting related to the prescribed chemotherapy in spite of the use of antiemetics. The mother is pushing the child to eat the food. Which statement by the nurse is appropriate to address this situation? 1. "Since your child is receiving IV fluids, it is not important to push oral intake of food." 2. "A food aversion may occur if you continue to force your child to eat." 3. "Emesis that is caused by your child being force-fed can damage the stomach." 4. "A psychological conflict could occur between you and your child if you continue to push eating." Answer: 2 Explanation: 1. Intravenous fluids do not replace normal food intake. 2. If the child is forced to eat and then vomits, the child can develop a food aversion in which the child associates that food with vomiting. 3. Vomiting is unpleasant but does not usually lead to stomach damage. 4. This is not a correct statement. Parents and children often disagree, but the child will still relate to the parent. Page Ref: 1236 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.6 Prioritize elements of comprehensive care planning for children with soft-tissue tumors. 20) The school-age child, diagnosed with a medulloblastoma, will receive intrathecal chemotherapy injections after surgery. Which rationale for this type of chemotherapy administration should the nurse include in the medication teaching? 1. It reduces side effects. 2. It does not require the child being "stuck." 3. Many chemotherapy drugs do not cross the blood-brain barrier. 4. Intrathecal administration is less expensive than intravenous administration. Answer: 3 Explanation: 1. Intrathecal administration does not reduce side effects. 2. Intrathecal administration is through a spinal tap, so the child will be "stuck" for administration. 3. This is correct for the selection of intrathecal administration of chemotherapy. 4. This is not accurate and would not be a reason to change administration modes. Page Ref: 1242 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures. 15 Copyright © 2022 Pearson Education, Inc.

21) The school-age child is admitted to the pediatric neurologic unit with a suspected craniopharyngioma. Which assessment data collected by the nurse supports the suspected diagnosis? Select all that apply. 1. Evening nausea 2. Excessive urination 3. Nystagmus 4. Headaches 5. Orbital ecchymosis Answer: 2, 3, 4 Explanation: 1. Nausea is a common symptom of a brain tumor due to effect on the vomiting center of the brain. However, it occurs primarily in the morning on arising. 2. Diabetes insipidus is common in tumors involving the pituitary gland, such as craniopharyngioma. 3. Nystagmus is a symptom of pressure on the optic nerve chiasm. 4. The headaches may be due to the increased bulk in the cranium and/or the ventricular blockage leading to hydrocephalus. 5. Orbital ecchymosis is seen in neuroblastoma secondary to metastasis to the bone. Page Ref: 1241 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.6 Prioritize elements of comprehensive care planning for children with soft-tissue tumors.

22) Which nursing actions will decrease the risk of extravasation when administering chemotherapy to a pediatric client through a peripheral line? Select all that apply. 1. Ensuring that the intravenous line is a free flowing line 2. Administering the medication by infusion pump 3. Checking for blood return before and during chemotherapy administration 4. Diluting the medication with normal saline 5. Administering the vesicant drug last Answer: 1, 3 Explanation: 1. This is critical, as extravasation is leaking into the tissues. 2. An infusion pump does not ensure that the line is free flowing; this is inappropriate. 3. This checks for intravenous administration and is appropriate. 4. Not all medications can be mixed with normal saline, and this does not protect against extravasation. 5. The vesicant drug should be administered first. Page Ref: 1224 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

23) The nurse is preparing to assist with a lumbar puncture for a pediatric client who is diagnosed with cancer. Which statements should the nurse include in the teaching session for the client and family? Select all that apply. 1. "This procedure assesses the bone marrow." 2. "This procedure assesses cerebrospinal fluid." 3. "This procedure confirms the diagnosis of acute lymphoblastic leukemia." 4. "This procedure determines if malignant cells are affecting the nervous system." 5. "This procedure assesses cellular components of the blood." Answer: 2, 4 Explanation: 1. A bone marrow aspiration, not a lumbar puncture, is used to assess bone marrow. 2. A lumbar puncture is used to assess cerebrospinal fluid. 3. A bone marrow aspiration, not a lumbar puncture, is used to confirm the diagnosis of acute lymphoblastic leukemia. 4. A lumbar puncture is used to assess if malignant cells are affecting the central nervous system. 5. A complete blood count with differential, not a lumbar puncture, is used to assess the cellular components of the blood. Page Ref: 1241 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.2 Synthesize information about diagnostic tests and clinical therapy for cancer to plan comprehensive care for children undergoing these procedures.

24) Which assessment findings, indicative of a hematologic emergency, should the nurse report to the healthcare provider due to the need for immediate intervention? Select all that apply. 1. Anemia 2. Thrombocytopenia 3. Disseminated intravascular coagulation 4. Cardiac arrhythmias 5. Tetany Answer: 1, 2, 3 Explanation: 1. Anemia is a clinical manifestation associated with a hematologic emergency necessitating the need for immediate intervention. 2. Thrombocytopenia is a clinical manifestation associated with a hematologic emergency necessitating the need for immediate intervention. 3. Disseminated intravascular coagulation is a clinical manifestation associated with a hematologic emergency necessitating the need for immediate intervention. 4. Cardiac arrhythmias are associated with metabolic, not hematologic, emergencies. 5. Tetany is associated with metabolic, not hematologic, emergencies. Page Ref: 1227 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

25) Which pediatric cancer diagnoses necessitate priority assessment by the nurses for clinical manifestations associated with emergencies related to space-occupying lesions? Select all that apply. 1. Hodgkin disease 2. Leukemia 3. Neuroblastoma 4. Melanoma 5. Lymphoma Answer: 1, 3, 5 Explanation: 1. A pediatric client diagnosed with Hodgkin disease is at risk for emergencies related to space-occupying lesions. 2. Leukemia is not a pediatric cancer associated with emergencies related to space-occupying lesions. 3. A pediatric client diagnosed with neuroblastoma is at risk for emergencies related to spaceoccupying lesions. 4. Melanoma is not a pediatric cancer associated with emergencies related to space-occupying lesions. 5. A pediatric client diagnosed with lymphoma is at risk for emergencies related to spaceoccupying lesions. Page Ref: 1228 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 50.3 Integrate information about oncologic emergencies into plans for monitoring all children with cancer.

26) The nurse is providing care to a pediatric client who will require surgery as a portion of the treatment regimen. Which topics should the nurse include in the teaching session related to longterm ramifications associated with this treatment option? 1. Scoliosis 2. Adhesions 3. Hypothyroidism 4. Visual impairment 5. Cardiotoxicity Answer: 2, 4 Explanation: 1. Scoliosis is a long-term ramification associated with radiation, not surgical, intervention for cancer. 2. Adhesions are a long-term ramification associated with surgical intervention for cancer. 3. Hypothyroidism is a long-term ramification associated with radiation, not surgical, intervention for cancer. 4. Visual impairment is a long-term ramification associated with surgical intervention for cancer. 5. Cardiotoxicity is a long-term ramification associated with radiation, not surgical, intervention for cancer. Page Ref: 1231 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.7 Analyze the impact of cancer survival on children and use this information to plan for ongoing physiologic and psychosocial care in the children's futures.

27) The nurse is providing care to a pediatric client who will require radiation as a portion of the treatment regimen. Which topics should the nurse include in the teaching session related to longterm ramifications associated with this treatment option? 1. Scoliosis 2. Adhesions 3. Hypothyroidism 4. Visual impairment 5. Cardiotoxicity Answer: 1, 3, 5 Explanation: 1. Scoliosis is a long-term ramification associated with radiation treatment for cancer. 2. Adhesions are a long-term ramification associated with surgical intervention, not radiation treatment, for cancer. 3. Hypothyroidism is a long-term ramification associated with radiation treatment for cancer. 4. Visual impairment is a long-term ramification associated with surgical intervention, not radiation treatment, for cancer. 5. Cardiotoxicity is a long-term ramification associated with radiation treatment for cancer. Page Ref: 1232 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 50.7 Analyze the impact of cancer survival on children and use this information to plan for ongoing physiologic and psychosocial care in the children's futures.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 51 The Child with Alterations in Gastrointestinal Function 1) The nurse is providing care to a pediatric client, diagnosed with inflammatory bowel disease, who is prescribed daily prednisone. Which parental statement regarding administration of this drug indicates correct understanding of the teaching provided by the nurse? 1. "I will administer this medication between meals." 2. "I will administer this medication at bedtime." 3. "I will administer this medication one hour before meals." 4. "I will administer this medication with meals." Answer: 4 Explanation: 1. Prednisone can cause gastric irritation and should not be given on an empty stomach. 2. Prednisone can cause gastric irritation and should not be given before bedtime on an empty stomach. 3. Prednisone can cause gastric irritation and should not be given on an empty stomach one hour before meals. 4. Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

2) Which assessment data would cause the nurse to suspect that a 3-year-old child has Hirschsprung disease? 1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period 3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea Answer: 3 Explanation: 1. Clay-colored stools and dark urine are not associated with Hirschsprung disease. 2. The infant with Hirschsprung disease often has delayed meconium stools. 3. These are symptoms of Hirschsprung disease in an older infant or child. 4. Diarrhea is not typical; obstruction is more likely. Page Ref: 1270 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 51.3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system. 3) An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data? 1. Necrotizing enterocolitis (NEC) 2. Ulcerative colitis (UC) 3. Crohn disease 4. Appendicitis Answer: 2 Explanation: 1. NEC is usually seen in premature infants and generally not in an adolescent client. 2. Diarrhea and bloody stools are typical symptoms of UC. 3. The teen with Crohn disease might have abdominal pain and diarrhea, but stools usually do not have blood in them. 4. Appendicitis is not associated with bloody stools and usually not with diarrhea. Page Ref: 1277 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 51.3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system.

4) The nurse is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate? 1. Measuring the girth just below the umbilicus 2. Measuring the girth just below the sternum 3. Measuring the girth just above the pubic bone 4. Measuring the girth around the portion of the stomach Answer: 4 Explanation: 1. The circumference below the umbilicus would not be an accurate abdominal girth. 2. The circumference just below the sternum would not be an accurate abdominal girth. 3. The circumference just above the pubic bone would not be an accurate abdominal girth. 4. An abdominal girth should be taken around the largest circumference of the abdomen, just above the umbilicus. Page Ref: 1260 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

5) Which is the priority problem when planning care for a newborn who is born with esophageal atresia and tracheoesophageal fistula? 1. Poor tissue perfusion 2. Problems with feeding 3. Pain 4. Potential for aspiration Answer: 4 Explanation: 1. Tissue perfusion is not a primary problem with this condition. 2. The infant is always kept NPO (nothing by mouth) preoperatively, so problems with feeding would not apply. 3. Pain is not usually experienced preoperatively with this condition. 4. This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea. Page Ref: 1264 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

6) A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data? 1. Placing the newborn on a radiant warmer 2. Placing the newborn in an open crib 3. Preparing the newborn for phototherapy 4. Preparing the newborn for a bottle-feeding Answer: 1 Explanation: 1. Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The newborn loses heat through the viscera; a warmer is indicated to prevent hypothermia. 2. The crib would not provide adequate maintenance of temperature control. 3. Phototherapy is used to treat hyperbilirubinemia, not an omphalocele defect. 4. The newborn will require surgical correction of the defect prior to initiating bottle-feeding or breastfeeding. Page Ref: 1268 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

7) The nurse is planning care for a school-age client who is postoperative for the surgical removal of the appendix. In addition to pharmacologic pain management, which should the nurse include in the plan of care to address pain? 1. Applying a warm, moist pack every 4 hours 2. Applying EMLA cream to the incision site prior to ambulation 3. Applying a cold, moist pack every 2 hours 4. Applying a pillow against the abdomen to splint the incision site when coughing Answer: 4 Explanation: 1. Heat and moisture are not used on the incision area, as they can impair the healing process of the wound. 2. EMLA cream is a medication that requires a prescription. 3. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. 4. A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy. Page Ref: 1276 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management.

8) Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client? 1. "We will change the colostomy bag with each wet diaper." 2. "We will expect a moderate amount of bleeding after cleansing the area around the stoma." 3. "We will watch for skin irritation around the stoma." 4. "We will use adhesive enhancers when we change the bag." Answer: 3 Explanation: 1. Physical or chemical skin irritation can occur if the appliance is changed too frequently, or with each wet diaper. 2. Bleeding is usually attributable to excessive cleaning. 3. Skin irritation around the stoma should be assessed; it could indicate leakage. 4. Adhesive enhancers should be avoided on the skin of infants. Their skin layers are thin, and removal of the appliance can strip off the skin. Page Ref: 1273 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 51.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population. 9) A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse have on hand for the delivery? 1. Bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Endotracheal tube Answer: 4 Explanation: 1. A bag-valve-mask system, or Ambu bag, could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing. 2. The defect is not external, so sterile gauze and saline are not needed. 3. Soft arm restraints might be necessary but at are not an immediate concern. 4. A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized. Page Ref: 1272 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 51.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population. 7 Copyright © 2022 Pearson Education, Inc.

10) A child returns from exploratory surgery following a gunshot wound to the abdomen. Which nursing intervention should be excluded for the plan of care? 1. Immediate initiation of oral feedings 2. Assessment of the surgical site 3. Administration of opioid narcotics for pain management 4. Visitation at the bedside Answer: 1 Explanation: 1. The child will be NPO after an exploratory abdominal surgery. The nurse should exclude this from the child's plan of care. 2. The surgical site must be visualized frequently for bleeding. 3. Pain management is essential and opioid analgesics are often necessary after exploratory surgery. 4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up. Page Ref: 1291 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 51.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

11) A neonate is born with a bilateral cleft lip that was not detected during the pregnancy. The parents are distressed about the appearance of their infant. Which nursing actions are appropriate to assist the parents to bond with their newborn? Select all that apply. 1. Calling the newborn by the chosen name 2. Keeping the newborn's lower face covered with the blanket 3. Smiling and talking to the newborn in the parents' presence 4. Showing the parents before and after pictures of other children with cleft lips 5. Discussing positive features of the baby Answer: 1, 3, 4, 5 Explanation: 1. This behavior humanizes the child to the parents and is appropriate. 2. This indicates that the infant's appearance is distressing. Although the nurse would want to shield the child from a visitor's stare, the nurse would not want to hide the child from her own family. 3. This indicates acceptance of the infant by the nurse. 4. It is usually not appropriate to show before and after pictures as you cannot predict the success of the surgery on this child. But in the case of cleft lip, the improvement will be significant, and it is considered acceptable to show before and after pictures. 5. Statements like, "Your baby is the sweetest thing–she never cries," can help the parents recognize positive features about their baby. Page Ref: 1261 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population.

12) The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate? 1. Position the newborn in semi-Fowler position. 2. Allow the newborn to be taken to the mother's room for bonding. 3. Offer the newborn formula feeding instead of breastfeeding. 4. Wrap the newborn in blankets, and place in a crib by the viewing window. Answer: 1 Explanation: 1. This will reduce stomach juices from being aspirated into the lungs. 2. Because an anomaly is suspected, the newborn should remain under visualization until the diagnosis is confirmed and medical orders determined. 3. If an EA/TE fistula is suspected, the feeding should be withheld until the diagnosis is confirmed or cleared. 4. A newborn wrapped in blankets cannot be observed clearly. The child should be placed in an over-bed warmer. Page Ref: 1264 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management. 13) A nasogastric tube to suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate? 1. Weight loss 2. Metabolic alkalosis 3. Dehydration 4. Hyperbilirubinemia Answer: 2 Explanation: 1. Weight loss and inadequate nutrition are not the priority for this client. 2. When large quantities of gastric juice is removed, acid is lost and metabolic alkalosis follows. 3. The volume would not be sufficient to cause dehydration. 4. Hyperbilirubinemia is unrelated to gastric suction. Page Ref: 1264 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 51.3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system. 10 Copyright © 2022 Pearson Education, Inc.

