TEST BANK for Introductory Maternity and Pediatric Nursing 4th Edition by Hatfield. by StudyGuide

Introductory Maternity and Pediatric Nursing 4th Edition Hatfield Test Bank

Chapter 1: The Nurse's Role in a Changing Maternal–Child Health Care Environment MULTIPLE CHOICE 1. Which principle of teaching should the nurse use to ensure learning in a family situation? a. Motivate the family with praise and positive feedback. b. Learning is best accomplished with the lecture format. c. Present complex subject material first while the family is alert and ready to learn.

d. Families should be taught using medical jargon so they will be able to understand the technical language used by physicians.

ANS: A

Praise and positive feedback are particularly important when a family is trying to master a

frustrating task such as breastfeeding. A lively discussion stimulates more learning than a

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straight lecture, which tends to inhibit questions. Learning is enhanced when the teaching is structured to present the simple tasks before the complex material. Even though a family may that are used.

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understand English fairly well, they may not understand the medical terminology or slang terms

PTS: 1 DIF: Cognitive Level: Application REF: 18, 19

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 2. Which nursing intervention is an independent function of the nurse? a. Administering oral analgesics b. Requesting diagnostic studies c. Teaching the client perineal care d. Providing wound care to a surgical incision

ANS: C Nurses are now responsible for various independent functions, including teaching, counseling, and intervening in nonmedical problems. Interventions initiated by the physician and carried out by the nurse are called dependent functions. Administrating oral analgesics is a dependent function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is a dependent function. Providing wound care is a dependent function; it is usually initiated by the physician through direct orders or protocol. PTS: 1 DIF: Cognitive Level: Understanding REF: 24

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

a. Everything will be OK.

should be made by the nurse?

3. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth

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b. Dont worry about it. It will be over soon.

c. What concerns you most about a cesarean birth?

ANS: C

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d. The physician will be in later and you can talk to him.

The response, What concerns you most about a cesarean birth focuses on what the client is

saying and asks for clarification, which is the most therapeutic response. The response, Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will be over soon will indicate that the clients feelings are not important. The response, The physician will be in later and you can talk to him does not allow the client to verbalize her feelings when she wishes to do that. PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Psychosocial Integrity 4. Which action should the nurse take to evaluate the clients learning about performing infant care? a. Demonstrate infant care procedures. b. Allow the client to verbalize the procedure. c. Routinely assess the infant for cleanliness. d. Observe the client as she performs the procedure.

ANS: D The clients correct performance of the procedure under the nurses supervision is the best proof of her ability. Demonstration is an excellent teaching method, but not an evaluation method. During

verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is

not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being

used.

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PTS: 1 DIF: Cognitive Level: Application REF: 21

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 5. A nurse is reviewing teaching and learning principles. Which situation is most conducive to

learning?

a. An auditorium is being used as a classroom for 300 students. b. A teacher who speaks very little Spanish is teaching a class of Hispanic students. c. A class is composed of students of various ages and educational backgrounds. d. An Asian nurse provides nutritional information to a group of pregnant Asian women. ANS: D

A clients culture influences the learning process; thus, a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the clients cultural beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher cannot see nonverbal cues from the students to ensure understanding. The ability to understand the language in which teaching is done determines how much the client learns. Clients for whom English is not their primary language may not understand idioms, nuances, slang terms, informed usage of words, or medical terms. The teacher should be fluent in the language of the student. Developmental levels and educational levels influence how a person learns best. For the teacher to present the information in the best way, the class should be at the same level.

PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity

6. Which is the step of the nursing process in which the nurse determines the appropriate

interventions for the identified nursing diagnosis? a. Planning

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d. Intervention

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c. Assessment

b. Evaluation

ANS: A

The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During

the assessment phase, data are collected. The intervention phase is when the plan of care is carried out.

PTS: 1 DIF: Cognitive Level: Understanding REF: 24 OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment

7. Which goal is most appropriate for the collaborative problem of wound infection? a. The client will not exhibit further signs of infection. b. Maintain the clients fluid intake at 1000 mL/8 hr. c. The client will have a temperature of 98.6 F within 2 days. d. Monitor the client to detect therapeutic response to antibiotic therapy. ANS: D In a collaborative problem, the goal should be nurse-oriented and reflect the nursing interventions of monitoring or observing. Monitoring for complications such as further signs of

infection is an independent nursing role. Intake and output is an independent nursing role. Monitoring a clients temperature is an independent nursing role.

OBJ: Nursing Process Step: Planning

PTS: 1 DIF: Cognitive Level: Application REF: 18

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MSC: Client Needs: Safe and Effective Care Environment 8. Which nursing intervention is correctly written?

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a. Force fluids as necessary.

b. Observe interaction with the infant.

c. Encourage turning, coughing, and deep breathing.

d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM. ANS: D

Interventions might not be carried out if they are not detailed and specific. Force fluids is not specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is not detailed and specific. Observing interaction with the infant does not state how often this procedure should be done. PTS: 1 DIF: Cognitive Level: Application REF: 25

OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment 9. The client makes the statement: Im afraid to take the baby home tomorrow. Which response by the nurse would be the most therapeutic? a. Youre afraid to take the baby home? b. Dont you have a mother who can come and help? c. You should read the literature I gave you before you leave.

d. I was scared when I took my first baby home, but everything worked out. ANS: A

This response uses reflection to show concern and open communication. The other choices are

blocks to communication. Asking if the client has a mother who can come and help blocks further communication with the client. Telling the client to read the literature before leaving does

not allow the client to express her feelings further. Sharing your feelings about your experience

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with a new baby blocks further communication with the client. PTS: 1 DIF: Cognitive Level: Application REF: 18, 19

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Psychosocial Integrity

10. The nurse is writing an expected outcome for the nursing diagnosisacute pain related to trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of 10. Which is a correctly stated expected outcome for this problem? a. Client will state that pain is a 2 on a scale of 10. b. Client will have a reduction in pain after administration of the prescribed analgesic. c. Client will state an absence of pain 1 hour after administration of the prescribed analgesic.

d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of the prescribed analgesic. ANS: D The outcome should be client-centered, measurable, realistic, and attainable and have a time frame. Client stating that pain is now 2 on a scale of 10 lacks a time frame. Client having a reduction in pain after administration of the prescribed analgesic lacks a measurement. Client stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic. PTS: 1 DIF: Cognitive Level: Application REF: 25

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

a. Risk for anxiety related to upcoming birth

11. Which nursing diagnosis should the nurse set as a priority for a laboring client?

b. Risk for imbalanced nutrition related to NPO status

c. Risk for altered family processes related to new addition to the family

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d. Risk for injury (maternal) related to altered sensations and positional or physical changes

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ANS: D

The nurse should determine which problem needs immediate attention. Risk for injury is the

problem that has the priority at this time because it is a safety problem. Risk for anxiety,

imbalanced nutrition, and altered family processes are not the priorities at this time. PTS: 1 DIF: Cognitive Level: Application REF: 24, 25 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 12. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?

a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting. b. Clinical nurse specialists provide primary care to obstetric clients. c. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants. d. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse. ANS: C Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal

intensive care unit, as needed. FNPs do not participate in childbirth care but can take care of uncomplicated pregnancies and postbirth care outside of the hospital setting. CNSs work in hospital settings but do not provide primary care services to clients. A CNM is an advanced

practice nurse who receives additional certification in the specific area of midwifery.

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OBJ: Nursing Process Step: Evaluation

PTS: 1 DIF: Cognitive Level: Application REF: 17

MSC: Client Needs: Management of Care: Legal Rights and Responsibilities

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13. You are taking care of a couple postbirth who are very eager to learn about bathing techniques that they can use for their newborn. Which teaching technique could the nurse use to

facilitate parents learning about giving a bath to their newborn infant?

a. Provide direct, step-by-step demonstration to each parent separately to foster individual retention and comprehension. b. Present information to parents prior to discharge so that the information will be current. c. Have each parent bathe the newborn each time the infant comes to the room and provide commentary after the skill repetition. d. Demonstrate bathing techniques on the newborn infant with parents in attendance. ANS: D

Demonstration of bathing techniques is a form of role modeling that would enhance teaching and learning outcomes. Presenting the information at the time of discharge will not allow for identification of concerns and/or evaluation of whether the skill has been acquired. Although it may be advantageous to have each parent bathe their newborn, this action would not be advised in terms of time management and safety related to maintenance of core temperature. PTS: 1 DIF: Cognitive Level: Application REF: 21 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion: Teaching/Learning

14. Which statement is true regarding the shortage of nurses in the United States?

a. There are a larger proportion of younger nurses in the workforce as compared with older nurses.

b. As a result of decreased RN-to-client ratios, there is a decrease in client mortality in the clinical setting.

c. Increased needs for baccalaureate nurses are not being met by current enrollment.

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d. There are adequate classroom and clinical facilities for training RNs.

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ANS: C

According to an Institute of Medicine (IOM) report, by the year 2020, there will only be 50% of RNs with baccalaureate degrees. The required demand is at 80%. There are a larger proportion of

older nurses in the workforce based on current research by the IOM. Increased RN-to-client

ratios has resulted in decreased client mortality in the clinical setting. There are limitations of classroom and clinical facilities to train new nurses adequately. PTS: 1 DIF: Cognitive Level: Application REF: 16 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion: Teaching/Learning

15. A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification? a. There is stratification of communication in a directed manner between nursing staff and administration. b. There is increased job satisfaction of nurses, with a low staff turnover rate. c. Physicians are certified in their respective specialty areas. d. All nurses have baccalaureate degrees and certification in their clinical specialty area.

ANS: B Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center) in which hospitals apply based on designated criteria that consider nurse job satisfaction, staff

patterns, strength, quality of nursing staff, and open communication. It is not based on physician

status. Although the expectation is that at least 80% of the nurses will have baccalaureate degrees, most hospitals that achieve Magnet status have 50% of RNs at that level. Also,

certification is not required for all nurses at this point. The expectation with Magnet status is that

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nurses will continue to expand their knowledge by earning additional degrees and certification. PTS: 1 DIF: Cognitive Level: Application REF: 17

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OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion: Teaching/Learning

16. Which of the following indicates a nurses role as a researcher? a. Reading peer-reviewed journal articles b. Working as a member of the interdisciplinary team to provide client care c. Helping client to obtain home care post-discharge from the hospital d. Delegating tasks to unlicensed personnel to allow for more teaching time with clients ANS: A

A nurse in a researcher role should look to improve her or his knowledge base by reading and reviewing evidence-based practice information as found in peer-reviewed journals. Working as a member of the interdisciplinary team to provide client care indicates that the nurse is working as a collaborator. Helping the client to obtain home care post-discharge from the hospital indicates that the nurse is working as a client advocate. Delegating tasks to unlicensed personnel to allow for more teaching time with clients indicates that the nurse is working as a manager. PTS: 1 DIF: Cognitive Level: Application REF: 21 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion: Teaching/Learning 17. A 16-year-old primipara has just completed her first prenatal visit with the health care

nurse include in the patients teaching plan?

provider. The nurse is preparing to teach her about nutrition during pregnancy. What must the

a. Provide her with pictures of dairy products.

b. Ask her, Are you ready to hear this information now?

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c. Read directly from the pamphlet prepared for teen mothers.

ANS: D

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d. Provide a comfortable and warm setting after she has put on her street clothes.

The nurse must structure teaching for teens in a way that suits them best. For teaching to be most

effective, the physical environment must be comfortable and distractions to learning must be

kept at a minimum. Pictures, videos, and computer-based materials are more effective teaching tools for younger clients. Patients must have an attitude of readiness and openness for the teaching to be effective. However, if the environment is not conducive to learning, efforts for effective teaching will be minimized. PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

18. The nurse states to the newly pregnant patient, Tell me how you feel about being pregnant. Which communication technique is the nurse using with this patient? a. Clarifying b. Paraphrasing c. Reflection d. Structuring ANS: A The nurse is attempting to follow up and check the accuracy of the patients message.

Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing comprehension of what the patient has said. Structuring takes place when the nurse has set

guidelines or set priorities.

PTS: 1 DIF: Cognitive Level: Understanding REF: 19

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

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19. The pregnant woman tells the nurse, I think something may be wrong with my pregnancy. Which statement by the nurse demonstrates therapeutic communication?

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a. Most women worry; I felt the same way when I was pregnant. b. Tell me more about what concerns you about this pregnancy.

c. That is a very common concern, but your pregnancy will turn out just fine.

d. You should focus on taking care of yourself and not worry so much. ANS: B

Questioning is a therapeutic communication technique in which additional information is elicited by using open-ended questions. The remaining options are examples of three behaviors that block communicationinappropriate self-disclosure, providing false reassurance, and giving advice. PTS: 1 DIF: Cognitive Level: Analysis REF: 18

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity MULTIPLE RESPONSE 20. The nurse is formulating a nursing care plan for a postpartum client. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply). a. Using a standardized postpartum care plan

b. Determining priorities for each diagnosis written c. Writing interventions from a nursing diagnosis book

d. Reflecting and suspending judgment when writing the care plan

e. Clustering data during the assessment process according to normal versus abnormal

ANS: B, D, E

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Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes reflective skepticism. Determining priorities, reflecting and suspending judgment, and clustering data are actions that indicate the use of critical thinking. Using a standardized care plan and

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writing interventions from a nursing diagnosis book do not show that reflection about the clients

individual care is being done.

Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing MULTIPLE CHOICE 1. The nurse is teaching a homeless pregnant teenager about prenatal care. Which should the nurse emphasize in the teaching session? a. The importance of naming the baby b. Risk factors associated with pregnancy c. Information about employment opportunities

d. Eating habits that will provide adequate nutrition ANS: D Homeless teens are more likely to have poor eating habits, smoke, and have greater risks for preterm labor, anemia, and hypertension during pregnancy and to deliver a low-birth-weight (LBW) infant. Teaching about proper eating habits is the priority at this time. Naming the baby, risk factors associated with pregnancy, and information about employment are not the highest priorities to teach at this time. PTS: 1 DIF: Cognitive Level: Application REF: 35

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

2. The United States ranks 27th in terms of worldwide infant mortality rates. Which factor has

the greatest impact on decreasing the mortality rate of infants? a. Providing more womens shelters

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b. Ensuring early and adequate prenatal care

c. Resolving all language and cultural differences

ANS: B

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d. Enrolling pregnant women in the Medicaid program by their eighth month of pregnancy

Because preterm infants form the largest category of those needing expensive intensive care, early pregnancy intervention is essential for decreasing infant mortality. The women in shelters have the same difficulties in obtaining health care as other poor people, particularly lack of transportation and inconvenient clinic hours. Language and cultural differences are not infant mortality issues but must be addressed to improve overall health care. Medicaid provides health care for poor pregnant women, but the process may take weeks to take effect. The eighth month is too late to apply and receive benefits for this pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 35 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. Which statement is true regarding the quality assurance or incident report? a. Reports are a permanent part of the patients chart. b. The report assures the legal department that there is no problem. c. The nurses notes should contain this statement: Incident report filed and copy placed in chart.

d. This report is a form of documentation of an event that may result in legal action. ANS: D

Documentation on the chart should include all factual information regarding the clients condition that would be recorded in any situation. The nurse completes an incident report when something

occurs that might result in a legal action against the clinic or hospital. Incident reports are not part of the patients chart. The report is a warning to the legal department to be prepared for a

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potential legal action. Incident reports are not mentioned in the nurses notes. PTS: 1 DIF: Cognitive Level: Analysis REF: 39

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment 4. The nurse is planning a teaching session for staff on ethical theories. Which situation best

reflects the deontologic theory? a. Approving a physician-assisted suicide b. Supporting the transplantation of fetal tissue and organs c. Using experimental medications for the treatment of AIDS d. Initiating resuscitative measures on a 90-year-old patient with terminal cancer ANS: D

In the deontologic theory, life must be maintained at all costs, regardless of quality of life. Approving a physician-assisted suicide, supporting the transplantation of fetal tissue and organs, and using experimental medications for the treatment of AIDS are examples of a utilitarian model. PTS: 1 DIF: Cognitive Level: Application REF: 29 OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity 5. Which step of the nursing process is being used when the nurse decides whether an ethical dilemma exists?

a. Analysis b. Planning

c. Evaluation

d. Assessment

ANS: A

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When a nurse uses the collected data to determine whether an ethical dilemma exists, the data are being analyzed. Planning is done after the data have been analyzed. Evaluation occurs once the

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outcome has been achieved. Assessment is the data collection phase. PTS: 1 DIF: Cognitive Level: Understanding REF: 30

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment: Coordinated Care 6. The nurse is interviewing a 6-week pregnant client. The client asks the nurse, Why is elective abortion considered an ethical issue? Which is the best response that the nurse should make? a. Abortion requires third-party consent. b. The U.S. Supreme Court ruled that life begins at conception. c. Abortion law is unclear about a womans constitutional rights.

d. There is a conflict between the rights of the woman and the rights of the fetus. ANS: D Elective abortion is an ethical dilemma because two opposing courses of action are available. Abortion does not require third-party consent. The Supreme Court has not ruled on when life begins. Abortion laws are clear concerning a womens constitutional rights. PTS: 1 DIF: Cognitive Level: Application REF: 31 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

7. At the present time, surrogate parenting is governed by which of the following?

c. Individual court decision

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d. Protective child services

b. Federal law

a. State law

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ANS: C

Each surrogacy case is decided individually in a court of law. Surrogacy is not governed by state law. Surrogacy is not governed by federal law. Protective child services does not make decisions

about surrogacy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 33 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Which client will most likely seek prenatal care? a. Janice, 15 years old, tells her friends, I dont believe I am pregnant. b. Carol, 28 years old, is in her second pregnancy and abuses drugs and alcohol.

c. Margaret, 20 years old, is in her first pregnancy and has access to a free prenatal clinic. d. Glenda, 30 years old, is in her fifth pregnancy and delivered her last infant at home with the help of her mother and sister. ANS: C The client who acknowledges the pregnancy early, has access to health care, and has no reason to avoid health care is most likely to seek prenatal care. Being in denial about the pregnancy will prevent a client from seeking health care. Substance abusers are less likely to seek health care.

PTS: 1 DIF: Cognitive Level: Understanding REF: 35

Some women see pregnancy and birth as a natural occurrence and do not seek health care.

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. A medical surgical nurse is asked to float to a womens health unit to care for clients who are scheduled for therapeutic abortions. The nurse refuses to accept this assignment and expresses

her personal beliefs as being incongruent with this medical practice. The nursing supervisor states that the unit is short-staffed and that they could really use her expertise because it just

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involves taking care of clients who have undergone a surgical procedure. In consideration of

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legal and ethical practices, can the nursing supervisor enforce this assignment? a. The staff nurse has the responsibility of accepting any assignment that is made while working for a health care unit, so the nursing supervisor is within his or her rights to enforce this assignment.

b. Because the unit is short-staffed, the staff nurse should accept the assignment to provide care by benefit of her or his experience to clients who need care. c. The staff nurse has expressed a legitimate concern based on his or her feelings; the nursing supervisor does not have the authority to enforce this assignment. d. The nursing supervisor should emphasize that this assignment requires care of a surgical client for which the staff nurse is adequately trained and should therefore enforce the assignment. ANS: C

The Nurse Practice Act allows nurses to refuse assignments that involve practices that they have expressed as being opposed to their religious, cultural, ethical, and/or moral values. Although the nursing supervisor has a right to arrange assignments, the supervisor, if made aware of a potential bias or limitation, must act accordingly and accept the nurses position. This should be upheld regardless of staffing limitations and independent of persuasive efforts to make the nurse feel guilty for her or his stated beliefs. PTS: 1 DIF: Cognitive Level: Analysis REF: 31 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe Effective Care: Ethical Practice/Assignment, Delegation and Supervision

10. With regard to an obstetric litigation case, a nurse working in labor and birth is found to be negligent. Which intervention performed by the nurse indicates that a breach of duty has

occurred?

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a. The nurse did not document fetal heart tones (FHR) during the second stage of labor. b. The client was only provided ice chips during the labor period, which lasted 8 hours.

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c. The nurse allowed the client to use the bathroom rather than a bedpan during the first stage of labor.

ANS: A

d. The nurse asked family members to leave the room when she prepared to do a pelvic exam on the client.

A breach of duty is indicated by a nurse (or health care provider) failing to provide treatment relative to the standard of care. In this case, documentation of FHR during the second stage of labor is a standard of care. Providing ice chips to laboring clients is within the standard of care. The time period of 8 hours is not excessive. A client without any risk factors can use the bathroom and be ambulatory during the first stage of labor. Asking family members to leave during a vaginal exam helps maintain client privacy.

PTS: 1 DIF: Cognitive Level: Analysis REF: 37 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities 11. A nurse is working with a labor client who is in preterm labor and is designated as a high-risk client. The client is very apprehensive and asks the nurse, Is everything going to be all right? The nurse tells the client, Everything will be okay. Following birth via an emergency cesarean section, the newborn undergoes resuscitation and does not survive. The client is distraught over the outcome and blames the nurse for telling her that everything would be okay. Which ethical

principle did the nurse violate? a. Autonomy

b. Fidelity

c. Beneficence

d. Accountability

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ANS: B

In this type of situation, the nurse (and/or health care provider) cannot make statements

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(promises) that cannot be kept. Telling the client that everything will be okay is not based on the accuracy of medical diagnosis and should not be conveyed to the client. The other ethical principles of autonomy (self-determination), beneficence (greatest good), and accountability

(accepting responsibility) do not apply.

PTS: 1 DIF: Cognitive Level: Analysis REF: 30 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities 12. A nurse is working in the area of labor and birth. Her assignment is to take care of a gravida 1 para 0 who presents in early labor at term. Vaginal exam reflects the following: 2 cm, cervix posterior, 1 station, and vertex with membranes intact. The client asks the nurse if she can break

her water so that her labor can go faster? The nurses response, based on the ethical principle of nonmaleficence, is which of the following? a. Tell the client that she will have to wait until she has progressed further on the vaginal exam and then she will perform an amniotomy. b. Have the client write down her request and then call the physician for an order to implement the amniotomy. c. Instruct the client that only a physician or certified midwife can perform this procedure. d. Give the client an enema to stimulate labor.

ANS: C The ethical principle of nonmaleficence conveys the concept that one should avoid risk taking or

harm to others. The procedure of amniotomy is performed by a physician and/or certified nurse midwife. It is not in the scope of practice of a RN, so option C validates that the nurse is

upholding this ethical principle. Options A and B are not within the scope of practice. The use of

an enema as a labor stimulant is no longer considered to be part of labor and birth practices.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 30

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities

13. A nurse working in a labor and birth unit is asked to take care of two high-risk clients in the labor and birth suite: a 34 weeks gestation 28-year-old gravida 3, para 2 in preterm labor and a

40-year-old gravida 1, para 0 who is severely preeclamptic. The nurse refuses this assignment telling the charge nurse that based on individual client acuity, each client should have one-onone care. Which ethical principle is the nurse advocating? a. Accountability b. Beneficence c. Justice d. Fidelity

ANS: B In this situation, the clients are each exhibiting significant high-risk conditions and should receive individual nursing care. The nurse is advocating the principle of beneficence in that she is trying to do the greatest good or the least harm to improve client outcomes. The other ethical principles do not apply in this situation. PTS: 1 DIF: Cognitive Level: Analysis REF: 30 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities 14. A charge nurse is working on a postpartum unit and discovers that one of the clients did not receive AM care during her shift assessment. The charge nurse questions the nurse assigned to

provide care and finds out that the nurse thought that the client should just do it by herself

because she will have to do this at home. On further questioning of the nurse, it is determined that the rest of her assigned clients were provided AM care. The assigned nurse has violated

b. Truth

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c. Confidentiality

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a. Justice

which ethical principle?

ANS: A

d. Autonomy

The ethical principle of justice indicates that all clients should be treated equally and fairly. In this case, the charge nurse ascertained that the AM care was not equally applied to all the nurses assigned clients. The other ethical principles do not apply to this situation. PTS: 1 DIF: Cognitive Level: Analysis REF: 30 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities

15. A nurse is entering information on the clients electronic health record (EHR) and is called to assist in an emergency situation with regard to another client in the labor and birth suite. The nurse rushes to the scene to assist but leaves the chart open on the computer screen. The emergent client situation is resolved satisfactorily, and the nurse comes back to the computer entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with the nurse and tells her that she is concerned with what happened today on the unit because there was a breach in confidentiality. Which response by the nurse indicates that she understands the nurse managers concerns? a. The nurse acknowledges that she should have made sure that her client was safe before assisting with the emergency.

b. The nurse states that she should have logged out of the EHR prior to attending to the emergency. c. The nurse indicates that the unit was understaffed.

d. The nurse indicates that the she changed her password following the clinical emergency to maintain confidentiality.

ANS: B

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With the use of electronic health records, it is necessary to take all steps to maintain confidentiality and limit access to nonhealth care personnel. In an emergent care situation, the

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nurse should have logged out of the system to maintain confidentiality. Although it is important to make sure that ones client is safe, there is no information here to suggest that there were any safety issues applicable to her assigned client. The staffing of the unit should not affect

confidentiality. Changing the password for logging in to a system is an option for clinical

practice but does not affect the situation as described. PTS: 1 DIF: Cognitive Level: Analysis REF: 30 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities 16. Which of the following statements is true regarding late preterm infants?

a. These infants are born before 32 weeks gestation and thus are at higher risk than LBW infants. b. These infants do better than LBW infants because their weight provides added protection against physiologic stressors. c. Care of these infants has led to increased health care costs compared with LBW infants. d. These infants suffer fewer respiratory problems than LBW infants. ANS: C Late preterm infants are born between 34 and 36 weeks and present with more complications

than LBW infants, according to evidence-based practice. The added weight does not provide protection, and these infants are more likely to experience respiratory distress.

PTS: 1 DIF: Cognitive Level: Application REF: 36

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Adaptation

17. A nurse is admitting a client to the labor and birth unit in early labor who was sent to the

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facility following her checkup with her health care provider in the office. The client is a gravida 1, para 0, and is at term. No health issues are discerned from the initial assessment, and the nurse prepares to initiate physician orders based on standard procedures. Which action is warranted by

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the nurse manager in response to this situation? a. No action is indicated because the nurse is acting within the scope of practice.

b. The nurse manager should intervene and ask the nurse to clarify admission orders directly with the physician. c. The nurse manager should review standard procedures with the nurse to validate that orders are being carried out accurately. d. The nurse manger should review the admission procedure with the nurse. ANS: A Standard procedures are often used in labor and birth settings because they are based on physician-directed orders that apply to general admissions. The nurse is acting appropriately because the client was sent directly to the unit by the health care provider. The nurse manager

does not have to intervene at this point. There is no additional need to review standard procedures or the admission process with the nurse at this time. There is no evidence that the nurse needs additional training and/or does not have the prerequisite knowledge to admit the client. PTS: 1 DIF: Cognitive Level: Application REF: 36, 37 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion Maintenance 18. A nurse who works in the emergency department (ED) is assigned to a client who is

experiencing heavy vaginal bleeding at 12 weeks gestation. An ultrasound has confirmed the absence of a fetal heart rate, and the client is scheduled for a dilation and evacuation of the

pregnancy. The nurse refuses to provide any further care for this client based on moral

principles. What is the nurse managers initial response to the nurse?

a. I recall you sharing that information in your interview. I will arrange for another nurse to take report on this client.

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b. Because we are shorthanded today, you have to continue to provide care. There is no one else available to provide care for this client.

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c. I understand your point of view. You were hired to work here in the ED so you had to know this situation was possible.

ANS: A

d. Abandonment is a serious issue. I have to advise you to continue to provide care for this client.

Nurses do not have to provide care if the care is in violation of their moral, ethical, or religious principles. However, it is the responsibility of the nurse to share these views at the time of the initial interview. Disclosing beliefs that would affect the care of clients at the point of care and refusing to provide care is unethical on behalf of the nurse. The manager cannot force the nurse to provide care if the nurses principles were shared at the time of the initial interview. It is the managers responsibility to disclose the type of care delivered in the department at the time of the interview. Threats of abandonment are unwarranted at this time.

PTS: 1 DIF: Cognitive Level: Application REF: 32 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is providing care to a patient who was just admitted to the labor and birth unit in active labor at term. The patient informed the nurse that she has not received any prenatal care because I cannot afford to go to the doctor. And, this is my third baby, so I know what to expect. What is the nurses primary concern when developing the patients plan of care? a. Low birth weight

b. Oligohydramnios c. Gestational diabetes

d. Gestational hypertension ANS: A

Because of adverse living conditions, poor health care, and poor nutrition, infants born to low-

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income women are more likely to begin life with problems such as low birth weight. Oligohydramnios is too little amniotic fluid and is not directly correlated with poverty.

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Gestational diabetes and gestational hypertension are associated with poverty but are seen during pregnancy. This client is in active labor and the primary concern is the fetus.

PTS: 1 DIF: Cognitive Level: Application REF: 34

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 20. Which of the following complications are associated with late preterm infants? (Select all that apply.) a. Hyperglycemia b. Tachycardia

c. Jaundice d. Thermoregulation problems e. Require mechanical ventilation f. Feeding problems ANS: C, D, E, F Complications associated with preterm infants include ventilator assistance, thermoregulation problems, feeding problems, bradycardia, jaundice, and possible sepsis.

PTS: 1 DIF: Cognitive Level: Application REF: 36

MSC: Client Needs: Physiologic Adaptation

OBJ: Nursing Process Step: Implementation

nurse delegate? (Select all that apply.)

21. The RN is delegating tasks to the unlicensed assistive personnel (UAP). Which tasks can the

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a. Teaching the client about breast care

b. Assessment of a clients lochia and perineal area

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c. Assisting a client to the bathroom for the first time after birth d. Vital signs on a postpartum client who delivered the night before

e. Assisting a postpartum client to take a shower on the second postpartum day

ANS: D, E

Nurses must be aware that they remain legally responsible for patient assessments and must make the critical judgments necessary to ensure patient safety when delegating tasks to unlicensed personnel. The nurse cannot delegate assessment, teaching, or evaluation. The two tasks that the nurse can delegate are vital signs on a stable postpartum client and assisting a stable postpartum client on the second postpartum day to take a shower. PTS: 1 DIF: Cognitive Level: Application REF: 40

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 22. The clinic nurse often cares for clients who are considering an abortion. Which responsibilities does this nurse have in regard to this issue? (Select all that apply.) a. Informing the client about pro-life options b. Informing the client about pro-choice support groups c. Being informed about abortion from a legal standpoint d. Being informed about abortion from an ethical standpoint

e. Recognizing that this issue may result in confusion for the client

ANS: C, D, E

Nurses have several responsibilities that cannot be ignored in the conflict about abortion. First, they must be informed about the complexity of the abortion issue from a legal and an ethical

standpoint and know the regulations and laws in their state. Second, they must realize that for

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many people, abortion is an ethical dilemma that results in confusion, ambivalence, and personal distress. Informing the client about pro-life options or pro-choice support groups would not be

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appropriate because it is the clients decision and these interventions show bias on the nurses part. PTS: 1 DIF: Cognitive Level: Analysis REF: 32

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

23. A couple asks the nurse about the procedure for surrogate parenting. Which correct responses should the nurse give to the couple? (Select all that apply.) a. Donated embryos can be implanted into the surrogate mother. b. The surrogate mother needs to have carried one previous birth to term. c. You both need to be infertile to be eligible for surrogate parenting. d. Conception can take place outside the surrogate mothers body and then implanted.

e. The surrogate mother can be inseminated artificially with sperm from the intended father. ANS: A, D, E In surrogate parenting, conception may take place outside the body using ova and sperm from the couple who wishes to become parents. These embryos are then implanted into the surrogate mother, or the surrogate mother may be inseminated artificially with sperm from the intended father. Donated embryos may also be implanted into a surrogate mother. The couple does not need to be infertile. The surrogate parent does not need to have previously carried a pregnancy to

PTS: 1 DIF: Cognitive Level: Application REF: 33

OBJ: Nursing Process Step: Implementation

term.

MSC: Client Needs: Health Promotion and Maintenance

24. Which actions by the nurse indicate compliance with the Health Insurance Portability and

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Accountability Act (HIPAA)? (Select all that apply.) a. The nurse posts an update about a client on Facebook.

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b. The nurse gives the report to the oncoming nurse in a private area. c. The nurse gives information about the clients status over the phone to the clients friend.

d. The nurse logs off any computer screen showing client data before leaving the computer unattended.

e. The nurse puts any documentation with the clients information in the shred bin at the hospital before leaving for the day. ANS: B, D, E HIPAA regulations provide consumers with significant power over their records, including the right to see and correct their records, the application of civil and criminal penalties for violations of privacy standards, and protection against deliberate or inadvertent misuse or disclosure. Discussions about a patient with other professionals should be restricted to those who need to

know and should occur in a private location. Nurses must take care to avoid violating patient confidentiality when using electronic patient data formats. For example, nurses must promptly log off terminals when finished so that unauthorized individuals cannot gain access to the system. Shredding documentation with client identifiers should be done before leaving the hospital. Discussing a clients status in any online forum is a violation of HIPAA. Giving information to a clients friend over the phone, without the clients consent, is a violation of HIPAA. PTS: 1 DIF: Cognitive Level: Application REF: 33

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

Match each term with the correct definition.

MATCHING

a. The nurses breach of duty caused harm.

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b. The nurse has a responsibility to give care to the client.

25. Damage

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c. An actual injury or harm to the client occurred because of the nurses breach of duty.

26. Proximate cause

27. Duty

25. ANS: C PTS: 1 DIF: Cognitive Level: Understanding REF: 37 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment NOT: Duty is defined as the nurses duty to act or give care to the patient. It must be part of the nurses responsibility. Damage is defined as an actual injury or harm to the patient that occurred

as a result of the nurses breach of duty. Proximate cause is when the nurses breach of duty is proved to be the cause of harm to the patient. 26. ANS: A PTS: 1 DIF: Cognitive Level: Understanding REF: 37 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment NOT: Duty is defined as the nurses duty to act or give care to the patient. It must be part of the nurses responsibility. Damage is defined as an actual injury or harm to the patient that occurred as a result of the nurses breach of duty. Proximate cause is when the nurses breach of duty is

proved to be the cause of harm to the patient.

Chapter 3: Structure and Function of the Reproductive System

MULTIPLE CHOICE

1. A postpartum client who had a vaginal birth asks the nurse, Will my cervix return to its

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previous shape before I had my baby? Which is the best response by the nurse? a. The cervix will now have a slitlike shape.

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b. The cervix will be round and smooth after healing occurs. c. The cervix will remain 50% effaced now that you have had a baby.

ANS: A

d. The cervix will be slightly dilated to 2 cm for about 6 months.

After vaginal birth, the external os has an irregular slitlike shape and may have tags of scar tissue. The external os of a childless woman is round and smooth, but after a vaginal birth it will not be round and smooth. During labor, the cervix effaces (thins) and dilates (opens) to allow passage of the fetus. Once the baby is born, the cervix will close and return to close to 100% effacement. PTS: 1 DIF: Cognitive Level: Application REF: 47

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. The school nurse is conducting health education classes for a group of adolescents. Which statement best describes a secondary sexual characteristic? a. Maturation of ova b. Production of sperm c. Female breast development

d. Secretion of gonadotropin-releasing hormone ANS: C

A secondary sexual characteristic is one not directly related to reproduction, such as

development of the characteristic female body form. Maturation of ova is directly related to reproduction and is a primary sexual characteristic. Production of sperm is directly related to

reproduction and is a primary sexual characteristic. Secretion of hormones is directly related to

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reproduction and is a primary sexual characteristic.

PTS: 1 DIF: Cognitive Level: Understanding REF: 43, 44

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

3. Which 16-year-old girl may experience secondary amenorrhea? a. Jackie, 5 ft 2 in, 130 lb b. Karen, 5 ft 9 in, 150 lb c. Carol, 5 ft 7 in, 96 lb d. Linda, 5 ft 4 in, 120 lb ANS: C

Because of her height and low body weight, Carol is at risk of developing secondary amenorrhea, which occurs in women who are thin and have a low percentage of body fat. Fat is necessary to make the sex hormones that stimulate ovulation and menstruation. Jackie, Karen, and Linda are of sufficient height and weight to promote sex hormone production. PTS: 1 DIF: Cognitive Level: Application REF: 44 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 4. Which describes the levator ani? a. Division of the fallopian tube

b. Collection of three pairs of muscles

c. Imaginary line that divides the true pelvis and false pelvis

d. Basin-shaped structure at the lower end of the spine ANS: B

The levator ani is a collection of three pairs of muscles that support internal pelvic structures and

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resist increases in intraabdominal pressure. The fallopian tube divisions are the interstitial portion, isthmus, ampulla, and infundibulum. The linea terminalis is the imaginary line that

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divides the false from the true pelvis. The basin-shaped structure at the lower end of the spine is the bony pelvis.

PTS: 1 DIF: Cognitive Level: Remembering REF: 49

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. The nurse is describing the size and shape of the nonpregnant uterus to a client. Which is an accurate description? a. The nonpregnant uterus is the size and shape of a pear. b. The nonpregnant uterus is the size and shape of a cantaloupe. c. The nonpregnant uterus is the size and shape of a grapefruit. d. The nonpregnant uterus is the size and shape of a large orange.

ANS: A The nonpregnant uterus is about 7.5 5 2.5 cm, which is close to the size and shape of a pear. A cantaloupe would be too large and is the wrong shape for the uterus. A grapefruit is too large for the nonpregnant uterus; the uterus is larger at the upper end and tapers down. An orange may be the appropriate size, but it is not the appropriate shape. PTS: 1 DIF: Cognitive Level: Application REF: 47 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 6. If a womans menstrual cycle began on June 2, on which date should ovulation mostly likely

have occurred?

a. June 10 b. June 16

c. June 29

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d. July 5

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ANS: B

June 16 would be 18 days into the cycle; ovulation should have occurred at this point. June 10 would just be 8 days into the cycle and too early for ovulation. Ovulation occurs about 12 to 14

days after the beginning of the next menstrual period in a 28-day cycle; ovulation normally

occurs about 14 days before the beginning of the next period. June 29 is at the end of the cycle. July 5 would be 27 days into the cycle and about time for the next period. PTS: 1 DIF: Cognitive Level: Application REF: 45 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. A client states, My breasts are so small. I dont think I will be able to breastfeed. Which is the nurses best response?

a. It may be difficult but you should try anyway. b. You can always supplement with formula. c. All women have about the same amount of glandular tissue to secrete milk. d. The ability to produce breast milk depends on increased levels of estrogen and progesterone. ANS: C All women have 15 to 20 lobes arranged around and behind the nipple and areola. These lobes, not the size of the breast, are responsible for milk production. The size of the breasts does not ensure success or failure in breastfeeding. Supplementation decreases the production of breast

milk by decreasing stimulation. Stimulation of the breast, not the size of the breast, brings about milk production. Increased levels of estrogen decrease the production of milk by affecting

prolactin.

PTS: 1 DIF: Cognitive Level: Application REF: 53

OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Physiologic Integrity

8. The nurse is explaining the function of the males cremaster muscle to a group of nursing

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students. Which statement accurately describes the function of the cremaster muscle? a. Assists with transporting sperm

b. Aids in temperature control of the testicles

c. Aids in voluntary control of excretion of urine d. Entraps blood in the penis to produce an erection ANS: B A cremaster muscle is attached to each testicle. Its function is to bring the testicle closer to the body to warm it or allow it to fall away from the body to cool it, thus promoting normal sperm production. Seminal fluid assists with transporting sperm. The urinary meatus aids in controlling the excretion of urine. Entrapment of the blood in the penis is caused by its spongy tissue.

PTS: 1 DIF: Cognitive Level: Understanding REF: 54 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 9. A newly pregnant client asks the nurse, What is the false pelvis? Which is a correct statement that the nurse should give the client? a. It is the total anterior portion of the pelvis. b. It is considered to be the lower portion of the pelvis. c. It provides support for the internal organs and the upper part of the body.

d. It is the narrowest part of the pelvis through which a fetus will pass during birth. ANS: C

The linea terminalis, also called the pelvic brim or ileopectineal line, is an imaginary line that

divides the upper, or false, pelvis from the lower, or true, pelvis. The false pelvis provides support for the internal organs and upper part of the body. The false pelvis is the upper portion,

not the total anterior portion. The lower portion of the pelvis is the true pelvis, which is most during childbirth.

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important during childbirth because it has the narrowest portion through which the fetus will pass

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PTS: 1 DIF: Cognitive Level: Understanding REF: 49 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. Which hormone is responsible for milk production after the birth of the placenta? a. Pitocin

b. Prolactin c. Estrogen

d. Progesterone ANS: B

During pregnancy, high levels of estrogen and progesterone produced by the placenta stimulate growth of the alveoli and ductal system to prepare them for lactation. Prolactin secretion by the anterior pituitary gland stimulates milk production during pregnancy, but this effect is inhibited by estrogen and progesterone produced by the placenta. Inhibiting effects of estrogen and progesterone stop when the placenta is expelled after birth, and active milk production occurs in response to the infants suckling while breastfeeding. Pitocin is the hormone that causes the letdown reflex during breastfeeding. PTS: 1 DIF: Cognitive Level: Understanding REF: 53

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. Which hormonal effect is noted during the menstrual cycle?

a. LH and FSH secretion rise during the ovulatory phase.

b. A negative feedback mechanism is exhibited by the anterior pituitary gland and ovaries. c. The posterior pituitary gland secretes LH.

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d. Estrogen secretion enhances FSH secretion. ANS: A

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Levels of LH and FSH rise dramatically during the ovulatory phase and are known as the LH surge prior to ovulation. A positive feedback mechanism occurs with regard to the menstrual

cycle. The anterior pituitary gland secretes LH. Estrogen secretion minimizes FSH secretion.

PTS: 1 DIF: Cognitive Level: Application REF: 51 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential/System-Specific Assessments 12. To evaluate an individuals progression through puberty, which assessment tool would be used during the assessment phase of the nursing process?

a. Bishop score b. Tanner staging c. Braden score d. SOFA score ANS: B Tanner staging provides a gender-based criteria approach that defines the physical findings of primary and secondary sex characteristics for children and adolescents during puberty. The Bishop score would be used to evaluate whether a labor client is ready for the induction of labor. The Braden score provides documentation of skin condition relative to potential breakdown

and/or complications. The SOFA score is used to evaluate critical care clients who are at risk to

develop SIRS or MODS.

OBJ: Nursing Process Step: Planning

PTS: 1 DIF: Cognitive Level: Application REF: 43, 44

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MSC: Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 13. A female client who has gone through puberty and started menstruating without any

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problems now has cessation of periods after 2 years of normal cycles. Which of the following would indicate a possible cause for this occurrence?

a. Lag in development of secondary sexual characteristics b. Overproduction of androgenic hormones

c. Negative pregnancy test d. Clinical diagnosis of primary amenorrhea ANS: B An overproduction of androgenic hormones can cause the development of secondary amenorrhea. This client has progressed through puberty, which would indicate that there is no problem with the development of secondary sexual characteristics. If the client had a positive

pregnancy test, then menstruation would stop. The signs and symptoms identify the occurrence of secondary amenorrhea. PTS: 1 DIF: Cognitive Level: Application REF: 44 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. On speculum examination of the cervix, it is found to be round and smooth. These findings suggest that the client: a. is a multipara.

b. has had vaginal deliveries. c. is a nulliparous.

d. is a gravida 1, para 0.

ANS: C

These findings indicate that the client has never been pregnant and she would be classified as

nulliparous. The options indicating that the client is a multipara, has had vaginal deliveries, or is

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a gravida 1, para 0 are incorrect because they refer to a client with a history of pregnancy.

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PTS: 1 DIF: Cognitive Level: Application REF: 47 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

15. Which of the following statements is incorrect with regard to reproductive anatomy and physiology?

a. Female clients who are past puberty and sexually active can become pregnant even if they have not had a menstrual cycle. b. Puberty symptoms are more prominent in males than females. c. Females enter puberty earlier than their male counterparts. d. Secondary sexual characteristics develop during puberty.

ANS: B Puberty symptoms are usually more subtle in males than females. The other statements are correct. PTS: 1 DIF: Cognitive Level: Application REF: 55 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. The nurse is reviewing normal female development with a mother of a 10-year-old daughter. The mother states, I noticed that my daughter developed breast buds about a year ago. When do

you think she will start her menstrual cycle? What is the nurses best response? a. In about a year.

c. Does your daughter know what to expect?

b. Likely any time now.

d. It is impossible to predict when she will start her cycle.

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ANS: A

Menarche occurs about 2 to 2.5 years after breast development. Asking the mother if her

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daughter knows what to expect does not answer the mothers question. PTS: 1 DIF: Cognitive Level: Understanding REF: 44

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 17. The middle school nurse is reviewing the phases of the endometrial cycle with a group of female students. Which student statement will the nurse need to correct? a. The proliferative phase occurs when the ovum is maturing. b. The expulsion phase occurs when the ovum is discharged from the ovary. c. The secretory phase occurs during the second half of the menstrual cycle.

d. The menstrual phase occurs after the levels of estrogen and progesterone fall. ANS: B The menstrual cycle has only three phasesproliferative, secretory, and menstrual. Occurrences of each of the three phases have been described. There is no expulsion phase in the menstrual cycle. PTS: 1 DIF: Cognitive Level: Understanding REF: 51 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 18. The clinic nurse is reviewing breastfeeding with a pregnant client. Which hormone will the

nurse include in the patients teaching plan as the one primarily responsible for lactation after birth?

a. Prolactin

b. Estrogen c. Luteinizing

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d. Progesterone ANS: A

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Prolactin is secreted by the anterior pituitary gland. Secretion of prolactin is suppressed by estrogen and progesterone produced by the placenta. When the placenta separates after birth, the effects of the estrogen and progesterone stop and milk is produced with infant suckling.

Luteinizing hormone is present in the ovulatory cycle. PTS: 1 DIF: Cognitive Level: Understanding REF: 44 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 19. A young female client comes to the health unit at school to discuss her irregular periods. In providing education regarding the female reproductive cycle, the nurse describes the regular and recurrent changes related to theovaries and the uterine endometrium. Although this is generally

referred to as the menstrual cycle, the ovarian cycle includes which phases? (Select all that apply.) a. Follicular b. Ovulatory c. Luteal d. Proliferative e. Secretory ANS: A, B, C

The follicular phase is the period during which the ovum matures. It begins on day 1 and ends around day 14. The ovulatory phase occurs near the middle of the cycle, about 2 days before

ovulation. After ovulation and under the influence of the luteinizing hormone, the luteal phase corresponds with the last 12 days of the menstrual cycle. The proliferative and secretory phases

are part of the endometrial cycle. The proliferative phase takes place during the first half of the ovarian cycle, when the ovum matures. The secretory phase occurs during the second half of the

cycle, when the uterus is prepared to accept the fertilized ovum. These are followed by the

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menstrual phase if fertilization does not occur.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 51 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

20. The school nurse is conducting health education classes for a group of adolescent girls.

Which are the actions of the estrogen hormone on the female body? (Select all that apply.) a. Stimulates contractions during birth b. Relaxes pelvic ligaments during pregnancy c. Stimulates the endometrium before ovulation d. Stimulates growth of uterus during pregnancy e. Stimulates the let-down reflex during breastfeeding ANS: B, C, D

The hormone estrogen relaxes pelvic ligaments during pregnancy, stimulates the endometrium before ovulation, and stimulates the growth of the uterus during pregnancy. Oxytocin stimulates contractions during pregnancy and stimulates the let-down reflex during breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 45 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance MATCHING

Match each term with the correct definition.

a. Ovulation marks the beginning of this stage and occurs about 14 days before the next menstrual period.

b. The period in which an ovum matures begins with the first day of menstruation and ends about 14 days later.

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c. This occurs as the ovum matures and is released during the first half of the ovarian cycle. 21. Follicular phase of the female reproductive cycle

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22. Luteal phase of the female reproductive cycle

23. Proliferative phase of the female reproductive cycle

21. ANS: B PTS: 1 DIF: Cognitive Level: Understanding REF: 44 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: Ovulation marks the beginning of the luteal phase of the female reproductive cycle and occurs about 14 days before the next menstrual period. The follicular phase is the period during which an ovum matures. It begins with the first day of menstruation and ends about 14 days later

in a 28-day cycle. The proliferative phase occurs as the ovum matures and is released during the first half of the ovarian cycle. 22. ANS: A PTS: 1 DIF: Cognitive Level: Understanding REF: 51 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance NOT: Ovulation marks the beginning of the luteal phase of the female reproductive cycle and occurs about 14 days before the next menstrual period. The follicular phase is the period during which an ovum matures. It begins with the first day of menstruation and ends about 14 days later

in a 28-day cycle. The proliferative phase occurs as the ovum matures and is released during the first half of the ovarian cycle.

23. ANS: C PTS: 1 DIF: Cognitive Level: Understanding

REF: 51 OBJ: Nursing Process Step: Assessment

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MSC: Client Needs: Health Promotion and Maintenance NOT: Ovulation marks the beginning of the luteal phase of the female reproductive cycle and occurs about 14 days before the next menstrual period. The follicular phase is the period during

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which an ovum matures. It begins with the first day of menstruation and ends about 14 days later in a 28-day cycle. The proliferative phase occurs as the ovum matures and is released during the

first half of the ovarian cycle.

SHORT ANSWER

24. Delayed onset of menstruation or primary amenorrhea is considered if the girls periods have not begun by which age in years? Record your answer in a whole number. _____ ANS: 16

Delayed onset of menstruation is called primary amenorrhea if the girls periods have not begun within 2 years after the onset of breast development or by age 16, or if the girl is more than 1 year older than her mother or sisters were when their menarche occurred.

Chapter 4: Special Issues of Women's Health Care and Reproduction MULTIPLE CHOICE 1. Which are the most common sites of breast cancer metastasis? a. Kidneys

b. Bones and liver c. Heart and blood vessels

d. Central nervous system

ANS: B

Metastasis occurs when the cancer cells spread to the vascular sites, commonly the lungs, liver,

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and bones. Kidney metastasis is uncommon. Metastasis to the heart and blood vessels is uncommon. The brain is one of the final areas to be reached by metastasis.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 730 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

2. Which sexually transmitted disease can be cured? a. Herpes b. AIDS c. Chlamydia d. Venereal warts ANS: C

The usual treatment for chlamydial bacterial infection is doxycycline hyclate or tetracycline. Concurrent treatment of all sexual partners is needed to prevent recurrence. Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections. Because no cure is known for AIDS, prevention and early detection are the main focus. Condylomata acuminata is caused by the human papillomavirus. No treatment eradicates the virus. PTS: 1 DIF: Cognitive Level: Understanding REF: 750 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 3. Which statement by a client diagnosed with premenstrual syndrome indicates that further

health teaching is needed? a. I will not eat chips or pickles.

b. Ill eat only three meals per day.

c. Drinking alcohol makes me more depressed.

d. Coffee and chocolate can make me more irritable and nervous.

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ANS: B

The client should be encouraged to eat six small meals a day to decrease the risk of

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hypoglycemia. Less intake of salty foods helps decrease fluid retention. Alcohol consumption aggravates depression. Caffeine consumption increases irritability, insomnia, anxiety, and nervousness.

PTS: 1 DIF: Cognitive Level: Analysis REF: 739 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 4. A benign breast condition that includes dilation and inflammation of the collecting ducts is: a. fibroadenoma. b. ductal ectasia. c. intraductal papilloma. d. chronic cystic disease.

ANS: B Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge. Fibroadenoma is evidenced by fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules. Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts. Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated. PTS: 1 DIF: Cognitive Level: Understanding REF: 729

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. Which client is most at risk for fibroadenoma of the breast?

a. Janice, 38 years old

b. Helen, 50 years old c. Mary, 16 years old

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d. Anna, 27 years old ANS: C

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Although it may occur at any age, fibroadenoma is most common in the teenage years. Ductal ectasia becomes more common as a client approaches menopause. Intraductal papilloma develops most often just before or during menopause. Fibrocystic breast changes are more

common during the reproductive years. PTS: 1 DIF: Cognitive Level: Understanding REF: 729 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 6. Which statement is true about primary dysmenorrhea? a. Primary dysmenorrhea is experienced by all women. b. It is unaffected by oral contraceptives.

c. It occurs in young multiparous women. d. It may be caused by excessive endometrial prostaglandin. ANS: D Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping. Primary dysmenorrhea is not experienced by all women. Oral contraceptives can be a treatment choice. It occurs in young nulliparous women.

PTS: 1 DIF: Cognitive Level: Understanding REF: 737 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

7. A client states, Im sure that I am suffering from PMS. How can I get my doctor to take this

seriously? The nurses best response is:

a. Men are not usually sympathetic to PMS sufferers.

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b. You are probably right. You should remind your doctor of your symptoms every time you visit. c. Since you feel certain you are right, you should just treat yourself with over-thecounter medications.

ANS: D

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d. You should keep a daily record of the occurrence and severity of your symptoms for 3 months.

Symptom charting for at least 3 months is necessary to make an accurate diagnosis of PMS. Suggesting lack of sympathy from men is an inaccurate statement and will not help the client with the present problem. Reminding the physician of the symptoms will not assist in making a diagnosis. Listing symptoms for 3 months will help the physician make the diagnosis better. The client should not treat herself with over-the-counter medications. PTS: 1 DIF: Cognitive Level: Application REF: 738, 739 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 8. Which should the nurse stress in teaching a client to deal with the symptoms of PMS? a. Decrease her consumption of caffeine. b. Drink a small glass of wine with her evening meal. c. Decrease her fluid intake to prevent fluid retention. d. Eat three large meals a day to maintain glucose levels. ANS: A

Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates depression and should be avoided. Fluid intake should not be decreased. Six smaller meals a day

will help maintain glucose levels.

PTS: 1 DIF: Cognitive Level: Application REF: 739

OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Health Promotion and Maintenance 9. A client, age 49, confides in the nurse that she has started experiencing pain with intercourse.

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She asks, Is there anything I can do about this? The nurses best response is: a. No, it is part of the aging process.

b. Water-soluble vaginal lubricants may provide relief.

c. You need to be evaluated for a sexually transmitted disease. d. You may have vaginal scar tissue that is producing the discomfort. ANS: B Loss of lubrication, with resulting discomfort in intercourse, is a symptom of estrogen deficiency. It is part of the aging process, but the use of lubrication will help relieve the symptoms. This is a normal occurrence with the aging process and does not indicate an STD. It

is caused by loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier. PTS: 1 DIF: Cognitive Level: Application REF: 741 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Which client is most likely to have osteoporosis?

b. A 55-year-old client with a sedentary lifestyle c. A 65-year-old client who walks 2 miles each day

a. A 50-year-old client on estrogen therapy

d. A 60-year-old client who takes supplemental calcium

ANS: B

Risk factors for the development of osteoporosis include smoking, alcohol consumption,

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sedentary lifestyle, family history of the disease, and a high-fat diet. Hormone therapy may prevent bone loss. Weight-bearing exercises have been shown to increase bone density.

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Supplemental calcium will help prevent bone loss, especially when combined with vitamin D. PTS: 1 DIF: Cognitive Level: Understanding REF: 743

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. A client with a history of a cystocele should contact the physician if she experiences: a. backache. b. constipation. c. urinary frequency and burning. d. involuntary loss of urine when she coughs. ANS: C

Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele. Back pain is a symptom of uterine prolapse. Constipation may be a problem with rectoceles. Involuntary loss of urine during coughing is stress incontinence and is not an emergency. PTS: 1 DIF: Cognitive Level: Application REF: 745 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

12. Which should the nurse teach to assist a client to regain control of her urinary sphincter? a. Do Kegel exercises.

c. Drink 8 to 10 glasses of water each day.

b. Void every hour while awake.

d. Allow the bladder to become distended before voiding.

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ANS: A

Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter. A prescribed schedule may help, but every hour is too frequent. Restricting

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fluids will cause bladder irritation, which exacerbates the problem. Drinking adequate fluids will not help the problem. Overdistention of the bladder will cause incontinence.

PTS: 1 DIF: Cognitive Level: Application REF: 746 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 13. The physician diagnoses a 3-cm cyst in the ovary of a 28-year-old client. You expect the initial treatment to include: a. beginning hormone therapy. b. scheduling a laparoscopy to remove the cyst.

c. examining the client after her next menstrual period. d. aspirating the cyst and sending the fluid to pathology. ANS: C Most ovarian cysts regress spontaneously. Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point. It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle. A transvaginal ultrasound examination will help determine if the cyst is fluid-filled or solid. The cyst can then be removed if warranted.

PTS: 1 DIF: Cognitive Level: Understanding REF: 748

b. tetracycline (Achromycin).

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d. acyclovir (Zovirax).

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c. ceftriaxone (Rocephin).

a. penicillin G (Pfizerpen).

14. The drug of choice to treat gonorrhea is:

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

ANS: C

Ceftriaxone is effective for treatment of all gonococcal infections. Penicillin G is used to treat

syphilis. Tetracycline is used to treat chlamydial infections. Acyclovir is used to treat herpes

genitalis.

PTS: 1 DIF: Cognitive Level: Understanding REF: 750 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 15. Which option could be used for the treatment and management of a client who reports mild pain associated with a clinical diagnosis of fibrocystic breast disease?

a. Chamomile tea as a relaxant therapy b. Danazol (Danocrine) c. Tamoxifen (Nolvadex) d. Over-the-counter nonsteroidal antiinflammatory drug (NSAID) therapy ANS: D Because the client is reporting mild pain, NSAIDs may provide adequate pain relief and comfort. It is recommended that tea, coffee, and/or other stimulants be limited or restricted for clients with fibrocystic breast disease. Danazol is typically used for moderate to severe pain for clients with fibrocystic breast disease because its use is associated with more serious side effects. The client

reports mild pain so this would not be warranted. Tamoxifen is a selective estrogen receptor modulator (SERM) used for the treatment of breast cancers and also for moderate to severe pain

in fibrocystic breast disease. The client reports mild pain, so this would not be warranted.