14) Which statements, made by the adolescent following dietary teaching for Crohn disease, indicate correct understanding of the content presented by the nurse? Select all that apply. 1. "I can promote solid stools by increasing fiber in my diet." 2. "Small, frequent meals are preferred over three meals a day." 3. "I should identify foods that cause distress, and eliminate them from my diet." 4. "High-calorie dietary supplement shakes can help me to meet my nutritional requirements." 5. "Socialization during my meal times is important even if my parents do not agree with my food choices." Answer: 2, 3, 4 Explanation: 1. Fiber should be decreased, not increased, as diarrhea is one of the symptoms of Crohn disease. 2. This is correct information. 3. This is individualizing the diet and is appropriate. 4. This addition provides an easy way to meet the nutritional needs. 5. Stress should be avoided at mealtimes. Page Ref: 1279 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 51.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population. 15) Which parental action, observed during a home care visit for an infant diagnosed with gastroesophageal reflux, requires intervention by the nurse? 1. The infant's formula has rice cereal added. 2. The mother holds the infant in a high Fowler position while feeding. 3. After feeding, the infant is placed in a car seat. 4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration. Answer: 3 Explanation: 1. Rice cereal thickens the formula and helps prevent regurgitation. This is appropriate. 2. This position will help prevent regurgitation and is appropriate. 3. Infant seats are not recommended, as they put pressure on the abdomen and may contribute to regurgitation. 4. Since dosing is small, it is appropriate to use a syringe for accurate measurement. Page Ref: 1267 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 51.5 Analyze developmentally appropriate approaches for nursing management of gastrointestinal disorders in the pediatric population. 11 Copyright © 2022 Pearson Education, Inc.

16) Which is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery? 1. Placing the infant feet first into a bowel bag 2. Wrapping the newborn warmly in two or three blankets 3. Providing sterile water feeding to maintain hydration during transport 4. Allowing the parents of the newborn to see their child prior to transport Answer: 1 Explanation: 1. It is important to keep the intestine from drying during transport. 2. Placement in a transport isolette would be preferred to wrapping due to the nature of the birth defect. 3. The newborn should be NPO. 4. While it is important for the parents to see their child before transport, this is not the priority nursing intervention. Page Ref: 1268 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management. 17) A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question? 1. Clear liquids today. NPO tomorrow. 2. Type and cross-match for 1 unit of packed red blood cells. 3. Check rectal temperatures every 4 hours. 4. Start an intravenous line with D5NS at 20 mL per hour. Answer: 3 Explanation: 1. This is appropriate in anticipation of surgery. 2. Although not always required during surgery, this would not be inappropriate planning for the surgical procedure. 3. Rectal temperatures are avoided due to the fragile state of the rectum. 4. An IV is appropriate for surgical access. Page Ref: 1271 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 51.4 Contrast nursing management and plan care for disorders of the gastrointestinal system for the child needing abdominal surgery versus the child needing nonoperative management. 12 Copyright © 2022 Pearson Education, Inc.

18) Which gastrointestinal defects, often diagnosed shortly after birth, should the nurse include in the assessment process of all newborns? Select all that apply. 1. Pyloric stenosis 2. Biliary atresia 3. Hirschsprung disease 4. Umbilical hernia 5. Diaphragmatic hernia Answer: 3, 5 Explanation: 1. Pyloric stenosis is not diagnosed in the newborn nursery, but in the 2- to 4week-old infant. 2. Symptoms of biliary atresia would not be observable until several weeks of age. 3. Symptoms of Hirschsprung disease may be observable in the newborn nursery. 4. Umbilical hernia cannot be diagnosed at birth. 5. Diaphragmatic hernia will show symptoms immediately after birth due to compression of the lung. Page Ref: 1270, 1272 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 51.3 Identify signs and symptoms that may indicate a disorder of the gastrointestinal system.

19) The nurse is providing care to a newborn client who presents in the pediatric clinic for a 2week health maintenance visit. The parents of the newborn are concerned, as their baby has "gas all the time." Which responses from the nurse are appropriate? Select all that apply. 1. "Your baby has a relaxed lower esophageal sphincter, which is causing the gas." 2. "Your baby lacks the enzyme amylase, which is causing the gas." 3. "Your baby lacks the enzyme insulin, which is causing the gas." 4. "Your baby has an immature liver, which is causing the gas." 5. "Your baby lacks an enzyme that helps to digest fats, which is causing the gas." Answer: 2, 5 Explanation: 1. Newborns and infants do have a relaxed lower esophageal sphincter; however, this is not responsible for gas but for frequent regurgitation of small amounts of oral feedings. 2. Newborns and infants lack several enzymes that assist with the digestive process. One of these enzymes is amylase, which assists with carbohydrate digestion. The lack of this enzyme causes abdominal distention due to gas. 3. Insulin is not an enzyme and is not lacking in the newborn. 4. While newborns and infants do have immature livers, that is not what is causing the gas. 5. Lipase is a digestive enzyme that assists in fat digestion. Infants and newborns do lack this enzyme, which would cause abdominal distention due to gas. Page Ref: 1259 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.1 Describe the general function of the gastrointestinal system.

20) Which statements should the nurse include in a presentation related to the general function of the gastrointestinal (GI) system for parents of pediatric clients? Select all that apply. 1. "The GI tract is responsible for the ingestion and absorption of food." 2. "Newborns have smaller stomachs but increased peristalsis." 3. "All children require smaller, more frequent feedings." 4. "Infants lack certain digestive enzymes which increases the risk for regurgitation." 5. "By the second year of life a child is able to accommodate three meals each day." Answer: 1, 2, 5 Explanation: 1. This statement is correct. The GI system is responsible for the ingestion and absorption of food. 2. This statement is correct. Newborns have smaller stomachs but an increased rate of peristalsis. 3. This statement is false. All children do not require smaller, more frequent feedings. This statement is true for newborns and infants. 4. This statement is false. While infants do lack certain digestive enzymes, this does not increase regurgitation but causes abdominal distention due to gas. 5. This statement is true. By the second year of life, children are able to accommodate three meals each day. Page Ref: 1259 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.1 Describe the general function of the gastrointestinal system.

21) Which are the leading causes of pediatric abdominal injuries for which the nurse should provide client teaching during scheduled health maintenance visits? Select all that apply. 1. Motor vehicle crashes 2. Falls 3. Blunt trauma 4. Stabbing 5. Impalement Answer: 1, 2, 3 Explanation: 1. Motor vehicle crashes are a leading cause of pediatric abdominal injuries. The nurse should provide education related to proper use of seat belts during health maintenance visits to decrease the incidence of abdominal injuries. 2. Falls are a leading cause of pediatric abdominal injuries. The nurse should include education regarding age-appropriate pediatric fall prevention during health maintenance visits. 3. Blunt trauma is a leading cause of pediatric abdominal injuries. The nurse should include prevention strategies during health maintenance visits. 4. While stabbing can cause abdominal injury, this is not a common cause in the pediatric population. 5. While impalement can cause abdominal injury, this is not a common cause in the pediatric population. Page Ref: 1291 Cognitive Level: Understanding Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.6 Plan nursing care for the child with an injury to the gastrointestinal system.

22) Which topics should the nurse include in discharge instructions related to enhanced safety for a pediatric client who experienced an abdominal injury after a biking accident? Select all that apply. 1. Use of hand signals 2. Age-appropriate use of child safety seats 3. Age-appropriate bicycles 4. Use of a helmet 5. Avoid assigning blame Answer: 1, 3, 4 Explanation: 1. Information related to appropriate hand signals when riding a bicycle is an injury prevention strategy that the nurse should include in the teaching session. 2. The use of an age-appropriate child safety seat is not an appropriate discharge instruction for a child who experienced an abdominal injury after a biking accident. 3. Information related to an age-appropriate bicycle is an injury prevention strategy that the nurse should include in the teaching session. 4. Information related to the use of a helmet is an injury prevention strategy that the nurse should include in the teaching session. 5. While the nurse should avoid assigning blame when providing care for a child who experienced an abdominal injury as a result of a biking accident, this is not an appropriate injury prevention topic to include in the discharge teaching session. Page Ref: 1292 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 51.6 Plan nursing care for the child with an injury to the gastrointestinal system.

23) Which factors in the maternal medical history should cause the nurse concern regarding the development of cleft lip or cleft palate during pregnancy? Select all that apply. 1. Cigarette smoking 2. Alcohol use 3. Excessive folate intake 4. Glucocorticoid use 5. Anticoagulant use Answer: 1, 2, 4 Explanation: 1. Cigarette smoking during pregnancy is a risk factor for cleft lip and cleft palate. 2. Alcohol use during pregnancy is a risk factor for cleft lip and cleft palate. 3. Excessive folate intake is not a risk factor for cleft lip and cleft palate. A folate deficiency is often the cause for these disorders. 4. Glucocorticoid use is a risk factor for cleft lip and cleft palate. 5. Anticoagulant use is not a risk factor for cleft lip and cleft palate. Page Ref: 1260 Cognitive Level: Understanding Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 51.2 Discuss the pathophysiologic processes associated with specific gastrointestinal disorders in the pediatric population.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 52 The Child with Alterations in Genitourinary Function 1) Which clinical manifestations should the nurse anticipate when assessing a child with minimal change nephrotic syndrome (MCNS)? 1. Massive proteinuria, hypoalbuminemia, and edema 2. Hematuria, bacteriuria, and weight gain 3. Urine specific gravity decreased and urinary output increased 4. Gross hematuria, albuminuria, and fever Answer: 1 Explanation: 1. Nephrotic syndrome is an alteration in kidney function secondary to increased glomerular basement membrane permeability to plasma protein. It is characterized by massive proteinuria, hypoalbuminemia, and edema. 2. Bacteriuria and fever are associated with a urinary tract infection. Because of the edema, a weight gain, not a weight loss, would be seen. 3. In MCNS, the urine output decreases and the specific gravity of urine increases. 4. Gross hematuria and hypertension are associated with glomerulonephritis. Page Ref: 1305 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

2) Which is the appropriate nursing intervention when providing care to a child, diagnosed with nephrotic syndrome, who is edematous and on bed rest? 1. Monitor blood pressure every 30 minutes. 2. Reposition every 2 hours. 3. Limit visitors. 4. Encourage fluids. Answer: 2 Explanation: 1. Vital signs are taken every 4 hours. 2. A child with severe edema, on bed rest, is at risk for altered skin integrity. To prevent skin breakdown, the child should be repositioned every 2 hours. 3. The child needs social interaction, so visitors should not be limited. 4. Fluids need to be monitored; they should not be encouraged. Page Ref: 1308 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 52.6 Plan nursing care for the child with acute kidney injury and chronic kidney disease. 3) Which urinalysis result should the nurse anticipate for a child who is admitted with acute glomerulonephritis? 1. Bacteriuria and increased specific gravity 2. Hematuria and proteinuria 3. Proteinuria and decreased specific gravity 4. Bacteriuria and hematuria Answer: 2 Explanation: 1. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present. But because the urine is concentrated, the specific gravity is increased. 2. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. The clinical manifestation of glomerulonephritis is grossly bloody hematuria with mild to moderate proteinuria, and because the urine is concentrated, the specific gravity is increased. 3. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Because the urine is concentrated, the specific gravity is increased. 4. Glomerulonephritis is an inflammation of the glomeruli of the kidneys. Bacteriuria is not present. Page Ref: 1312, 1322 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population. 2 Copyright © 2022 Pearson Education, Inc.

4) A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN) and is admitted to the hospital. Which problem would be a priority for this client? 1. Monitor for hypertension 2. Noncompliance with medications 3. Fatigue 4. Weight gain Answer: 1 Explanation: 1. The child with APIGN has marked hypertension, which can lead to cardiac failure and cerebral injuries. 2. There is no evidence that the child would be noncompliant with medications. 3. Fatigue is not a major problem. 4. Weight gain would be caused by fluid retention. Page Ref: 1310 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 52.1 Describe the pathophysiologic processes associated with genitourinary disorders in the pediatric population.

5) Which laboratory tests should the nurse prepare to monitor in a pediatric client with possible obstructive uropathy? Select all that apply. 1. Platelet count 2. Blood urea nitrogen (BUN) 3. Partial thromboplastin time (PTT) 4. Blood culture 5. Creatinine Answer: 2, 5 Explanation: 1. Platelet count is drawn when a bleeding disorder is suspected. 2. BUN is a serum laboratory test for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the BUN will be elevated. 3. PTT is drawn when a bleeding disorder is suspected. 4. A blood culture is done when an infectious process is suspected. 5. Creatinine is a serum laboratory test for kidney function. Obstructive uropathy is a structural or functional abnormality of the urinary system that interferes with urine flow and results in urine backflow into the kidneys; therefore, the creatinine will be elevated. Page Ref: 1302 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.3 Discuss the nursing management of a child with a structural defect of the genitourinary system.

6) Which clinical manifestations should the nurse anticipate upon assessment for a preschool-age child with a urinary tract infection (UTI)? 1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure (BP), and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache Answer: 3 Explanation: 1. Hematuria might be present, but there will be no complaints of headache or vertigo. 2. While foul-smelling urine and hematuria can be present, there is no elevated BP, headache, or vertigo. 3. Clinical manifestations of UTI in a preschool-age child include fever, urgency, and dysuria. 4. There could be flank pain, although the preschooler might be unable to describe it. There will be no complaints of headache. Page Ref: 1298 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.2 Develop a nursing care plan for the child with a urinary tract infection. 7) The nurse is preparing medication instruction for a child who has undergone a kidney transplant and is prescribed cyclosporine. The parents ask the nurse about the reason for the cyclosporine. Which rationale for this medication should the nurse include in the response? 1. Suppress rejection. 2. Decrease pain. 3. Improve circulation. 4. Boost immunity. Answer: 1 Explanation: 1. Cyclosporine is given to suppress rejection. 2. Cyclosporine does not decrease pain. 3. Cyclosporine does not affect circulation. 4. Cyclosporine does not boost immunity. Page Ref: 1321 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 52.6 Plan nursing care for the child with acute kidney injury and chronic kidney disease.

8) Which menu choices for a child who is diagnosed with renal failure and experiencing hyperkalemia indicate the need for further instruction by the nurse? 1. Carrots and green, leafy vegetables 2. Spaghetti and meat sauce with breadsticks 3. Hamburger on a bun and cherry gelatin 4. Chips, cold cuts, and canned foods Answer: 1 Explanation: 1. Carrots and green, leafy vegetables are high in potassium. 2. Spaghetti and meat sauce with breadsticks would be acceptable choices for a low-potassium diet. 3. Hamburger on a bun with cherry gelatin would be acceptable choices for a low-potassium diet. 4. Chips, cold cuts, and canned foods are high in sodium but not necessarily in potassium. Page Ref: 1321 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 52.4 Outline a plan to meet the fluid and dietary restrictions for the child with a renal disorder. 9) Which parental statement indicates understanding of the process involved with a kidney transplant for a child with renal failure? 1. "We are happy our child will not have to take any more medicine after the transplant." 2. "We understand our child will not be at risk anymore for catching colds from other children at school." 3. "We will be glad we will not have to bring our child in to see the doctor again." 4. "We know it is important to see that our child takes prescribed medications after the transplant." Answer: 4 Explanation: 1. Medications and general health promotion will be necessary. 2. The child will be on immunosuppressing drugs and will be at increased risk for colds and other illnesses. 3. Follow-up appointments will be necessary, as well as medications and general health promotion. 4. It is important that the nurse emphasizes compliance with treatments that will need to be followed after the transplant. Page Ref: 1321 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 52.7 Summarize psychosocial issues for the child requiring surgery on the genitourinary system. 6 Copyright © 2022 Pearson Education, Inc.