OBJ: Nursing Process Step: Evaluation

PTS: 1 DIF: Cognitive Level: Application REF: 729

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MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

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16. Which treatment option minimizes the development of lymphedema in the surgical management of a client with breast cancer?

a. Radical mastectomy procedure b. Radiation therapy

c. Sentinel lymph node mapping d. Ultrasound ANS: C The use of sentinel lymph node mapping identifies only those affected lymph node tissues that require surgical removal so it helps minimize the development of lymphedema in the surgical management of a client with breast cancer. Radical mastectomy is associated with lymphedema

in the postsurgical breast cancer client because of the removal of lymph node tissue. Radiation therapy is not associated with a decrease in lymphedema for the breast cancer client. Ultrasound as an intervention does not affect the development of lymphedema. PTS: 1 DIF: Cognitive Level: Analysis REF: 731 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 17. You are taking care of a client who has had a colporrhaphy. Which option would indicate a

priority assessment during the postoperative period? a. Documentation of a pessary in the operative procedure notes by the physician

b. Removal of vaginal packing as ordered by the physician

c. Use of a cell saver for transfusion therapy in the postoperative period

d. Order for removal of staples 2 to 3 days post-procedure

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ANS: B

Vaginal packing is typically used in this type of pelvic surgery so it is a priority assessment that its removal be verified and documented. A pessary would be used as a nonsurgical intervention

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for a client who has had uterine prolapse and was not a surgical candidate based on medical history. A cell saver is used in orthopedic surgeries that are at risk for blood loss so that the clients own blood can be re-infused based on established protocol. There are no staples used in

this type of surgical procedure, which is also known as an A & P (anterior and posterior) repair. PTS: 1 DIF: Cognitive Level: Analysis REF: 746 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities 18. In reviewing genetic testing for a female client, you note the presence of BRCA1, BRCA2, and CHEK2. How should these findings be interpreted?

a. There is no increased likelihood that the client will develop breast or ovarian cancer. b. There is an increased likelihood only for the development of breast cancer in a woman. c. More information is needed to interpret these findings based on the clients family history and the clients current and past medical history. d. A radical bilateral mastectomy is required immediately because the cancer may have already undergone sub-metastasis. ANS: C The presence of genetic markers (BRCA1, BRCA2, and CHEK2) provides strong indicators of the

increased risk for the development of breast cancer in males and females and ovarian cancer. It is important to obtain additional information so that a treatment plan can be developed and

implemented to improve client outcomes. There is an increased likelihood that the client will develop breast or ovarian cancer, but stating that there is an increased likelihood only for the

development of breast cancer in a woman fails to include that men are also at risk of developing breast cancer. At this point, surgical intervention is speculative because the presence of

biomarkers does not indicate that sub-metastasis has occurred or that the cancer has even

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developed.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 748 OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

MULTIPLE RESPONSE 19. A 38-year-old client presents to the clinic office complaining of increased bilateral tenderness of her breasts prior to the onset of menses. On questioning the client, this presentation has occurred off and on for several years, but the pain has increased. Physical examination reveals lumpy areas bilaterally on the upper outer quadrants of each breast tissue. The areas of concern are approximately 2 cm in size. Based on this assessment, what diagnostic testing would be required? (Select all that apply.)

a. Ultrasound examination b. Open biopsy c. Fine-needle aspiration (FNA) biopsy d. CBC with differential e. Mammogram ANS: A, C, E Based on the clinical presentation, the client may have fibrocystic breast disease. Although this condition is typically benign, the fact that the client has noted a change in tenderness should be

evaluated. Ultrasound, FNA, and mammography may be indicated to provide a baseline for comparison and rule out any malignancy. An open or surgical biopsy is not indicated at the

indicated at this time relative to the diagnosis.

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Chapter 5: Fetal Development MULTIPLE CHOICE

present time but may be needed if the other test results indicate any pathology. Blood work is not

1. An expectant father asks the nurse, Which part of the mature sperm contains the male

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chromosomes? What is the best response by the nurse? a. X-bearing sperm

b. The tail of the sperm

c. The head of the sperm d. The middle portion of the sperm ANS: C The head of the sperm contains the male chromosomes that will join the chromosomes of the ovum. If an X-bearing sperm fertilizes the ovum, the baby will be female. The tail of the sperm helps propel the sperm toward the ovum. The middle portion of the sperm supplies energy for the tails whiplike action.

PTS: 1 DIF: Cognitive Level: Application REF: 75 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. One of the assessments performed in the birth room is checking the umbilical cord for blood vessels. Which finding is considered to be within normal limits? a. One artery and one vein b. Two veins and one artery

c. Two arteries and one vein d. Two arteries and two veins

ANS: C

The umbilical cord contains two arteries and one vein to transport blood between the fetus and the placenta. Any option other than two arteries and one vein is considered abnormal and

requires further assessment. Two veins and one artery is abnormal and may indicate an anomaly. other anomalies.

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Two arteries instead of one is considered normal; this infant would require further assessment for

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PTS: 1 DIF: Cognitive Level: Understanding REF: 86

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. Which is the purpose of the ovums zona pellucida? a. Prevents multiple sperm from fertilizing the ovum b. Stimulates the ovum to begin mitotic cell division c. Allows the 46 chromosomes from each gamete to merge d. Makes a pathway for more than one sperm to reach the ovum ANS: A

Fertilization causes the zona pellucida to change its chemical composition so that multiple sperm cannot fertilize the ovum. Miotic cell division begins when the nuclei of the sperm and ovum unite. Each gamete (sperm and ovum) has only 23 chromosomes; there will be 46 chromosomes when they merge. Once sperm has entered the ovum, the zona pellucida changes to prevent other sperm from entering. PTS: 1 DIF: Cognitive Level: Understanding REF: 75 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. The nurse is explaining the process of cell division during the preembryonic period to a group

a. Fertilized ovum before mitosis begins

b. Double layer of cells that becomes the placenta

of nursing students. Which describes the morula?

c. Flattened, disk-shaped layer of cells within a fluid-filled sphere

d. Solid ball composed of the first cells formed after fertilization

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ANS: D

The morula is so named because it resembles a mulberry. It is a solid ball of 12 to 16 cells that

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develops after fertilization. The fertilized ovum is called the zygote. The placenta is formed from two layers of cellsthe trophoblast, which is the other portion of the fertilized ovum, and the decidua, which is the portion of the uterus where implantation occurs. The flattened, disk-shaped

layer of cells is the embryonic disk; it will develop into the body.

PTS: 1 DIF: Cognitive Level: Understanding REF: 77 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. The upper uterus is the best place for the fertilized ovum to implant because the: a. maternal blood flow is lower.

b. placenta attaches most firmly. c. uterine endometrium is softer. d. developing baby is best nourished. ANS: D The uterine fundus is richly supplied with blood and has the thickest endometrium, both of which promote optimum nourishment of the fetus. The blood supply is rich in the fundus, which allows for optimal nourishment of the fetus. If the placenta attaches too deeply, it does not easily detach. Softness is not a concern with implantation; attachment and nourishment are the major concerns.

PTS: 1 DIF: Cognitive Level: Understanding REF: 77, 78

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. Some of the embryos intestines remain within the umbilical cord during the embryonic period because the:

a. intestines need this time to grow until week 15.

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b. nutrient content of the blood is higher in this location. c. abdomen is too small to contain all the organs while they are developing.

ANS: C

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d. umbilical cord is much larger at this time than it will be at the end of pregnancy.

The abdominal contents grow more rapidly than the abdominal cavity, so part of their

development takes place in the umbilical cord. By 10 weeks, the abdomen is large enough to contain them. The intestines remain within the umbilical cord only until about week 10. Blood supply is adequate in all areas; intestines stay in the umbilical cord for about 10 weeks because they are growing faster than the abdomen. Intestines begin their development within the umbilical cord, but only because the liver and kidneys occupy most of the abdominal cavity, not because of the size of the umbilical cord. PTS: 1 DIF: Cognitive Level: Understanding REF: 83

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. A client who is 16 weeks pregnant with her first baby asks how long it will be before she feels the baby move. Which is the nurses best answer? a. You should have felt the baby move by now. b. The baby is moving, but you cant feel it yet. c. Some babies are quiet and you dont feel them move. d. Within the next month you should start to feel fluttering sensations.

ANS: D Maternal perception of fetal movement (quickening) usually begins between 17 and 20 weeks after conception. Because this is her first pregnancy, movement is felt toward the later part of the

17 to 20 weeks. The baby is moving, but you cant feel it yet may be alarming to the woman.

Some babies are quiet and you dont feel them move is a true statement; the fetus movements are not strong enough to be felt until 17 to 20 weeks. However, this statement does not answer the

womans concern. Fetal movement should be felt between 17 and 20 weeks; if movement is not

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felt by the end of that time, further assessment will be necessary.

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PTS: 1 DIF: Cognitive Level: Application REF: 84 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

8. Which best describes what occurs during the fetal period of development? a. Maturation of organ systems b. Development of basic organ systems c. Resistance of organs to damage from external agents d. Development of placental oxygencarbon dioxide exchange ANS: A

During the fetal period, the body systems grow in size and mature in function to allow independent existence after birth. Basic organ systems are developed during the embryonic period. The organs are always at risk for damage from external sources; however, the older the fetus, the more resistant will be the organs. The greatest risk is when the organs are developing. The placental system is complete by week 12, but that is not the best description of the fetal period. PTS: 1 DIF: Cognitive Level: Understanding REF: 83 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. An expectant parent says to the nurse, When my sisters baby was born, it was covered in a cheeselike coating. What is the purpose of this coating? The correct response by the nurse is to

a. regulate fetal temperature.

b. protect the fetal skin from amniotic fluid.

explain that the purpose of vernix caseosa is to:

c. promote normal peripheral nervous system development.

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d. allow the transport of oxygen and nutrients across the amnion.

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ANS: B

Prolonged exposure to amniotic fluid during the fetal period could result in breakdown of the skin without the protection of the vernix caseosa. The amniotic fluid aids in maintaining fetal

temperature. Normal peripheral nervous system development is dependent on the nutritional intake of the mother. The amnion is the inner membrane that surrounds the fetus. It is not

involved in the oxygen and nutrient exchange. PTS: 1 DIF: Cognitive Level: Application REF: 84 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

10. An expectant client, diagnosed with oligohydramnios, asks the nurse about what this condition means for the baby. Which statement should the nurse give to the client? a. Oligohydramnios can cause poor fetal lung development. b. Oligohydramnios means that the fetus is excreting excessive urine. c. Oligohydramnios could mean that the fetus has a gastrointestinal blockage. d. Oligohydramnios is associated with fetal central nervous system abnormalities. ANS: A Because an abnormally small amount of amniotic fluid restricts normal lung development, the

fetus may have poor fetal lung development. Oligohydramnios may be caused by a decrease in urine secretion. Excessive amniotic fluid production may occur when the gastrointestinal tract

prevents normal ingestion of amniotic fluid. Excessive amniotic fluid production may occur

when the fetus has a central nervous system abnormality.

PTS: 1 DIF: Cognitive Level: Application REF: 88

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

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11. The nurse is conducting a staff in-service on multifetal pregnancy. Which statement about dizygotic twin development should the nurse include in the teaching session?

a. Dizygotic twins arise from two fertilized ova and are the same sex.

b. Dizygotic twins arise from a single fertilized ovum and are always of the same sex. c. Dizygotic twins arise from two fertilized ova and may be the same sex or different sexes. d. Dizygotic twins arise from a single fertilized ovum and may be the same sex or different sexes. ANS: C

Dizygotic twins arise from two ova that are fertilized by different sperm. They may be the same or different gender, and they may not have similar physical traits. Monozygotic twins are always the same sex. A single fertilized ovum that produces twins is called monozygotic. Dizygotic twins are from two fertilized ova and may or may not be the same sex. PTS: 1 DIF: Cognitive Level: Application REF: 90 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. Which medication would the nurse anticipate administering to the labor client who is

delivering a premature infant?

a. Phytonadione (AquaMEPHYTON) b. Betamethasone

c. Bromocriptine (Parlodel)

d. Newborn eye prophylaxis

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ANS: B

Betamethasone (a corticosteroid) is given to the labor client who will be delivering a premature

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infant to promote surfactant production in the fetus to maximize lung function. Vitamin K, also known as phytonadione, is administered postbirth to the infant to prevent hemorrhagic disease of the newborn. Parlodel has been used historically to stop milk production in a client postbirth.

Newborn eye prophylaxis is given to the baby to prevent the transmission of certain sexually

transmitted diseases.

PTS: 1 DIF: Cognitive Level: Analysis REF: 84 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/ Pharmacologic and Parenteral Therapies 13. An infant is diagnosed with fetal anemia. What information would support that clinical diagnosis?

a. Presence of excess maternal hormones b. Maternal blood type O-negative, Rh-negative, and infant blood type O-negative, Rh- negative c. Passive immunity d. Rh-negative mother and Rh-positive baby ANS: C Passive immunity provides temporary protection to the baby based on the transfer of maternal antibodies. Maternal hormones would not lead to a clinical diagnosis of fetal anemia. These blood types and Rh factors are the same; therefore, no antibodies will be created. In this

OBJ: Nursing Process Step: Assessment

PTS: 1 DIF: Cognitive Level: Analysis REF: 87

that will stimulate a reaction leading to hemolysis.

situation, an Rh-negative mother and Rh-positive baby will result in stimulation of antibodies

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MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 14. The nurse is explaining the function of the placenta to a pregnant client. Which statement

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indicates to the nurse the need for further client teaching? a. My baby gets oxygen from the placenta. b. The placenta functions to help excrete waste products.

c. The nourishment that I take in passes through the placenta.

d. The placenta helps maintain a stable temperature for my baby. ANS: D Amniotic fluid and not the placenta helps with thermoregulation. The remaining statements are correct regarding placental function. PTS: 1 DIF: Cognitive Level: Application REF: 84

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 15. The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score of 9, the nurse notes two vessels in its umbilical cord. What is the nurses next action? a. Assess for other abnormalities of the infant. b. Note the assessment finding in the infants chart. c. Notify the health care provider of the assessment finding. d. Call for the neonatal resuscitation team to attend the infant immediately.

ANS: A The normal finding in the umbilical cord is two arteries and one vein. Two vessels may indicate other fetal anomalies. Notation of the finding is the appropriate next step when the finding is

expected. The health care provider will need to be notified; however, the infant is the nurses

primary concern and must be assessed for abnormalities first. The initial Apgar score is 9,

indicating no signs of distress or need of resuscitation.

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PTS: 1 DIF: Cognitive Level: Application REF: 86

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

response?

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16. A pregnant client asks the nurse how her baby gets oxygen to breathe. What is the nurses best

a. Oxygen-rich blood is delivered through the umbilical vein to the baby.

b. Take lots of deep breaths because the baby gets all of its oxygen from you. c. You dont need to be concerned about your baby getting enough oxygen. d. The babys lungs are not mature enough to actually breathe, so dont worry. ANS: A Oxygen-rich blood travels from the mothers circulatory system to the placenta and from the placenta to the umbilical vein (veins carry blood to the heart). From the vein, most of the oxygenated blood travels to the fetal liver or the inferior vena cava. Taking deep breaths can

temporarily increase oxygenation but can also lead to increased carbon dioxide retention and dizziness. The patient is asking a normal fetal developmental question often asked by pregnant women. Fetal lungs reach maturity by 37 weeks of gestation, but fetal breathing movements are common. Oxygen transport across lung tissue occurs with the first breath. PTS: 1 DIF: Cognitive Level: Application REF: 86 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE 17. Which physical characteristics decrease as the fetus nears term? (Select all that apply.)

a. Vernix caseosa

b. Lanugo c. Port wine stain

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d. Brown fat ANS: A, B

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Both vernix caseosa and lanugo decrease as the fetus reaches term. Port wine stain is a birthmark and, if present, will be exhibited at or shortly after birth. Brown fat in the fetus will be

maintained to maintain core temperature.

PTS: 1 DIF: Cognitive Level: Application REF: 84 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance/Techniques of Physical Assessment 18. Along with gas exchange and nutrient transfer, the placenta produces many hormones necessary for normal pregnancy, including which of the following? (Select all that apply.) a. Insulin

b. Estrogen c. Progesterone d. Testosterone e. Human chorionic gonadotropin (hCG) ANS: B, C, E HCG causes the corpus luteum to persist and produce the necessary estrogens and progesterone for the first 6 to 8 weeks. Estrogens cause enlargement of the womans uterus and breasts and growth of the ductal system in the breasts and, as term approaches, plays a role in the initiation of labor. Progesterone causes the endometrium to change, providing early nourishment.

Progesterone also protects against spontaneous abortion by suppressing maternal reactions to fetal antigens and reduces unnecessary uterine contractions. Other hormones produced by the

placenta include hCT, hCA, and a number of growth factors. Insulin and testosterone are not

secreted by the placenta.

PTS: 1 DIF: Cognitive Level: Understanding REF: 77

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is planning a prenatal class on fetal development. Which characteristics of prenatal

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development should the nurse include for a fetus of 24 weeks, based on fertilization age? (Select all that apply.)

a. Ear cartilage firm

b. Skin wrinkled and red c. Testes descending toward the inguinal rings d. Surfactant production nears mature levels e. Fetal movement becoming progressively more noticeable ANS: B, C, E A fetus of 24 weeks, based on fertilization age, will have wrinkled and red skin, testes descending toward inguinal rings, and the fetal movement becoming progressively more

noticeable. Surfactant production nearing the mature levels does not occur until 32 weeks and ear cartilage is not firm until 38 weeks. PTS: 1 DIF: Cognitive Level: Application REF: 80 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 20. The nurse is explaining fetal circulation to a group of nursing students. Which should be included in the teaching session? (Select all that apply.) a. After birth the ductus venosus remains open, but the other shunts close.

b. The foramen ovale shunts blood from the right atrium to the left atrium. c. The ductus venosus shunts blood from the liver to the inferior vena cava.

d. The ductus arteriosus shunts blood from the right ventricle to the left ventricle.

ANS: B, C

The foramen ovale shunts oxygenated blood from the right atrium to the left atrium, bypassing

the lungs. The ductus venosus shunts oxygenated blood from the liver to the inferior vena cava.

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All shunts close after birth. The ductus arteriosus shunts blood from the right ventricle to the aorta.

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PTS: 1 DIF: Cognitive Level: Application REF: 88

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 21. A nurse is conducting prenatal education classes for a group of parents. Which purposes should the nurse explain that are performed by the amniotic fluid? (Select all that apply.) a. Cushions the fetus b. Protects the skin of the fetus c. Provides nourishment for the fetus d. Allows for buoyancy for fetal movement

e. Maintains a stable temperature for the fetus ANS: A, D, E The amniotic fluid provides cushioning for the fetus against impacts to the maternal abdomen. It provides a stable temperature and allows room and buoyancy for fetal movement. Vernix caseosa, the cheeselike coating on the fetus, provides skin protection. The placenta provides nourishment for the fetus.

Chapter 6: Maternal Adaptation during Pregnancy

MULTIPLE CHOICE 1. A pregnant clients mother is worried that her daughter is not big enough at 20 weeks of

gestation. The nurse palpates and measures the fundal height at 20 cm, which is even with the

womans umbilicus. Which should the nurse report to the client and her mother? a. Youre right. Well inform the practitioner immediately.

b. Lightening has occurred, so the fundal height is lower than expected.

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c. The body of the uterus is at the belly button level, just where it should be at this time.

ANS: C

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d. When you come for next months appointment, well check you again to make sure that the baby is growing.

At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks gestation is located at the level of the umbilicus. Lightening has not yet occurred. At 20 weeks, the uterus should be at the umbilical level. The descent of the fetal head (lightening) occurs in late pregnancy. Waiting until the next appointment avoids the direct question and might increase the anxiety of the mother and grandmother. PTS: 1 DIF: Cognitive Level: Application REF: 94

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. While the vital signs of a pregnant client in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? a. Have the client stand up and retake her blood pressure. b. Have the client sit down and hold her arm in a dependent position. c. Have the client turn to her left side and recheck her blood pressure in 5 minutes.

d. Have the client lie supine for 5 minutes and recheck her blood pressure on both arms.

ANS: C

Blood pressure is affected by positions during pregnancy. The supine position may cause

occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine

hypotension. Pressures are significantly higher when the patient is standing. This would cause an

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increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating

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hypotension.

PTS: 1 DIF: Cognitive Level: Analysis REF: 96

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 3. A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider? a. Nasal stuffiness and nosebleeds are caused by a decrease in progesterone. b. These conditions are abnormal. Refer the client to an ear, nose, and throat specialist.

c. Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits. d. Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds. ANS: D As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy. Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone levels increase during pregnancy. The client should be reassured that these symptoms are within

normal limits. No referral is needed at this time. Relaxation of the smooth muscles in the respiratory tract is affected by progesterone.

PTS: 1 DIF: Cognitive Level: Analysis REF: 97

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

4. Which suggestion is appropriate for the pregnant client who is experiencing heartburn?

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a. Drink plenty of fluids at bedtime.

b. Eat only three meals a day so the stomach is empty between meals.

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c. Drink coffee or orange juice immediately on arising in the morning.

ANS: D

d. Use Tums or Alkamints to obtain relief, as directed by the health care provider.

Antacids high in calcium (e.g., Tums, Alkamints) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the woman to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach. PTS: 1 DIF: Cognitive Level: Understanding REF: 114 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 5. While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions? a. These contractions may indicate preterm labor. b. These are contractions that never cause any discomfort. c. Braxton Hicks contractions only start during the third trimester. d. These occur throughout pregnancy, but you may not feel them until the third trimester.

ANS: D Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks

contractions. During the first two trimesters, the contractions are infrequent and usually not felt

by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor. Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton

Hicks contractions occur throughout the whole pregnancy.

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PTS: 1 DIF: Cognitive Level: Application REF: 94

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

6. What is the reason for vascular volume increasing by 40% to 60% during pregnancy?

a. Prevents maternal and fetal dehydration b. Eliminates metabolic wastes of the mother c. Provides adequate perfusion of the placenta d. Compensates for decreased renal plasma flow ANS: C

The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. Physiologic anemia often occurs during pregnancy because of: a. inadequate intake of iron.

b. the fetus establishing iron stores.

d. decreased production of erythrocytes.

c. dilution of hemoglobin concentration.

ANS: C

When blood volume expansion is more pronounced and occurs earlier than the increase in red

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blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may

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lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 95 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which is a positive sign of pregnancy? a. Amenorrhea b. Breast changes c. Fetal movement felt by the woman d. Visualization of fetus by ultrasound

ANS: D The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 105 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. A client is currently pregnant; she has a 5-year-old son and a 3-year-old daughter. She had one

other pregnancy that terminated at 8 weeks. Which are her gravida and para?

a. 3, 2 b. 4, 3

c. 4, 2

d. 3, 3

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ANS: C

She has had four pregnancies, including the current one (gravida 4). She had two pregnancies

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that terminated after 20 weeks (para 2). The pregnancy that terminated at 8 weeks is classified as an abortion. Because she is currently pregnant, she is classified as a gravida 4. Gravida 4 is correct, but she is para 2; the pregnancy that was terminated at 8 weeks is classified as an

abortion. Because she is currently pregnant, she would be classified as a gravida 4, not 3. PTS: 1 DIF: Cognitive Level: Analysis REF: 106 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 10. A clients last menstrual period was June 10. What is her estimated date of birth (EDD)? a. April 7 b. March 17

c. March 27 d. April 17 ANS: B To determine the EDD, the nurse uses the first day of the last menstrual period (June 10), subtracts 3 months (March 10), and adds 7 days (March 17). April 7 would be subtracting 2 months instead of 3 months and then subtracting 3 days instead of adding 7 days. March is the correct month, but instead of adding 7 days, 17 days were added. April 17 is subtracting 2 months instead of 3.

PTS: 1 DIF: Cognitive Level: Understanding REF: 107

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

a. Problems can be eliminated.

provider every 4 weeks?

11. Why should a woman in her first trimester of pregnancy expect to visit her health care

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b. She develops trust in the health care team.

c. Her questions about labor can be answered.

ANS: D

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d. The conditions of the expectant mother and fetus can be monitored.

This routine allows for monitoring maternal health and fetal growth and ensures that problems

will be identified early. All problems cannot be eliminated because of prenatal visits, but they can be identified. Developing a trusting relationship should be established during these visits, but that is not the primary reason. Most women do not have questions concerning labor until the last trimester of the pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 112 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. A client in her first trimester complains of nausea and vomiting. She asks, Why does this happen? What is the nurses best response? a. It is due to an increase in gastric motility. b. It may be due to changes in hormones. c. It is related to an increase in glucose levels. d. It is caused by a decrease in gastric secretions. ANS: B Nausea and vomiting are believed to be caused by increased levels of hormones, decreased

gastric motility, and hypoglycemia. Gastric motility decreases during pregnancy. Glucose levels decrease in the first trimester. Gastric secretions decrease, but this is not the main cause of

nausea and vomiting.

PTS: 1 DIF: Cognitive Level: Application REF: 113

OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Physiologic Integrity

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13. Which advice to the client is one of the most effective methods for preventing venous stasis? a. Sit with the legs crossed.

b. Rest often with the feet elevated.

c. Sleep with the foot of the bed elevated.

d. Wear elastic stockings in the afternoon. ANS: B Elevating the feet and legs improves venous return and prevents venous stasis. Sitting with the legs crossed will decrease circulation in the legs and increase venous stasis. Elevating the legs at night may cause pressure on the diaphragm and increase breathing problems. Elastic stockings should be applied before lowering the legs in the morning.

PTS: 1 DIF: Cognitive Level: Application REF: 119 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 14. A client notices that the health care provider writes positive Chadwicks sign on her chart. She asks the nurse what this means. Which is the nurses best response? a. It means the cervix is softening. b. That refers to a positive sign of pregnancy. c. It refers to the bluish color of the cervix in pregnancy.

d. The doctor was able to flex the uterus against the cervix. ANS: C

Increased vascularity of the pelvic organs during pregnancy results in the bluish color of the

cervix, vagina, and labia, called Chadwicks sign. Softening of the cervix is Goodells sign. Chadwicks sign is a probable sign of pregnancy. The softening of the lower segment of the

uterus is Hegars sign, which can allow the uterus to be flexed against the cervix.

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PTS: 1 DIF: Cognitive Level: Application REF: 102

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OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

15. Which is the gravida and para for a client who delivered triplets 2 years ago and is now

pregnant again? a. 2, 3 b. 1, 2 c. 2, 1 d. 1, 3 ANS: C

She has had two pregnancies (gravida 2); para refers to the outcome of the pregnancy rather than the number of infants from that pregnancy. She is pregnant now, so that would make her a gravida 2. She is para 1 because she had one pregnancy that progressed to the age of viability. PTS: 1 DIF: Cognitive Level: Analysis REF: 106 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. To relieve a leg cramp, what should the client be instructed to perform? a. Dorsiflex the foot.

b. Apply a warm pack. c. Stretch and point the toe.

d. Massage the affected muscle.

ANS: A

Dorsiflexion of the foot stretches the leg muscle and relieves the painful muscle contraction.

Warm packs can be used to relax the muscle, but more immediate relief is necessary, such as

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dorsiflexion of the foot. Pointing the toes will contract the muscle and not relieve the pain. Because she is prone to blood clots, massaging the affected leg muscle is contraindicated.

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PTS: 1 DIF: Cognitive Level: Application REF: 115

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 17. A client, gravida 2, para 1, comes for a prenatal visit at 20 weeks of gestation. Her fundus is palpated 3 cm below the umbilicus. This finding is: a. appropriate for gestational age. b. a sign of impending complications. c. lower than normal for gestational age. d. higher than normal for gestational age.

ANS: C By 20 weeks, the fundus should reach the umbilicus. The fundus should be at the umbilicus at 20 weeks, so 3 cm below the umbilicus is an inappropriate height and needs further assessment. This is lower than expected at this date. It may be a complication, but it may also be because of incorrect dating of the pregnancy. PTS: 1 DIF: Cognitive Level: Analysis REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

18. Which complaint made by a client at 35 weeks of gestation requires additional assessment? a. Abdominal pain

c. Backache with prolonged standing

d. Shortness of breath when climbing stairs

b. Ankle edema in the afternoon

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ANS: A

Abdominal pain may indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae. Ankle edema in the afternoon is a normal finding at this stage of the pregnancy.

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Backaches while standing is a normal finding in the later stage of pregnancy. Shortness of breath is an expected finding at 35 weeks.

PTS: 1 DIF: Cognitive Level: Analysis REF: 121 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 19. A gravida client at 32 weeks of gestation reports that she has severe lower back pain. What should the nurses assessment include? a. Palpation of the lumbar spine b. Exercise pattern and duration c. Observation of posture and body mechanics

d. Ability to sleep for at least 6 hours uninterrupted ANS: C Correct posture and body mechanics can reduce lower back pain caused by increasing lordosis. Pregnancy should not cause alterations in the spine. Any assessment for malformation should be done early in pregnancy. Certain exercises can help relieve back pain. Rest is important for wellbeing, but the main concern with back pain is to assess posture and body mechanics. PTS: 1 DIF: Cognitive Level: Application REF: 113

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. A pregnant woman is the mother of two children. Her first pregnancy ended in a stillbirth at

32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the five-digit system to describe this

womans current obstetric history, what should the nurse record?

a. 4-1-2-0-2

c. 4-2-1-0-1

ANS: A

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d. 3-1-1-1-3

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b. 3-1-2-0-2

Gravida (the first number) is 4 because this woman is now pregnant and was pregnant three

times before. Para (the next four numbers) represents the outcomes of the pregnancies and would be described as follows: T: 1 = term birth at 41 weeks of gestation (son) P: 2 = preterm birth at 32 weeks of gestation (stillbirth) and 36 weeks of gestation (daughter) A: 0 = abortion; none L: 2 = living children, her son and her daughter

She is currently pregnant so she is a gravida 4. She had one term infant, two preterm infants, no abortion, and three living children. PTS: 1 DIF: Cognitive Level: Application REF: 107 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 21. Which laboratory result would be a cause for concern if exhibited by a client at her first prenatal visit during the second month of her pregnancy? a. Rubella titer, 1:6 b. Platelets, 300,000/mm3

c. White blood cell count, 6000/mm3

d. Hematocrit 38%, hemoglobin 13 g/dL

ANS: A

A rubella titer of less than 1:8 indicates a lack of immunity to rubella, a viral infection that has

the potential to cause teratogenic effects on fetal development. Arrangements should be made to

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administer the rubella vaccine after birth during the postpartum period because administration of rubella, a live vaccine, would be contraindicated during pregnancy. Women receiving the

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vaccine during the postpartum period should be cautioned to avoid pregnancy for 3 months. The lab values for WBCs, platelets, and hematocrit/hemoglobin are within the expected range for pregnant women.

PTS: 1 DIF: Cognitive Level: Analysis REF: 110 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 22. A client in her third trimester of pregnancy is asking about safe travel. Which statement should the nurse give about safe travel during pregnancy? a. Only travel by car during pregnancy. b. Avoid use of the seat belt during the third trimester. c. You can travel by plane until your 38th week of gestation.

d. If you are traveling by car stop to walk every 1 to 2 hours. ANS: D Car travel is safe during normal pregnancies. Suggest that the woman stop to walk every 1 to 2 hours so she can empty her bladder. Walking also helps decrease the risk of thrombosis that is elevated during pregnancy. Seat belts should be worn throughout the pregnancy. Instruct the woman to fasten the seat belt snugly, with the lap belt under her abdomen and across her thighs and the shoulder belt in a diagonal position across her chest and above the bulge of her uterus. Travel by plane is generally safe up to 36 weeks if there are no complications of the pregnancy,

PTS: 1 DIF: Cognitive Level: Application REF: 119

so only travelling by car is an inaccurate statement.

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. The client has just learned she is pregnant and overhears the gynecologist saying that she has a positive Chadwicks sign. When the client asks the nurse what this means, how should the nurse

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respond?

a. Chadwicks sign signifies an increased risk of blood clots in pregnant women because of a congestion of blood.

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b. That sign means the cervix has softened as the result of tissue changes that naturally occur with pregnancy.

c. This means that a mucous plug has formed in the cervical canal to help protect you from uterine infection.

d. This sign occurs normally in pregnancy, when estrogen causes increased blood flow in the area of the cervix. ANS: D Increasing levels of estrogen cause hyperemia (congestion with blood) of the cervix, resulting in the characteristic bluish purple color that extends to include the vagina and labia. This discoloration, referred to as Chadwicks sign, is one of the earliest signs of pregnancy. Although Chadwicks sign occurs with hyperemia (congestion with blood), the sign does not signify an increased risk of blood clots. The softening of the cervix is called Goodells sign, not Chadwicks

sign. Although the formation of a mucous plug protects from infection, it is not called Chadwicks sign. PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. When a pregnant woman develops ptyalism, what should the nurse advise? a. Chew gum or suck on lozenges between meals. b. Eat nutritious meals that provide adequate amounts of essential vitamins and minerals.

c. Take short walks to stimulate circulation in the legs and elevate the legs periodically.

d. Use pillows to support the abdomen and back during sleep.

ANS: A

Some women experience ptyalism, or excessive salivation. The cause of ptyalism may be

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decreased swallowing associated with nausea or stimulation of the salivary glands by the ingestion of starch. Small frequent meals and use of chewing gum and oral lozenges offer limited relief for some women. All other options include recommendations for pregnant women;

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however, they do not address ptyalism.

PTS: 1 DIF: Cognitive Level: Application REF: 97

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort 25. A pregnant immigrant has an unknown immunization history. When she presents for routine vaccinations, which will the nurse administer? a. Hepatitis B b. Measles c. Rubella

d. Varicella ANS: A In general, immunizations with live virus vaccines (e.g., measles, mumps, rubella, varicella, smallpox) are contraindicated during pregnancy because they may have teratogenic effects on the fetus. Inactivated vaccines are safe and can be used in women who have a risk of developing diseases such as tetanus, hepatitis B, and influenza. PTS: 1 DIF: Cognitive Level: Understanding REF: 119

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

26. When the pregnant woman develops changes caused by pregnancy, the nurse recognizes that

the darkly pigmented vertical midabdominal line is the:

a. epulis.

c. melasma.

ANS: B

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d. striae gravidarum.

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b. linea nigra.

The linea nigra is a dark pigmented line from the fundus to the symphysis pubis. Epulis refers to

gingival hypertrophy. Melasma is a different kind of dark pigmentation that occurs on the face. Striae gravidarum (stretch marks) are a different kind of line caused by lineal tears that occur in connective tissue. PTS: 1 DIF: Cognitive Level: Knowledge REF: 99 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 27. When documenting a client encounter, what term will the nurse use to describe the woman who is in the 28th week of her first pregnancy?

a. Multigravida b. Multipara c. Nullipara d. Primigravida ANS: D A primigravida is a woman pregnant for the first time. A multigravida has been pregnant more than once. A nullipara is a woman who has never been pregnant or has not completed a pregnancy of 20 weeks or more. A primipara has delivered one pregnancy of at least 20 weeks.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Knowledge REF: 106

A multipara has delivered two or more pregnancies of at least 20 weeks.

MSC: Client Needs: Health Promotion and Maintenance

28. You are performing assessments for an obstetric client who is 5 months pregnant with her

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third child. Which finding would cause you to suspect that the client was at risk?

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a. Client states that she doesnt feel any Braxton Hicks contractions like she had in her prior pregnancies. b. Fundal height is below the umbilicus.

c. Cervical changes, such as Goodells sign and Chadwicks sign, are present.

d. She has increased vaginal secretions. ANS: B

Based on gestational age (20 weeks), the fundal height should be at the umbilicus. This finding is abnormal and warrants further investigation about potential risk. With subsequent pregnancies, multiparas may not perceive Braxton Hicks contractions as being evident compared with their initial pregnancy. Cervical changes such as Goodells and Chadwicks signs should be present and are considered a normal finding. Increased vaginal secretions are normal during pregnancy as a result of increased vascularity.

PTS: 1 DIF: Cognitive Level: Application REF: 111 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential 29. What is the best explanation that you can provide to a pregnant client who is concerned that she has pseudoanemia of pregnancy? a. Have her write down her concerns and tell her that you will ask the physician to respond once the lab results have been evaluated.

b. Tell her that this is a benign self-limiting condition that can be easily corrected by switching to a high-iron diet.

c. Inform her that because of the pregnancy, her blood volume has increased, leading to a substantial dilution effect on her serum blood levels, and that most women experience this condition.

d. Contact the physician and get a prescription for iron pills to correct this condition.

ANS: C

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Providing factual information based on physiologic mechanisms is the best option. Although having the client write down her concerns is reasonable, the nurse should not refer this conversation to the physician but rather address the clients specific concerns. Switching to a

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high-iron diet will not correct this condition. This physiologic pattern occurs during pregnancy as a result of hemodilution from excess blood volume. Iron medication is not indicated for

correction of this condition. There is no need to contact the physician for a prescription.

PTS: 1 DIF: Cognitive Level: Application REF: 95 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 30. Which physiologic finding is consistent with normal pregnancy? a. Systemic vascular resistance increases as blood pressure decreases.

b. Cardiac output increases during pregnancy. c. Blood pressure remains consistent independent of position changes. d. Maternal vasoconstriction occurs in response to increased metabolism. ANS: B Cardiac output increases during pregnancy as a result of increased stroke volume and heart rate. Systemic vascular resistance decreases while blood pressure remains the same. Maternal blood pressure changes in response to client positioning. In response to increased metabolism, maternal vasodilation is seen during pregnancy.

PTS: 1 DIF: Cognitive Level: Analysis REF: 96

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 31. A pregnant client complains that since she has been pregnant, her nose is always stuffed and

she feels like she has a cold. Past medical history is negative for respiratory problems such as

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hay fever, sinusitis, or other allergies. What is the most likely cause for the clients presentation? a. Increased effects of progesterone to maintain the pregnancy

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b. Effects of estrogen on the respiratory tract c. Development of allergies as a result of pregnancy because of altered immunity

ANS: B

d. Increase in fluid consumption during pregnancy leading to overhydration

Increasing estrogen levels during pregnancy can affect the respiratory tract passages, leading to increased vascular responses that manifest as coldlike symptoms. Progesterone, as the hormone of pregnancy, maintains the pregnancy and does not have any direct effects on the maternal respiratory passages. Although it is possible for a client to develop allergies based on exposure to antigen triggers, it is not typically associated with pregnancy states. An increase in fluid may lead to potential edema, but it is not associated with coldlike symptoms.

PTS: 1 DIF: Cognitive Level: Analysis REF: 97 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 32. A pregnant client complains of frequent heartburn. The client states that she has never had these symptoms before and wonders why this is occurring now. The best response that the nurse can provide is: a. examine her dietary intake pattern and tell her to avoid certain foods.

b. tell her that this is a normal finding during early pregnancy and will resolve as she gets closer to term.

c. explain to the client that physiologic changes caused by the pregnancy make her more likely to experience these types of symptoms.

d. refer her to her health care provider for additional testing because this is an abnormal finding.

ANS: C

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The presentation of heartburn is a normal abnormal finding that can occur in pregnant woman because of relaxation of the lower esophageal sphincter as a result of the physiologic effects of

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pregnancy. Although foods may contribute to the heartburn, the client is asking why this presentation is occurring, so the nurse should address the cause first. It is independent of gestation. There is no need to refer to the physician at this time because this is a normal

abnormal finding. There is no evidence of complications ensuing from this presentation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 113 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 33. Which physiologic event may lead to increased constipation during pregnancy? a. Increased emptying time in the intestines

b. Abdominal distention and bloating c. Decreased absorption of water d. Decreased motility in the intestines ANS: D Decreased motility in the intestines leading to increased water absorption would cause constipation. Increased emptying time in the intestines leads to increased nutrient absorption. Abdominal distention and bloating are a result of increased emptying time in the intestines.

PTS: 1 DIF: Cognitive Level: Application REF: 98

OBJ: Nursing Process Step: Assessment

Decreased absorption of water would not cause constipation.

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 34. Which physiologic findings are seen with respect to gallbladder function that might lead to

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the development of gallstones during pregnancy?

a. Decrease in alkaline phosphatase levels compared with nonpregnant women b. Increase in albumin and total protein as a result of hemodilution

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c. Hypertonicity of gallbladder tissue

ANS: D

d. Prolonged emptying time

Prolonged emptying time is seen during pregnancy and may lead to the development of gallstones. In pregnancy, there is a twofold to fourfold time increase in alkaline phosphatase levels as compared with those in nonpregnant woman. During pregnancy, a decrease in albumin level and total protein are seen as a result of hemodilution. Gallbladder tissue becomes hypotonic during pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 98

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation 35. Which of these findings would indicate a potential complication related to renal function during pregnancy? a. Increase in glomerular filtration rate (GFR) b. Increase in serum creatinine level c. Decrease in blood urea nitrogen (BUN)

d. Mild proteinuria ANS: B

With pregnancy, one would expect the serum creatinine and BUN levels to decrease. An

elevation in the serum creatinine level should be investigated. With pregnancy, the GFR increases because of increased renal blood flow and is thus a normal expected finding. A

decrease in the blood urea nitrogen level and mild proteinuria are expected findings in

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pregnancy.

PTS: 1 DIF: Cognitive Level: Application REF: 98

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OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

36. A pregnant client notices that she is beginning to develop dark skin patches on her face. She denies using any different type of facial products as a cleansing solution or makeup. What would the priority nursing intervention be in response to this situation? a. Refer the client to a dermatologist for further examination. b. Ask the client if she has been eating different types of foods. c. Take a culture swab and send to the lab for culture and sensitivity (C&S). d. Let the client know that this is a common finding that occurs during pregnancy.

ANS: D This condition is known as chloasma or melasma (mask of pregnancy) and is a result of pigmentation changes relative to hormones. It can be exacerbated by exposure to the sun. There is no need to refer to a dermatologist. Intake of foods is not associated with exacerbation of this process. There is no need for a C&S to be taken. The client should be assured that this is a normal finding of pregnancy. PTS: 1 DIF: Cognitive Level: Application REF: 98 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation

37. Determine the obstetric history of a client in her fifth pregnancy who had two spontaneous

abortions in the first trimester, one infant at 32 weeks gestation, and one infant at 38 weeks

gestation.

a. G5 T1 P2 A2 L 2

c. G5 T0 P2 A2 L2

ANS: D

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d. G5 T1 P1 A2 L2

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b. G5 T1 P1 A1 L2

This client is in her fifth pregnancy, which is G5, she had one viable term infant (between 38 and

42 weeks gestation), which is T1, she had one viable preterm infant (between 20 and 37 weeks gestation), which is P1, two spontaneous abortions (before 20 weeks gestation), which is A2, and she has two living children, which is L2. PTS: 1 DIF: Cognitive Level: Application REF: 107 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 38. Use Ngeles rule to determine the EDD (estimated day of birth) for a client whose last menstrual period started on April 12.

a. February 19 b. January 19 c. January 21 d. February 7 ANS: B Ngeles rule subtracts 3 months from the month of the last menstrual period (month 4 month 3 = January) and adds 7 days to the day that the last menstrual period started (April 12 + 7 days =

PTS: 1 DIF: Cognitive Level: Application REF: 107

April 19), so the correct answer is January 19.

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

39. Which of the client health behaviors in the first trimester would the nurse identify as a risk factor in pregnancy?

a. Sexual intercourse two or three times weekly

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b. Moderate exercise for 30 minutes daily

c. Working 40 hours a week as a secretary in a travel agency

ANS: D

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d. Relaxing in a hot tub for 30 minutes a day, several days a week

Pregnant women should avoid activities that might cause hyperthermia. Maternal hyperthermia,

particularly during the first trimester, may be associated with fetal anomalies. She should not be in a hot tub for more than 10 minutes at less than 100 F. Sexual intercourse is generally safe for the healthy pregnant woman; moderate exercise during pregnancy can strengthen muscles, reduce backache and stress, and provide a feeling of well-being; working during pregnancy is acceptable as long as the woman is not continually on her feet or exposed to environmental toxins and industrial hazards. PTS: 1 DIF: Cognitive Level: Analysis REF: 118

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 40. A client who smokes one pack of cigarettes daily has a positive pregnancy test. The nurse will explain that smoking during pregnancy increases the risk of which condition? a. Congenital anomalies b. Death before or after birth c. Neonatal hypoglycemia d. Neonatal withdrawal syndrome

ANS: B Smoking during pregnancy increases the risk for spontaneous abortion, low birth weight, abruptio placentae, placenta previa, preterm birth, perinatal mortality, and SIDS. Smoking does

not appear to cause congenital anomalies, hypoglycemia, or withdrawal syndrome. PTS: 1 DIF: Cognitive Level: Understanding REF: 120

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

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41. The patient reports that the first day of her last normal menstrual period was December 8. Using Ngeles rule, what date will the nurse identify as the estimated date of birth?

a. March 1

b. March 15

c. September 1

d. September 15 ANS: D Ngeles rule is often used to establish the EDD. This method involves subtracting 3 months from the date the LNMP began and adding 7 days. The incorrect responses add months instead of subtracting months and subtract days instead of adding days.

PTS: 1 DIF: Cognitive Level: Analysis REF: 107 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 42. The client with an IUD has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action? a. A therapeutic abortion will need to be scheduled because fetal damage is inevitable. b. Hormonal analyses will be done to determine the underlying cause of the falsepositive test result.

c. The IUD will need to be removed to avoid complications such as miscarriage or infection.

d. The IUD will need to remain in place to avoid injuring the fetus.

ANS: C

Pregnancy with an intrauterine device (IUD) in place is unusual but it can occur and cause

complications such as spontaneous abortion and infection. A therapeutic abortion is not indicated

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unless infection occurs.

PTS: 1 DIF: Cognitive Level: Understanding REF: 107

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OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

43. The health care provider reports that the primigravidas fundus can be palpated at the umbilicus. Which priority question will the nurse include in the clients assessment? a. Have you noticed that it is easier for you to breathe now? b. Would you like to hear the babys heartbeat for the first time? c. Have you felt a fluttering sensation in your lower pelvic area yet? d. Have you recently developed any unusual cravings, such as for chalk or dirt? ANS: C

Quickening is the first maternal sensation of fetal movement and is often described as a fluttering sensation. Quickening is detected at approximately 20 weeks in the primigravida and as early as 16 weeks in the multigravida. The fundus is at the umbilicus at 20 weeks gestation. Lightening is associated with descent of the fetal head into the maternal pelvis and is associated with improved lung expansion. Lightening occurs approximately 2 weeks before birth in the primipara. Fetal heart tones can be detected by Doppler as early as 9 to 12 weeks of gestation. Pica is the craving for non-nutritive substances such as chalk, dirt, clay, or sand. It can develop at any time during pregnancy. It can be associated with malnutrition and the health care provider should monitor the clients hematocrit/hemoglobin, zinc, and iron levels.

PTS: 1 DIF: Cognitive Level: Synthesizing REF: 112 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

44. A patient at 24 week gestation reports to the clinic nurse that she is tired all the time. What is

the nurses best response?

a. Everyone has chronic anemia at this time in pregnancy.

b. Ill make sure your health care provider is informed of your concern.

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c. Your urine is clean of protein and sugar. You are doing well at this time.

ANS: B

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d. Make sure you are drinking enough fluid to keep up with the demands of your body.

The patient is experiencing classic signs of physiologic anemia, or an increase in the amount of

plasma resulting in a dilution of circulating red blood cells (RBCs). Red blood cell production will continue to increase throughout pregnancy, with a resulting resolution in physiologic anemia. The health care provider will likely order a complete blood count to verify this. The anemia is physiologic and not chronic because there is no decrease in circulating RBCs. The absence of proteinuria and glucosuria is reassuring, but these findings are not correlated with fatigue. Adequate fluid volume intake is essential in pregnancy but is not responsible for the development of physiologic anemia or the corresponding fatigue. PTS: 1 DIF: Cognitive Level: Analysis REF: 95, 96

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 45. A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all of the time. The patients urine test is positive for hCG. What is the best nursing action related to this information? a. Ask the patient if she has had any nausea or vomiting in the morning. b. Schedule the patient to be seen by a health care provider within the next 4 weeks. c. Send the patient to the maternity screening area of the clinic for a routine ultrasound.

d. Determine if there are any factors that might prohibit her from seeking medical care.

ANS: D

The patient has presumptive and probable indications of pregnancy. However, she has not sought

out health care until late in the first or early in the second trimester. The nurse must assess for barriers to seeking health care, physical or emotional, because regular prenatal care is key to a

positive pregnancy outcome. Asking if the patient has nausea or vomiting will only add to the list

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of presumptive signs of pregnancy, and this information will not add to the assessment data to determine whether the client is pregnant. The patient needs to see a health care provider before

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the next 4 weeks because she is late in seeking early prenatal care. Ultrasounds must be prescribed by a health care provider and ordering one is not in the nurses scope of practice.

Chapter 7: Prenatal Care

MULTIPLE CHOICE 1. The birth educator is discussing the advantages and disadvantages of birthing options. Which disadvantage is common with epidural anesthesia? a. Effective pushing is optimized. b. The risk of catheterization is decreased. c. The length of labor and birth may be decreased.

d. The use of forceps and oxytocin administration is increased. ANS: D Administration of oxytocic drugs and the use of forceps are more likely with epidural anesthesia. Epidural anesthesia can cause less effective pushing because the woman cannot feel the contractions. Catheterizing the patient is common because the woman does not have the urge to empty her bladder. Epidural anesthesia usually removes most pain but may increase the length of labor. PTS: 1 DIF: Cognitive Level: Application REF: 186

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

2. What is covered by early pregnancy classes offered in the first and second trimesters?

a. Methods of pain relief

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b. The phases and stages of labor

c. Coping with common discomforts of pregnancy

ANS: C

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d. Prebirth and postbirth care of a client having a cesarean birth

Early pregnancy classes focus on the first two trimesters and cover information on adapting to

pregnancy, dealing with early discomforts, and understanding what to expect in the months ahead. Methods of pain relief are discussed in a childbirth preparation class. The phases and stages of labor are usually covered in a childbirth preparation class. Cesarean birth preparation classes discuss prebirth and postbirth of a client having a cesarean birth. PTS: 1 DIF: Cognitive Level: Understanding REF: 185 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. Which client is most likely to experience pain during labor?

a. Gravida 1 whose fetus is in a breech presentation b. Gravida 3 who is using Lamaze breathing techniques c. Gravida 2 who is anxious because her last labor was difficult d. Gravida 2 who has not attended childbirth preparation classes ANS: C Anxiety affects a womans perception of pain. Tension during labor causes tightening of abdominal muscles, impeding contractions and increasing pain by stimulation of nerve endings. A breech presentation does not mean that the woman will experience a painful labor. Lamaze breathing techniques use the mind to prevent pain; they involve concentration and conditioning

to help the woman respond to contractions with relaxation to decrease pain. Childbirth preparation classes can help a woman prepare for the pain but will not prevent the woman from

experiencing pain during labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 188

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

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4. When reading a new clients birth plan, the nurse notices that the client will be bringing a doula to the hospital during labor. What does the nurse think that this means?

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a. The client will have her grandmother as a support person. b. The client will bring a paid, trained labor support person with her during labor.

c. The client will have a special video she will play during labor to assist with relaxation. d. The client will have a bag that contains all the approved equipment that may help with the labor process. ANS: B A doula is a trained labor support person who is employed by the mother to provide labor support. She gives physical support such as massage, helps with relaxation, and provides emotional support and advocacy throughout labor. A doula is usually not a relative of the woman. A doula is a trained labor support person.

PTS: 1 DIF: Cognitive Level: Understanding REF: 184 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor? a. Bradley b. Lamaze c. Leboyer

d. Dick-Read ANS: D

The Dick-Read method helps prevent the fear-tension-pain cycle by using slow abdominal

breathing in early labor and rapid chest breathing in advanced labor. The Lamaze method involves concentration and conditioning to help the woman respond to contractions with

relaxation to decrease pain. Viewing childbirth as a traumatic experience, the Leboyer method uses decreased light and noise to help the newborn adapt to extrauterine life more easily. The

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Bradley method teaches women to use abdominal muscles to increase relaxation and breath

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control; it emphasizes avoidance of all medications and interventions. PTS: 1 DIF: Cognitive Level: Understanding REF: 188, 189

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

6. Which type of cutaneous stimulation involves massage of the abdomen? a. Imagery

b. Effleurage c. Mental stimulation d. Thermal stimulation ANS: B

Effleurage is massage usually performed on the abdomen during contractions. Imagery exercises enhance relaxation by teaching the woman to imagine herself in a relaxing setting. Mental stimulation is a group of methods to decrease pain by increasing mental stimulation. Thermal stimulation decreases pain by using applications of heat and cold. PTS: 1 DIF: Cognitive Level: Understanding REF: 190 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. What does a birth plan help the parents accomplish? a. Avoidance of an episiotomy

b. Determining the outcome of the birth c. Assuming complete control of the situation

d. Taking an active part in planning the birth experience ANS: D

The birth plan helps the woman and her partner look at the available options and plan the birth

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experience to meet their personal needs. A birth plan cannot dictate the need for or avoidance of an episiotomy. The outcome of the birth is not an absolute determinant. A birth plan does not

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assume complete control of the situation; it allows for expanding communication. PTS: 1 DIF: Cognitive Level: Understanding REF: 192

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. Which client could safely be cared for by a certified nurse-midwife? a. Gravida 3, para 2, with no complications b. Gravida 1, para 0, with mild hypertension c. Gravida 2, para 1, with insulin-dependent diabetes d. Gravida 1, para 0, with borderline pelvic measurements ANS: A

A certified nurse-midwife (CNM) cares for women who are at low risk for complications. The CNM would not care for a woman with hypertension. The CNM would not care for a woman with insulin-dependent diabetes. The CNM would not care for a woman with borderline pelvic measurements. PTS: 1 DIF: Cognitive Level: Analysis REF: 184 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 9. Martha is a gravida 3, para 2, whose last child was born 5 years ago. She attended childbirth preparation classes with her first pregnancy. Which class would be most appropriate for her?

a. Refresher course b. Infant care classes

c. Postpartum classes

d. Early pregnancy classes

ANS: A

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When 2 or more years elapse between a prepared childbirth class and a subsequent pregnancy, a refresher course is recommended to provide couples with an update on new developments and to

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review techniques. Infant care classes cover the basics of infant care, with which she is familiar. She has experienced the postpartum period so this class would not be as beneficial as a refresher class. Early pregnancy classes cover information on adapting to pregnancy, dealing with

discomforts such as morning sickness and fatigue, and understanding what to expect in the

months ahead.

PTS: 1 DIF: Cognitive Level: Analysis REF: 186 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 10. A client asks, What can I do to help decrease the amount of pain with labor? What should be the nurses best response? a. Nothing. That is the way God intended it to be.

b. We can give you medications to help with the pain. c. You should not worry about the pain; leave that concern up to the staff. d. By trying to relax, the contractions will be more efficient and the pain may be less. ANS: D Anxiety and tension will make the uterine contractions less effective and increase the length of labor. Relaxation will help the contractions to be more effective and the labor will be less painful. Stating nothing is demeaning and does not answer the womans questions. The woman may not want medications but instead is looking for alternatives. You should not worry about the alleviate her concern about pain control.

PTS: 1 DIF: Cognitive Level: Application REF: 188

pain; leave that concern up to the staff does not answer the womans questions and would not

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

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11. Which phrase best describes neuromuscular dissociation? a. Loosening taut muscles when touched by another person b. Contracting and consciously releasing different muscle groups

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c. Relaxing while someone is applying pressure against a tendon or large muscle

ANS: D

d. Relaxing the rest of the body while one group of muscles is strongly contracted

Neuromuscular dissociation helps the woman learn to relax her body, even when one group of muscles is strongly contracted. Loosening taut muscles when touched by another person describes touch relaxation. Contracting and consciously releasing different muscle groups refers to progressive relaxation. Relaxing while someone is applying pressure against a tendon or large muscle describes sacral pressure. PTS: 1 DIF: Cognitive Level: Understanding REF: 189

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 12. A primipara client asks about possible support options for her during the labor process. She is apprehensive that her family members will not be prepared to assist her during this time. Which option would be most effective for this client? a. Reassure the client that the labor and birth staff consists of highly trained nurses who are well educated to take care of laboring clients, so that should be sufficient. b. Encourage the client to take prepared childbirth classes with her husband because that should provide the best support by a family member. c. Provide information to the client about obtaining a doula during the labor process.

d. Tell the client that this is a normal feeling based on fear of the unknown and that it will subside once she starts the labor process.

ANS: C

Providing information about a doula addresses the clients concern because the doulas designated role is to provide support during labor. Although it is true that labor and birth nurses are trained

in their specialty, the client is voicing concern for support so her feelings should not be

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minimized. Encouraging the client to take prepared childbirth classes is also important but does not address the clients concern for support. Because this client is a primipara, it is normal to have some anxiety over the unknown process of the labor experience but, again, this response

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minimizes the clients concern.

PTS: 1 DIF: Cognitive Level: Analysis REF: 191

OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychologic Integrity 13. Which statement is incorrect regarding prepared childbirth education? a. No use of anesthetics or drugs is to be administered to clients so they can have a natural childbirth experience. b. Clients can take refresher courses if they have delivered within the last 2 years. c. Prepared childbirth classes may differ slightly based on the available resources of health care facilities.

d. Prepared childbirth classes are aimed at increasing awareness of the childbirth experience for parents and significant others to promote better control of pain and decrease anxiety. ANS: A Medications and anesthesia information are provided during childbirth education. It is up to the client to decide if she wants to use these treatment options during the course of labor. Refresher courses are available up to 3 years postbirth for clients. Different information may be provided based on the availability of resources in health care facilities that provide obstetric care to clients. Goals of childbirth classes are to increase knowledge of the birth experience, foster control of the

situation to decrease anxiety, and minimize the pain experience. PTS: 1 DIF: Cognitive Level: Analysis REF: 188, 189

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Psychosocial Integrity: Therapeutic Communication

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pain perception is:

14. A relaxation technique that can be used during the childbirth experience to decrease maternal

a. using increased environmental stimulation as a method of distraction.

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b. restricting family and friends from visiting during the labor period to keep the client focused on breathing techniques.

c. medicating the client frequently to reduce pain perception.

d. assisting the client in breathing methods aimed at taking control of pain perception based on the contraction pattern. ANS: D Relaxation techniques are aimed at incorporating mind and body activities to maintain control over pain. Additional environmental stimuli may have the opposite effect and increase client anxiety, which will affect pain perception. Restricting visitors may have the opposite effect, leading to increased anxiety because of isolation. Medicating a client may not decrease pain

perception but may place the client at risk for adverse reactions and/or complications of pregnancy related to medications. PTS: 1 DIF: Cognitive Level: Analysis REF: 189 OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity: Therapeutic Communication 15. During the course of labor, a client has been having her labor coach rub her lower back to relieve pain. After 30 minutes, the client complains that this method is no longer working and becomes increasingly frustrated with the labor coach. The vaginal exam is 2 to 3 cm, 80%

effaced, and 1 station, membranes intact. Which option would you recommend to decrease the clients perceived pain?

a. Have the labor coach change the touch location and begin gently massaging another area on the back. b. Perform a vaginal exam to determine progress.

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c. Have the labor coach step outside the room (LDR) and take a break because it is best to try and defuse the confrontation.

ANS: A

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d. Suggest to the client that perhaps the use of a narcotic opioid will relieve her pain and facilitate the labor process.