10) Which complications should the nurse monitor for when providing care to a child who is having hemodialysis for the treatment of kidney failure? Select all that apply. 1. Migraines 2. Hypotension 3. Infections 4. Fluid overload 5. Shock Answer: 2, 3, 5 Explanation: 1. Migraines are not a clinical manifestation associated with hemodialysis. 2. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to hypotension. 3. Infection is another complication that may occur during hemodialysis. 4. Fluid overload is not a clinical manifestation associated with hemodialysis. 5. Rapid changes in fluid and electrolyte balance during hemodialysis can lead to shock. Page Ref: 1321 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.6 Plan nursing care for the child with acute kidney injury and chronic kidney disease. 11) Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent? 1. Bloody urine 2. One void since returning from surgery 3. Bladder spasms responding to pharmacologic intervention 4. Double diapering from the previous shift Answer: 2 Explanation: 1. Bloody urine is expected in the immediate postoperative period. 2. A 10-month-old child will void more often than 1 time in 4 hours. This could indicate the stent is occluded. The surgeon should be notified. 3. This is a normal finding. 4. This is a desired finding and does not need to be reported to the surgeon. Page Ref: 1302 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.3 Discuss the nursing management of a child with a structural defect of the genitourinary system.

12) Which risks of undescended testes should the nurse include in the teaching session for the parents of a newborn diagnosed with this condition? Select all that apply. 1. Sperm production will be affected after puberty. 2. Abdominal testes are subject to injury. 3. Abdominal testes have a higher risk of developing cancer. 4. Hormonal production will be affected. 5. The testes are at greater risk of torsion. Answer: 1, 2, 3, 5 Explanation: 1. Sperm production by abdominal testes is affected by the heat of the body. 2. Positioning of the testes in the scrotum reduces the risk of injury. 3. Statistics have shown this statement is correct. 4. Production of hormones is not affected by the location of the testes. 5. Abdominal testes have a higher risk of twisting on its blood supply. Page Ref: 1323 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 52.7 Summarize psychosocial issues for the child requiring surgery on the genitourinary system. 13) Which assessment finding, after the dialysate is drained during peritoneal dialysis for a child experiencing acute renal failure, would warrant further action by the nurse? 1. The dialysate is clear on return. 2. The volume of drained dialysate is less than the volume infused. 3. The child is restless, wanting to get up and play. 4. The child's vital signs are basically the same as were noted on infusion. Answer: 2 Explanation: 1. This is a normal finding and does not require reporting. 2. This indicates fluids are being retained and is not desirable. The healthcare provider should be notified. 3. This could indicate the child is feeling better. It is a desired effect and does not require reporting to the healthcare provider. 4. This is an expected finding. No dramatic differences in vital signs should be noted. Page Ref: 1319 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.6 Plan nursing care for the child with acute kidney injury and chronic kidney disease.

14) Which instructions should be provided to the parents of a 4-year-old girl who has experienced chronic urinary tract infections (UTIs) in the last 2 years? Select all that apply. 1. Wear only nylon underwear for better airflow. 2. Teach the child to wipe from front to back. 3. Encourage the child to take long baths by allowing the child bubbles and toys in the tub. 4. Encourage the child to drink additional fluids throughout the day. 5. Plan potty breaks every 2 hours throughout the day. Answer: 2, 4, 5 Explanation: 1. The child should wear cotton underwear. 2. This prevents bacteria from the rectum from being introduced into the urethra. 3. Bubble baths should be avoided. 4. Extra fluids will "wash" bacteria out of the bladder. 5. Children get so involved in playing that they often hold their urine. Voiding every 2 hours will reduce the time for bacteria to grow in the bladder. Page Ref: 1300 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 52.2 Develop a nursing care plan for the child with a urinary tract infection. 15) Which is the priority nursing intervention when caring for a neonate who is born with bladder exstrophy? 1. Measuring intake and output 2. Inserting a Foley catheter 3. Covering the defect with sterile plastic wrap 4. Palpating the bladder mass to ensure urine is expelled Answer: 3 Explanation: 1. Because the bladder constantly drains onto the skin of the abdomen, measuring output is not possible. 2. The bladder is open to the abdomen. A Foley catheter cannot be inserted. 3. This reduces the contamination of the bladder, which should be sterile. 4. The bladder is very sensitive and palpation would cause unnecessary pain. Page Ref: 1300 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 52.3 Discuss the nursing management of a child with a structural defect of the genitourinary system.

16) Which clean-catch urinalysis finding should the nurse be most concerned for a child who is admitted to an urgent care center to rule out a urinary tract infection? 1. 2+ white blood cells 2. 1+ red blood cells 3. Urine appearance: cloudy 4. Specific gravity: 1.009 Answer: 4 Explanation: 1. White blood cells are expected. 2. Red blood cells are common in the urine of a child with a urinary tract infection. 3. With white blood cells in the urine, this is a common finding. 4. This is very dilute urine. With white blood cells (WBCs), red blood cells (RBCs), and bacteria in the urine, you would expect the urine to contain more solutes. Page Ref: 1313 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.2 Develop a nursing care plan for the child with a urinary tract infection.

17) Which assessment questions should the nurse include in the psychosocial assessment to determine the effects of chronic renal failure treatments on the growth and development of a school-age child? Select all that apply. 1. "How does it make you feel to have to follow a special diet?" 2. "Do you take your medications every day?" 3. "How does it make you feel to undergo dialysis treatments?" 4. "Do you attend school each day?" 5. "How does it make you feel when your parents come home late from work?" Answer: 1, 3 Explanation: 1. School-age children are often embarrassed about being seen as different from peers. It is appropriate for the nurse to ask the child how it feels to have to follow a special diet. 2. While it is important to assess medication use, this question is not appropriate for the psychosocial portion of the assessment. 3. School-age children are often embarrassed about being seen as different from peers. It is appropriate for the nurse to ask the child how it feels to have to undergo dialysis treatments. 4. While it is important to determine if the child attends school every day, this question is not appropriate for the psychosocial portion of the assessment. 5. This question will not help the nurse to determine the effects of the treatments for chronic renal failure on the child's growth and development. Page Ref: 1316 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.5 Identify growth and developmental issues for the child with chronic kidney disease.

18) Which actions should the nurse implement when assessing the physical growth for a child who is diagnosed with chronic renal failure? Select all that apply. 1. Asking the child to step on the scale 2. Measuring the child's height 3. Measuring the child's head circumference 4. Using the Denver II with the child 5. Monitoring the child's blood pressure Answer: 1, 2, 3 Explanation: 1. Weight is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 2. Height is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 3. Head circumference is a physical growth assessment parameter the nurse uses for a child diagnosed with chronic renal failure. 4. The Denver II is a developmental assessment tool. It is not used to assess physical growth. 5. Blood pressure is not a criterion used to measure physical growth. Page Ref: 1317 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.5 Identify growth and developmental issues for the child with chronic kidney disease.

19) Which nursing actions are appropriate to assess growth and development for an adolescent client diagnosed with chronic renal failure? Select all that apply. 1. Using the Denver II during a health maintenance visit 2. Educating parents on normal milestones 3. Monitoring for delayed sexual maturation 4. Comparing blood pressure values from previous visit 5. Plotting height and weight measurements Answer: 1, 3, 5 Explanation: 1. The Denver II is a developmental assessment tool that is appropriate for the nurse to use when assessing growth and development for an adolescent client diagnosed with chronic renal failure. 2. It is appropriate for the nurse to educate the client's parents on normal milestones; however, this is not a nursing assessment. 3. Monitoring for delayed sexual maturation is appropriate when assessing growth and development for an adolescent client diagnosed with chronic renal failure. 4. Blood pressure is not a growth and development parameter. 5. Plotting height and weight measurements is an appropriate nursing action to assess growth and development for an adolescent client diagnosed with chronic renal failure. Page Ref: 1317 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 52.5 Identify growth and developmental issues for the child with chronic kidney disease.

20) Which nutritional interventions should the nurse include in the plan of care for a pediatric client who is receiving peritoneal dialysis in the treatment of chronic renal failure? Select all that apply. 1. Provide small, frequent meals. 2. Avoid battles over nutritional intake. 3. Administer supplements by tube feedings, if needed. 4. Implement hand hygiene frequently. 5. Perform daily catheter site care. Answer: 1, 2, 3 Explanation: 1. The child will feel full with smaller amounts of food because of the dialysate. 2. The child will be more inclined to eat if there is less stress. 3. Adequate nutrition is important for growth and development, and must be supported if oral intake is inadequate. 4. This intervention is appropriate to prevent infection; it is not a nutritional intervention. 5. This intervention is appropriate to prevent infection; it is not a nutritional intervention. Page Ref: 1320 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 52.6 Plan nursing care for the child with acute kidney injury and chronic kidney disease.

21) Which interventions should the nurse include in the plan of care for a pediatric client who is receiving peritoneal dialysis in the treatment of chronic renal failure to prevent infection? Select all that apply. 1. Provide small, frequent meals. 2. Avoid battles over nutritional intake. 3. Administer supplements by tube feedings, if needed. 4. Implement hand hygiene frequently. 5. Perform daily catheter site care. Answer: 3, 4 Explanation: 1. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 2. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 3. This intervention is appropriate to meet the child's nutritional needs; however, this will not prevent infection. 4. Aseptic technique reduces chance of introducing bacteria into the abdomen. 5. Skin around the catheter site will have fewer organisms that could potentially cause infection. Page Ref: 1320 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 52.6 Plan nursing care for the child with acute kidney injury and chronic kidney disease.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 53 The Child with Alterations in Endocrine Function 1) The home health nurse is visiting a 3-month-old infant who is diagnosed with congenital hypothyroidism and is prescribed daily levothyroxine. Which should the nurse include in the infant's continued plan of care? 1. Stopping the medication as long as the child continues to grow 2. Preventing hypothermia with appropriate clothing 3. Changing formula because it is contraindicated with prescribed medication 4. Monitoring growth and development without any other prescribed interventions Answer: 2 Explanation: 1. The medication should not be stopped without discussing with the healthcare provider. 2. The parents should be cautioned to dress the child appropriately to prevent hypothermia. 3. The healthcare provider should be contacted about the choice of formula. 4. The child may have additional health problems because of the condition and may need additional prescribed interventions. Page Ref: 1337 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.4 Prioritize nursing care for each type of acquired metabolic disorder.

2) The nurse is providing information to an adolescent newly diagnosed with diabetes. Which clinical manifestations of diabetic ketoacidosis (DKA) should the nurse include in the teaching session? Select all that apply. 1. Change in mental status 2. Tachycardia 3. Fruity breath odor 4. Rapid, shallow respirations 5. Abdominal pain Answer: 1, 2, 3, 4, 5 Explanation: 1. A change in mental state can be associated with DKA. 2. Tachycardia is associated with DKA 3. A fruity breath odor is common when the client is in a state of ketoacidosis. 4. Kussmaul respirations is a deep, rapid breathing pattern is commonly seen in DKA. 5. Abdominal pain is commonly seen with DKA. Page Ref: 1350 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes. 3) A child weighing 18.2 kg with a history of diabetes insipidus (DI) has been admitted to the hospital. Which healthcare provider prescription should the nurse question? 1. Stat electrolytes 2. Urine specific gravity with each void 3. DDAVP (desmopressin) PO 4. Restrict oral fluids to 500 mL every 24 hours Answer: 4 Explanation: 1. Stat electrolytes should be obtained upon admission. 2. Urine specific gravity should be checked to determine hydration status. 3. DDAVP should be administered per provider order. 4. Fluid replacement, not fluid restriction, is necessary for child with DI. Page Ref: 1334 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.4 Prioritize nursing care for each type of acquired metabolic disorder.

4) A 5-year-old child with a history of hypopituitarism presents with complaints of right hip and leg pain. Which prescribed medication for the diagnosis should the nurse identify as the cause for the current symptoms? 1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin) at bedtime 4. Cortisone injections Answer: 1 Explanation: 1. Growth hormone injections and hypopituitarism have been associated with slipped capital femoral epiphysis, which manifests with complaints of hip or knee pain. 2. Hip or leg pain is not a common side effect of insulin. 3. Hip or leg pain is not a common side effect of DDAVP 4. Hip or leg pain is not a common side effect of cortisone injections. Page Ref: 1333 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system. 5) Which clinical manifestations should the nurse anticipate when providing care to an adolescent client who presents with untreated Graves disease? 1. Hyperglycemia, ketonuria, and glucosuria 2. Weight gain, hirsutism, and muscle weakness 3. Tachycardia, fatigue, and heat intolerance 4. Dehydration, metabolic acidosis, and hypertension Answer: 3 Explanation: 1. Hyperglycemia, ketonuria, and glucosuria are not all symptoms of untreated Graves disease. 2. Weight gain, hirsutism, and muscle weakness are not all symptoms of untreated Graves disease. 3. Clinical manifestations of Graves disease are tachycardia, fatigue, and heat intolerance, seen with hyperthyroidism. 4. Dehydration, metabolic acidosis, and hypertension are not all symptoms of untreated Graves disease. Page Ref: 1337 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system. 3 Copyright © 2022 Pearson Education, Inc.

6) A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate antidiuretic hormone), a complication of his meningitis. Which laboratory data should the nurse anticipate for this child? 1. Hyponatremia 2. Hypocalcemia 3. Hyperglycemia 4. Hypernatremia Answer: 1 Explanation: 1. SIADH is associated with increased permeability in distal renal tubes, leading to water intoxication and low sodium. 2. Laboratory findings for a child diagnosed with SIADH include low serum osmolality, low serum sodium, high urine sodium, and decreased blood urea nitrogen not hypocalcemia. 3. Laboratory findings for a child diagnosed with SIADH include low serum osmolality, low serum 4. sodium, high urine sodium, and decreased blood urea nitrogen, not hyperglycemia. 4. Laboratory findings for a child diagnosed with SIADH include low serum osmolality, low serum sodium, high urine sodium, and decreased blood urea nitrogen, not hypernatremia. Page Ref: 1335 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

7) The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed due to a tumor. Which parental statement indicates the need for further education? 1. "I will call the doctor if my child has restlessness and confusion." 2. "If my child has any gastric irritation, I will give him antacids." 3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone." 4. "I will give my child his hydrocortisone in the morning." Answer: 3 Explanation: 1. Restlessness and confusion are common symptoms for a child whose adrenal gland has been removed. 2. The oral preparations of cortisone have a bitter taste and can cause gastric irritation. Antacids can help reduce these side effects. 3. If the child is ill and cannot take hydrocortisone by mouth, the child would need to have an injection. Failure to give hydrocortisone could lead to severe illness and cardiovascular collapse. The mother needs additional instruction. 4. Giving the dose of hydrocortisone at mealtimes and using antacids between meals help reduce side effects. Page Ref: 1340 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 53.5 Develop a family education plan for the child who needs lifelong cortisol replacement. 8) The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which healthcare provider prescription should the nurse question? 1. Neurologic checks hourly 2. Insert urinary catheter, and measure output hourly 3. NPH insulin IV at 0.1 unit/kg per hour 4. Stat serum electrolytes Answer: 3 Explanation: 1. Neurologic status can indicate a change in the patients status that requires intervention. 2. Accurate intake and output is needed for these patients. 3. NPH insulin is never administered IV. A short-acting insulin needs to be ordered. 4. Electrolytes are ordered to determine if any replacement is needed. Page Ref: 1352 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes. 5 Copyright © 2022 Pearson Education, Inc.