It would appear that habituation has occurred and a change of location may lead to improved pain control relief through touch. A vaginal exam does not address the clients concern of pain,

and there is no evidence to support the use of this option at this time. Current data from the vaginal exam indicate that the client is in early labor. The client and labor coach have a bond so to remove the labor coach from the room would further isolate the client and potentially raise the perceived pain level. The nurse should encourage the client and labor coach to work together during the labor process. It is too early in the labor process to recommend the use of narcotics because this might further delay labor. Alternate treatment options involve the use of nonpharmacologic methods such as touch and positioning. PTS: 1 DIF: Cognitive Level: Analysis REF: 189, 190

OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity: Therapeutic Communication 16. Which technique would provide the best pain relief for a pregnant woman with an occiput posterior position? a. Neuromuscular disassociation b. Effleurage c. Psychoprophylaxis

d. Sacral pressure ANS: D

The use of sacral pressure may provide relief for clients who are experiencing back labor. The

presentation of the fetus in a posterior position indicates this. Neuromuscular dissociation is used as a conditioned response to affect pain relief based on the mother tensing one group of muscles

and focusing on releasing tension in the rest of her body. Effleurage is the process of using of prepared childbirth.

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circular massage to effect pain relief. Psychoprophylaxis is another name for the Lamaze method

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PTS: 1 DIF: Cognitive Level: Analysis REF: 190 OBJ: Nursing Process Step: Planning

MSC: Client Needs: Psychosocial Integrity: Sensory Perceptual Alterations 17. The support person for your labor client has been applying gentle massage to the clients upper back frequently over the past hour. Now, the labor client states that it just isnt helping anymore. Both the support person and labor client are becoming frustrated with each others inability to make things less stressful during the labor process. What would be the best nursing response at this time? a. Have the client change position and tell the support person to take a break.

b. Discuss the effects of habituation and suggest alternate measures that could be used to relieve pain. c. Advise the client that this may be the best time to ask for an epidural. d. Tell the client and support person that she must be progressing further and you will do a vaginal exam to determine progress. ANS: B The process of habituation occurs as nerve fibers become less responsive to massage efforts, so alternative methods should be suggested to reduce frustration and improve outcomes. Although it might be advisable to suggest a break for the support person, that will leave the client alone when

she is clearly frustrated. Change of position may be advisable. There is no indication that the client wants to have anesthesia as part of the labor-birth plan. Vaginal exams are done to determine progress but the situation as stated does not indicate that the client is progressing

further so this might lead to further frustration if the findings do not indicate progress. PTS: 1 DIF: Cognitive Level: Analysis REF: 189, 190

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Psychosocial Integrity: Sensory Perceptual Alterations

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18. A pregnant client is anticipating a vaginal birth without complications. During the course of her labor, complications arise and the fetus has to be delivered via cesarean section. The client is visibly upset and wants to know why this has happened to her because she did everything right

during her pregnancy. Which priority nursing diagnosis would apply?

a. Risk for injury b. Pain

c. Impaired skin integrity d. Anxiety ANS: D

Although risk for injury, pain, and impaired skin integrity apply as nursing diagnoses, the client situation is such that she was anticipating a vaginal birth. Thus, she is more likely to be experiencing anxiety related to the change in birth plan so the nurse should respond to that as the priority need. PTS: 1 DIF: Cognitive Level: Analysis REF: 188 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Psychosocial Integrity: Sensory Perceptual Alterations 19. The nurse is reviewing the option of childbirth classes with a patient in her second trimester.

a. My labor will likely be shorter if I go to classes.

Which statement indicates to the nurse that the patient has understood the teaching?

b. I will likely perceive less pain during labor if I go to classes.

c. I will likely be more satisfied with my labor if I go to classes.

d. I will likely use fewer medications during labor if I go to classes.

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ANS: C

Many studies agree that couples receiving prenatal preparation for childbirth are more satisfied

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with their birth experiences and have greater feelings of control, even when unexpected complications occur. Studies to determine whether education for childbirth affects patient

results.

satisfaction, pain relief, length of labor, and frequency of complications have had conflicting

PTS: 1 DIF: Cognitive Level: Application REF: 188 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 20. The labor nurse is reviewing breathing techniques with a primipara admitted for induction of labor. When is the best time to encourage the laboring patient to use slow, deep chest breathing with contractions?

a. During labor, when she can no longer talk through contractions b. During the first stage of labor, when the contractions are 3 to 4 minutes apart c. Between contractions, during the transitional phase of the first stage of labor d. Between her efforts to push to facilitate relaxation between contractions ANS: A Focused breathing techniques should not be used in labor until they are actually needed, which is usually when the woman can no longer walk and talk during a contraction. If breathing techniques are used too early, the woman tends to move through the different techniques too quickly, and she may stop using them. In addition, the use of the more complex breathing

patterns in latent labor may increase fatigue. Women should be encouraged to adapt the techniques to their own comfort and needs. Breathing deeply between contractions or pushing

can increase the possibility of carbon dioxide retention and make the patient dizzy.

PTS: 1 DIF: Cognitive Level: Application REF: 191

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

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21. In a prenatal education class, the nurse is reviewing the importance of using relaxation techniques during labor. Which client statement will the nurse need to correct?

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a. We will practice relaxation techniques only in a quiet setting so I can focus. b. Relaxation is important during labor because it will help me conserve my energy.

c. If I relax in between contractions, my baby will get more oxygen during labor.

d. My partner and I will practice relaxation throughout the remainder of my pregnancy. ANS: A Relaxation exercises must be practiced frequently to be useful during labor. Couples begin practice sessions in a quiet, comfortable setting. Later, they practice in other places that simulate the noise and unfamiliar setting of the hospital. The ability to relax during labor is an important component of coping effectively with childbirth. Relaxation conserves energy, decreases oxygen

use, and enhances other pain relief techniques. Women learn exercises to help them recognize and release tension. The labor partner assists the woman by providing feedback during exercise sessions and labor. PTS: 1 DIF: Cognitive Level: Application REF: 189 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 22. The nurse assesses a patient in active labor and determines that the fetus is in the left occiput posterior position. The patient indicates to the nurse that she does not want an epidural. Which is the best technique for the nurse to include in the patients plan of care?

a. Effleurage b. Sacral pressure

c. Progressive relaxation

d. Rapid, paced breathing

ANS: B

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The fetus in the occiput posterior position will place pressure against the sacral area. Firm pressure against the sacral area may help relieve strain on the sacroiliac joint from a fetal occiput

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posterior position (often calledback labor). The partner begins to increase pressure on the sacrum as soon as the contraction begins. Effleurage is the slow massage of the abdomen; it does not focus on the sacral area. Progressive relaxation involves contracting and then consciously

releasing different muscle groups. The exercise is repeated throughout the body until all voluntary muscles are relaxed. It does not focus on the sacral area. Rapid, paced breathing

techniques are used during the transitional phase of labor and are not specifically focused on the sacral area.

PTS: 1 DIF: Cognitive Level: Analysis REF: 190 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE

23. The prenatal nurse educator is teaching couples the technique of using sacral pressure during labor. Which should be included in the teaching session? (Select all that apply.) a. The technique can be combined with heat to the area. b. A jiggling motion should be used while applying the pressure. c. Tennis balls may be used to apply the pressure to the sacral area. d. The pressure against the sacrum should be intermittent during the contraction. e. The hand may be moved slowly or remain positioned directly over the sacrum. ANS: A, C, E

Sacral pressure can be combined with thermal stimulation to increase effectiveness.

The hand may be moved slowly over the area or remain positioned directly over the sacrum, but pressure should be continuous and firm throughout the contraction. Care should be taken not to

jiggle the woman, which may be irritating.

PTS: 1 DIF: Cognitive Level: Application REF: 190

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OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Physiologic Integrity

24. A couple asks the nurse to explain the use of breathing techniques during the labor process.

Which should the nurse include in the response? (Select all that apply.)

a. Start to use the focused breathing as soon as labor begins. b. The use of complex breathing patterns should start during early labor. c. The breathing pattern chosen to use during labor should be practiced frequently. d. Focused or controlled breathing techniques are considered just one of many coping strategies. e. One helpful technique with breathing is to visualize oxygen entering on inhalation and tension leaving on exhalation. ANS: C, D, E

If a couple plans to use specific breathing patterns, the woman and her partner should practice the techniques frequently to gain comfort with them. If the woman has not practiced, they may not be helpful during labor. Although they were once the major focus of many classes, focused or controlled breathing techniques are now considered just one of many coping strategies used to enhance the womans ability to work with her labor during birth. While practicing relaxation techniques, the woman can picture oxygen entering her body to nourish her baby as she inhales and tension leaving each time she exhales. Use of the more complex breathing patterns in latent labor may increase fatigue. Focused breathing techniques should not be used in labor until they are actually needed, which is usually when the woman can no longer walk and talk during a

contraction.

Chapter 8: The Labor Process

MULTIPLE CHOICE

1. A new mother asks the nurse when the soft spot on her sons head will go away. The nurses

answer is based on the knowledge that the anterior fontanel closes after birth by:

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ANS: D

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a. 2 months. b.8 months. c. 12 months. d.18 months.

Feedback AThe larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. B The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. CThe larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. DThe anterior fontanel closes by 18 months after birth. DIF:Cognitive Level: KnowledgeREF:266 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 2. When assessing a woman in labor, the nurse is aware that the relationship of the fetal body parts to one another is called fetal:

a. Lie. b.Presentation. c. Attitude. d.Position. ANS: C Feedback ALie is the relation of the long axis (spine) of the fetus to the long axis (spine) of the mother. B Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. CAttitude is the relation of the fetal body parts to one another. DPosition is the relation of the presenting part to the four quadrants of the mothers pelvis.

DIF:Cognitive Level: KnowledgeREF:268

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 3. When assessing the fetus using Leopold maneuvers, the nurse feels a round, firm, movable

fetal part in the fundal portion of the uterus and a long, smooth surface in the mothers right side

close to midline. What is the likely position of the fetus?

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ANS: C

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a. ROA b.LSP c. RSA d.LOA

Feedback AFetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. B Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head,

indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. CThe fetus is positioned anteriorly in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. DFetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relation to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mothers right side denotes the location of the presenting part in the mothers pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. DIF:Cognitive Level: ComprehensionREF:269

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

4. The nurse has received a report about a woman in labor. The womans last vaginal examination

was recorded as 3 cm, 30%, and -2. The nurses interpretation of this assessment is that:

ANS: B

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a. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm above the ischial spines. b.The cervix is 3 cm dilated, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. c. The cervix is effaced 3 cm, it is dilated 30%, and the presenting part is 2 cm below the ischial spines. d.The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm below the ischial spines.

Feedback AThe sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. B This is the correct description of the vaginal examination for this woman in labor. CThe sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines.

DThe sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. DIF:Cognitive Level: ComprehensionREF:269 OBJ:Client Needs: Health Promotion and Maintenance TOP:Nursing Process: Assessment, Planning 5. Which position would the nurse suggest for second-stage labor if the pelvic outlet needs to be

increased?

a. Semirecumbent b.Sitting c. Squatting d.Side-lying ANS: C

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Feedback AKneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. B Kneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet. CThis position may help increase the pelvic outlet. DKneeling or squatting moves the uterus forward and aligns the fetus with the pelvic inlet; this can facilitate the second stage of labor by increasing the pelvic outlet.

DIF:Cognitive Level: ComprehensionREF:275

OBJ:Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Implementation 6. To adequately care for a laboring woman, the nurse should know which stage of labor varies the most in length? a. First b.Second c. Third

d.Fourth ANS: A Feedback AThe first stage of labor is considered to last from the onset of regular uterine contractions to full dilation of the cervix. The first stage is much longer than the second and third stages combined. In a first-time pregnancy, the first stage of labor can take up to 20 hours. B The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. CThe third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. DThe fourth stage of labor, recovery, lasts about 2 hours after delivery of the placenta.

DIF:Cognitive Level: KnowledgeREF:277

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

7. The nurse would expect which maternal cardiovascular finding during labor?

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a. Increased cardiac output b.Decreased pulse rate c. Decreased white blood cell (WBC) count d.Decreased blood pressure

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ANS: A

Feedback ADuring each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system. This increases cardiac output by about 10%, to 155, in the first stage of labor and by about 30% to 50% in the second stage. B The heart rate increases slightly during labor. CThe WBC count can increase during labor. DDuring the first stage of labor, uterine contractions cause systolic readings to increase by about 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg. DIF:Cognitive Level: ComprehensionREF:281 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis

8. The factors that affect the process of labor and birth, known commonly as the five Ps, include all except: a. Passenger. b.Passageway. c. Powers. d.Pressure. ANS: D

Feedback AThe five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. B The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. CThe five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. DPressure is not one of the five Ps. The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. DIF:Cognitive Level: KnowledgeREF:266

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OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 9. With regard to fetal positioning during labor, nurses should be aware that:

ANS: B

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a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal. b.Birth is imminent when the presenting part is at +4 to +5 cm, below the spine. c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter. d.Engagement is the term used to describe the beginning of labor.

Feedback APosition is the relation of the presenting part of the fetus to the four quadrants of the mothers pelvis; station is the measure of degree of descent. B The station of the presenting part should be noted at the beginning of labor so that the rate of descent can be determined. CThe largest diameter usually is the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. DEngagement often occurs in the weeks just before labor in nulliparas and before or during labor in multiparas.

DIF:Cognitive Level: KnowledgeREF:269 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 10. With regard to primary and secondary powers, the maternity nurse should know that: a. Primary powers are responsible for effacement and dilation of the cervix. b.Effacement generally is well ahead of dilation in women giving birth for the first time; they are closer together in time in subsequent pregnancies. c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation. d.Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

ANS: A

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Feedback AThe primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. B Effacement generally is well ahead of dilation in first-timers; they are closer together in time in subsequent pregnancies. CScarring of the cervix may slow dilation. DPushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so. DIF:Cognitive Level: KnowledgeREF:274

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OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 11. With regard to the position of the laboring woman, maternity nurses should be able to tell the

woman that:

a. The supine position commonly used in the United States increases blood flow. b.The all fours position, on her hands and knees, is hard on her back. c. Frequent changes in position will help relieve her fatigue and increase her comfort. d.In a sitting or squatting position her abdominal muscles will have to work harder. ANS: C Feedback ABlood flow can be compromised in the supine position; any upright position benefits cardiac output. B The all fours position is used to relieve backache in certain situations.

CFrequent position changes relieve fatigue, increase comfort, and improve circulation. DIn a sitting or squatting position the abdominal muscles work in greater harmony with uterine contractions. DIF:Cognitive Level: ComprehensionREF:275 OBJ:Client Needs: Health Promotion and Maintenance TOP:Nursing Process: Planning, Implementation 12. Which description of the four stages of labor is correct for both definition and duration?

a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b.Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third state: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer) d.Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

ANS: A

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Feedback AFull dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. B The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. CThe third stage extends from birth to expulsion of the placenta and usually takes a few minutes. DThe fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours). DIF:Cognitive Level: ComprehensionREF:277, 278

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis

13. With regard to the turns and other adjustments of the fetus during the birth process, known as the mechanism of labor, nurses should be aware that: a. The seven critical movements must progress in a more or less orderly sequence. b.Asynclitism sometimes is achieved by means of the Leopold maneuver. c. The effects of the forces determining descent are modified by the shape of the womans pelvis and the size of the fetal head. d.At birth the baby is said to achieve restitution (i.e., a return to the C-shape of the womb). ANS: C

Feedback AThe seven identifiable movements of the mechanism of labor occur in combinations simultaneously, not in precise sequences. B Asynclitism is the deflection of the babys head; the Leopold maneuver is a means of judging descent by palpating the mothers abdomen. CThe size of the maternal pelvis and the ability of the fetal head to mold also affect the process. DRestitution is the rotation of the babys head after the infant is born. DIF:Cognitive Level: ComprehensionREF:278 OBJ:Client Needs: Health Promotion and Maintenance TOP:Nursing Process: Planning, Implementation

14. To assess the health of the mother accurately during labor, the nurse should be aware that:

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a. The womans blood pressure will increase during contractions and fall back to prelabor normal between contractions. b.Use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. c. Having the woman point her toes will reduce leg cramps. d.The endogenous endorphins released during labor will raise the womans pain threshold and produce sedation. ANS: D

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Feedback ABlood pressure increases during contractions but remains somewhat elevated between them. B Use of the Valsalva maneuver is discouraged during second stage labor because of a number of possible unhealthy outcomes, including fetal hypoxia. CPointing the toes can cause leg cramps, as can the process of labor itself. DIn addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mothers perception of pain. DIF:Cognitive Level: ComprehensionREF:281 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning MULTIPLE RESPONSE 1. Signs that precede labor include (choose all that apply): a. Lightening.

b.Exhaustion. c. Bloody show. d.Rupture of membranes. e. Decreased fetal movement. ANS: A, C, D Feedback Correct Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Incorrect Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor.

DIF:Cognitive Level: ComprehensionREF:277 OBJ:Client Needs: Health Promotion and Maintenance

TOP:Nursing Process: Planning, Implementation

COMPLETION

1. The _________ pelvic shape is ideal for a vaginal birth.

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ANS:

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Gynecoid

The gynecoid pelvis is the classic female type ideally suited for a vaginal delivery. The android pelvis resembles that of the male. An anthropoid pelvis resembles that of anthropoid apes. The

fourth type of pelvis, the platypelloid is flat and not suited for vaginal birth.

Chapter 9: Pain Management during Labor and Birth MULTIPLE CHOICE 1. Childbirth preparation can be considered successful if the outcome is described as which of the following? a. Labor was pain-free.

b. The birth experiences of friends and families were ignored. c. Only nonpharmacologic methods for pain control were used. d. The client rehearsed labor and practiced skills to master pain. ANS: D Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a painfree labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realistic information about nonpharmacologic methods alone.

PTS: 1 DIF: Cognitive Level: Analysis REF: 281

labor pain. Women will not always achieve their desired level of pain control by using

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

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with opiate-dependent patients?

2. A woman with a known heroin habit is admitted in early labor. Which drug is contraindicated

a. Nalbuphine (Nubain)

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b. Hydroxyzine (Vistaril)

c. Promethazine (Phenergan)

ANS: A

d. Diphenhydramine (Benadryl)

Nalbuphine may precipitate withdrawal if given to an opiate-dependent woman. Hydroxyzine is an antihistamine with antiemetic effects. Promethazine usually relieves nausea and vomiting. Diphenhydramine is commonly used to relieve pruritus from epidural narcotics. PTS: 1 DIF: Cognitive Level: Understanding REF: 293 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

3. A client is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or do procedures? a. After the contraction is over b. When it is all right with the coach c. During increment of next contraction d. After administration of analgesic-anesthetic ANS: A

Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor

and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during

each contraction. An analgesic or anesthetic may cause adverse reactions in the woman,

preventing her from answering questions correctly.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 297

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Childbirth pain is different from other types of pain in that it is:

a. less intense.

b. associated with a physiologic process.

c. more responsive to pharmacologic management. d. designed to make one withdraw from the stimulus. ANS: B Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during

labor may affect the course and length of labor. The pain with childbirth is a normal process; it is not caused by the type of injury as when withdrawal from the stimulus occurs. PTS: 1 DIF: Cognitive Level: Understanding REF: 278 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. Excessive anxiety during labor heightens the clients sensitivity to pain by increasing: a. muscle tension. b. the pain threshold.

c. blood flow to the uterus. d. rest time between contractions.

ANS: A

Anxiety and fear increase muscle tension, diverting oxygenated blood to the womans brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and

reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can between contractions.

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decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets

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PTS: 1 DIF: Cognitive Level: Understanding REF: 280

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

6. Which fetal position may cause the laboring client more back discomfort? a. Left occiput anterior b. Left occiput posterior c. Right occiput anterior d. Right occiput transverse ANS: B

In the left occiput posterior position, each contraction pushes the fetal head against the mothers sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position. PTS: 1 DIF: Cognitive Level: Understanding REF: 280 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. A major advantage of nonpharmacologic pain management is that: a. a more rapid labor is likely.

c. the woman remains fully alert at all times.

d. there are no side effects or risks to the fetus.

b. more complete pain relief is possible.

ANS: D

Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or

anesthesia, it is harmless to the mother and the fetus. There is less pain relief with

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nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at

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a quicker pace. The womans alertness is not altered by medication, but the increase in pain will decrease alertness.

PTS: 1 DIF: Cognitive Level: Understanding REF: 281

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a. Latent phase b. Active phase c. Second stage d. Transition phase

ANS: A The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time. PTS: 1 DIF: Cognitive Level: Understanding REF: 282

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 9. The primary side effect of maternal narcotic analgesia in the newborn is:

c. acrocyanosis.

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d. respiratory depression.

b. bradycardia.

a. tachypnea.

ANS: D

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An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase.

Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected

finding in a newborn and is not related to maternal analgesics. PTS: 1 DIF: Cognitive Level: Understanding REF: 293 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 10. A client received 25 mg of meperidine (Demerol) intravenously 1 hour before birth. Which drug should the nurse have readily available?

a. Naloxone (Narcan) b. Butorphanol (Stadol) c. Nalbuphine (Nubain) d. Promethazine (Phenergan) ANS: A Naloxone (Narcan) reverses narcotic-induced respiratory depression, which may occur with the administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol

PTS: 1 DIF: Cognitive Level: Application REF: 294

are analgesics given to women in labor.

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

11. The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n):

b. epidural. c. pudendal.

ANS: C

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d. spinal block.

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a. local.

A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an

episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs. PTS: 1 DIF: Cognitive Level: Understanding REF: 295 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

12. A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session? a. It usually results in a more rapid labor. b. It has no effect on the outcome of labor. c. It is considered to be a normal occurrence. d. It may result in decreased placental perfusion. ANS: D When experiencing excessive pain, the woman may react with a stress response that diverts

blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause

and the effect on the woman. Pain is considered normal for labor. However, excessive pain may

be an indication of other problems and must be assessed.

PTS: 1 DIF: Cognitive Level: Application REF: 279

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OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

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13. Which client will most likely have increased anxiety and tension during labor? a. Gravida 2 who refused any medication

b. Gravida 2 who delivered a stillborn baby last year

c. Gravida 1 who did not attend prepared childbirth classes d. Gravida 3 who has two children younger than 3 years ANS: B If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what

to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect. PTS: 1 DIF: Cognitive Level: Analysis REF: 280 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 14. Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? a. Narcotics

b. Spinal block c. Epidural anesthesia

d. Breathing and relaxation techniques

ANS: D

Nonpharmacologic methods of pain management may be the best option for a woman in

advanced labor. At 8 cm cervical dilation there probably not enough time remaining to

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administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn.

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PTS: 1 DIF: Cognitive Level: Application REF: 297

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

15. A laboring client who imagines her body opening to let the baby out is using a mental technique called: a. imagery. b. effleurage. c. distraction. d. dissociation. ANS: A

Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working. PTS: 1 DIF: Cognitive Level: Understanding REF: 283 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 16. When giving a narcotic to a laboring client, which statement explains why the nurse should

a. The medication will be rapidly circulated. b. Less medication will be transferred to the fetus.

inject the medication at the beginning of a contraction?

c. The maternal vital signs will not be adversely affected.

d. Full benefit of the medication is received during that contraction.

ANS: B

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Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter

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the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus.

PTS: 1 DIF: Cognitive Level: Application REF: 293, 294

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. The method of anesthesia in labor that is considered the safest for the fetus is: a. epidural block. b. pudendal block. c. local infiltration.

d. spinal (subarachnoid) block. ANS: C Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension. PTS: 1 DIF: Cognitive Level: Understanding REF: 295 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should:

b. turn the woman to the right side.

a. give the woman oxygen.

c. decrease the intravenous infusion rate.

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d. place a wedge under the womans right hip. ANS: D

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Tilting the womans pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine

position for proper dispersal of the medication. However, placing a wedge under the hip will

relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension. PTS: 1 DIF: Cognitive Level: Application REF: 286 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

19. Which clinical effect can occur in the presence of increased maternal pain perception during labor? a. Increase in uterine contractions in response to catecholamine secretion b. Decrease in blood pressure in response to alpha receptors c. Decreased perfusion to the placenta in response to catecholamine secretion d. Increased uterine blood flow, causing increase in maternal blood pressure ANS: C Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A

decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an

increase in maternal blood pressure.

OBJ: Nursing Process Step: Assessment

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

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MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

client?

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20. Which of the following factors would affect pain perception or tolerance for the laboring

a. Right occiput posterior fetal position during labor

b. Bishop score of 10 prior to the induction of labor

c. Gynecoid pelvis

d. Absence of Fergusons reflex ANS: A A fetus in the posterior position during labor can cause increased back pain to the mother because it is spine against spine. A Bishop score of 10 indicates that conditions are favorable for induction; the cervix is soft, anterior, effaced, and dilated and the presenting part is engaged. A

gynecoid pelvic structure is considered to be an adequate passage for vaginal birth. Fergusons reflex occurs when a contraction is stimulated as a result of vaginal stimulation. PTS: 1 DIF: Cognitive Level: Analysis REF: 280 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 21. A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority

intervention should be done by the nurse to help evaluate clinical response to treatment? a. Obtain a pain scale response from the client based on a 0 to 10 scale.

b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations.

c. Document intake and output on the electronic health record (EHR).

d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.

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ANS: B

Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based

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practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic

pain clients. Intake and output should be documented as part of the clinical record but is not the

priority intervention based on this clients situation. Increasing the flow rate of parenteral fluids requires a physicians order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess. PTS: 1 DIF: Cognitive Level: Analysis REF: 285 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

22. The process of labor places significant metabolic demands on the obstetric client. Which physiologic findings would be expected? a. Decreased maternal blood pressure as a result of stimulation of alpha receptors b. Uterine vasoconstriction as a result of stimulation of beta receptors c. Increased maternal demand for oxygen d. Increased blood flow to placenta because of catecholamine release ANS: C With regard to labor, one would expect to see an increase in maternal blood pressure because of

stimulation of alpha receptors. Uterine vasoconstriction would occur in response to stimulation of alpha receptors. One would expect to see a decrease in blood flow to the placenta. The

maternal metabolic rate is increased during labor, along with an increase in maternal demand for

oxygen.

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

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OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

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23. A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which

medication does the nurse anticipate would be required in the birth room for administration? a. Oxytocin (Pitocin) b. Naloxone (Narcan) c. Bromocriptine (Parlodel) d. Oxygen ANS: B

Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression. PTS: 1 DIF: Cognitive Level: Analysis REF: 291

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

24. Which statement is true with regard to the type of pain associated with childbirth experience?

a. Pain is constant throughout the labor experience.

b. Labor pain during childbirth is considered to be an abnormal response.

c. Pain associated with childbirth is self-limiting.

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d. Pain associated with childbirth does not allow for adequate preparation.

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ANS: C

The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a

normal response during childbirth. Pregnant woman can prepare for the expected pain of

childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 278 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

25. A pregnant woman is in the second stage of labor and is actively pushing. What type of pain would she be most likely to experience? a. Deep, poorly localized pain b. Visceral pain c. Slow, dull, aching pain d. Somatic pain ANS: D Somatic pain is quick, sharp, and precisely localized and is seen during the second stage of labor.

Deep, poorly localized pain is associated with visceral pain, which predominates during the first stage of labor. Visceral pain is slow, deep, dull, aching, and poorly localized. Slow, dull, aching

pain is characteristic of visceral pain.

OBJ: Nursing Process Step: Assessment

PTS: 1 DIF: Cognitive Level: Analysis REF: 279

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MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 26. A client in labor reports a feeling of burning pain during the second stage of labor. This type

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of pain is associated with: a. visceral pain.

b. tissue ischemia.

c. somatic pain.

d. cervical dilation. ANS: C This is an example of somatic pain experienced as a result of distention of the vagina and perineum during the second stage of labor. Visceral pain occurs in response to pressure on pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the uterus.

The pain of cervical dilation is a major pain source during labor but, during the second stage of labor, the client is already fully dilated so this would not be a factor. PTS: 1 DIF: Cognitive Level: Analysis REF: 279 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 27. Which of the following clients could be a candidate for a vaginal birth after cesarean section (VBAC)?

a. A 32-year-old gravida 2, para 1, who had a primary cesarean section for fetal distress

b. A 23-year-old gravida 3, para 2, who had two cesarean sections with classic incisions

c. An 18-year-old gravida 3, para 2, who had cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively

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d. A 25-year-old gravida 1, para 0, who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth

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ANS: A

VBAC can be done if the need for the primary cesarean section was based on factors other than

cephalopelvic disproportion (CPD) and macrosomia. A client who has had a prior classic incision into the uterus is not a candidate for this type of procedure. Based on the presented

history of a cesarean section for labor dystocia during second stage with birth of newborns who weighed 8 pounds 10 ounces, and 9 pounds, respectively, this client is at risk for uterine rupture and for delivering another macrosomic infant because she has already had two cesarean sections for the same indications. A client who wants to have a scheduled cesarean section rather than go through the process of labor because she is very fearful of the pain associated with childbirth is not a candidate for a VBAC because she does not meet the clinical criteria.

Chapter 10: Nursing Care during Labor and Birth

MULTIPLE CHOICE 1. The nurse is preparing to perform Leopolds maneuvers. Why are Leopolds maneuvers used by practitioners? a. To determine the status of the membranes b. To determine cervical dilation and effacement c. To determine the best location to assess the fetal heart rate d. To determine whether the fetus is in the posterior position

ANS: C Leopolds maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be

performed to determine the status of the fetal membranes. Dilation and effacement are best

determined by vaginal examination. Assessment of fetal position is more accurate with vaginal

examination.