9) An adolescent presents in the emergency department (ED) with confusion. The healthcare provider suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 7l5 mg/dL. Which clinical manifestations does the nurse anticipate upon assessment for this client? 1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration Answer: 1, 3 Explanation: 1. All 3 of these symptoms can be DKA. 2. Sweating and tremors are clinical manifestations of hypoglycemia. 3. Dry mucous membranes, blurred vision, and weakness are seen with hyperglycemia. 4. Deep, rapid breathing is a clinical manifestation of DKA. Page Ref: 1353 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes. 10) Which teaching point should the nurse include when providing education to an adolescent client, who participates in soccer, regarding the plan of care for diabetes mellitus? 1. Decreased food intake 2. Increased doses of insulin 3. Increased food intake 4. Decreased doses of insulin Answer: 3 Explanation: 1. Encourage regular physical activity, and educate the child to increase not decrease food intake for extra physical activity periods. 2. The insulin dose should be based on the blood sugar. 3. An increase in physical activity requires an increase in caloric intake to prevent hypoglycemia. 4. The insulin dose should be based on the blood sugar. Page Ref: 1354 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

11) Which action related to insulin administration should the nurse include in the teaching plan for an adolescent client who has been newly diagnosed with diabetes mellitus to avoid the development of lipoatrophy? 1. Rotating injection sites 2. Checking blood sugars at mealtime and bedtime 3. Using a sliding scale for additional coverage 4. Administration of insulin via insulin pump Answer: 1 Explanation: 1. Lipoatrophy is caused by using the same insulin injection site. 2. Checking blood sugars at mealtime and bedtime is necessary for care of this client and will not cause lipoatrophy if done correctly. 3. A sliding scale will keep the client's blood sugars more controlled but does not cause lipoatrophy. 4. An insulin pump will decrease the risk of lipoatrophy as it decreases the number of injection sites. Page Ref: 1348 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

12) The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions should the nurse include in the teaching session? Select all that apply. 1. Do not reuse needles. 2. Remove all bubbles from the syringe before injecting. 3. Have the child flex the muscle during injection. 4. Inject insulin when it is cold. 5. Do not change the direction of the needle during insertion or withdrawal. Answer: 1, 2, 5 Explanation: 1. Reusing needles leads to more pain on injection. 2. Removing bubbles from the syringe minimizes pain. 3. The child should relax their muscles during injection. 4. Insulin at room temperature will hurt less. 5. Keeping the direction of the syringe constant will minimize pain. Page Ref: 1352 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes. 13) Which food should the nurse remove from the food tray for a toddler-age client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Oatmeal 2. Yogurt 3. Biscuit 4. Watermelon Answer: 4 Explanation: 1. Oatmeal is an appropriate food for this client to eat. 2. Yogurt is an appropriate food for this client to eat. 3. A biscuit is an appropriate food for this client to eat. 4. A child with SIADH is on a fluid restriction. Watermelon contains significant fluid volume, so it would not be a good food for this child to consume. Page Ref: 1335 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.4 Prioritize nursing care for each type of acquired metabolic disorder.

14) Which sequela should the nurse include in the teaching session for a parent who does not believe in medication for the treatment of the newborn's hypothyroidism? 1. Heart disease 2. Intellectual disability 3. Renal failure 4. Thyroid storm Answer: 2 Explanation: 1. Developmental delay, alterations in growth, and poor body image are the main problems with a client who is not treated for hypothyroidism. 2. Untreated hypothyroidism will lead to intellectual disability. 3. Developmental delay, alterations in growth, and poor body image are the main problems with a client who is not treated for hypothyroidism. 4. Developmental delay, alterations in growth, and poor body image are the main problems with a client who is not treated for hypothyroidism. Page Ref: 1336 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.7 Plan care for the child with an inherited metabolic disorder.

15) Which changes should the school nurse implement to decrease the risk for the development of type 2 diabetes mellitus for a population who is identified as being at risk? Select all that apply. 1. Increase the amount of daily physical activity. 2. Meet with all parents, and explain the risk that is associated with obesity. 3. Test each child's urine monthly. 4. Teach the parents to avoid administering aspirin to their children. 5. Work with the cafeteria to decrease the amount of fat in the foods served. Answer: 1, 2, 5 Explanation: 1. Increased physical activity will decrease a child's risk of developing type 2 diabetes. 2. Obese children have an increased risk of type 2 diabetes. Working with the parents, the nurse can reduce the obesity in the school. 3. Blood glucose levels are a better indication of diabetes than urine checks. 4. There is no indication that administering aspirin will decrease the risk of these children developing type 2 diabetes mellitus. 5. A diet high in fat is associated with type 2 diabetes. Page Ref: 01355 Cognitive Level: Applying Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.6 Distinguish between the nursing care of the child with type 1 and type 2 diabetes.

16) Which assessment finding would cause the nurse to question whether a preschool-age boy, diagnosed with phenylketonuria shortly after birth, is following the prescribed dietary restrictions? 1. The child's body has a musty odor. 2. This child is a blue-eyed blonde. 3. The child appears sleepy and uninterested in the surroundings. 4. The child has sunburn over his entire body. Answer: 1 Explanation: 1. The odor is caused by the excretion of phenylketone by-products through the skin and would indicate noncompliance with the dietary restrictions. 2. Eye and hair color are not an indication of whether or not the child is following prescribed dietary restrictions. 3. Symptoms of phenylketonuria are irritability, vomiting, hyperactivity, hypertonia, hyperreflexive deep tendon reflexes, seizures, and an eczema-like rash. 4. Sunburn is not an indication of whether or not the child is following prescribed dietary restrictions. Page Ref: 1357 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

17) The nurse is providing care to a newborn who is suspected of having Turner syndrome. Which should the nurse assess the newborn for based on the current diagnosis? 1. Club foot (talipes equinovarus) 2. Congenital heart anomalies 3. Hyperbilirubinemia due to liver abnormalities 4. Diaphragmatic hernia Answer: 2 Explanation: 1. Club foot is not a usual finding for a newborn suspected of having Turner syndrome. 2. Congenital heart anomalies, including coarctation of the aorta, frequently are associated with Turner syndrome. 3. Hyperbilirubinemia is not a usual finding for a newborn suspected of having Turner syndrome. 4. A diaphragmatic hernia is not a usual finding for a newborn suspected of having Turner syndrome. Page Ref: 1356 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system. 18) Which prescription regarding an oral hydrocortisone for a toddler-age client diagnosed with congenital adrenal insufficiency should the nurse anticipate when the client is admitted to the hospital with pneumonia? 1. It will be discontinued. 2. It will be reduced. 3. It will be continued as previously prescribed. 4. It will be increased. Answer: 4 Explanation: 1. The medication should not be completely stopped. 2. The medication should be increased during illness, not decreased. 3. If the client is sick, the medication should be increased. 4. During periods of stress including illness and surgery, the dose of steroids needs to be increased. Page Ref: 1340 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.5 Develop a family education plan for the child who needs lifelong cortisol replacement. 12 Copyright © 2022 Pearson Education, Inc.

19) Which type of nutrition should the nurse include when planning care for a newborn who is diagnosed with galactosemia? 1. Goat's milk formula 2. Breast milk 3. Cow's milk-based formula 4. Lactose-free formula Answer: 4 Explanation: 1. The infant should be placed on a lactose- or galactose-free formula which does not include goat's milk. 2. The infant should be placed on a lactose- or galactose-free formula which does not include breast milk. 3. The infant should be placed on a lactose- or galactose-free formula which does not include cow's milk-based formula. 4. A lactose-free formula is the type of nutrition the nurse should include in the teaching plan for this newborn. Page Ref: 1358 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.7 Plan care for the child with an inherited metabolic disorder.

20) The nurse is providing care to a newborn female who is born with ambiguous genitalia. The follow-up investigation discovers adrenogenital syndrome (also called congenital adrenal hyperplasia [CAH]). The parents question why the baby's genitalia looks more male than female. Which response by the nurse is accurate? 1. "The disorder caused your baby to be a hermaphrodite with both male and female sex organs." 2. "The changes in the genitalia are due to increased androgens secondary to deficient cortisol." 3. "The excessive cortisol caused the enlargement of the female tissue, creating a male appearance." 4. "Your baby has only one sex chromosome resulting in an XO configuration." Answer: 2 Explanation: 1. Adrenogenital syndrome does not mean the newborn is a hermaphrodite and only has female sex organs. 2. Deficient cortisol causes the amount of adrenocorticotropic hormone (ACTH) to be high, overstimulating the adrenal production of androgens, which causes the pseudomasculinization. 3. The serum cortisol level is inappropriately low in comparison to ACTH. 4. Children with CAH have insufficient production of aldosterone and cortisol and an overproduction of androgen Page Ref: 1340 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

21) Which pediatric client diagnoses would cause the nurse to include information related to short stature? Select all that apply. 1. Hypothyroidism 2. Turner syndrome 3. Chronic renal failure 4. Cushing syndrome 5. Diabetes mellitus Answer: 1, 2, 3, 4 Explanation: 1. Hypothyroidism is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 2. Turner syndrome is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 3. Chronic renal failure is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 4. Cushing syndrome is a pediatric client diagnosis that would cause the nurse to include information related to short stature. 5. Diabetes mellitus is not a diagnosis that includes short stature as a clinical manifestation. Page Ref: 1331 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.3 Identify all conditions for which short stature is a sign. 22) Which functions of the adrenal hormone aldosterone should the nurse include in a teaching session for a pediatric client diagnosed with alterations in adrenal function? Select all that apply. 1. Stimulates bone development. 2. Increases sodium ion reabsorption. 3. Stimulates secondary sexual characteristics. 4. Increases potassium excretion by the kidneys. 5. Activates the sympathetic nervous system. Answer: 2, 4 Explanation: 1. This is not a function of aldosterone. 2. This is a function of aldosterone. 3. This is not a function of aldosterone. 4. This is a function of aldosterone. 5. This is not a function of aldosterone. Page Ref: 1340 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.1 Identify the function of important hormones of the endocrine system. 15 Copyright © 2022 Pearson Education, Inc.

23) Which functions of the adrenal androgens should the nurse include in a teaching session for a pediatric client diagnosed with alterations in adrenal function? Select all that apply. 1. Stimulates bone development. 2. Increases sodium ion reabsorption. 3. Stimulates secondary sexual characteristics. 4. Increases potassium excretion by the kidneys. 5. Activates the sympathetic nervous system. Answer: 1, 3 Explanation: 1. This is a function of androgens. 2. This is not a function of adrenal androgens. 3. This is a function of androgens. 4. This is not a function of adrenal androgens. 5. This is not a function of adrenal androgens. Page Ref: 1330 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.1 Identify the function of important hormones of the endocrine system. 24) Which diagnostic tests should the nurse include in the plan of care for a pediatric client who is at risk for short stature? Select all that apply. 1. Thyroid function studies 2. Adrenocorticotropic hormone (ACTH) and cortisol levels 3. Complete blood count 4. Blood culture 5. Urine creatinine Answer: 1, 2, 3, 5 Explanation: 1. Thyroid function tests are often included in the plan of care for a pediatric client at risk for short stature. 2. ACTH and cortisol levels are often included in the plan of care for a pediatric client at risk for short stature. 3. A complete blood count often included in the plan of care for a pediatric client at risk for short stature. 4. A blood culture is not indicated for a client at risk for short stature. 5. A urine creatinine is often included in the plan of care for a pediatric client at risk for short stature. Page Ref: 1332 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 53.3 Identify all conditions for which short stature is a sign. 16 Copyright © 2022 Pearson Education, Inc.

25) Which assessment data for a pediatric client supports the diagnosis of familial or idiopathic central diabetes insipidus (DI)? Select all that apply. 1. Polyuria 2. Polydipsia 3. Nocturia 4. Enuresis 5. Constipation Answer: 3, 4, 5 Explanation: 1. Polyuria is not a clinical manifestation of central diabetes insipidus (DI) 2. Polydipsia is not a clinical manifestation of central diabetes insipidus (DI) 3. Nocturia is a clinical manifestation associated with familial or idiopathic central DI. 4. Enuresis a clinical manifestation associated with familial or idiopathic central DI. 5. Constipation a clinical manifestation associated with familial or idiopathic central DI. Page Ref: 1334 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 53.2 Summarize signs and symptoms that may indicate a disorder of the endocrine system.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 54 The Child with Alterations in Neurologic Function 1) Which assessment finding for a 4-month-old infant would require further action by the nurse? 1. The anterior fontanel is bulging. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft. Answer: 1 Explanation: 1. A bulging anterior fontanel is a characteristic of hydrocephalus. 2. Good head control is expected at 4 months of age. 3. Rolling from abdomen to back is a skill the 4-month-old infant should be learning. 4. An open anterior fontanel, which is soft, is a normal finding at 4 months. Page Ref: 1306 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.1 Describe the pediatric differences associated with the anatomy and physiology of the neurologic system. 2) The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question? 1. Passive range-of-motion exercises to promote hip flexion 2. Oxygen at 2 L nasal cannula to keep saturation above 95% 3. Hourly vital signs and neurologic checks 4. Elevate head of bed 30 degrees Answer: 1 Explanation: 1. Range-of-motion exercises, especially hip flexion, would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible. 2. Oxygen should be ordered to keep the child's O2 saturation above 95%. 3. Hourly vital signs and neurologic checks are appropriate to watch for changes in this child's condition. 4. The head is elevated 30 degrees to help decrease increased intracranial pressure. Page Ref: 1399 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.2 Choose the appropriate assessment guidelines and tools to examine infants and children with altered levels of consciousness and other neurologic conditions. 1 Copyright © 2022 Pearson Education, Inc.

3) A 4-year-old client with intractable seizures has been on a ketogenic diet for the last 6 months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. Which possible complication to this diet does the nurse suspect? 1. Appendicitis 2. Bowel obstruction 3. Urinary tract infection 4. Kidney stones Answer: 4 Explanation: 1. Appendicitis does not occur as a result of the ketogenic diet. 2. The ketogenic diet does not cause a bowel obstruction. 3. Urinary tract infections are not a result of a ketogenic diet. 4. Kidney stones are seen in 5% of children on a ketogenic diet. Page Ref: 1375 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition. 4) A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurologic assessment. 4. Maintain patent airway. Answer: 4 Explanation: 1. Taking vital signs is important, but airway always comes first. 2. Once the airway is secure, securing an IV is vital. 3. A rapid neurologic assessment is appropriate once the airway is secure. 4. Airway is always the priority of care. Page Ref: 1372 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 54.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition.

5) The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child is prescribed valproic acid (Depakote) for control of seizures. Which parental statement indicates the need for further education? 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician's office for regular blood work to check bleeding times." Answer: 2 Explanation: 1. Carbonated beverages should never be used to dilute valproic acid. 2. Valproic acid (Depakote) should be given with foods to decrease gastrointestinal irritation. 3. This child should not be allowed to chew a valproic acid tablet. 4. It is appropriate to have periodic blood studies to check bleeding times and platelet count. Page Ref: 1373 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 54.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition. 6) A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. For which reason should a lumbar puncture be completed? 1. Evaluate for white blood cells. 2. Reduce intracranial pressure. 3. Rule out a cerebral bleed. 4. Inject antibiotic medication. Answer: 4 Explanation: 1. In meningitis, a lumbar puncture is performed to culture the cerebrospinal fluid, and evaluate it for white blood cells. 2. A lumber puncture is not done to reduce intracranial pressure. 3. A lumbar puncture is not done to rule out a cerebral bleed. 4. A lumbar puncture is not done to inject antibiotic medication. Page Ref: 1378 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Reduction of Risk Potential Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, and Guillain-Barré syndrome in infants and children.

7) Which is the priority problem when planning care for a pediatric client who is diagnosed with bacterial meningitis? 1. Insufficient oxygenation 2. Infection 3. Parental anxiety 4. Pain Answer: 1 Explanation: 1. The child is at risk for insufficient oxygenation if the airway is impeded. 2. The child already has an infection. 3. The parents will be anxious about the outcome for their child, but this is not the priority problem. 4. Pain management is important but is not the priority. Page Ref: 1380 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 54.4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, and Guillain-Barré syndrome in infants and children. 8) The nurse is caring for a 9-month-old infant who just returned from the postanesthesia care unit (PACU) after a shunt placement for hydrocephalus. Which healthcare provider prescription should the nurse question? 1. Vital signs and neurologic checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference Answer: 3 Explanation: 1. Frequent vital signs and neurologic checks are needed postoperatively. 2. Small, frequent feedings are appropriate to decrease the chance of vomiting. 3. The 9-month-old should be placed in a flat position so that cerebrospinal fluid drainage is not too rapid. 4. Daily head circumferences are needed to help evaluate shunt functioning. Page Ref: 1388 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.6 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

9) A neonate with a meningomyelocele is to have surgery in the morning. Which nursing action is appropriate for this neonate? 1. Applying a diaper to prevent contamination of sac 2. Positioning the newborn in a side-lying position 3. Encouraging the mother to hold the newborn because she will not be able to pick him up after surgery 4. Positioning the newborn in a prone position Answer: 4 Explanation: 1. A diaper is not used because it also puts pressure on the sac. 2. A side-lying position would be contraindicated because it would place pressure on the sac. 3. The mother should not hold the baby because that would put too much pressure on the sac. 4. The newborn should be placed in a prone position to keep pressure off the sac. Page Ref: 1390 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 54.6 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

10) Which should the nurse include in the plan of care for a hospitalized school-age child with myelodysplasia? Select all that apply. 1. Implementing interventions for a client of normal intelligence 2. Using latex precautions when providing client care 3. Allowing the client to self-catheterize 4. Ensuring that the client has a low-fiber diet 5. Encouraging the client to shift positions hourly when in the wheelchair Answer: 1, 2, 3, 5 Explanation: 1. Many children with myelodysplasia have normal intellect. They should be treated according to their intellectual level rather than their motor development. 2. Children with myelodysplasia are at great risk for latex allergy. It is important to use latex-free products. 3. Self-catheterization fosters independence in this child. It is important to maintain the same schedule as much as possible when this child is hospitalized. 4. Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function. 5. Due to decreased sensation in the buttocks and lower extremities, it is very important for the child to shift positions while in the wheelchair, to prevent pressure sores. Page Ref: 1380 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.6 Develop a nursing care plan for the infant with hydrocephalus and spina bifida.

11) Which side effect should the nurse include in the parent teaching for a child who is prescribed a baclofen pump for cerebral palsy? 1. Diarrhea 2. Hypertonia 3. Hypotonia 4. Restlessness Answer: 3 Explanation: 1. Continuous baclofen infusion does not cause diarrhea. 2. Hypertonia is not seen as a side effect of baclofen infusion. 3. Hypotonia is possible if the child is getting too much baclofen. 4. Restlessness is not seen with baclofen; rather, these children can be drowsy and sleepy. Page Ref: 1395 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.7 Plan family-centered nursing care for the child with cerebral palsy in a community setting. 12) A 9-month-old infant who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? 1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia Answer: 1 Explanation: 1. Hypotonia in infancy and muscle instability are seen in ataxic CP. 2. Hypertonia and persistent primitive reflexes are seen in spastic CP. 3. Tremors and exaggerated posturing are seen in dyskinetic CP. 4. Hemiplegia and hypertonia are seen in spastic CP. Page Ref: 1394 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.7 Plan family-centered nursing care for the child with cerebral palsy in a community setting.

13) A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, and respiratory rate 28 and irregular. Which does the nurse suspect based on these data? 1. Spinal cord injury 2. Increased intracranial pressure. 3. Typical for sleep 4. Improvement Answer: 2 Explanation: 1. If the child suffered a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. 2. These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. 3. Normal sleeping pulse at this age is 60 to 90 bpm. 4. Without previous vital signs, there is no way to determine if the current changes in the vital signs indicate improvement. Page Ref: 1367 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.8 Contrast the appropriate initial nursing management for mild versus severe traumatic brain injury. 14) Which clinical manifestation should the nurse monitor for when assessing a pediatric client who is diagnosed with a basilar skull fracture? 1. Periorbital ecchymosis 2. Subdural hematoma 3. Protruding bone 4. Epidural hematoma Answer: 1 Explanation: 1. Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture. 2. Subdural hematoma might be seen with a linear fracture. 3. Protruding bone might be seen with a compound fracture. 4. Epidural hematoma is seen with linear fracture. Page Ref: 1402 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.8 Contrast the appropriate initial nursing management for mild versus severe traumatic brain injury. 8 Copyright © 2022 Pearson Education, Inc.

15) A teacher states to the school nurse, "I have a student who will often just stare at me for 15 seconds after asking a question; then, the student blinks and asks me to repeat the question. Should I be concerned?" Which should the nurse include in the response to the teacher? 1. The child has a crush on the teacher. 2. The child has increased intracranial pressure. 3. The child may have had a head injury. 4. The child is experiencing absence seizures. Answer: 4 Explanation: 1. There are no data to suspect a childhood crush is creating the situation. 2. There is no indication of increased intracranial pressure. 3. There is no indication of a head injury. 4. Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher. Page Ref: 1371 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 54.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition. 16) The nurse is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the nurse concern? 1. Nausea, vomiting, and confusion 2. Headache, vomiting, and seizures 3. Sore throat, moist respirations, and cough 4. Fever, rash, and photophobia Answer: 1 Explanation: 1. These are the early symptoms of Reye syndrome. 2. These symptoms are associated with a malfunctioning shunt and not the early symptoms of Reye syndrome. 3. These symptoms are more likely to indicate pneumonia, not Reye syndrome. 4. These are not the early symptoms of Reye syndrome. Page Ref: 1382 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.2 Choose the appropriate assessment guidelines and tools to examine infants and children with altered levels of consciousness and other neurologic conditions.

17) Which preventative strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures? Select all that apply. 1. Increasing oral intake of fluids 2. Administering dose-appropriate aspirin 3. Providing a sponge bath with cold water 4. Decreasing oral fluid intake 5. Using complementary methods to reduce the fever Answer: 1, 5 Explanation: 1. Fluid intake will help heat loss. 2. Aspirin should be avoided due to the risk for Reye syndrome. 3. Cold water may cause shivering, which will increase the body temperature. 4. Decreasing fluid intake would increase the retention of heat. 5. Complementary methods should be used to reduce the fever. Page Ref: 1372 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 54.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition. 18) When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? 1. The mother leaves the filled mop bucket on the floor while in another room. 2. The mother turns all panhandles to the back of the stove. 3. The mother fills the bathtub before bringing the baby into the bathroom. 4. When riding in a car, the child is in a car seat in the middle of the back seat. Answer: 1 Explanation: 1. Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in headfirst. Because of mobility limitations, the child may not be able to get out of the bucket without help. 2. This is appropriate to reduce the risk of injury. 3. This allows the mother to adjust the temperature of the bath water and reduces the risk of burns. 4. This is the safest place for the child. Page Ref: 1405 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.9 Discuss initiatives to prevent drowning in children. 10 Copyright © 2022 Pearson Education, Inc.

19) Which problems should the nurse include in the plan of care for a pediatric client who experiences a traumatic brain injury (TBI)? Select all that apply. 1. Reduced blood flow to the brain 2. Potential for aspirating 3. Insufficient body fluids 4. Problems with family functioning 5. Pain Answer: 1, 2, 3, 4 Explanation: 1. This is an appropriate problem for the nurse to include in the plan of care for the client. 2. This is an appropriate problem for the nurse to include in the plan of care for the client. 3. This is an appropriate problem for the nurse to include in the plan of care for the client. 4. This is an appropriate problem for the nurse to include in the plan of care for the client. 5. This nursing diagnosis is problem for a client diagnosed with cerebral palsy, not a TBI. Page Ref: 1400 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 54.5 Develop a plan of nursing care for the child hospitalized with an acute neurologic condition. 20) Which problems should the nurse include in the plan of care for a pediatric client diagnosed with cerebral palsy? Select all that apply. 1. Constipation 2. Risk for skin breakdown 3. Problems with communication 4. Pain 5. Delays in development Answer: 1, 2, 3, 5 Explanation: 1. This is an appropriate problem for a pediatric client diagnosed with cerebral palsy. 2. This is an appropriate problem for a pediatric client diagnosed with cerebral palsy. 3. This is an appropriate problem for a pediatric client diagnosed with cerebral palsy. 4. Chronic, not acute, pain is a problem for a pediatric client diagnosed with cerebral palsy. 5. This is an appropriate problem for a pediatric client diagnosed with cerebral palsy. Page Ref: 1395-1396 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.5 Develop a plan of nursing care for the child hospitalized with an acute neurologic condition. 11 Copyright © 2022 Pearson Education, Inc.

21) Which problem should the nurse include in the plan of care for a pediatric client diagnosed with hydrocephalus? Select all that apply. 1. Potential for infection 2. Problems with mobility 3. Caregiver burden 4. Potential for injury 5. Constipation Answer: 1, 2, 3, 4 Explanation: 1. This is an appropriate problem for a pediatric client diagnosed with hydrocephalus. 2. This is an appropriate problem for a pediatric client diagnosed with hydrocephalus. 3. This is an appropriate problem for a pediatric client diagnosed with hydrocephalus. 4. This is an appropriate problem for a pediatric client diagnosed with hydrocephalus. 5. Risk for constipation is not an appropriate problem for a pediatric client diagnosed with hydrocephalus. Page Ref: 1388 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 54.5 Develop a plan of nursing care for the child hospitalized with an acute neurologic condition. 22) Which clinical manifestations support the diagnosis of viral meningitis? Select all that apply. 1. Abrupt onset of fever 2. Headache 3. Myalgia 4. Hemorrhagic rash 5. Purpura Answer: 1, 2, 3 Explanation: 1. Abrupt onset of fever is a clinical manifestation associated with viral meningitis. 2. Headache is a clinical manifestation associated with viral meningitis. 3. Myalgia is a clinical manifestation associated with viral meningitis. 4. Hemorrhagic rash is a clinical manifestation associated with bacterial, not viral, meningitis. 5. Purpura is a clinical manifestation associated with bacterial, not viral, meningitis. Page Ref: 1382 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54.4 Differentiate between signs of bacterial meningitis, viral meningitis, encephalitis, and Guillain-Barré syndrome in infants and children. 12 Copyright © 2022 Pearson Education, Inc.

23) The nurse is planning a teaching session for the parents of a child who is diagnosed with simple partial seizures. Which causes should the nurse include when teaching the parents? Select all that apply. 1. Lesions 2. Cysts 3. Tumor 4. Brain abscesses 5. Brain trauma Answer: 1, 2, 3, 4 Explanation: 1. Lesions are a cause of simple partial seizures. 2. Cysts are a cause of simple partial seizures. 3. Tumors are a cause of simple partial seizures. 4. Brain abscesses are a cause of simple partial seizures. 5. Brain trauma a cause of complex partial seizures. Page Ref: 1371 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Implementation Learning Outcome: 54.3 Differentiate between the signs of a seizure and status epilepticus in infants and children, and describe appropriate nursing management for each condition.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 55 The Child with Alterations in Mental Health and Cognitive Function 1) The nurse is assessing a 4-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Select all that apply. 1. Fails to make eye contact. 2. Flinches when touched on the arm. 3. History of limited prenatal care and precipitate delivery 4. Head circumference has not changed in over 1 year. 5. Flat facial expressions Answer: 1, 2, 3, 5 Explanation: 1. Making eye contact with the nurse and caregiver is part of the child's overall affect and social skills. A child who fails to make eye contact may have an alteration in mental health. 2. Flinching may indicate a desire to avoid contact; this can indicate a mental health issue and should be further evaluated. 3. History of prenatal care and delivery can help determine potential alterations in mental health in a child. 4. Head circumference is not measured in a 4-year-old. 5. Affect can be determined by facial expression and response to the nurse, helping to determine mental health. Page Ref: 1413 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.1 Define mental health and describe major mental health alterations in childhood.

2) Which factor, noted by the nurse during the pediatric health history portion of the assessment process, would indicate the child is at risk for attention deficit/hyperactivity disorder (ADHD)? 1. Measles, mumps, and rubella vaccine 2. Advanced parental age 3. Prenatal exposure to smoke 4. Immune response Answer: 3 Explanation: 1. Measles, mumps, and rubella vaccine has been thought to be associated with autism spectrum disorder, though a relationship has never been established through research. 2. Advanced parental age has been associated with autism spectrum disorders. 3. Research shows that a mother's use of cigarettes during pregnancy can increase the risk for ADHD. 4. Immune response can be associated with autism spectrum disorders. Page Ref: 1417 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence. 3) Which data, noted by the nurse during the physical assessment, would indicate the need to refer an adolescent client for further treatment due to possible depression? Select all that apply. 1. Agoraphobia 2. Somatic complaints 3. Focus on violence 4. Poor self-care 5. Poor school performance Answer: 3, 4, 5 Explanation: 1. Agoraphobia, which is a fear of being in places or situations from which escape might be difficult or embarrassing, is seen in children with a panic disorder, not with depression. 2. Somatic complaints are more commonly associated with depression in the younger school-age child. 3. Focus on violence can be associated with depression in the adolescent. 4. Poor self-care can be associated with depression in an adolescent. 5. Poor school performance is associated with depression in the adolescent with depression. Page Ref: 1420 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence. 2 Copyright © 2022 Pearson Education, Inc.

4) Which statement from the parent of a child diagnosed with attention deficit/hyperactivity disorder (ADHD) indicates the need for further education by the nurse? 1. "I will develop a reward system for desired behaviors." 2. "I will take my child to the physician every 3 months for a weight and height check." 3. "I will let him do his homework while he is watching his favorite television show." 4. "I will stick to the same routine each day after school." Answer: 3 Explanation: 1. A reward system is a part of behavior modification and is appropriate to help the child behave appropriately. 2. Children with ADHD should be screened regularly for height and weight to monitor growth, which can be affected by medication. 3. This child should do homework in a quiet environment, away from distractions. 4. Maintaining the same daily routine helps the child know expectations, and a nighttime routine helps counteract insomnia. Page Ref: 1418 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence. 5) A child diagnosed with autism spectrum disorder (ASD) is admitted to the hospital with dehydration. Which should the nurse include in the plan of care for this child? 1. Discourage the parents from bringing favorite toys from home that might be lost. 2. Take the child on a tour of the pediatric unit. 3. Assign the child to a single-bed hospital room. 4. Take the child to the playroom for arts and crafts. Answer: 3 Explanation: 1. Children with autism often carry a special toy. This should be kept with the child. 2. Taking a child with autism on a tour of the pediatric unit would be too much stimulation for this child. A quiet, controlled environment is best for a child with autism. 3. A single room is the best place for an autistic child if the child must be hospitalized. 4. Arts and crafts might be appropriate for an autistic child if they are done in the child's room. Going to the playroom would be too much stimulation for this child. Page Ref: 1416 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 55.3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings. 3 Copyright © 2022 Pearson Education, Inc.