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PTS: 1 DIF: Cognitive Level: Application REF: 227

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

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2. Which comfort measure should a nurse use to assist a laboring woman to relax? a. Recommend frequent position changes.

b. Palpate her filling bladder every 15 minutes.

c. Offer warm wet cloths to use on the clients face and neck. d. Keep the room lights lit so the client and her coach can see everything. ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours. Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

PTS: 1 DIF: Cognitive Level: Application REF: 236 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 3. Which assessment finding could indicate hemorrhage in the postpartum patient? a. Elevated pulse rate b. Elevated blood pressure c. Firm fundus at the midline

d. Saturation of two perineal pads in 4 hours

ANS: A

An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were

diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad

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within normal limits.

within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is

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PTS: 1 DIF: Cognitive Level: Analysis REF: 224 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

4. Which is an essential part of nursing care for a laboring client?

a. Helping the woman manage the pain b. Eliminating the pain associated with labor c. Feeling comfortable with the predictable nature of intrapartal care d. Sharing personal experiences regarding labor and birth to decrease her anxiety ANS: A

Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority. PTS: 1 DIF: Cognitive Level: Application REF: 220 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 5. A client at 40 weeks gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:

a. fetal movement.

c. a trickle of fluid from the vagina.

d. thick pink or dark red vaginal mucus.

b. irregular contractions for 1 hour.

ANS: C

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A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment.

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Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Application REF: 221 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 6. Which client at term should go to the hospital or birth center the soonest after labor begins? a. Gravida 2, para 1, who lives 10 minutes away b. Gravida 1, para 0, who lives 40 minutes away

c. Gravida 2, para 1, whose first labor lasted 16 hours d. Gravida 3, para 2, whose longest previous labor was 4 hours ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor. her first labor was 16 hours.

PTS: 1 DIF: Cognitive Level: Analysis REF: 221

The gravida 2 would be expected to have a longer labor than the gravida 3, especially because

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Safe and Effective Care Environment

assessments are:

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7. A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing

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a. contraction pattern, amount of discomfort, and pregnancy history. b. fetal heart rate, maternal vital signs, and the womans nearness to birth.

c. last food intake, when labor began, and cultural practices the couple desires.

d. identification of ruptured membranes, the womans gravida and para, and her support person. ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple

desires is an assessment that can occur later in the admission process, if time permits. Identification of ruptured membranes, the womans gravida and para, and her support person are assessments that can occur later in the admission process if time permits. PTS: 1 DIF: Cognitive Level: Application REF: 222 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from

admission). Membranes are intact. The nurse should expect the client to be: a. discharged home with a sedative.

c. admitted and prepared for a cesarean birth.

b. admitted for extended observation.

d. discharged home to await the onset of true labor.

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ANS: D

The situation describes a client with normal assessments who is probably in false labor and will

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probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false

labor without fetal distress. There is no indication that a cesarean birth is indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate? a. Inform the mother that the rate is normal. b. Reassess the fetal heart rate in 5 minutes because the rate is too high.

c. Report the fetal heart rate to the physician or nurse-midwife immediately. d. Tell the mother that she is going to have a boy because the heart rate is fast. ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 235 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

10. Which should the nurse recognize as being associated with fetal compromise?

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b. Fetal heart rate in the 140s

a. Active fetal movements

c. Contractions lasting 90 seconds

ANS: D

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d. Meconium-stained amniotic fluid

When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of

meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow. PTS: 1 DIF: Cognitive Level: Application REF: 235 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

a. Every 15 minutes b. Every 30 minutes c. Every 45 minutes d. Every 1 hour ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent frequent enough to monitor for complications.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 231

enough to monitor for complications. 1-hour assessments during the active phase of labor are not

MSC: Client Needs: Physiologic Integrity

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12. Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth?

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a. Bloody mucous discharge increases.

b. The vulva bulges and encircles the fetal head.

c. The membranes rupture during a contraction.

d. The fetal head is felt at 0 station during the vaginal examination. ANS: B

A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

PTS: 1 DIF: Cognitive Level: Analysis REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 13. During labor a vaginal examination should be performed only when necessary because of the risk of: a. infection. b. fetal injury. c. discomfort.

d. perineal trauma. ANS: A

Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward

toward the uterus. Properly performed vaginal examinations should not cause fetal injury. Vaginal examinations may be uncomfortable for some women in labor, but that is not the main

reason for limiting them. A properly performed vaginal examination should not cause perineal

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trauma.

PTS: 1 DIF: Cognitive Level: Understanding REF: 231, 233

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 14. A 25-year-old primigravida client is in the first stage of labor. She and her husband have

been holding hands and breathing together through each contraction. Suddenly, the client pushes

her husbands hand away and shouts, Dont touch me! This behavior is most likely: a. abnormal labor. b. a sign that she needs analgesia. c. normal and related to hyperventilation. d. common during the transition phase of labor. ANS: D

The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis. PTS: 1 DIF: Cognitive Level: Application REF: 223 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 15. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk

is pink, but the hands and feet are blue. The Apgar score for this infant is: a. 7.

b. 8.

c. 9.

d. 10.

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ANS: C

The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue

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hands and feet. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this

category is given a grade of 1. The infant had 1 point deducted because of the blue color of the

hands and feet.

PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 16. If a womans fundus is soft 30 minutes after birth, the nurses first response should be to: a. massage the fundus. b. take the blood pressure.

c. notify the physician or nurse-midwife. d. place the woman in Trendelenburg position. ANS: A The nurses first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not and produce further bleeding.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 249

allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot

MSC: Client Needs: Physiologic Integrity

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17. The nurse thoroughly dries the infant immediately after birth primarily to: a. reduce heat loss from evaporation.

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b. stimulate crying and lung expansion.

c. increase blood supply to the hands and feet.

ANS: A

d. remove maternal blood from the skin surface.

Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss. Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood. PTS: 1 DIF: Cognitive Level: Understanding REF: 248

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 18. The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take? a. Request a social service consult for psychosocial support. b. Observe for other signs that the mother may not be accepting of the infant. c. Document this evidence of normal early maternal-infant attachment behavior.

d. Determine whether the mother is too fatigued to interact normally with her infant.

ANS: C

Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that

a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother

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may be fatigued but is interacting with the infant in an expected manner.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 251 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity

19. Which nursing diagnosis would take priority in the care of a primipara client with no visible

support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?

a. Fluid volume deficit (FVD) related to fluid loss during labor and birth process b. Fatigue related to length of labor requiring increased energy expenditure c. Acute pain related to increased intensity of contractions d. Anxiety related to imminent birth process ANS: D

A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of

OBJ: Nursing Process Step: Nursing Diagnosis

PTS: 1 DIF: Cognitive Level: Analysis REF: 244

imminent birth.

MSC: Client Needs: Psychosocial Integrity

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injury in a client who is in labor?

20. Which of the following behaviors would be applicable to a nursing diagnosis of risk for

a. Length of second-stage labor is 2 hours.

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b. Client has received an epidural for pain control during the labor process. c. Client is using breathing techniques during contractions to maximize pain relief.

d. Client is receiving parenteral fluids during the course of labor to maintain hydration. ANS: B

A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

PTS: 1 DIF: Cognitive Level: Application REF: 244 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Safe and Effective Care Environment/Management of Care 21. A gravida 1, para 0, 38 weeks gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, 1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?

a. Performing more frequent vaginal exams will not make the labor go any quicker.

b. Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection. c. Tell the client that she will check every 30 minutes.

d. Medicate the client as needed for anxiety so that the labor can progress.

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ANS: B

Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has

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increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address clients anxiety. Telling the client that the nurse will continue checking every 30

minutes without adequate clinical indication is not the standard of care. Medicating the client is

not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 231, 233 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care 22. When using the second Leopolds maneuver in fetal assessment, the nurse would palpate (the): a. both sides of the maternal abdomen. b. lower abdomen above the symphysis pubis. c. both upper quadrants of the maternal abdomen . d. lower abdomen for flexion of the presenting part.

ANS: A

The second Leopolds maneuver involves determining the location of the fetal back and is

performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above

the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is

the fourth maneuver.

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PTS: 1 DIF: Cognitive Level: Application REF: 230, 231

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

23. A nursing priority during admission of a laboring client who has not had prenatal care is: a. obtaining admission labs. b. identifying labor risk factors. c. discussing her birth plan choices. d. explaining importance of prenatal care. ANS: B

When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patients history has been completed. PTS: 1 DIF: Cognitive Level: Analysis REF: 223 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity 24. The nurse has given the newborn an Apgar score of 5. She should then: a. begin ventilation and compressions.

b. do nothing except place the infant under a radiant warmer. c. observe the infant and recheck the score after 10 minutes.

d. gently stimulate by rubbing the infants back while administering O 2. ANS: D

An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation.

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An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing

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and rechecking the infant will not improve newborns transition to extrauterine life. PTS: 1 DIF: Cognitive Level: Application REF: 249

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 25. The client in labor experiences a spontaneous rupture of membranes. What information related to this event must the nurse include in the clients record? a. Fetal heart rate b. Pain level c. Test results ensuring that the fluid is not urine

d. The clients understanding of the event ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The clients understanding of the event would only need to be documented if it presents a problem. PTS: 1 DIF: Cognitive Level: Understanding REF: 222

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

26. At 5 minutes after birth, the nurse assesses that the neonates heart rate is 96 bpm, respirations

are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are

brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign? a. 7

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b. 8

d. 10

ANS: B

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c. 9

The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8. PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

27. The gynecologist performs an amniotomy. What will the nurses role include immediately following the procedure? a. Assessing for ballottement b. Conducting a pH and/or fern test c. Labeling of specimens for chromosomal analysis d. Recording the character and amount of amniotic fluid ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important

to note and record the character and amount of amniotic fluid following this procedure. Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because

an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a

specimen for chromosomal analysis.

PTS: 1 DIF: Cognitive Level: Understanding REF: 229

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OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential

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28. The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

a. Bloody

b. Clear with bits of vernix caseosa c. Green and thick d. Yellow and cloudy with foul odor ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium.

Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation. PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential 29. The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?

b. To assess for Goodells sign

d. To determine strength of contractions

c. To determine cervical dilation and effacement

a. To apply internal monitoring electrodes

ANS: C

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The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodells sign is assessed in early pregnancy, not during labor. Although application of monitoring electrodes is done by entering the vagina, it is not the contractions.

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primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of

PTS: 1 DIF: Cognitive Level: Knowledge REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct? a. Obtain a fetal heart rate. b. Determine the estimated due date.

c. Auscultate anterior and posterior breath sounds. d. Ask the client when she last had something to eat. ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and painlocation, intensity, factors that intensify or relieve,

duration, whether constant or intermittent, and whether the pain is acceptable to the woman. Generally, women of childbearing years are healthy and auscultation of lung sounds can be

delayed until the initial intake assessment has been completed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 227

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

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31. The health care provider has asked the nurse to prepare for an amniotomy. What is the nurses priority action with this procedure?

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a. Perform Leopolds maneuvers.

b. Determine the color of the amniotic fluid.

c. Assess the fetal heart rate immediately after the procedure.

d. Prepare the patient for a change in her pain level after the procedure. ANS: C

An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopolds maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal

status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 229 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient? a. 18-gauge

b. 20-gauge c. 22-gauge

d. 24-gauge ANS: A

The larger the number, the smaller the diameter of the cannula. The nurse should select the

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largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily

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accomplished with a large bore cannula.

PTS: 1 DIF: Cognitive Level: Understanding REF: 229

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 33. The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter? a. Place the catheter as quickly as possible. b. Place a small pillow under the patients left hip. c. Omit the use of a cleansing agent, such as Betadine. d. Set up the catheter tray before positioning the patient.

ANS: B To promote placental function, the nurse can place a small pillow or rolled blanket under the patients left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care. PTS: 1 DIF: Cognitive Level: Analysis REF: 235

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

34. The nurse examines a primiparas cervix at 8-9/100%/+2; it is tight against the fetal head. The

a. Palpate her bladder for fullness.

patient reports a strong urge to bear down. What is the nurses priority action?

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b. Assess the frequency and duration of her contractions. c. Determine who will stay with the patient for the birth.

ANS: D

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d. Encourage the patient to exhale in short breaths with contractions.

Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause

cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patients urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds. Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

PTS: 1 DIF: Cognitive Level: Analysis REF: 237 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 35. The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the babys head? a. Expulsion b. Restitution

c. Internal rotation d. External rotation

ANS: B

After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior

diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal

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rotation occurs prior to birth of the head.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 247 OBJ: Nursing Process Step: Planning MSC: Client needs: Health Promotion and Maintenance

36. The nurse is performing Leopolds maneuvers on a client. Which figure depicts the Leopolds

maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis. Refer to Figures a to d. a. b. c. d. ANS: C

The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is done by palpating the suprapubic area. Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, the grasping movement of the fingers moves it upward in the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus. Palpating the uterine fundus distinguishes between a cephalic and breech presentation. Holding the left hand steady on one side of the uterus while palpating the opposite side of the uterus determines on which side of the uterus is the fetal back and on which side are the fetal arms and legs. Placing your hands on each side of the uterus with fingers pointed toward the inlet determines

PTS: 1 DIF: Cognitive Level: Analysis REF: 230

MULTIPLE RESPONSE

MSC: Client Needs: Physiologic Integrity

OBJ: Nursing Process Step: Implementation

whether the head is flexed (vertex) or extended (face).

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37. A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the

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following? (Select all that apply.) a. Less maternal fatigue

b. Less birth canal injuries

c. Decreased pushing time

d. Faster descent of the fetus e. An increase in frequency of contractions ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time. Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed

spontaneously and in response to her bodys signals. A brief slowing of contractions often occurs at the beginning of the second stage. PTS: 1 DIF: Cognitive Level: Analysis REF: 238 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 38. Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.) a. Place the infant covered with blankets in the radiant warmer.

c. Place stockinette cap on infants head. d. Bathe the newborn within 30 minutes of birth.

e. Remove wet linen as needed.

b. Dry the infant off with sterile towels.

ANS: B, C, E

Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are

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aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing

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a cap on the infants head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for

at least a few hours so that the newborn temperature can stabilize during the transition period.

PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care 39. When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.)

a. Check the DTR each shift. b. Monitor and record vital signs frequently during the course of labor. c. Document the FHR pattern, noting baseline and response to contraction patterns. d. Indicate on the EFM tracing when maternal position changes are done. e. Provide food, as tolerated, during the course of labor. ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for

assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because

the introduction of food may lead to nausea and vomiting in response to the labor process and

might affect the mode of birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 229

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OBJ: Nursing Process Step: Implementation

Care

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MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn

40. Which interventions are required following an amniotomy procedure? (Select all that apply.) a. Notation related to amount of fluid expelled

b. Color and consistency of fluid c. Fetal heart rate d. Maternal blood pressure e. Maternal heart rate ANS: A, B, C

Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required. PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 41. The nurse is monitoring a client in the active stage of labor. Which conditions associated

with fetal compromise should the nurse monitor? (Select all that apply.) a. Maternal hypotension

c. Meconium-stained amniotic fluid

d. Maternal fever38 C (100.4 F) or higher

b. Fetal heart rate of 140 to 150 bpm

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ANS: A, C, D

e. Complete uterine relaxation of more than 30 seconds between contractions

Conditions associated with fetal compromise include maternal hypotension (may divert blood

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flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38 C [100.4 F] or higher). Fetal

finding.

heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal

PTS: 1 DIF: Cognitive Level: Analysis REF: 234 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 42. The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.) a. Soft boggy uterus

b. Maternal temperature of 99 F c. High uterine fundus displaced to the right d. Intense vaginal pain unrelieved by analgesics e. Half of a lochia pad saturated in the first hour after birth ANS: A, C, D Assessment findings that may indicate a potential complication in the fourth stage include a soft boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the expected amounts.

PTS: 1 DIF: Cognitive Level: Analysis REF: 249

inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

SHORT ANSWER

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43. The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should

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prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places.

ANS:

_____ mL

0.75

Use the medication calculation formula to calculate the correct dose: Desired/available volume = milliliters per dose (0.3 mg/0.4 mg) 1 mL = 0.75 mL/dose

Chapter 11: Assisted Delivery and Cesarean Birth MULTIPLE CHOICE 1. A postpartum client overhears the nurse tell the health care provider that she has a positive Homans sign and asks what it means. Which is the nurses best response? a. You have pitting edema in your ankles. b. You have deep tendon reflexes rated 2+. c. You have calf pain when the nurse flexes your foot.

d. You have a fleshy odor to your vaginal drainage.

ANS: C

Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis.

Edema is within normal limits for the first few days until the excess interstitial fluid is

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odor, is within normal limits.

remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul

PTS: 1 DIF: Cognitive Level: Application REF: 338

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OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

2. Which client would be most likely to have severe afterbirth pains and request a narcotic

analgesic?

The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse. PTS: 1 DIF: Cognitive Level: Understanding REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 3. Which maternal event is abnormal in the early postpartal period?

a. Diuresis and diaphoresis

c. Extreme hunger and thirst

d. Lochial color changes from rubra to alba

b. Flatulence and constipation

ANS: D

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For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased

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plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum.

The new mother is hungry because of energy used in labor and thirsty because of fluid

restrictions during labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus.

c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus. ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours

PTS: 1 DIF: Cognitive Level: Application REF: 329

postpartum, but is still appropriate.

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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a. Document the finding.

which action should the nurse take?

5. If the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day,

b. Tell the health care provider.

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c. Begin antibiotic therapy immediately.

d. Have the laboratory draw blood for reanalysis.

ANS: A

An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. Because this is a normal finding, there is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated. PTS: 1 DIF: Cognitive Level: Application REF: 331 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 6. Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection ANS: D

Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no

correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after

the birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 332

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

response?

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7. A postpartum client asks, Will these stretch marks go away? Which is the nurses best

a. No, never.

b. Yes, eventually.

c. They will fade to silvery lines but wont disappear completely. d. They will continue to fade and should be gone by your 6-week checkup. ANS: C Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.

PTS: 1 DIF: Cognitive Level: Application REF: 333 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after birth because of: a. increased estrogen. b. increased progesterone.

d. decreased melanocyte-stimulating hormone.

ANS: D

c. decreased human placental lactogen.

Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth.

Progesterone levels decrease after birth. Human placental lactogen production continues to aid in

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lactation. However, it does not affect pigmentation.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 332 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. If the fundus is palpated on the right side of the abdomen above the expected level, the nurse

should suspect that the client has which? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus ANS: A

The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus. PTS: 1 DIF: Cognitive Level: Understanding REF: 340 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 10. The Centers for Disease Control and Prevention (CDC) recommends the use of which personal protective equipment with which the nurse is likely to come into contact? a. Any body fluids

b. Any client at any time

d. Any client suspected of being HIV-positive

c. Blood and blood products

ANS: C

Possible contamination of medical personnel can result from contact with blood, blood products,

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and only certain body fluids. Only certain body fluids can cause contamination. It is not necessary to wear protective equipment continually with all clients. Protective equipment is

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important with a client if the nurse is at risk for contamination with blood or certain body fluids. The equipment does not have to be worn with casual contact.

PTS: 1 DIF: Cognitive Level: Understanding REF: 334

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment 11. Rho(D) immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive

d. Mother Rh-positive, baby Rh-negative ANS: A An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mothers blood, not the

PTS: 1 DIF: Cognitive Level: Analysis REF: 334

infants.

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

be included?

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a. No specific instructions

12. If rubella vaccine is indicated for a postpartum client, which instructions to the client should

b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection

ANS: D

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d. Explanation of the risks of becoming pregnant within 28 days following injection

Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 334 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 13. Which is the best measure to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing abdominal muscles ANS: C

Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs, but do not prevent it. Carbonated beverages

may increase distention. Ambulation is the best prevention.

PTS: 1 DIF: Cognitive Level: Application REF: 342, 343

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

involution process?

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14. Which documentation in the clients chart on the 14th postpartum day indicates a normal

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a. Breasts firm and tender

b. Episiotomy slightly red and puffy

c. Moderate bright red lochial flow

d. Fundus below the symphysis and not palpable ANS: D

The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa. PTS: 1 DIF: Cognitive Level: Understanding REF: 329

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 15. To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

ANS: D Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged.

Assessing lochial flow is not adequate; the fundus also needs to be checked. PTS: 1 DIF: Cognitive Level: Application REF: 336

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

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16. The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount?

a. Saturated peripad

b. 4- to 6-inch stain on the peripad c. 1- to 4-inch stain on the peripad d. Less than a 1-inch stain on the peripad ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels:

Scantless than a 1-inch stain on the peripad Light1- to 4-inch stain Moderate4- to 6-inch stain Heavysaturated peripad Excessivesaturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for surgery.

PTS: 1 DIF: Cognitive Level: Analysis REF: 330

women who have had a cesarean birth because some of the endometrial lining is removed during

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 17. The postpartum nurse has completed discharge teaching for a client being discharged after an

uncomplicated vaginal birth. Which statement by the client indicates that further teaching is

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needed?

a. I may not have a bowel movement until the 2nd postpartum day.

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b. If I breastfeed and supplement with formula, I wont need any birth control. c. I know my normal pattern of bowel elimination wont return until about 8 to 10 days.

d. If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband. ANS: B

For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs

within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 333 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 18. The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50

b. Temperature of 38 C (100.4 F) c. Firm fundus, but excessive lochia

d. Lightheaded when moving from a lying to standing position

ANS: C

Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal.

The health care provider must be notified so that lacerations can be located and repaired.

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Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature

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of up to 38 C (100.4 F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman

moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or

lightheaded or to faint when they stand. PTS: 1 DIF: Cognitive Level: Application REF: 337 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

19. The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a. Decrease IV fluid rate. b. Document the finding. c. Encourage the use of an incentive spirometer. d. Ambulate the client around the nurses station. ANS: C

Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the

reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse

should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses station should not be done

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at this time.

PTS: 1 DIF: Cognitive Level: Application REF: 342

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OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

20. Which of the following would indicate an abnormal finding during the postpartum period? a. Lochia flow changing from alba to rubra b. Unable to palpate uterine fundus at 6-week postpartum checkup c. Presence of afterbirth pains d. Lochia flow heavier in the early morning 2 days following vaginal birth ANS: A

Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding. The uterine fundus should no longer be palpable at 2 weeks postbirth. Afterbirth pains during the postpartum period are a normal finding based on involution of the uterus. Lochia flow may be heavier on arising because of the effects of gravity and pooling of blood while recumbent. PTS: 1 DIF: Cognitive Level: Analysis REF: 329, 330 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

21. Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history?

a. Client has not been pregnant.

b. Client has had a C section as a method of birth.

c. Client has been treated for an STD with resultant scarring of the cervix.

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d. Client has a history of pregnancy. ANS: D

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With pregnancy, the cervix becomes slitlike in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth. Treatment of STD is

not associated with cervical changes.

PTS: 1 DIF: Cognitive Level: Application REF: 330 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 22. To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a. Have the client drink carbonated beverages to promote urinary excretion.

b. Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the client to do pelvic floor exercises to combat potential stress incontinence. ANS: D Educating the client to use pelvic floor exercises will help strengthen pelvic muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the client is at greater risk for dehydration and thus should increase fluids.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 332

Limitation of fluids is not warranted during the postpartum period.

MSC: Client Needs: Health Promotion and Maintenance

23. In which area should the nurse expect that the postbirth care of a cesarean section will differ

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from that of a vaginal birth?

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a. Quantity of lochia rubra

b. Pain management techniques

c. Frequency of vital signs and fundal checks

d. Assessment of infection risk from loss of skin integrity ANS: B

A cesarean section is major surgery. Pain relief is provided in various ways, including patientcontrolled analgesia and oral and intramuscular analgesics. Postvaginal birth pain is managed with oral analgesic combinations that include acetaminophen; the quantity of lochia, frequency of vital signs, and fundal checks and assessment of infection risk are the same for both types of birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 341 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 24. When assessing the A of the acronym REEDA, the nurse should assess the: a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other

letters of the acronym refer to other components of wound assessment: R = redness, E = edema,

E = ecchymosis, and D = drainage.

PTS: 1 DIF: Cognitive Level: Application REF: 337

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

intervention?

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25. Which assessment finding 24 hours after vaginal birth would indicate a need for further

a. Pain level 5 on scale of 0 to 10

b. Saturated pad over a 2-hour period

c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus ANS: D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client.

PTS: 1 DIF: Cognitive Level: Analysis REF: 336 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity 26. The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots.

d. Document the finding in the patients chart.

ANS: D

The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs

approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately

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further action is needed.

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the level of the umbilicus. This finding is expected and can be followed with documentation. No

PTS: 1 DIF: Cognitive Level: Application REF: 329

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

27. The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider.

d. Document the finding in the patients chart. ANS: C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

PTS: 1 DIF: Cognitive Level: Analysis REF: 330

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 28. The nurse includes the addition of ice sitz baths for the postpartum patient. Which

assessment finding indicates the treatment has been effective?

a. No swelling or edema to the perineal area

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b. Patient complains that the sitz bath is too cold

c. Patient reports she took two sitz baths in 12 hours

ANS: A

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d. Edges of the perineal laceration are well approximated

Sitz baths may be offered two to four times a day to women with episiotomies, painful

hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma. PTS: 1 DIF: Cognitive Level: Evaluating REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

29. The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment? a. Check for edema. b. Check for range of motion. c. Check for adequate reflexes. d. Check for deep vein thrombosis. ANS: D Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may

indicate deep vein thrombosis. Edema is checked by palpating and pressing on the top of the foot, range of motion is not a postpartum assessment, and reflexes are checked at the patellar

area.

PTS: 1 DIF: Cognitive Level: Analysis REF: 338

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MULTIPLE RESPONSE

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

30. Which vaccinations are indicated for the postpartum client if she does not have immunity?

a. Pertussis

b. Rubella

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(Select all that apply.)

c. Diphtheria, tetanus (Tdap) d. RhoGAM ANS: A, B, C If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results.

PTS: 1 DIF: Cognitive Level: Application REF: 335 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 31. The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a. I will gently pat the perineum dry rather than wipe. b. I will only use the perineal bottle after bowel movements. c. I will use cold water in the perineal bottle as I cleanse.

d. I will use the perineal bottle without touching the perineum.

ANS: A, D

The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel

movement. Therefore, cold water should not be used; perineal care should be performed after

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voiding and after bowel movements.

PTS: 1 DIF: Cognitive Level: Analysis REF: 339

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is planning comfort measures to implement for a client after a vaginal birth. Which

measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas ANS: A, C, D

Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

Chapter 12: The Postpartum Woman

MULTIPLE CHOICE 1. A postpartum client overhears the nurse tell the health care provider that she has a positive

a. You have pitting edema in your ankles.

Homans sign and asks what it means. Which is the nurses best response?

b. You have deep tendon reflexes rated 2+.

c. You have calf pain when the nurse flexes your foot.

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d. You have a fleshy odor to your vaginal drainage.

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ANS: C

Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is

remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul

odor, is within normal limits. PTS: 1 DIF: Cognitive Level: Application REF: 338 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 2. Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic?

a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Client who is bottle feeding her first child d. Client who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing

mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse.

PTS: 1 DIF: Cognitive Level: Understanding REF: 329

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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3. Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis

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b. Flatulence and constipation c. Extreme hunger and thirst

ANS: D

d. Lochial color changes from rubra to alba

For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that

is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the

umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum.

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postpartum, but is still appropriate.

The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours

PTS: 1 DIF: Cognitive Level: Application REF: 329

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. If the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day,

which action should the nurse take? a. Document the finding. b. Tell the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis. ANS: A

6. Postpartal overdistention of the bladder and urinary retention can lead to which complication?

b. Postpartum hemorrhage and eclampsia

c. Urinary tract infection and uterine rupture

a. Fever and increased blood pressure

d. Postpartum hemorrhage and urinary tract infection

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ANS: D

Incomplete emptying and overdistention of the bladder can lead to urinary tract infection.

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Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after

the birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 332 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. A postpartum client asks, Will these stretch marks go away? Which is the nurses best response? a. No, never.

b. Yes, eventually. c. They will fade to silvery lines but wont disappear completely. d. They will continue to fade and should be gone by your 6-week checkup. ANS: C Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.

PTS: 1 DIF: Cognitive Level: Application REF: 333 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

8. A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The

nurse knows the pigmentation will decrease after birth because of:

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a. increased estrogen. b. increased progesterone.

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c. decreased human placental lactogen.

d. decreased melanocyte-stimulating hormone.

ANS: D

Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation. PTS: 1 DIF: Cognitive Level: Understanding REF: 332 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

9. If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus ANS: A The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the

abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus.

PTS: 1 DIF: Cognitive Level: Understanding REF: 340

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

10. The Centers for Disease Control and Prevention (CDC) recommends the use of which

a. Any body fluids

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personal protective equipment with which the nurse is likely to come into contact?

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b. Any client at any time

c. Blood and blood products

ANS: C

d. Any client suspected of being HIV-positive

Possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids. Only certain body fluids can cause contamination. It is not necessary to wear protective equipment continually with all clients. Protective equipment is important with a client if the nurse is at risk for contamination with blood or certain body fluids. The equipment does not have to be worn with casual contact. PTS: 1 DIF: Cognitive Level: Understanding REF: 334

ANS: A An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that

entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to

destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be

anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mothers blood, not the

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infants.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 334 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

12. If rubella vaccine is indicated for a postpartum client, which instructions to the client should

be included?

a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection ANS: D

13. Which is the best measure to prevent abdominal distention following a cesarean birth?

a. Rectal suppositories b. Carbonated beverages

c. Early and frequent ambulation

d. Tightening and relaxing abdominal muscles

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ANS: C

Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal

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suppositories can be helpful after distention occurs, but do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention.