6) A school-age child is diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. Which term should the nurse use when documenting this child's disorder in the medical record? 1. Dysgraphia 2. Dyscalculia 3. Dyspraxia 4. Dyslexia Answer: 3 Explanation: 1. Children with dysgraphia have difficulty with writing, spelling, and composition. 2. Children with dyscalculia have problems with mathematics and computation problems. 3. Children with dyspraxia have problems with manual dexterity and coordination. 4. Children with dyslexia have difficulty with writing, reading, and spelling. Page Ref: 1430 Cognitive Level: Applying Client Need/Sub: Safe and Effective Care Environment / Management of Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Implementation/Communication and Documentation Learning Outcome: 55.4 Describe characteristics of common cognitive alterations of childhood. 7) The nurse is assessing a child with Down syndrome. Which illness should the nurse monitor for due to the increased risk for children with Down syndrome? 1. Rheumatic heart disease 2. Glomerulonephritis 3. Leukemia 4. Hepatitis Answer: 3 Explanation: 1. Heart defects might be seen with Down syndrome, but not rheumatic heart disease, which is associated with group A beta-hemolytic streptococcus infection. 2. Glomerulonephritis is not seen in association with Down syndrome. 3. Children with Down syndrome have a significantly higher than average risk of developing leukemia. 4. Hepatitis is not associated with Down syndrome. Page Ref: 1430 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.4 Describe characteristics of common cognitive alterations of childhood.

8) Which children should the nurse identify as exhibiting a delay in meeting developmental milestones? Select all that apply. 1. An 18-month-old toddler who is unable to speak in sentences 2. A 2-year-old child who is unable to cut with scissors 3. A 2-year-old child who cannot recite her phone number 4. A 6-year-old child who is unable to sit still for a short story 5. A 5-year-old child who is unable to button his shirt Answer: 4, 5 Explanation: 1. An 18-month-old toddler is not usually able to speak in sentences. This is a skill to be accomplished by the age of 2.5 years. 2. A child who cannot cut with scissors by kindergarten age is considered abnormal. 3. A 2-year-old child is not expected to be able to recite a phone number. 4. A 6-year-old child should be able to sit still for a short story. A 3- to 5-year-old child should be able to sit still through a short story. 5. A 5-year-old child should be able to button his shirt. Page Ref: 1418, 1430 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.4 Describe characteristics of common cognitive alterations of childhood.

9) The nurse is planning care for a school-age child diagnosed with separation anxiety disorder. Which aspects of cognitive-behavior therapy (CBT) should the nurse include in the teaching plan for the child's family? Select all that apply. 1. Self-talking 2. Relaxation 3. Hypnosis 4. Antidepressant medications 5. Recognition of feelings Answer: 1, 2, 5 Explanation: 1. Self-talking helps a child to focus the inner thoughts on the desired behavior. 2. Teaching self-relaxation skills can help the child to reduce anxiety. 3. Hypnosis is not a component of cognitive-behavioral therapy. 4. Although medications may be a part of the treatment plan, it is not a component of cognitivebehavioral therapy. 5. Recognition and acceptance of feelings helps the child to move forward toward a desired behavior. Page Ref: 1424 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 55.3 Plan for the nursing management of children and adolescents with mental health alterations in the hospital and community settings.

10) Which information should the nurse include in the teaching plan for the parents of a child who is diagnosed with autism spectrum disorder (ASD) as methods to increase the child's socialization? 1. Create a reward system when the child interacts with a person. 2. Punish the child when the child's social behaviors are inappropriate. 3. Use dolls to demonstrate appropriate social interactions to the child. 4. Enroll the child in a day care facility to encourage interaction with other children. Answer: 1 Explanation: 1. This is appropriate treatment involving behavior modification. 2. Behavior modification uses positive, not negative, reinforcement to encourage the desired behavior. 3. This activity would be a component of play therapy. 4. Enrolling the child in a day care facility may help with interactions, but this is not a description of behavior modification. Page Ref: 1416 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 55.6 Establish and evaluate expected outcomes of care for the child with a cognitive alteration.

11) Which child should the nurse refer for further assessment due to a probable diagnosis for autism spectrum disorder (ASD)? 1. A 4-year-old girl who doesn't make eye contact with mother, and resists the mother's touch 2. A 3-year-old boy who joins one group of children, then moves to another group of children without joining their activities 3. An 18-month-old child who walks around the area using the furniture to provide balance 4. A 6-year-old boy who chatters constantly to anyone who will listen Answer: 1 Explanation: 1. Although boys are affected more often than girls, lack of eye contact and resistance to physical touch are common symptoms of autism. 2. Although this child is not interacting with other children, it is obvious that the child is aware of other children and interested in their activities, actions that are not indicative of autism. 3. This child may be developmentally delayed, as this behavior is typical of a 10- to 12-monthold child. 4. Children with autism often have language delays and impairment. This child does not have any obvious language issues. Page Ref: 1415 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.4 Describe characteristics of common cognitive alterations of childhood.

12) Which activities should the nurse include in the plan of care for a child diagnosed with attention deficit/hyperactivity disorder (ADHD) to improve behavior and learning? Select all that apply. 1. Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child 2. Placing the child's desk at the back of the room to reduce distractions 3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom 5. Determining areas where the child performs well and using these areas to promote self-esteem Answer: 3, 4, 5 Explanation: 1. It is not the nurse's or teacher's place to suggest medications for this child. 2. The child's desk should be placed at the front of the room to promote attention. 3. Consistency is important for the child with ADD/ADHD, and reduces impulsive behavior. 4. Decorations are distracting and should be limited. 5. This is appropriate and will help reduce "acting out" behaviors. Page Ref: 1418 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 55.5 Use evidence-based practice to plan nursing management for children with cognitive alterations.

13) A school-age client presents to the pediatric clinic with a history of abdominal pain 3 to 4 mornings per week over the last 2 months. The mother states the child usually complains on school days and always seems to be better by afternoon. Which mental health disorder does the nurse suspect? 1. Separation anxiety 2. Depression 3. School phobia 4. Bipolar disorder Answer: 3 Explanation: 1. Separation anxiety is most common in girls between the ages of 7 and 9 and may be accompanied by depression when separated. The child was able to successfully separate for a nonschool activity. 2. Depression is often manifested by sleep issues, avoidance of social interactions, and low energy. 3. The child is using somatic complaints to avoid attending school. 4. Bipolar disorder involves periods of hyperactivity alternating with periods of lethargy. Page Ref: 1425 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence.

14) Which nursing action assists in the diagnosis of mental health and cognitive disorders that occur during childhood? 1. Monitoring vital signs 2. Administering prescribed medications 3. Conducting a developmental assessment 4. Documenting an accurate history and physical Answer: 3 Explanation: 1. Monitoring vital signs is not a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. 2. Administering prescribed medications is not a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. 3. Conducting a developmental assessment is a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. 4. Documenting an accurate history and physical is not a nursing action that assists in the diagnosis of mental health and cognitive disorders in pediatric clients. Page Ref: 1433 Cognitive Level: Understanding Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence.

15) The mother of a 22-month-old child states, "My child does not seem to be developing like my sister's daughter, who is the same age." Which diagnostic test should the nurse expect to be prescribed? 1. Magnetic resonance imaging (MRI) of the head 2. An electroencephalogram (EEG) 3. Developmental screening tests 4. Chromosomal study Answer: 3 Explanation: 1. The MRI is a diagnostic test, not a screening test, and it is not performed by the nurse. 2. An electroencephalogram evaluates brains wave activity of the brain. It does not evaluate the child's behavior. 3. Several screening tests are available for use in health maintenance visits. Once these are completed, additional testing may be performed to rule out other causes for the delay in development. 4. A chromosomal test is not used to determine developmental delay. Page Ref: 1416 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 55.5 Use evidence-based practice to plan nursing management for children with cognitive alterations.

16) Which statements should the nurse include in the definition of mental health during a health maintenance fair for pediatric clients? Select all that apply. 1. Mental health is the change in thought that occurs during childhood. 2. Mental health is foundational to a sense of personal well-being. 3. Mental health does not impact physical health. 4. Mental health involves successful engagement in activities. 5. Mental health changes over time. Answer: 2, 4 Explanation: 1. Cognition, not mental health, is the change in thought that occurs during childhood; therefore, the nurse should not include this information. 2. Mental health is foundational to a sense of personal well-being; therefore, the nurse should include this information in the presentation. 3. Mental health does impact physical health; therefore, the nurse should not include this information. 4. Mental health does involve successful engagement in activities; therefore, the nurse should include this information in the presentation. 5. Cognition, not mental health, changes over time; therefore, the nurse should not include this information. Page Ref: 1410 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 55.1 Define mental health and describe major mental health alterations in childhood.

17) Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with autism spectrum disorder (ASD)? Select all that apply. 1. Arm flapping 2. Language delays 3. Ritualistic behavior 4. Impulsive behavior 5. Sleep disturbances Answer: 1, 2, 3 Explanation: 1. Arm flapping is a clinical manifestation associated with ASD. 2. Language delay is a clinical manifestation associated with ASD. 3. Ritualistic behavior is a clinical manifestation associated with ASD. 4. Impulsive behavior is a clinical manifestation associated with attention deficit hyperactivity disorder, not ASD. 5. Sleep disturbance is a clinical manifestation associated with attention deficit hyperactivity disorder, not ASD. Page Ref: 1415 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence.

18) Which clinical manifestations should the nurse expect when conducting an assessment for a child who is diagnosed with attention deficit/ hyperactivity disorder (ADHD)? Select all that apply. 1. Arm flapping 2. Language delays 3. Ritualistic behavior 4. Impulsive behavior 5. Sleep disturbances Answer: 4, 5 Explanation: 1. Arm flapping is a clinical manifestation associated with autism spectrum disorder, not ADHD. 2. Language delay is a clinical manifestation associated with autism spectrum disorder, not ADHD. 3. Ritualistic behavior is a clinical manifestation associated with autism spectrum disorder, not ADHD. 4. Impulsive behavior is a clinical manifestation associated with ADHD. 5. Sleep disturbance is a clinical manifestation associated with ADHD. Page Ref: 1418 Cognitive Level: Analyzing Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.2 Discuss the clinical manifestations of the major mental health alterations of childhood and adolescence.

19) Which interventions should the nurse include in the plan of care for a child who is diagnosed with an intellectual disability? Select all that apply. 1. Providing emotional support to the family 2. Maintaining a safe environment for the client 3. Educating the family that maintenance of activities of daily living (ADL) is impossible to achieve 4. Participating in the individualized education program (IEP) process 5. Recommending permanent institutionalization Answer: 1, 2, 4 Explanation: 1. The nurse should include interventions in the plan of care for a child diagnosed with an intellectual disability that support the family. 2. The nurse should include interventions in the plan of care for a child diagnosed with an intellectual disability that maintain a safe environment. 3. Maintenance of ADL will be determined by the severity of the intellectual disability. 4. The nurse should participate in the IEP process for a child who is diagnosed with an intellectual disability. 5. Permanent institutionalization is no longer recommended for children diagnosed with an intellectual disability. Page Ref: 1433-1434 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 55.5 Use evidence-based practice to plan nursing management for children with cognitive alterations.

20) Which items noted in a pediatric client's medical record indicate the child may be experiencing a learning disability? Select all that apply. 1. Dyslexia 2. Dysphagia 3. Dyspraxia 4. Scoliosis 5. Hypotonia Answer: 1, 3 Explanation: 1. Dyslexia is the medical term indicating problems with reading, writing, and spelling. This indicates the child may be experiencing a learning disability. 2. Dysphagia is a medical term indicating problems with swallowing. This would not indicate the child is experiencing a learning disability. 3. Dyspraxia is the medical term indicating problems with manual dexterity and coordination. This indicates the child may be experiencing a learning disability. 4. Scoliosis is curvature of the spine. This does not indicate the child may be experiencing a learning disability; however, this is often associated with Down syndrome. 5. Hypotonia is decreased muscle tone. This does not indicate the child may be experiencing a learning disability; however, this is often associated with Fragile X syndrome. Page Ref: 1430 Cognitive Level: Applying Client Need/Sub: Psychosocial Integrity Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 55.4 Describe characteristics of common cognitive alterations of childhood.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 56 The Child with Alterations in Musculoskeletal Function 1) Which finding, noted during the newborn admission assessment, would lead the nurse to suspect developmental dysplasia of the hip (DDH)? 1. Lordosis 2. Trendelenburg sign 3. Asymmetry of the gluteal and thigh fat folds 4. Telescoping of the affected limb Answer: 3 Explanation: 1. Lordosis does not occur with DDH. 2. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with DDH. 3. A sign of developmental dysplasia of the hip in the infant would be asymmetry of the gluteal and thigh fat folds. 4. Trendelenburg sign and telescoping of the affected limb are signs that present in an older child with DDH. Page Ref: 1445 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.1 Describe pediatric variations in the musculoskeletal system.

2) Which clinical manifestations should the nurse monitor for when conducting a scoliosis screening for a school-age child? Select all that apply. 1. Lordosis 2. Prominent scapula 3. Pain 4. A one-sided rib hump 5. Uneven shoulders and hips Answer: 2, 4, 5 Explanation: 1. Lordosis is not present with scoliosis. 2. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. 3. Pain generally is not present with scoliosis unless it is severe. 4. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. 5. The classic signs of scoliosis include uneven shoulders and hips, a one-sided rib hump, and prominent scapula. Page Ref: 1452 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.1 Describe pediatric variations in the musculoskeletal system. 3) Which parental statement would cause the nurse to include further education related to the care required for a child who is diagnosed with congenital clubfoot? 1. "We're getting a special car seat to accommodate the casts." 2. "We'll watch for any swelling of the feet while the casts are on." 3. "We'll keep the casts dry." 4. "We're happy this is the only cast our baby will need." Answer: 4 Explanation: 1. Using a car seat is the law. Special car seats to accommodate the casts are available and should be utilized. 2. Parents should be watching for swelling while the casts are on. 3. Keeping the casts dry is important to prevent complications. 4. Serial casting is the treatment of choice for congenital clubfoot. The cast is changed every 1 to 2 weeks until the corrected foot position is achieved. Page Ref: 1443 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 56.2 Plan nursing care for children with structural deformities of the foot, leg, hip, and spine. 2 Copyright © 2022 Pearson Education, Inc.

4) Which is the priority problem for nurse to use when planning care for a school-age child who must wear a brace for correction of scoliosis? 1. Problems breathing 2. Developmental delays 3. Potential for skin breakdown 4. Difficulty with mobility Answer: 3 Explanation: 1. Problem with breathing is a late effect of scoliosis and would not be the priority. If the client is compliant with wearing the brace, the risk should be minimized. 2. Developmental delays would not be the priority and should be corrected by the wearing of the brace. 3. The skin should be monitored for breakdown in any area where the brace might rub against the skin. 4. Difficulty with mobility would not be the priority and should be corrected if the client is compliant with wearing the brace. Page Ref: 1453 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.2 Plan nursing care for children with structural deformities of the foot, leg, hip, and spine. 5) Which assessment finding would require an immediate nursing action when providing care to an adolescent who is postoperative for spinal fusion surgery? 1. Sleeps when not bothered but arouses easily with stimuli 2. Impaired color, sensitivity, and movement to lower extremities 3. Nausea relieved by antiemetics 4. Pain relieved by analgesics Answer: 2 Explanation: 1. This is a normal response postanesthesia. 2. When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities. 3. Nausea in the postoperative period is not uncommon, but it is not the priority at this time. 4. Pain is a common finding in the postoperative period and should be addressed, but impaired color, sensitivity, and movement of the lower extremities constitute the priority at this time. Page Ref: 1454 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care. 3 Copyright © 2022 Pearson Education, Inc.

6) The nurse is providing care to a child who is diagnosed with Legg-Calvé-Perthes disease. Which parental statement regarding the child's care required further teaching from the nurse? 1. "We're glad this will only take about 6 weeks to correct." 2. "We understand abduction of the affected leg is important." 3. "We know to watch for areas on the skin that the brace might rub." 4. "We understand swimming is a good sport for Legg-Calvé-Perthes." Answer: 1 Explanation: 1. The treatment for Legg-Calvé-Perthes disease takes approximately 2 years. 2. The leg should be kept in the abducted position to prevent damage to the head of the femur due to Legg-Calvé-Perthes disease. 3. A brace is a component of the treatment of Legg-Calvé-Perthes disease and is worn to prevent damage to the head of the femur, so skin irritation should be monitored. 4. Swimming is a good activity to increase mobility in a child with Legg-Calvé-Perthes disease. Page Ref: 1448 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 56.4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care. 7) Which teaching topic is the priority for the nurse who is teaching the family of an infant diagnosed with osteogenesis imperfecta? 1. Cast care 2. Trunk and extremity support during everyday care 3. Postoperative spinal surgery care 4. Traction care Answer: 2 Explanation: 1. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta. 2. With osteogenesis imperfecta, nursing care focuses on preventing fractures. Because the bones are fragile, the entire body must be supported when the child is moved. 3. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta. 4. Traction, casts, and spinal surgery are not routinely done for osteogenesis imperfecta. Page Ref: 1456 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

8) An infant returns to the unit following surgical correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The nurse notes that the toes on both feet are edematous, but there is color, sensitivity, and movement to them. Which action by the nurse is the priority? 1. Apply a warm, moist pack to the feet. 2. Elevate the legs on pillows. 3. Encourage movement of the toes. 4. Call the surgical provider to report the edema. Answer: 2 Explanation: 1. Warm, moist heat will increase swelling and the moisture may cause the cast to disintegrate. 2. The infant's legs should be elevated on a pillow for 24 hours to promote healing and help with venous return. This is the priority action. 3. An infant would not be able to follow directions to move the toes, and in this case, it would not be as effective as would elevating the legs on pillows. 4. Some amount of swelling can be expected, so it would not be appropriate to notify the physician, especially if the color, sensitivity, and movement to the toes remained normal. Page Ref: 1443 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

9) Which should the nurse include in a teaching session for the parents of an infant who will be placed in a Pavlik harness for the treatment of congenital developmental dysplasia? 1. Apply lotion or powder to minimize skin irritation. 2. Check at least 2 or 3 times a day for red areas under the straps. 3. Put clothing over the harness for maximum effectiveness of the device. 4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper. Answer: 2 Explanation: 1. Lotion or powder can contribute to skin breakdown and should not be used. 2. The skin underneath the straps of the brace should be checked 2 or 3 times a day for red areas, which might indicate skin breakdown. 3. A light layer of clothing should be worn under the brace to assist in preventing skin breakdown, not over the brace. 4. The diaper should be placed under the brace, along with a light layer of clothing. Page Ref: 1447 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery. 10) Which action by the nurse is appropriate for a child who presents in the emergency department with an ankle injury? 1. Avoid compressing the area to allow tissue swelling as necessary. 2. Perform passive range-of-motion to the extremity. 3. Lower the extremity below the level of the heart. 4. Apply ice to the extremity. Answer: 4 Explanation: 1. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should apply a compression bandage to the extremity. 2. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should rest the extremity rather than perform range-of-motion. 3. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should elevate the extremity. 4. For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should apply ice to the extremity. Page Ref: 1465 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery. 6 Copyright © 2022 Pearson Education, Inc.

11) Which clinical data noted by the nurse during the shift assessment indicate the pediatric client may be experiencing compartment syndrome? Select all that apply. 1. Pink, warm extremity 2. Dorsalis pedis pulse present 3. Prolonged capillary refill time 4. Pain not relieved by pain medication 5. Paresthesia of the leg Answer: 3, 4, 5 Explanation: 1. Pink, warm extremity is a normal finding post fracture reduction. 2. A present dorsalis pedis pulse would be a normal finding post fracture reduction. 3. A prolonged capillary refill time is a sign of compartment syndrome. 4. A prolonged capillary refill time with loss of paresthesia and pain not relieved by medication are signs of compartment syndrome. 5. Paresthesia is tingling and numbness of the affected extremity and is a sign of compartment syndrome. Page Ref: 1468 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.6 Develop a nursing care plan for fractures, including teaching for injury prevention and nursing implementations for the child who has sustained a fracture. 12) The father of a school-age child who requires hospital admission for intravenous antibiotics to treat osteomyelitis states, "I don't understand why normal antibiotics can't be used." Which should the nurse include in the response to the father? 1. The antibiotic of choice is not available in oral form. 2. Blood flow to bones is limited, and parenteral administration is necessary to get appropriate blood levels. 3. Because the child is older now, it is harder to get the child to cooperate with oral antibiotics. 4. Because 2 weeks of therapy is necessary, the intravenous route will produce fewer side effects. Answer: 2 Explanation: 1. Most antibiotics are available in multiple forms. 2. This is accurate information. 3. The older child can understand the reason for antibiotics and cooperate. 4. Both oral and intravenous antibiotics may have side effects. Page Ref: 1458 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 56.3 Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care. 7 Copyright © 2022 Pearson Education, Inc.

13) Which assessment finding for a toddler-age child in balanced Bryant traction for a fractured right femur would require immediate action by the nurse? 1. The child keeps trying to turn and lie on his belly. 2. The ropes are unequal in length. 3. The child's buttocks are resting on the bed. 4. The Ace bandage wrapping the legs is wrinkled. Answer: 3 Explanation: 1. This child needs a jacket restraint to maintain appropriate positioning if someone cannot stay with him. It does not require notifying the surgeon. 2. In balanced traction, the ropes and pulleys determine the traction and the length of the rope is unimportant. 3. In order to provide adequate counter-traction, the buttocks should be slightly elevated off the bed. The surgeon should be notified. 4. This is not a significant finding. Page Ref: 1369 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

14) Which interventions should the nurse include in the plan of care for an adolescent client who is on complete bed rest after spinal fusion surgery secondary to scoliosis to prevent complications associated with immobility? Select all that apply. 1. Encouraging use of the spirometer every 2 hours while the child is awake 2. Log-rolling the client every 2 hours while awake 3. Increasing intake of milk to maintain bone calcium 4. Increasing fruit and grains in the diet 5. Limiting fluid intake to reduce the need to void Answer: 1, 2, 4 Explanation: 1. Respiratory complications are a common complication of immobility. 2. Turning the client frequently will reduce pressure on bony prominences. 3. Calcium will be pulled from the bones due to immobility. Adding additional calcium in the form of milk will increase the risk of kidney stones. 4. Fruit and grains will provide extra fiber to reduce the risk of complication. 5. Fluid intake should be increased to "flush" the kidneys. Page Ref: 1447, 1453-1454 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery. 15) A school nurse suspects that a child who fell at recess has a fractured arm. Which should the nurse consider when applying a splint to transport the child to the hospital? 1. The splint is applied firmly enough to prevent swelling. 2. The arm is fully extended in the splint. 3. The splint is fully padded to prevent skin damage. 4. The joints above and below the suspected fracture are immobilized by the splint. Answer: 4 Explanation: 1. The purpose of the splint is not to prevent swelling. 2. The nurse will not want to manipulate the arm, so the nurse will splint the arm in the position it is found. 3. The splint does not need to be padded. 4. This is the important concept in splinting–immobilizing the joint above and below the fracture to prevent movement of the bones. Page Ref: 1468 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 56.6 Develop a nursing care plan for fractures, including teaching for injury prevention and nursing implementations for the child who has sustained a fracture. 9 Copyright © 2022 Pearson Education, Inc.

16) Which assessment data obtained by the nurse during the health history portion of the assessment process support the current diagnosis of Duchenne muscular dystrophy (MD) for an 18-month-old child? 1. Infant was postmature by almost 2 weeks. 2. The child seems very muscular. 3. The child walked early and without support at 10 months. 4. The child's older sister developed scoliosis in the fourth grade. Answer: 2 Explanation: 1. Postmaturity is not related to Duchenne MD. 2. Duchenne MD is also called pseudohypertrophic due to the enlarged appearance of the muscle. The pathophysiology is infiltration of the muscle fibers with fatty tissue. 3. This finding is not indicative of Duchenne MD. 4. The older sister's scoliosis is not related to MD. Duchenne MD is sex-linked recessive and affects only boys. Page Ref: 1461 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.3 Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care.

17) Which should the nurse include in the neurovascular assessment for an infant following casting of the leg for talipes equinovarus? 1. Warmth 2. Capillary refill 3. Pedal pulse 4. Sensation 5. Movement of the toes Answer: 1, 2, 4, 5 Explanation: 1. The temperature of the foot of the casted leg should be compared to the temperature of the other foot. 2. This indicates blood return to the tissues and is an important finding. 3. The pedal pulse cannot be reached in the casted foot. 4. Nerve function is evaluated by touching the toes and noting the child's response. 5. The child is encouraged to wiggle the toes. If the client is an infant, tickling will cause the child to respond with movement. Page Ref: 1468 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

18) Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with developmental dysplasia of the hip (DDH)? Select all that apply. 1. Limited adduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles Answer: 2, 3 Explanation: 1. The nurse would anticipate limited abduction, not adduction, of the affected hip for a child diagnosed with DDH. 2. Asymmetry of the thigh fat folds is a clinical manifestation associated with DDH. 3. Telescoping of the thigh is a clinical manifestation associated with DDH. 4. Muscle weakness is not an expected clinical manifestation associated with DDH. 5. Atrophy of the muscles is not an expected clinical manifestation associated with DDH. Page Ref: 1446 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.3 Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care.

19) Which clinical manifestations should the nurse expect when assessing a pediatric client who is diagnosed with Legg-Calvé-Perthes disease? Select all that apply. 1. Limited abduction of the affected hip 2. Asymmetry of thigh fat folds 3. Telescoping of the thigh 4. Muscle weakness 5. Atrophy of the muscles Answer: 4, 5 Explanation: 1. Limited abduction of the affected hip is a clinical manifestation associated with clinical hip dysplasia, not Legg-Calvé-Perthes disease. 2. Asymmetry of the thigh fat folds is a clinical manifestation associated with clinical hip dysplasia, not Legg-Calvé-Perthes disease. 3. Telescoping of the thigh is a clinical manifestation associated with clinical hip dysplasia, not Legg-Calvé-Perthes disease. 4. Muscle weakness is an expected clinical manifestation associated with Legg-Calvé-Perthes disease. 5. Atrophy of the muscles is not an expected clinical manifestation associated with Legg-CalvéPerthes disease. Page Ref: 1449 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 56.3 Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care.

20) Which are appropriate interventions for the nurse to include in the plan of care for a child who is receiving traction? Select all that apply. 1. Monitoring breath sounds 2. Assessing neurovascular status every 2 hours 3. Repositioning every 2 to 3 hours 4. Using moleskin to protect the skin from rough edges 5. Encouraging the parents cuddle with their child Answer: 1, 2, 5 Explanation: 1. Children who are receiving traction are at risk for atelectasis and pneumonia; therefore, the nurse should monitor breath sounds frequently. 2. Children who are receiving traction are at risk for circulatory compromise; therefore, the nurse should perform neurovascular checks every 2 hours. 3. Repositioning every 2 to 3 hours is more appropriate for a child who is casted. 4. Using moleskin to protect the skin from rough edges is more appropriate for a child who is casted. 5. Children who are receiving traction should be allowed up to 1 hour per day without the traction device, at which time the child can eat and cuddle with parents. Page Ref: 1469 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

21) Which are appropriate interventions for the nurse to include in the plan of care for a child who is casted? Select all that apply. 1. Monitoring breath sounds 2. Assessing neurovascular status every 4 hours 3. Repositioning every 2 to 3 hours 4. Using moleskin to protect the skin from rough edges 5. Encouraging the parents cuddle with their child Answer: 1, 3, 4, 5 Explanation: 1. Children who are casted are at risk for atelectasis and pneumonia; therefore, the nurse should monitor breath sounds frequently. 2. Children who are casted are at risk for circulatory compromise; therefore, the nurse should perform neurovascular checks every 2, not 4, hours. 3. Repositioning every 2 to 3 hours is appropriate for a child who is casted. 4. Using moleskin to protect the skin from rough edges is appropriate for a child who is casted. 5. Children who are casted should be allowed to cuddle with parents to promote developmentally appropriate care. Page Ref: 1442 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.5 Prioritize nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery.

22) Which injury prevention strategies should the nurse include in the plan of care for a pediatric client who is diagnosed with muscular dystrophy? 1. Develop a home fire evacuation plan. 2. Provide information regarding oxygen safety. 3. Recommend the use of portable generator. 4. Teach safe transfer methods. 5. Perform neurovascular checks every 2 hours. Answer: 1, 2, 3, 4 Explanation: 1. Helping the family to develop a home fire evacuation plan is an injury prevention strategy the nurse should include in the plan of care. 2. Providing information regarding oxygen safety is an injury prevention strategy the nurse should include in the plan of care. 3. Recommending the use of a portable generator is an injury prevention strategy the nurse should include in the plan of care. 4. Teaching safe transfer methods is an injury prevention strategy the nurse should include in the plan of care. 5. Performing neurovascular checks is appropriate to include in the plan of care for a client who is receiving traction or casting, not for a client diagnosed with muscular dystrophy. Page Ref: 1462-1463 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 56.4 Partner with families to plan care for children with musculoskeletal conditions that are chronic or require long-term care.

Maternal & Child Nursing Care, 6e (London et al.) Chapter 57 The Child with Alterations in Skin Integrity 1) Which is the most likely cause for a bright red perianal inflammation with scaly plaques and small papules noted by the nurse during the assessment of a 12-month-old infant? 1. Candida albicans (yeast) 2. Impetigo (staphylococcus) 3. Infrequent diapering 4. Urine and feces Answer: 1 Explanation: 1. Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with C. albicans occurs, the rash has bright red, scaly plaques with sharp margins. Small papules and pustules might be seen, along with satellite lesions. 2. Even though diaper dermatitis can be caused by impetigo, urine, feces, and infrequent diapering, the lesions and persistent characteristics are common for Candida infection. 3. Infrequent diapering, along with urine and feces, can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida infection. 4. Urine and feces can cause diaper dermatitis, but the persistence and characteristics of the lesions are common for Candida infection. Page Ref: 1480 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 57.1 Classify characteristics of skin lesions caused by irritants, drug reactions, mites, infection, and injury.

2) Which finding noted by the school nurse while conducting pediculosis capitis (head lice) checks would indicate the need for treatment? 1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area Answer: 4 Explanation: 1. Lice and nits must be distinguished from dandruff, which appears as white, flaky particles. 2. Lesions might be present from itching, but the positive sign of head lice is evidence of nits. 3. Lesions might be present from itching, but the positive sign of head lice is evidence of nits. 4. Evidence of pediculosis capitis includes silver/white sacs (nits) that are attached to the hair shafts, frequently in the occiput area. Page Ref: 1494 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 57.1 Classify characteristics of skin lesions caused by irritants, drug reactions, mites, infection, and injury. 3) The 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. Which finding would the nurse expect to see while changing the child's dressing and assessing the wound? 1. The wound is contracting, and the edges are growing together. 2. A blood clot has formed, sealing the wound. 3. Epithelial cells are growing into the wound. 4. The wound is pale and weepy. Answer: 2 Explanation: 1. Wound contraction and inward movement of the wound edge occur during the reconstruction phase of wound healing. 2. Clot formation to seal the wound with fibrin and trapped cells and platelets occurs during the inflammation phase of wound healing, in the first 3 to 5 days. 3. Epithelial cells growing into the wound occurs in the reconstruction phase of wound healing. 4. During the initial phase of healing, there is increased blood flow, giving the area an "inflamed" appearance. Page Ref: 1447 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 57.2 Differentiate stages of wound healing. 2 Copyright © 2022 Pearson Education, Inc.

4) A child had an appendectomy and was discharged home at 48 hours postoperative. A week later, the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child? Select all that apply. 1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia Answer: 1, 2, 4, 5 Explanation: 1. Infection can affect healing and cause excessive scarring. 2. Conditions such as diabetes affect circulating blood volume and are known to affect healing. 3. Hypovolemia, not hypervolemia, would inhibit inflammation due to low circulating blood volume. 4. Poor nutrition without proper protein and calorie intake will affect healing. 5. Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation. Page Ref: 1479 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 57.2 Differentiate stages of wound healing.