PTS: 1 DIF: Cognitive Level: Application REF: 342, 343 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 14. Which documentation in the clients chart on the 14th postpartum day indicates a normal involution process? a. Breasts firm and tender b. Episiotomy slightly red and puffy c. Moderate bright red lochial flow

d. Fundus below the symphysis and not palpable ANS: D The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa. PTS: 1 DIF: Cognitive Level: Understanding REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform?

a. Assess lochial flow rather than palpating the fundus.

b. Palpate forcefully through the abdominal dressing.

c. Place hands on both sides of the abdomen and press downward.

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d. Gently palpate, applying the same technique used for vaginal deliveries. ANS: D

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Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged.

Assessing lochial flow is not adequate; the fundus also needs to be checked.

PTS: 1 DIF: Cognitive Level: Application REF: 336 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 16. The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad

Light1- to 4-inch stain

Moderate4- to 6-inch stain

Heavysaturated peripad

Excessivesaturated peripad in 15 minutes

Determining the time interval that the peripad is in place is also important. Lochia is less for

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women who have had a cesarean birth because some of the endometrial lining is removed during

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surgery.

PTS: 1 DIF: Cognitive Level: Analysis REF: 330

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

17. The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a. I may not have a bowel movement until the 2nd postpartum day. b. If I breastfeed and supplement with formula, I wont need any birth control. c. I know my normal pattern of bowel elimination wont return until about 8 to 10 days.

d. If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband. ANS: B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14

PTS: 1 DIF: Cognitive Level: Analysis REF: 333

days after birth.

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

18. The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago.

Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50

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b. Temperature of 38 C (100.4 F)

c. Firm fundus, but excessive lochia

ANS: C

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d. Lightheaded when moving from a lying to standing position

Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38 C (100.4 F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

PTS: 1 DIF: Cognitive Level: Application REF: 337 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 19. The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a. Decrease IV fluid rate.

c. Encourage the use of an incentive spirometer.

d. Ambulate the client around the nurses station.

b. Document the finding.

ANS: C

Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result

from immobility and shallow, slow respirations. The IV rate should not be decreased as the

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reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse

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should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses station should not be done at this time.

PTS: 1 DIF: Cognitive Level: Application REF: 342 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 20. Which of the following would indicate an abnormal finding during the postpartum period? a. Lochia flow changing from alba to rubra b. Unable to palpate uterine fundus at 6-week postpartum checkup

c. Presence of afterbirth pains d. Lochia flow heavier in the early morning 2 days following vaginal birth ANS: A Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding. The uterine fundus should no longer be palpable at 2 weeks postbirth. Afterbirth pains during the postpartum period are a normal finding based on involution of the uterus. Lochia flow may be heavier on arising because of the effects of gravity and pooling of blood while recumbent.

PTS: 1 DIF: Cognitive Level: Analysis REF: 329, 330

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 21. Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct

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a. Client has not been pregnant.

interpretation of this finding with regard to obstetric history?

b. Client has had a C section as a method of birth.

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c. Client has been treated for an STD with resultant scarring of the cervix.

ANS: D

d. Client has a history of pregnancy.

With pregnancy, the cervix becomes slitlike in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth. Treatment of STD is not associated with cervical changes. PTS: 1 DIF: Cognitive Level: Application REF: 330 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

22. To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a. Have the client drink carbonated beverages to promote urinary excretion. b. Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the client to do pelvic floor exercises to combat potential stress incontinence.

ANS: D Educating the client to use pelvic floor exercises will help strengthen pelvic muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the

postpartum period, the client is at greater risk for dehydration and thus should increase fluids.

Limitation of fluids is not warranted during the postpartum period.

PTS: 1 DIF: Cognitive Level: Application REF: 332

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OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Health Promotion and Maintenance 23. In which area should the nurse expect that the postbirth care of a cesarean section will differ

from that of a vaginal birth?

a. Quantity of lochia rubra

b. Pain management techniques c. Frequency of vital signs and fundal checks d. Assessment of infection risk from loss of skin integrity ANS: B A cesarean section is major surgery. Pain relief is provided in various ways, including patientcontrolled analgesia and oral and intramuscular analgesics. Postvaginal birth pain is managed

with oral analgesic combinations that include acetaminophen; the quantity of lochia, frequency of vital signs, and fundal checks and assessment of infection risk are the same for both types of birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 341 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 24. When assessing the A of the acronym REEDA, the nurse should assess the: a. skin color.

b. degree of edema. c. edges of the episiotomy.

d. episiotomy for discharge.

ANS: C

In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other

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E = ecchymosis, and D = drainage.

letters of the acronym refer to other components of wound assessment: R = redness, E = edema,

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PTS: 1 DIF: Cognitive Level: Application REF: 337 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

25. Which assessment finding 24 hours after vaginal birth would indicate a need for further

intervention?

a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus ANS: D

By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client. PTS: 1 DIF: Cognitive Level: Analysis REF: 336 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity 26. The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding?

a. Inform the health care provider.

c. Massage the uterus to expel clots.

d. Document the finding in the patients chart.

b. Encourage the patient to urinate.

ANS: D

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The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs

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approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No

further action is needed.

PTS: 1 DIF: Cognitive Level: Application REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 27. The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding?

a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patients chart. ANS: C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment

appropriate when the data are within normal limits.

can result in a delay of care. Replacing the peripad and documentation of the findings are

PTS: 1 DIF: Cognitive Level: Analysis REF: 330

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 28. The nurse includes the addition of ice sitz baths for the postpartum patient. Which

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assessment finding indicates the treatment has been effective?

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a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold c. Patient reports she took two sitz baths in 12 hours

d. Edges of the perineal laceration are well approximated ANS: A

Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma.

PTS: 1 DIF: Cognitive Level: Evaluating REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 29. The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment? a. Check for edema. b. Check for range of motion. c. Check for adequate reflexes.

d. Check for deep vein thrombosis. ANS: D

Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may

indicate deep vein thrombosis. Edema is checked by palpating and pressing on the top of the foot, range of motion is not a postpartum assessment, and reflexes are checked at the patellar

area.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 338

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

30. Which vaccinations are indicated for the postpartum client if she does not have immunity?

(Select all that apply.) a. Pertussis b. Rubella

c. Diphtheria, tetanus (Tdap) d. RhoGAM ANS: A, B, C

If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results. PTS: 1 DIF: Cognitive Level: Application REF: 335 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 31. The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that

apply.) a. I will gently pat the perineum dry rather than wipe.

b. I will only use the perineal bottle after bowel movements.

c. I will use cold water in the perineal bottle as I cleanse.

d. I will use the perineal bottle without touching the perineum.

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ANS: A, D

The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry.

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Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements.

PTS: 1 DIF: Cognitive Level: Analysis REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care

d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas ANS: A, C, D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks

together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

Chapter 13: Nursing Assessment of Newborn Transition

MULTIPLE CHOICE

1. The hips of a newborn are examined for developmental dysplasia. Which sign indicates an

b. Equal knee heights

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a. Negative Barlow test

incomplete development of the acetabulum?

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c. Negative Ortolani sign

ANS: D

d. Thigh and gluteal creases are asymmetric

Asymmetric thigh and gluteal creases may indicate potential dislocation of the hip. If the hip is dislocated, the knee on the affected side will be lower. A positive Ortolani sign yields a clunking sensation and indicates a dislocated femoral head moving into the acetabulum. During a positive Barlow test, the examiner can feel the femoral head move out of the acetabulum. PTS: 1 DIF: Cognitive Level: Understanding REF: 389 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which newborn reflex is elicited by stroking the lateral sole of the infants foot from the heel to the ball of the foot? a. Babinski b. Stepping c. Tonic neck d. Plantar grasp ANS: A The Babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The stepping

reflex occurs when infants are held upright, with their heel touching a solid surface, and the infant appears to be walking. The tonic neck reflex (also called the fencing reflex) refers to the

posture assumed by newborns when in a supine position. Plantar grasp reflex is similar to the palmar grasp reflex; when the area below the toes is touched, the infants toes curl over the nurses

finger.

PTS: 1 DIF: Cognitive Level: Application REF: 392, 393

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

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3. Infants who develop cephalohematoma are at increased risk for: a. infection.

b. jaundice.

c. caput succedaneum. d. erythema toxicum. ANS: B Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Because of the breakdown of the red blood cells within a hematoma, the infants are at greater risk for jaundice. Cephalohematomas do not increase the risk for infections. Caput is

an edematous area on the head from pressure against the cervix. Erythema toxicum is a benign rash of unknown cause that consists of blotchy red areas. PTS: 1 DIF: Cognitive Level: Understanding REF: 387 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 4. Which action should the nurse take if a discrepancy is found between the measurements of a newborn and the normative criteria? a. Remeasure the infant.

b. Consider this a normal deviation. c. Perform an expanded assessment.

d. Inform the parents so that they can follow the infants growth.

ANS: C

An expanded assessment is necessary to look for data to verify the measurements of the infant.

Remeasuring the infant is helpful but an expanded assessment would be a better action. A

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discrepancy is not a normal deviation. An expanded assessment is needed first so as not to alarm the parents unnecessarily.

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PTS: 1 DIF: Cognitive Level: Application REF: 390

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. Which explains why a newborn with a congenital defect of the penis should not be circumcised?

a. There is increased risk of infection. b. The foreskin might be needed for future repairs. c. A circumcision will make the defect more visible. d. There is no medical rationale for a circumcision. ANS: B

The foreskin may be used to correct a defect. There is no significant increase in infection. A circumcision would not make the defect more noticeable. A circumcision is a decision made by the parents, but in this case the foreskin might be used to correct a defect. PTS: 1 DIF: Cognitive Level: Understanding REF: 399 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 6. A maculopapular rash with a red base and a small white papule in the center is: a. milia.

b. Mongolian spots. c. erythema toxicum.

d. caf-au-lait spots.

ANS: C

A maculopapular rash with a red base and a small white papule in the center is a description of

erythema toxicum, a normal rash in the newborn. Milia are minute epidermal cysts on the face of

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the newborn. Mongolian spots are bluish-black discolorations found on dark-skinned newborns, usually on the sacrum. Caf-au-lait spots are pale tan (the color of coffee with milk) macules.

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Occasional spots occur normally in newborns. PTS: 1 DIF: Cognitive Level: Analysis REF: 400

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 7. A newborn who is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?

a. Below the 90th b. Less than the 10th c. Greater than the 90th d. Between the 10th and 90th

ANS: C The LGA rating is based on weight and is defined as greater than the 90th percentile in weight. An infant between the 10th and 90th percentiles is average for gestational age. An infant in less than the 10th percentile is small for gestational age. PTS: 1 DIF: Cognitive Level: Analysis REF: 411 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 8. A new client asks, Why are you doing a gestational age assessment on my baby? The nurses

best response is: a. It was ordered by your physician.

b. This must be done to meet insurance requirements.

c. It helps us identify infants who are at risk for any problems.

d. The gestational age determines how long the infant will be hospitalized.

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ANS: C

The nurse should provide the mother with accurate information about various procedures performed on the newborn. Assessing gestational age is a nursing assessment and does not have

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to be ordered. It is not needed for insurance needs. Gestational age does not dictate hospital stays. Problems that occur because of gestational age may prolong the stay.

PTS: 1 DIF: Cognitive Level: Application REF: 411 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 9. Which nursing action is designed to avoid unnecessary heat loss in the newborn? a. Maintain room temperature at 70 F. b. Place a blanket over the scale before weighing the infant.

c. Take the rectal temperature every hour to detect early changes. d. Undress the infant completely for assessments so that they can be finished quickly. ANS: B Padding the scale prevents heat loss from the infant to a cold surface by conduction. The room temperature should be appropriate to prevent heat loss from convection. Also, if the room is warm enough, radiation will assist in maintaining body heat. Hourly assessments are not necessary for a normal newborn with a stable temperature. Undressing the infant completely will expose the child to cooler room temperatures and cause a drop in body temperature by

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 390

convection.

MSC: Client Needs: Physiologic Integrity

10. The nurse is performing a gestational age assessment on a newborn. Which characteristic

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shows the greatest gestational maturity?

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a. The infants arms and legs are extended.

b. There is some peeling and cracking of the skin. c. There are few rugae on the scrotum and the testes are high in the scrotum.

d. The arm can be positioned with the elbow beyond the midline of the chest. ANS: B

Peeling, cracking, dryness, and a few visible veins in the skin are signs of maturity in the newborn. Extended arms and legs is a sign of preterm infants. Few rugae on the scrotum show a younger age in the newborn. The arm being able to be positioned with the elbow beyond the midline of the chest is a result of the scarf sign and indicates a newborn of a younger age. PTS: 1 DIF: Cognitive Level: Application REF: 409

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. The clients says, My baby is so thin and wrinkled. It looks like he has too much skin. Which is the most therapeutic response by the nurse to the new clients statement? a. You sound disappointed about how your infant looks. b. All mothers are concerned about how their babies look. c. Dont worry. In no time hell fill out his skin and look just fine. d. You know, all the cigarettes you smoked interfered with the nourishment he needed.

ANS: A The nurse should clarify the clients statement and allow her to verbalize her feelings. All mothers

are concerned about how their babies look generalizes her concerns and does not answer the

mothers question. Dont worry. In no time hell fill out his skin and look just fine does not directly answer the mothers question and could leave her feeling like she asked an unacceptable question.

You know, all the cigarettes you smoked interfered with the nourishment he needed is condescending and hurtful and would not allow for further conversation between the nurse and

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mother.

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PTS: 1 DIF: Cognitive Level: Application REF: 408-409 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Psychosocial Integrity 12. Which assessment finding of a newborn requires prompt action by the nurse? a. Respiratory rate of 50 breaths/min b. Cyanosis of the extremities c. Pause in breathing lasting 20 seconds d. Pause in breathing for 15 seconds followed by rapid respirations ANS: C

Apnea is a pause in breathing lasting 20 seconds or more, or accompanied by cyanosis, pallor, bradycardia, and/or decreased muscle tone. Apnea is abnormal and requires prompt intervention. A respiratory rate of 50 breaths/min is still within the normal range. Tachypnea is considered to be 60 breaths/min or more. Cyanosis of the extremities or acrocyanosis is normal during the first day after birth and if the infant becomes cold. Periodic breathing is pauses in breathing lasting 5 to 10 seconds without other changes followed by rapid respirations for 10 to 15 seconds. This occurs in some full-term infants during the first few days but is more common in preterm infants. PTS: 1 DIF: Cognitive Level: Application REF: 384

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 13. The nurse is receiving a shift report in the newborn nursery. Which client should the nurse

assess first?

a. 38-weeks gestation female newborn with a blood sugar level of 60 mg/dL

b. Term male newborn with a noted axillary temperature of 37.2 C (99 F)

c. 40-weeks gestation female newborn with reported poor feed at last attempt

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d. 39-weeks gestation male newborn who has been crying prior to initial bath

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ANS: C

Newborns who are poor feeds may be showing initial signs of hypoglycemia, so this newborn should be assessed first at the start of the shift. Although the newborn is term, and it is more

likely to see hypoglycemia with preterm infants, sometimes hypoglycemia is asymptomatic. Blood sugar results are within normal range and the newborn is considered to be term.

Temperature is within normal range and the newborn is term. This newborn is considered to be term, and crying alone does not increase risk stratification. PTS: 1 DIF: Cognitive Level: Analysis REF: 396 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

14. Inspection of a newborns head following birth reveals a hard ridged area and significant molding. The anterior and posterior fontanels show no sign of depression. Delivery history indicates that the mother was pushing for over 3 hours and had epidural anesthesia, and vacuum extraction was used. Based on this information the nurse would first: a. continue to monitor newborn and anticipate that molding will subside. b. inspect and document location of fontanels to complete the head assessment. c. contact the neonatologist. d. note findings as being within normal limits as a result of the strenuous birth process.

ANS: C

Assessment data reveal a significant finding, and the nurse should suspect craniosynostosis

(premature closing of sutures) and therefore should contact the neonatologist immediately. Even

though the birth process was difficult and vacuum extraction was used, this does not account for the physical findings. Continuing to monitor is not a prudent action and, because this is more

than molding, it will not go away. Although it is important to note the presence of fontanels, the

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immediate action would be to make the appropriate referral for medical intervention.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 404 OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

15. The nurse is performing an initial assessment of a newborn and notes retractions, nasal flaring, and tachypnea. The nurse will continue to perform a focused assessment on which system? a. Respiratory b. Cardiovascular c. Gastrointestinal d. Musculoskeletal

ANS: A Tachypnea, a respiratory rate of more than 60 breaths/min, is the most common sign of respiratory distress. Retractions occur when the soft tissue around the bones of the chest is drawn in with the effort of pulling air into the lungs. Xiphoid (substernal) retractions occur when the area under the sternum retracts each time the infant inhales. When the muscles between the ribs are drawn in so that each rib is outlined, intercostal retractions are present. A reflex widening of the nostrils occurs when the infant is receiving insufficient oxygen. Nasal flaring helps decrease airway resistance and increase the amount of air entering the lungs.

PTS: 1 DIF: Cognitive Level: Understanding REF: 384 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

16. The postpartum nurse is providing care to a woman 2 hours after birth and to her newborn. On review of the newborns chart, the nurse sees a notation of caput succedaneum. What will the

a. Racenon-white

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b. A longer than usual labor

nurse expect to find in the mothers chart?

c. Administration of an epidural

ANS: B

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d. Delivery by cesarean section

A caput succedaneum is an area of localized edema that appears over the vertex of the newborns

head as a result of pressure against the mothers cervix during labor. The pressure interferes with blood flow from the area, causing localized edema at birth. The edematous area crosses suture lines, is soft, and varies in size. The longer the labor, the more pronounced the caput. Mongolian spots are associated with infants born to non-white parents. An epidural may be a contributing factor to a prolonged labor, but it is the pressure of the head against the cervix that gives rise to the caput. If labor is prolonged without descent of the head, a cesarean section may follow but is not the cause of the caput. PTS: 1 DIF: Cognitive Level: Analysis REF: 387

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 17. The nurse is assessing a newborn delivered 24 hours ago for jaundice. What is the best way to evaluate for this finding? a. Depress the tip of the nose. b. Stroke the outer aspect of the foot. c. Place a finger in the palm of the hand. d. Rotate the hips in an upward and outward direction.

ANS: A The nurse assesses for jaundice at least every 8 to 12 hours and is particularly watchful when infants are at increased risk for hyperbilirubinemia. Jaundice is identified by pressing the infants

skin over a firm surface, such as the end of the nose or the sternum. The skin blanches as the

blood is pressed out of the tissues, making it easier to see the yellow color that remains. Jaundice is more obvious when the nurse assesses in natural light. Jaundice begins at the head and moves

down the body, and the areas of the body involved should be documented. Jaundice becomes

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visible when the bilirubin level is greater than 5 mg/dL. The Babinski reflex is assessed by stroking the outer aspect of the foot. The grasp reflex is determined by placing a finger in the newborns palm. The Barlow and Ortolani tests are methods of assessing for hip instability in the

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newborn period. Both legs should abduct equally in normal infants. Abducting the affected hip may be difficult. A hip click may be felt or heard but is usually normal and is different from the

clunk of hip dysplasia when the femoral head moves in the hip socket.

PTS: 1 DIF: Cognitive Level: Application REF: 396 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 18. An infant at term was born at 0105, or 1:05 AM. The nurse is developing a plan of care for the newborn. During which time range will the nurse plan on performing the assessment to determine a Ballard score? a. 0115-0130

b. 0200-0600 c. 1400-1800 d. 2000-2300 ANS: B The new Ballard score is often used to assess gestational age based on neuromuscular and physical characteristics. It is designed to assess gestational age from 20 to 44 weeks and provides accurate information within 2 weeks. It is most accurate when performed within 12 hours of

PTS: 1 DIF: Cognitive Level: Application REF: 406

birth.

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. The nurse is assessing a newborn and notes a nevus flammeus birthmark. Which of the following figures depicts this birthmark?

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b. c.

ANS: C

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A nevus flammeus (port wine stain) is a permanent, flat, pink to dark reddish-purple mark that

varies in size and location. Erythema toxicum is a red blotchy area that may have white or yellow papules or vesicles in the center; it is not a birthmark. Mongolian spots are bluish-black marks that resemble bruises. They usually occur in the sacral area but may appear on the buttocks, arms, shoulders, and other areas. A nevus simplex is also called salmon patch, stork bite, or telangiectatic nevus. It is a flat pink or reddish discoloration from dilated capillaries that occurs over the eyelids, just above the bridge of the nose, or at the nape of the neck. PTS: 1 DIF: Cognitive Level: Analysis REF: 400, 401

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 20. The nurse is conducting a body system assessment of the newborn. Which are abnormal findings that the nurse should report? (Select all that apply.) a. Low-set ears b. Yellow sclera c. A dolls eye sign d. Edema of the eyelids

e. Absence of the grasp reflex

ANS: A, B, E

Low-set ears may indicate chromosomal abnormalities. The sclera should be white or bluish white. A yellow color indicates jaundice. Absence of reflexes may indicate a serious neurologic

problem. The dolls eye sign is a normal finding in the newborn; when the head is turned quickly

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to one side, the eyes move toward the other side. Edema of the eyelids and subconjunctival hemorrhages (reddened areas of the sclera) result from pressure on the head during birth, which

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causes capillary rupture in the sclera.

PTS: 1 DIF: Cognitive Level: Application REF: 392

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

21. To differentiate between caput succedaneum and cephalohematoma in a newborn, the nurse would consider the following clinical information. (Select all that apply.) a. These are both normal presentations because of the birth process and will resolve within 24 to 48 hours. b. Cephalohematoma manifests as a localized area of swelling as compared with caput succedaneum, which appears as a general swelling of the head. c. A cephalohematoma can develop several hours or days after the birth event, whereas caput succedaneum is noted shortly before or immediately after the birth event.

d. Edema that crosses suture lines is observed with caput succedaneum. e. With a cephalohematoma, bleeding occurs between the bone and skull. ANS: C, D, E Cephalohematoma can be detected up to 24 to 48 hours after the birth process. This clinical condition is caused by bleeding between the periosteum and skull and is a serious medical condition. Caput succedaneum occurs in the presence of pressure from the vaginal canal on the fetal head during the birth process. Swelling is localized and crosses the suture line, whereas with cephalohematoma the swelling is more generalized and crosses the suture line. Caput

OBJ: Nursing Process Step: Assessment

PTS: 1 DIF: Cognitive Level: Application REF: 387

resolves within 12 to 48 hours after the birth event.

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

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(Select all that apply.)

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22. Which are early signs of hypoglycemia in the newborn for which the nurse should assess?

a. Jitteriness

b. Poor feeding

c. Respiratory difficulty

d. An increase in temperature e. A capillary refill of 2 seconds ANS: A, B, C Early signs of hypoglycemia include jitteriness and other central nervous system signs and signs of respiratory difficulty, a decrease in temperature, and poor feeding. A capillary refill of 2 seconds is a normal finding in the newborn.

PTS: 1 DIF: Cognitive Level: Analysis REF: 395, 396 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 23. The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.) a. Translucent skin b. Extended limp arms and legs c. The ear springs back when folded d. Square window angle of 45 degrees or less

e. Large clitoris and labia minora in the female newborn

ANS: A, B, E

The very preterm infants skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle

tone. Therefore they have extended and limp arms and legs that offer little resistance to

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movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the

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angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy.

Chapter 14: Nursing Care of the Normal Newborn MULTIPLE CHOICE 1. A yellow crust has formed over the circumcision site. The mother calls the hotline at the local hospital 5 days after her son was circumcised. She is very concerned. On which rationale should the nurse base a reply? a. The yellow crust should not be removed. b. This yellow crust is an early sign of infection.

c. Discontinue the use of petroleum jelly to the tip of the penis. d. After circumcision, the diaper should be changed frequently and fastened snugly. ANS: A Crust is a normal part of healing. The normal yellowish exudate that forms over the site should be differentiated from the purulent drainage of infection. The only contraindication for petroleum jelly is the use of a PlastiBell. The diaper should be fastened loosely to prevent rubbing or pressure on the incision site.

PTS: 1 DIF: Cognitive Level: Application REF: 427 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

appropriate for the newborn?

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a. Deltoid muscle b. Gluteal muscles

2. Most newborns receive a prophylactic injection of vitamin K soon after birth. Which site is

c. Rectus femoris muscle

ANS: D

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d. Vastus lateralis muscle

The vastus lateralis muscle is located away from the sciatic nerve and femoral blood vessels. Gluteal muscles are not used until a child has been walking for at least 1 year to develop these muscles. The rectus femoris is used only if absolutely necessary because this muscle is located closer to the sciatic nerve and blood vessels, which poses a greater danger. The deltoid is not a recommended site for newborn injections. PTS: 1 DIF: Cognitive Level: Understanding REF: 416 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 3. What should the nurse teach to parents about using a bulb syringe? a. Use it only once a day. b. Suction the back of the throat vigorously. c. Insert the syringe into the sides of the mouth. d. Always suction the mouth before suctioning the nose. ANS: C

The syringe should be inserted into the sides of the mouth rather than the back of the throat to avoid a vagal response and bradycardia. Suction can occur as needed. Vigorous suction of the back of the throat may stimulate the vagal nerve and produce bradycardia. The mouth should be

suctioned first to prevent aspiration.

PTS: 1 DIF: Cognitive Level: Application REF: 417

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

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4. Which principle is important in providing and teaching cord care? a. Cord care is done only to control bleeding.

b. Alcohol is the only agent used for cord care.

c. It takes a minimum of 24 days for the cord to separate. d. Keeping the cord dry will decrease bacterial growth. ANS: D Bacterial growth increases in a moist environment, so keeping the umbilical cord dry impedes bacterial growth. Cord care is done to prevent infection and aid in the drying of the cord. No agents are necessary to facilitate drying of the cord. The cord will fall off within 10 to 14 days.

PTS: 1 DIF: Cognitive Level: Understanding REF: 422 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 5. Which is the purpose of state-required newborn screening? a. Keep the state records updated. b. Document the number of births. c. Allow for accurate statistical information.

d. Recognize and treat newborn disorders early.

ANS: D

Early treatment of disorders will prevent morbidity associated with some common newborn

disorders. Keeping state records and documenting the number of births are not the purposes of

newborn screening. The number of births is not indicated by the newborn screening test.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 432, 433

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 6. Which should the nurse implement to prevent the kidnapping of a newborn from the hospital?

a. Restricting the amount of time infants are out of the nursery

b. Questioning anyone who is seen walking in the hallways carrying an infant c. Allowing no visitors in the maternity area except those who have identification bracelets d. Instructing the parents to not give the baby to anyone except the nurse assigned that day ANS: B Infants should be transported in the hallways only in their cribs. Restricting the amount of time infants are out of the nursery will be difficult to monitor and will limit the mothers support

system from visiting. Infants need to spend time with the parents to facilitate the bonding process. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so the parents need to be able to identify the nurses who are working on the unit. PTS: 1 DIF: Cognitive Level: Application REF: 423, 424 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 7. A nursing student has been caring for a client and her newborn all morning. After taking the procedure is correct for identifying the newborn?

newborn to the nursery for tests, the student is returning the newborn to the mother. Which

a. Ask the mother to state her name and the name of her infant.

b. Call out the mothers full name before leaving the infant with her.

c. Have the mother read her printed band number and verify that it matches the infants number.

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d. Return the infant with no special procedure because the student knows the mother and infant.

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ANS: C

The mother and infant should have identifying arm bands with matching numbers. The other

actions do not adequately verify the identities of mother and infant.

PTS: 1 DIF: Cognitive Level: Application REF: 423 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 8. The nurse is explaining the procedure of newborn screening to parents before discharge. Which statement by the parents indicates a need for further teaching? a. We understand the tests are performed at 24 to 48 hours.

b. Were glad all the tests can be done on one blood sample. c. We wish the tests would screen for congenital hypothyroidism. d. We know that if the tests are done before 24 hours, the tests will need to be repeated at 1 to 2 weeks. ANS: C Common disorders often included in newborn screening are phenylketonuria (PKU), hypothyroidism, galactosemia, hemoglobinopathies such as sickle cell disease and thalassemia, and congenital adrenal hyperplasia. The parents need further teaching if they say that congenital hypothyroidism is not screened. The newborn screening tests are performed at 24 to 48 hours

after birth. Newborn screening requires a blood sample taken from the infants heel, and only one blood sample is needed for all tests. Tests performed within the first 24 hours of life are less sensitive than those performed after 24 hours. Infants tested before 12 to 24 hours of age should

have repeat tests at 1 to 2 weeks of age so that disorders are not missed because of early testing.

PTS: 1 DIF: Cognitive Level: Application REF: 433

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 9. Which newborn assessment finding requires the nurse to take an action?