5) Which is the priority intervention when planning care for an infant who is diagnosed with eczema? 1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions Answer: 4 Explanation: 1. Antibiotics are not routinely applied to the lesions, since the lesions are not related to infection. However, impaired skin barrier function and cutaneous immunity place the infant at greater risk for the development of skin infection. 2. Keeping the infant content is not as high a priority as is prevention of infection. An infant with eczema is at a greater risk for the development of skin infection. 3. Maintaining adequate nutrition is important, but it is not as high a priority. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infection. 4. Nursing care should focus on preventing infection of lesions. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms. Page Ref: 1488 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.3 Compare skin conditions that have a hereditary cause or predisposition.

6) Which is the priority problem when planning care for an infant who is diagnosed with a severe case of oral thrush (Candida albicans)? 1. Problem with feeding 2. Problem with breathing 3. Difficulty moving 4. Excess mucous production Answer: 1 Explanation: 1. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. 2. Problem with breathing is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. 3. Difficulty moving is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. 4. Excess mucous production is not usually associated with oral thrush. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt recognition and treatment are necessary so that a normal feeding pattern can be resumed. Page Ref: 1484 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 57.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

7) Which parental statement indicates to the nurse accurate understanding regarding the care of their child with tinea capitis (ringworm of the scalp)? 1. "We will give the griseofulvin with milk or peanut butter." 2. "We're glad ringworm isn't transmitted from person to person." 3. "Once the lesion is gone, we can stop the griseofulvin." 4. "Well, at least we don't have to worry about the family cat getting the ringworm." Answer: 1 Explanation: 1. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption. 2. All members of the family and household pets should be assessed for fungal lesions because person-to-person and animal-to-person transmission can occur. 3. The medication must be used for the entire prescribed period, even if the lesions are gone. 4. Dogs and cats can develop the fungal lesions and be sources of spread of the organism. Page Ref: 1484 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 57.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

8) Which nursing action is accurate when applying a 5% permethrin lotion to a toddler with scabies? 1. Applying the lotion to the scalp, forehead, and everywhere below the chin 2. Applying the lotion only on the areas with evidence of activity 3. Applying the lotion only to the hands 4. Applying the lotion only to the scalp Answer: 1 Explanation: 1. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face. 2. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead. 3. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, including the scalp and forehead. 4. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down, as well as the scalp and forehead. Page Ref: 1495 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 57.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

9) Which should the nurse include in the plan of care for a child with a minor burn to enhance nutrition and healing? 1. Protein 2. Minerals 3. Carbohydrates 4. Fats Answer: 1 Explanation: 1. Parents should be taught that management of a minor burn requires a highcalorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing. 2. A high-calorie, high-protein diet is required to meet the increased nutritional requirements for healing. 3. The family should be taught that a high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing. 4. A high-calorie, high-protein diet is best to meet the increased nutritional requirements for healing. Page Ref: 1504 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.6 Summarize the process to measure the extent of burns and burn severity in children.

10) Which is the priority problem during the acute phase of a third-degree circumferential burn of the right arm for a pediatric client? 1. Change in tissue integrity 2. Development of infection 3. Difficulty moving 4. Change in oral intake Answer: 1 Explanation: 1. Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Change in tissue integrity to the extremity is the greatest risk and therefore the priority diagnosis. 2. When the burn is circumferential, blood flow can become restricted due to edema and can result in tissue hypoxia. Development of infection would be a secondary priority in this case. 3. Difficulty moving is a secondary priority for the child with a circumferential burn. 4. There is no evidence that the client is having a change in oral intake; however, the burn will increase metabolism. Page Ref: 1498 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.4 Diagnose actual or potential health problems and needs. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 57.6 Summarize the process to measure the extent of burns and burn severity in children.

11) A toddler pulled a pot of boiling water off the stove and suffered partial- and full-thickness burns to the chest. The child is now in the recovery-management phase of burn treatment. Which common complication should the nurse assess this client for based on the current data? 1. Asphyxia 2. Metabolic acidosis 3. Shock 4. Wound infection Answer: 4 Explanation: 1. Asphyxia is not a common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication. 2. Metabolic acidosis is not common in the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication. 3. Shock is not the most common complication during the recovery-management phase of burn treatment. Infection of the burned area is a frequent complication. 4. Infection of the burned area is a frequent complication in the recovery-management phase. A goal of burn-wound care is protection from infection. Page Ref: 1500 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.3 Integrate assessment skills in practice. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 57.6 Summarize the process to measure the extent of burns and burn severity in children.

12) The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication? 1. Pain 2. Hypertrophic scarring 3. Poor circulation 4. Formation of thrombus in the burn area Answer: 2 Explanation: 1. The Jobst stockings, or pressure garments, do not prevent pain. They are used to prevent development of hypertrophic scarring and contractures. 2. During the rehabilitation stage, Jobst stockings, or pressure garments, are used to reduce development of hypertrophic scarring and contractures. 3. The Jobst pressure garments are used to prevent or minimize the development of hypertrophic scarring and contractures. 4. The elastic pressure garments are used to prevent development of hypertrophic scarring and contractures. They do not prevent the formation of thrombus in the burn area. Page Ref: 1501 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.2 Communicate effectively with individuals. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 57.6 Summarize the process to measure the extent of burns and burn severity in children.

13) Which is the priority nursing action when providing care to a child who is bitten by a snake? 1. Measuring the circumference of the extremity twice per hour 2. Monitoring respiratory status 3. Assessing vital signs 4. Evaluating response to pain medication Answer: 2 Explanation: 1. In order to track progression in swelling and response to treatment, the extremity with the bite is measured every 20 to 30 minutes. However, this does not take priority over airway, breathing, and circulation. 2. Emergency intervention for airway, breathing, and circulation takes priority and has a high probability of occurrence. 3. Vital signs and neurovascular status of the distal extremities should be monitored but do not take priority over airway, breathing, and circulation. 4. Pain medication will need to be given and the response to the treatment monitored; however, this should not take priority over airway, breathing, and circulation. Page Ref: 1509 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 57.8 Evaluate preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

14) Which parental statement regarding preventative strategies for insect bites and stings indicate the need for further education? 1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her." 2. "We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction." 3. "My child can use insect repellent containing DEET of 10% or less." 4. "My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them." Answer: 1 Explanation: 1. Bright-colored clothing and floral prints attract the insects. White- and lightcolored clothing should be worn. This statement requires clarification. 2. Standing water is a breeding ground for mosquitoes. Rid yards of all birdbaths, stagnant pools, and any standing water that mosquitoes could use for breeding. No clarification is needed. 3. DEET is an appropriate insect repellent and can be used in children. A concentration of 10% or less is recommended due to neurotoxic effects at greater concentrations. No clarification is needed. 4. Heavy colognes, perfumes, soaps, and detergents resemble flowers and plants and will attract the stinging insects. This statement is correct. Page Ref: 1509 Cognitive Level: Analyzing Client Need/Sub: Safe and Effective Care Environment / Safety and Infection Control Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 57.8 Evaluate preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

15) Which discharge instruction is appropriate for an adolescent client who is a paraplegic due to a motor vehicle accident, in order to prevent decubitus ulcer formation on the buttock? 1. Contract the muscles five times every 2 hours. 2. Increase fat in the diet to provide a protective coating over the bony prominences. 3. Do wheelchair push-ups every 15 to 30 minutes. 4. Avoid use of sheepskin, as it prevents air from reaching the area. Answer: 3 Explanation: 1. The child is a paraplegic and therefore unable to contract the buttock muscles. 2. Extra weight will add to pressure on the bony prominences and should be avoided. 3. Lifting the buttocks with the arms can help with blood flow to the buttocks and reduce the risk of breakdown. 4. Sheepskin can reduce pressure on the buttocks; it is one of many pressure reducing materials available. Page Ref: 1498 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.2 Differentiate stages of wound healing.

16) Which skin conditions should the nurse identify as having a genetic or inherited component during a presentation to the staff nurses who work in the integument clinic? Select all that apply. 1. Atopic dermatitis 2. Seborrheic dermatitis 3. Epidermolysis bullosa 4. Molluscum contagiosum 5. Psoriasis Answer: 1, 3, 5 Explanation: 1. Atopic dermatitis is an allergic skin disorder. Allergies have an inherited component. 2. Seborrheic dermatitis is thought to be an overgrowth of yeast and is influenced by hormones. It is not inherited. 3. Epidermolysis bullosa is inherited either as autosomal dominant or autosomal recessive depending on type. 4. Molluscum is caused by a poxvirus and is transmitted person to person. 5. Psoriasis is usually seen in clients with a family history. A multifactorial inheritance is suspected. Page Ref: 1486, 1491, 1493 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Implementation/Teaching and Learning Learning Outcome: 57.3 Compare skin conditions that have a hereditary cause or predisposition.

17) Which adolescent statement regarding skin care and acne prevention would indicate the need for further education by the nurse? 1. "I shouldn't squeeze my blackheads or pimples." 2. "I need to cut out all chocolates." 3. "I should avoid applying drying materials, such as astringents, to my face" 4. "I should wash my hands frequently and avoid touching my face." Answer: 2 Explanation: 1. This practice can introduce organisms into the lesions and should be avoided. This statement needs no clarification. 2. New evidence is revealing that some foods, such as a high glycemic index diet, skim milk, and whey protein are associated with acne. However, chocolate does not have to be excluded. 3. This statement is accurate and needs no clarification. 4. This is an important means of reducing facial irritation. Page Ref: 1491 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 57.5 Prepare an education plan for adolescents with acne to promote selfcare. 18) Which clinical therapy should the nurse anticipate when planning care for a toddler-age client who is admitted to the hospital unit with cellulitis of the neck? 1. Topical antibiotics 2. Intravenous antibiotics 3. Incision and drainage 4. Oral corticosteroids Answer: 2 Explanation: 1. This is an infection of the deeper tissues including the dermis and supporting connective tissues. Topical antibiotics will not reach the infection. 2. This infection usually requires parenteral antibiotics. 3. The infection is not consolidated into an abscess, so an incision and drainage would not be performed. 4. Corticosteroids are anti-inflammatories and would not be used to treat this infection. Page Ref: 1482 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Pharmacological and Parenteral Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

19) Which preventative strategies for tinea pedis, a fungal infection, also known as athlete's foot, should the nurse include in a teaching session for an adolescent client? Select all that apply. 1. Wear 100% white cotton socks, changed twice a day. 2. Use talc on feet daily. 3. Use an over-the-counter corticosteroid cream to treat the area. 4. Wear foot covers such as flip- flops in the locker room and shower. 5. Apply heat to the area twice a day. Answer: 1, 2, 4 Explanation: 1. The socks will wick moisture away from the feet to promote healing. 2. This process will help keep the feet dry. 3. Corticosteroids will not destroy the organism. An antifungal medication is required. 4. This will reduce the spread of the organism among team members. 5. Heat will not treat the problem. Antifungal medications are required. Page Ref: 1485 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.4 Plan the nursing care for the child with alterations in skin integrity, including dermatitis, infectious disorders, and infestations.

20) Which is the priority nursing intervention for a 4-year-old client brought to the emergency department (ED) for treatment of frostbite? 1. Administer analgesics. 2. Immerse the hands in extremely warm water (120°F). 3. Do not remove clothing. 4. Place the extremity in a dependent position. Answer: 1 Explanation: 1. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. 2. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. 3. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. 4. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return. Page Ref: 1508 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.6 Demonstrate accountability for care delivery. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 57.8 Evaluate preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

21) Which adolescent statements indicate the need for further education related to the prevention and treatment of acne? Select all that apply. 1. "I should wash my face each day with an approved cleanser." 2. "I should wash my hands frequently, and avoid touching my face." 3. "I should stay away from greasy foods, such as pizza." 4. "I should shampoo my hair only once per week." 5. "I should use my topical medication only when acne is present." Answer: 3, 4, 5 Explanation: 1. Washing the face with an approved cleanser each day indicates appropriate understanding of prevention and treatment for acne. 2. Performing frequent hand hygiene and not touching the face indicates appropriate understanding of prevention and treatment for acne. 3. There is no evidence to suggest that greasy foods, such as pizza, cause acne. This statement indicates the need for further education. 4. Hair should be shampooed frequently, as the oil hair can cause acne. This statement indicates the need for further education. 5. Prescribed topical medication should be used daily and spread over the entire face. This statement indicates the need for further education. Page Ref: 1491 Cognitive Level: Analyzing Client Need/Sub: Health Promotion and Maintenance Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.7 Evaluate outcomes of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 57.5 Prepare an education plan for adolescents with acne to promote selfcare.

22) Which pain interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound Answer: 1, 2, 3 Explanation: 1. Pain assessment with an age-appropriate scale is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 2. Covering the affected area to prevent temperature changes and air movement is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 3. Analgesics administration prior to wound care is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 4. Keeping the skin as clean and dry as possible is an appropriate intervention to decrease infection, not pain. 5. Clipping hair around the wound is an appropriate intervention to decrease infection, not pain. Page Ref: 1503-1504 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.7 Develop a nursing care plan for the child with a full-thickness burn injury.

23) Which interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury to decrease the risk for infection? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound Answer: 4, 5 Explanation: 1. Pain assessment with an age-appropriate scale is an appropriate intervention to address pain, not infection. 2. Covering the affected area to prevent temperature changes and air movement is an appropriate intervention to address pain, not infection. 3. Analgesics administration prior to wound care is an appropriate intervention to address pain, not infection. 4. Keeping the skin as clean and dry as possible is an appropriate intervention to decrease infection. 5. Clipping hair around the wound is an appropriate intervention to decrease infection. Page Ref: 1501 Cognitive Level: Analyzing Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.7 Develop a nursing care plan for the child with a full-thickness burn injury.

24) Which topics should be included in a teaching session with parents of school-age children to prevent sunburn? Select all that apply. 1. Playing in the shade 2. Wearing a hat while outdoors 3. Restricting outside activities between 10 a.m. and 2 p.m. 4. Using sunscreen with an SPF of 30 or higher 5. Avoiding sunglasses Answer: 1, 2, 4 Explanation: 1. The nurse should recommend that school-age children play in the shade while outdoors to decrease the risk for sunburn. 2. The nurse should recommend that school-age children wear a hat while outdoors to decrease the risk for sunburn. 3. Outdoor activities should be restricted between 10 a.m. and 4 p.m. to decrease the risk for sunburn. 4. The nurse should recommend that school-age children use sunscreen with an SPF of 30 or higher to decrease the risk for sunburn. 5. Sunglasses should be encouraged, not discouraged, to decrease the risk for sunburn around the eyes. Page Ref: 1507 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.8 Evaluate preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.

25) Which topics should be included in a teaching session with parents of school-age children to prevent frostbite? Select all that apply. 1. Dressing in layers 2. Having extra clothing available 3. Removing wet gloves immediately 4. Applying sunscreen twice per day 5. Wearing sunglasses while outside Answer: 1, 2, 3 Explanation: 1. Dressing in layers is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 2. Having extra clothing available is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 3. Removing wet gloves immediately is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 4. Application of sunscreen is an appropriate topic to prevent sunburn, not frostbite. 5. Wearing sunglasses while outside is an appropriate topic to prevent sunburn, not frostbite. Page Ref: 1508 Cognitive Level: Applying Client Need/Sub: Physiological Integrity / Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence | AACN 2021 Domains and Competencies: 2.5 Develop a plan of care. | NLN Competencies: Quality and Safety: Knowledge: Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 57.8 Evaluate preventive strategies to reduce the risk of injury from burns, hypothermia, bites, and stings.