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a. Glucose level of 40 mg/dL

b. Axillary temperature of 37 C (98.6 F)

c. Mild yellow tinge to skin at 32 hours of age

d. Mild inflammation of conjunctiva after eye prophylaxis ANS: A

A glucose level of 40 mg/dL requires an action. Follow agency policy and health care provider orders regarding feeding infants with low glucose levels. A common practice is to feed the newborn if the glucose screening shows a level of 40 to 45 mg/dL or less to prevent further depletion of glucose. Infants with severe hypoglycemia may need intravenous feedings to provide glucose rapidly. A normal temperature for a newborn is 36.5 to 37.5 C (97.7 to 99.5 F). Mild jaundice at 32 hours of age is physiologic jaundice and does not need an action by the

nurse, just further monitoring. Some infants develop a mild inflammation a few hours after prophylactic eye treatment. PTS: 1 DIF: Cognitive Level: Application REF: 419 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 10. The nurse is assessing a newborns circumcision 30 minutes after the procedure. The nurse notes excessive bleeding coming from the circumcised area. Which priority intervention should

a. Apply pressure to the site.

b. Continue to observe for another 30 minutes.

the nurse implement?

c. Apply the diaper tightly over the circumcised area.

d. Apply petroleum jelly to the site with a small piece of gauze.

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ANS: A

If excessive bleeding occurs after a circumcision, pressure is applied to the site. The nurse notifies the physician, who may apply Gelfoam or epinephrine or suture the small blood vessels.

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A small amount of blood loss may be significant in an infant, who has a small total blood volume. Continuing to observe could mean additional blood loss. Applying the diaper tightly will not stop the bleeding. Petroleum jelly is applied to keep the diaper from sticking to the

circumcised area. It will not stop the bleeding. PTS: 1 DIF: Cognitive Level: Application REF: 425 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 11. In which position should the parents be instructed to place their newborn for sleep? a. On the back

b. On the left side c. On the right side d. On the abdomen ANS: A The American Academy of Pediatrics (AAP) in 2011 recommended that mothers and fathers be taught to place infants on the back for sleep, because this position is associated with the lowest rate of SIDS. The side-lying position is not advised because of the possibility that the infant might roll to the prone position. The newborn should not be placed on the abdomen.

PTS: 1 DIF: Cognitive Level: Application REF: 423, 430

OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

12. A 38 weeks gestation fetus is delivered via cesarean section and transported to the newborn nursery in an isolette. Apgar scores were 8, 9, and 10. At this time, the infant is receiving an

initial assessment in the newborn nursery. Which is the priority nursing diagnosis?

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a. Risk for injury related to potential equipment malfunction of radiant warmer b. Altered tissue perfusion related to use of medications during delivery process

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c. Ineffective airway clearance due to mode of delivery and use of anesthetics d. Risk for ineffective thermoregulation related to gestational age

ANS: C

Delivery via cesarean section may affect the newborns ability to remove excess fluid secretions because the infant did not move down the birth canal and thus may be at risk for airway concerns. There is no evidence to support that the equipment is malfunctioning. Although the use of medications may affect the newborn in terms of respiratory, cardiac, and neurologic depression, Apgar scores do not indicate any immediate deficit. The infant is at term based on reported gestational age and therefore is not a risk for ineffective thermoregulation because of this fact. PTS: 1 DIF: Cognitive Level: Analysis REF: 417

OBJ: Nursing Process Step: Nursing Diagnosis MSC: Client Needs: Health Promotion and Maintenance/ Ante/Intra/Postpartum and Newborn Care 13. An infants temperature is recorded at 36 C (96.8 F) during the morning assessment in the newborn nursery. Which priority action should the nurse implement? a. Note the findings in the electronic health record (EHR). b. Unwrap the infant and inspect for abnormalities. c. Provide the infant with glucose water.

d. Make sure that the infant is wrapped securely with a blanket and recheck temperature in 15 minutes.

ANS: D

This temperature potentially indicates hypothermia, so the infant should be wrapped securely in a blanket and reassessed after that intervention. Findings should be documented in the EHR, but

this is not the priority intervention. Unwrapping the infant would lead to further compromise and

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additional risk for the core temperature to drop. Feeding the infant with glucose water may eventually be used as an intervention if the infant shows additional signs of hypoglycemia, which

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may accompany hypothermia.

PTS: 1 DIF: Cognitive Level: Application REF: 420

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities 14. In reviewing safety concerns for the newborn nursery, an ad hoc committee has been organized to discuss methods to prevent infant abduction. Which option can be used to facilitate improved outcomes related to this potential problem? a. Allow only immediate adult family members to visitor the newborn nursery during unrestricted visiting hours.

b. Require identification with picture ID confirmation of all family members and/or staff who want to have contact with the newborn. c. Make sure that all emergency exits are accessible to staff and clients on the unit. d. Limit the number of visitors to two per client who can be on the unit during visiting hours to maintain security. ANS: B Requiring appropriate identification is the best method of preventing possible infant abduction. Evidenced-based practice has indicated that potentially family and/or staff or someone representing themselves as such is more likely to attempt an infant abduction. The unit should be

a closed or locked unit and require admittance to maintain security. Limiting the visitors to two per client may cause increased stress to the new family because they want to share this experience. Preventing siblings from visiting by only allowing immediate adult family members

may prevent beginning sibling attachment and cause separation and stress anxiety to the mother

and children.

PTS: 1 DIF: Cognitive Level: Analysis REF: 423, 424

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OBJ: Nursing Process Step: Evaluation

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MSC: Client Needs: Safe and Effective Care Environment 15. When an infants temperature drops from 98.7 to 97.4 F (37 to 36.3 C), the nurse should:

a. instruct parents on cold stress.

b. determine time and amount of last feeding. c. increase the temperature in the mothers room. d. evaluate infant for the presence of a blood sugar level higher than 50 mg/dL. ANS: B Temperature instability in the neonate may be caused by a decrease in blood glucose levels. Infants who do not maintain adequate intake will not have adequate energy to maintain temperature; instructing parents on cold stress and increasing the temperature in the room are

interventions to maintain a stable temperature but will not correct the underlying problem. A blood sugar level higher than 50 mg/dL is a normal finding. PTS: 1 DIF: Cognitive Level: Application REF: 420 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 16. Administration of medications after birth is the topic of discussion during a prenatal education class. Which statement indicates to the nurse that the pregnant patient understands the

primary indication for the administration of vitamin K? a. The nurse will draw blood to determine if vitamin K is needed.

b. Vitamin K prevents the possibility of bleeding problems in my baby. c. My baby will receive a shot when the nurse administers the vitamin K.

d. Vitamin K will be administered shortly after birth, generally within the first hour.

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ANS: B

This indication is the reason for vitamin K administration. Vitamin K is given to neonates because they cannot synthesize it in the intestines without bacterial flora. This places them at risk

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for hemorrhagic disease of the newborn (vitamin K deficiency disease). One dose of vitamin K intramuscularly after birth prevents bleeding problems until the infant is able to produce vitamin K in sufficient amounts. Although the injection is usually given within the first hour after birth, it

can be delayed until the infant has finished breastfeeding shortly after birth. PTS: 1 DIF: Cognitive Level: Application REF: 415 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 17. The postpartum nurse is reviewing oral-nasal bulb suctioning with a first-time mom. Which statement will the nurse need to correct? a. Depress the bulb prior to inserting the tip.

b. Suction the nose first and then the mouth. c. Keep a bulb syringe in the bassinet at all times. d. Gradually release the pressure on the bulb while withdrawing it. ANS: B The mouth should be suctioned first because the infant may gasp when the nose is suctioned, causing aspiration of mucus or fluid in the mouth. Then the nose is suctioned gently and only if necessary. Suctioning is traumatic to the delicate tissues and may cause edema of the nasal

PTS: 1 DIF: Cognitive Level: Application REF: 417

passages. The remaining statements are correct.

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

18. An hour after birth, the nurse assesses a newborns temperature and notes that it is 36.2 C (97.2 F). The next activity planned for the newborn is the bath, and the new mother and father

are invited to participate in the procedure. What is the nurses next action?

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a. Take the infants temperature rectally.

b. Ask the father to test the water to determine if it is too hot.

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c. Delay the bath until the newborns temperature is above 36.7 C (98 F). d. Explain to the new parents that no soap should be used to cleanse the eyes.

ANS: C

A temperature of 36.7 C (98 F) or higher is often used to determine when to bathe the infant. The infant can lose heat in the bath through the process of evaporation. Rectal temperatures are avoided because they can traumatize the rectal mucosa. The water temperature should be approximately 38 to 40 C (100.4 to 104 F). The nurse and not the father needs to determine if the bath water is the correct temperature to avoid scalding the newborn. Explain the process of giving a bath during the procedure. Informing the parents before the procedure may result in loss of information. PTS: 1 DIF: Cognitive Level: Application REF: 421

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is preparing a male infant for circumcision. On review of the chart, the nurse notes that the consent has been signed, vitamin K has been administered, the temperature has been between 36.8 to 37 C (98.2 to 98.6 F), and the heart rate range is 126 to 144 beats per minute (bpm). Which finding, if omitted from the chart, would cause the nurse to have to cancel the circumcision? a. Consent

b. Vitamin K c. Heart rate

d. Temperature

ANS: B

The administration of the vitamin K prevents excessive bleeding. The infant could be at risk for hemorrhage without the vitamin K. Other assessment measures can be used to fulfill the

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remaining assessments, such as a verbal consent can be obtained, the skin can be palpated to determine temperature, and overall color can give the health care provider information about the

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infants heart rate. The only replacement for vitamin K is time to allow for the development of vitamin K in the gastrointestinal (GI) system.

PTS: 1 DIF: Cognitive Level: Synthesis REF: 426

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 20. Which newborn testing must be performed prior to discharge from the hospital? (Select all that apply.) a. Pulse oximetry b. Hearing

c. Guthrie d. Hypothyroidism e. Galactosemia ANS: A, C, D, E The pulse oximetry test is used to identify potential cardiac anomalies, so it must be done prior to infant discharge. The Guthrie test is another name for the metabolic screening panel test that is done to identify a group of metabolic diseases that would have a significant impact on newborn infants. Included in this test are observations related to thyroid activity, PKU, and galactosemia.

A hearing screening test is recommended during the first month of life. PTS: 1 DIF: Cognitive Level: Application REF: 432, 433

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Health Promotion and Maintenance/Health Screening

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life? (Select all that apply.)

21. Which are the reasons for having auditory screening on all newborns in the first month of

a. Early identification and treatment

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b. Reassurance for concerned new parents

c. To prevent or reduce developmental delay

d. To achieve one of the Healthy People 2020 goals

ANS: A, C, D

Newborn auditory screening is done to identify hearing loss and begin treatment. Treatment can help to reduce developmental delay. Newborn auditory screening is a Healthy People 2020 goal. New parents are often anxious regarding this test and the impending results; however, it is not a reason for the screening to be performed. PTS: 1 DIF: Cognitive Level: Application REF: 432, 433

OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity 22. The nurse is preparing a newborn for a circumcision. Which prescribed interventions should the nurse implement to alleviate pain? (Select all that apply.) a. Oral sucrose during the procedure b. Bright lights after the procedure c. Adequate stimulation before and after the procedure d. Acetaminophen (Tylenol) postprocedure, as needed e. EMLA cream (eutectic mixture of local anesthetics) before the procedure

ANS: A, D, E

Nonpharmacologic pain relief methods during and after the circumcision include pacifiers, oral sucrose, soothing music, recordings of intrauterine sounds, decreased lights, and talking softly to

the infant. Acetaminophen may be given throughout the first day for postprocedure pain. EMLA cream (eutectic mixture of local anesthetics) may be applied to anesthetize the skin before the

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procedure. Bright lights and stimulation would not be methods to reduce circumcision pain. PTS: 1 DIF: Cognitive Level: Application REF: 426

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OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

23. The nurse has just completed discharge teaching to parents on newborn bathing. Which

statement made by the parents indicates a further need for teaching? (Select all that apply.) a. We will clean the diaper area last. b. We will use cotton-tipped swabs to clean the ears. c. We will use an antibacterial soap during the sponge bath. d. We can submerge the baby in a tub of water after the cord falls off. e. We will shampoo the babys head using a football hold before unwrapping.

ANS: B, C Soap is not necessary for the young infant but if used, it should be gentle and nonalkaline to protect the natural acids of the infants skin. Do not use cotton-tipped swabs in the infants ears or nose because injury may occur if the baby moves suddenly. Clean the diaper area last. The cord generally falls off in about 10 to 14 days. Some care providers suggest waiting for the cord to fall off before tub bathing. Before fully undressing the baby, use the football position to shampoo the babys head. PTS: 1 DIF: Cognitive Level: Analysis REF: 431

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

a. Wearing gloves before touching neonates

24. Which nursing action is a priority to prevent infection in the newborn? (Select all that apply.)

b. Washing hands before and after handling any neonate

c. Washing hands and arms thoroughly at the beginning of the day

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d. Sharing some equipment that will not transmit infection from one neonate to another

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ANS: B, C

At the beginning of their shift, nurses wash their hands and arms thoroughly. Throughout the day, handwashing is important before and after touching any infant. Gloves are not necessary

unless personal protective equipment is required because of coming in contact with body fluids.

To avoid cross-contamination, each infants supplies are kept separately from those used for other infants. Supplies in drawers or cupboards of each crib unit should be used only for that infant because they are likely to be touched by nurses giving care. Using them for another neonate could result in the transfer of infectious organisms.

Chapter 15: Newborn Nutrition MULTIPLE CHOICE

1. The breastfeeding client should be taught a safe method to remove her breast from the babys mouth. Which suggestion by the nurse is most appropriate? a. Break the suction by inserting your finger into the corner of the infants mouth. b. A popping sound occurs when the breast is correctly removed from the infants mouth. c. Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. d. Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.

ANS: A Inserting a finger into the corner of the babys mouth between the gums to break the suction

avoids trauma to the breast. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. The infant who is sleeping may lose

grasp on the nipple and areola, resulting in chewing on the nipple, making it sore. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are

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recommended.

PTS: 1 DIF: Cognitive Level: Application REF: 446

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

2. Which woman is most likely to continue breastfeeding beyond 6 months? a. A woman who avoids using bottles b. A woman who uses formula for every other feeding c. A woman who offers water or formula after breastfeeding d. A woman whose infant is satisfied for 4 hours after the feeding ANS: A Women who avoid using bottles and formula are more likely to continue breastfeeding.

Use of formula decreases breastfeeding time and decreases the production of prolactin and, ultimately, the milk supply. Overfeeding after breastfeeding causes a sense of fullness in the infant, so the infant will not be hungry in 2 to 3 hours. Formula takes longer to digest. The new breastfeeding mother needs to nurse often to stimulate milk production. PTS: 1 DIF: Cognitive Level: Analysis REF: 453 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. In which condition is breastfeeding contraindicated? a. Triplet birth

b. Flat or inverted nipples

d. Inactive, previously treated tuberculosis

c. Human immunodeficiency virus infection

ANS: C

Human immunodeficiency virus is a serious illness that can be transmitted to the infant via body

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fluids. Because the amount of milk being produced depends on the amount of suckling of the breasts, providing enough milk should not be a problem. Nipple abnormality can begin to be

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treated during pregnancy but may begin after birth. Many methods help flat or inverted nipples to become more erect. Only active tuberculosis patients would be cautioned not to breastfeed.

PTS: 1 DIF: Cognitive Level: Understanding REF: 454

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment 4. Which type of formula should not be diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready to use

d. Modified cows milk ANS: C Ready to use formula can be poured directly from the can into the babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted. PTS: 1 DIF: Cognitive Level: Understanding REF: 458

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. How many kilocalories per kilogram (kcal/kg) of body weight does a full-term formula-fed

infant need each day? a. 50 to 75

b. 100 to 110

d. 150 to 200

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ANS: B

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c. 120 to 140

The term newborn being fed with formula requires 100 to 110 kcal/kg to meet nutritional needs

much.

each day. 50 to 75 kcal/kg is too little and 120 to 140 kcal/kg and 150 to 200 kcal/kg are too

PTS: 1 DIF: Cognitive Level: Understanding REF: 436 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. How many milliliters per kilogram (mL/kg) of fluids does a newborn need daily for the first 3 to 5 days of life? a. 20 to 30

b. 40 to 60 c. 60 to 100 d. 120 to 150 ANS: C The newborn needs 60 to 100 mL/kg of fluids daily for the first 3 to 5 days of life. 20 to 30 mL/kg and 40 to 60 mL/kg are too small an amount for the newborn. 120 to 150 mL/kg is too large an amount for the newborn.

PTS: 1 DIF: Cognitive Level: Understanding REF: 436, 437 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

7. Which is the hormone necessary for milk production?

a. Estrogen b. Prolactin

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ANS: B

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d. Lactogen

c. Progesterone

Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk.

Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk

from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. PTS: 1 DIF: Cognitive Level: Understanding REF: 441 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which recommendation should the nurse make to a client to initiate the milk ejection reflex?

a. Wear a well-fitting firm bra. b. Drink plenty of fluids. c. Place the infant to the breast. d. Apply cool packs to the breast. ANS: C Oxytocin, which causes the milk let-down reflex, increases in response to nipple stimulation. A firm bra is important to support the breast but will not initiate the let-down reflex. Drinking plenty of fluids is necessary for adequate milk production but will not initiate the let-down

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 441

reflex. Cool packs to the breast will decrease the let-down reflex.

MSC: Client Needs: Health Promotion and Maintenance

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9. Which is the first step in assisting the breastfeeding mother? a. Assess the womans knowledge of breastfeeding.

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b. Provide instruction on the composition of breast milk. c. Discuss the hormonal changes that trigger the milk ejection reflex.

ANS: A

d. Help her obtain a comfortable position and place the infant to the breast.

The nurse should first assess the womans knowledge and skill in breastfeeding to determine her teaching needs. Assessment should occur before instruction. Discussing the hormonal changes and helping her obtain a comfortable position may be part of the instructional plan, but assessment should occur first to determine what instruction is needed. PTS: 1 DIF: Cognitive Level: Application REF: 443, 444 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 10. Which is an important consideration in positioning a newborn for breastfeeding? a. Placing the infant at nipple level facing the breast b. Keeping the infants head slightly lower than the body c. Using the forefinger and middle finger to support the breast d. Limiting the amount of areola the infant takes into the mouth ANS: A

Positioning the infant at nipple level will prevent downward pulling of the nipple and subsequent nipple trauma. Keeping the infants head slightly lower will pull the nipple down and cause trauma. The forefinger and middle finger can be used to support the breast, but this is not an

possible to prevent trauma to the nipples.

important consideration in positioning the newborn. The infant should take in as much areola as

PTS: 1 DIF: Cognitive Level: Analysis REF: 444

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 11. The client should be taught that when her infant falls asleep after feeding for only a few

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minutes, she should do which of the following? a. Unwrap and gently arouse the infant.

b. Wait an hour and attempt to feed again.

c. Try offering a bottle at the next feeding. d. Put the infant in the crib and try again later. ANS: A The infant who falls asleep during feeding may not have fed adequately and should be gently aroused to continue the feeding. Breastfeeding should continue. By offering a bottle, breast milk production will decrease. The infant should be aroused and feeding continued.

PTS: 1 DIF: Cognitive Level: Application REF: 449 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. To prevent breast engorgement, what should the new breastfeeding mother be instructed to do? a. Feed her infant no more than every 4 hours. b. Limit her intake of fluids for the first few days.

c. Apply cold packs to the breast prior to feeding. d. Breast-feed frequently and for adequate lengths of time.

ANS: D

Engorgement occurs when the breasts are not adequately emptied at each feeding or if feedings are not frequent enough. Breast milk moves through the stomach within 1.5 to 2 hours, so

waiting 4 hours to feed is too long. Frequent feedings are important to empty the breast and

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establish lactation. Fluid intake should not be limited with a breastfeeding mother; that would decrease the amount of breast milk produced. Warm packs should be applied to the breast before

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feedings.

PTS: 1 DIF: Cognitive Level: Application REF: 453

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 13. What is the difference between the aseptic and terminal methods of sterilization? a. The aseptic method requires a longer preparation time. b. The aseptic method does not require boiling of the bottles. c. The terminal method requires boiling water to be added to the formula.

d. The terminal method sterilizes the prepared formula at the same time it sterilizes the equipment. ANS: D In the terminal sterilization method, the formula is prepared in the bottles, which are loosely capped, and then the bottles are placed in the sterilizer, where they are boiled for 25 minutes. The terminal method takes 25 minutes to boil; the aseptic method takes 5 minutes to boil. With the aseptic method, the bottles are boiled separate from the formula. With the terminal method, the formula is prepared, placed in bottles, and everything is boiled at one time.

PTS: 1 DIF: Cognitive Level: Understanding REF: 458 OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment

14. How many ounces will an infant who is on a 4-hour feeding schedule need to consume at

each feeding to meet daily caloric needs?

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a. 1 b. 1.5

ANS: C

d. 5

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c. 3.5

The newborn requires approximately 12 to 24 oz of formula each day (6 feedings/24-hour period). 1 and 1.5 ounces are too small to meet calorie needs; 5 ounces with every feeding would be overfeeding the infant. PTS: 1 DIF: Cognitive Level: Analysis REF: 459 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

15. A new mother is concerned because her 1-day-old newborn is taking only 1 oz at each feeding. What should the nurse explain? a. The infant is probably having difficulty adjusting to the formula. b. An infant does not require as much formula in the first few days of life. c. The infants stomach capacity is small at birth but will expand within a few days. d. The infant tires easily during the first few days but will gradually take more formula. ANS: C

The infants stomach capacity at birth is 10 to 20 mL and increases to 30 to 90 mL by the end of the first week. There are other symptoms if there is a formula intolerance. The infants requirements are the same, but the stomach capacity needs to increase before taking in adequate

amounts. The infants sleep patterns do change, but the infant should be awake enough to feed. PTS: 1 DIF: Cognitive Level: Application REF: 446

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

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16. As the nurse assists a new mother with breastfeeding, the mother asks, If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better? The

nurses best response is that it contains:

a. more calcium. b. more calories.

c. essential amino acids. d. important immunoglobulins. ANS: D Breast milk contains immunoglobulins that protect the newborn against infection. Calcium levels are higher in formula than breast milk. This higher level can cause an excessively high renal

solute load if the formula is not diluted properly. The calorie counts of formula and breast milk are about the same. All the essential amino acids are in formula and breast milk. The concentrations may differ. PTS: 1 DIF: Cognitive Level: Application REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. What should the nurse explain when responding to the question, Will I produce enough milk

for my baby as she grows and needs more milk at each feeding? a. Early addition of baby food will meet the infants needs.

b. The breast milk will gradually become richer to supply additional calories. c. As the infant requires more milk, feedings can be supplemented with cows milk.

d. The mothers milk supply will increase as the infant demands more at each feeding.

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ANS: D

The amount of milk produced depends on the amount of stimulation of the breast. Increased

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demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Solids should not be added until about 4 to 6 months, when the infants immune system is more mature. This will decrease the chance of allergy formations. Mature breast milk

will stay the same. The amounts will increase as the infant feeds for longer times.

Supplementation will decrease the amount of stimulation of the breast and decrease the milk production.

PTS: 1 DIF: Cognitive Level: Application REF: 441 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 18. Which should the nurse recommend to the postpartum client to prevent nipple trauma?

a. Assess the nipples before each feeding. b. Limit the feeding time to less than 5 minutes. c. Wash the nipples daily with mild soap and water. d. Position the infant so the nipple is far back in the mouth. ANS: D If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, causing trauma to the area. Assessing the nipples for trauma is important, but it will not prevent sore nipples. Stimulating the breast for less than 5 minutes will avoided during breastfeeding.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 458

not produce the extra milk the infant may need. Soap can be drying to the nipples and should be

MSC: Client Needs: Physiologic Integrity

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19. A breastfeeding client who was discharged yesterday calls to ask about a tender hard area on her right breast. What should be the nurses first response?

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a. This is a normal response in breastfeeding mothers. b. Notify your doctor so he can start you on antibiotics.

c. Stop breastfeeding because you probably have an infection.

d. Try massaging the area and apply heat; it is probably a plugged duct. ANS: D

A plugged lactiferous duct results in localized edema, tenderness, and a palpable hard area. Massage of the area followed by heat will cause the duct to open. This is a normal deviation but requires intervention to prevent further complications. Tender hard areas are not the signs of an infection, so antibiotics are not indicated. Fatigue, aching muscles, fever, chills, malaise, and headache are signs of mastitis. She may have a localized area of redness and inflammation.

PTS: 1 DIF: Cognitive Level: Application REF: 451 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 20. Which is an important consideration about the storage of breast milk? a. Can be thawed and refrozen b. Can be frozen for up to 2 months c. Should be stored only in glass bottles

d. Can be kept refrigerated for 48 hours

ANS: D

If used within 48 hours after being refrigerated, breast milk will maintain its full nutritional

value. It should not be refrozen. Frozen milk should be kept for 1 month only. Antibodies in the

milk will adhere to glass bottles. Only rigid polypropylene plastic containers should be used.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 458

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OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Safe and Effective Care Environment

21. What is the most serious consequence of propping an infants bottle?

a. Colic

b. Aspiration

c. Dental caries d. Ear infections ANS: B Propping the bottle increases the likelihood of choking and aspiration if regurgitation occurs. Colic can occur but is not the most serious consequence. Dental caries becomes a problem when

milk stays on the gums for a long period of time. This may cause a buildup of bacteria that will alter the growing teeth buds. However, this is not the most serious consequence. Ear infections can occur when the warm formula runs into the ear and bacterial growth occurs. However, this is not the most serious consequence. PTS: 1 DIF: Cognitive Level: Understanding REF: 459 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 22. A new mother asks why she has to open a new bottle of formula for each feeding. What is the nurses best response?

a. Formula may turn sour after it is opened. b. Bacteria can grow rapidly in warm milk.

c. Formula loses some nutritional value once it is opened.

d. This makes it easier to keep track of how much the baby is taking.

ANS: B

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Formula should not be saved from one feeding to the next because of the danger of rapid growth of bacteria in warm milk. Formula will have bacterial growth before turning sour. This will cause

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problems in a newborn with an immature immune system. The loss of some nutritional value after the formula is opened is not the reason for using fresh bottles with each feeding. The danger of bacterial growth is the main concern.

PTS: 1 DIF: Cognitive Level: Application REF: 459 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 23. A new mother asks whether she should feed her newborn colostrum because it is not real milk. The nurses best answer includes which information? a. Colostrum is unnecessary for newborns.

b. Colostrum is high in antibodies, protein, vitamins, and minerals. c. Colostrum is lower in calories than milk and should be supplemented by formula. d. Giving colostrum is important in helping the mother learn how to breast-feed before she goes home. ANS: B Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Colostrum provides immunity and enzymes necessary to clean the gastrointestinal system, among other things. Supplementation is not necessary. It will decrease stimulation to the breast and decrease the production of milk. It is important for the the infant is top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 437

mother to feel comfortable in this role before discharge, but the importance of the colostrum to

OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Physiologic Integrity

24. A newborn infant weighs 7 pounds, 2 ounces, on the fifth day of life. How much water

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should be given to the newborn based on required fluid needs? a. Fluid replacement should be based on weight and calculated in the range of 60 to 100 mL/kg.

b. Offer additional water to tolerance in between infant feedings to maintain hydration.

c. Give 12 ounces of fluid per feeding. d. No water is needed because formula and breast milk are adequate to maintain hydration. ANS: A There is an expected weight loss of up to 10% postdelivery, so fluid replacement should be calculated to improve health outcomes and maintain adequate hydration.12 ounces of fluid per feeding is excessive and may cause overdistention. Offering water between feedings to tolerance

may not provide enough fluid replacement. Newborn infants require additional water to supplement feedings and support hydration. PTS: 1 DIF: Cognitive Level: Analysis REF: 437 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 25. A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can

provide to help alleviate this physical complaint. The best nursing response would be to:

a. tell the client to wear a bra at all times to provide more support to breast tissue. b. have the client put the infant to her breast more frequently.

c. place ice packs on breast tissue after infant feeding.

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d. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing. ANS: B

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The client may be experiencing signs of engorgement. Intervention methods such as placing the infant to feed more frequently may help prevent physical complaints of tenderness to milk accumulation. Wearing a bra at all times will not help resolve engorgement issues but can

provide comfort. Ice packs provide symptomatic relief but do not resolve engorgement issues.

Warm water compresses are more likely to provide comfort. Engorgement is not a normal finding but is a common presentation in nursing mothers. These symptoms will not dissipate with continuation of breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 442, 451 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

26. A mother is attempting to breastfeed her infant in the hospital setting. The infant is sleepy and displays some audible swallowing, the maternal nipples are flat, and the breasts are soft. The nurse has attempted to teach the mother positioning on one side, and now the mother wants to place the infant to the breast on the other side. Based on LATCH scores, the nurse would designate a score of: a. 10 and document findings in the chart. b. 6 and further teach and assist the mother in feeding activities. c. 5 and tell the mother to discontinue feeding attempts at this time because the infant is too sleepy.

d. 8 and no further assistance is needed for feeding. ANS: B

The LATCH assessment tool is used to identify whether mothers need additional instruction in

the area of breastfeeding. The LATCH categories are latch, audible communication/swallowing, type of nipple, comfort of breasts, and holding position of infant. The assessment data reveal a

score of 6 (0 + 2 + 1 + 2 + 1) so the mother needs additional assistance during breastfeeding at

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this time.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 443 OBJ: Nursing Process Step: Evaluation

Care

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn

27. A mother conveys concern over the fact that she is not sure if her newborn child is getting enough nutrients from breastfeeding. This is the babys first clinic visit after birth. What information can you provide that will help alleviate her fears about nutrient status for her newborn? a. Monitor the infants output; as long as at least six or more diapers are changed in a 24-hour period, that should be sufficient.

b. Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy. c. Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition. d. Provide nutrition information in the form of pamphlets for the mother to take home with her so that she uses them as a point of reference. ANS: A The presence of wet diapers confirms that the infant is receiving enough milk. Recording weight and seeing an increase in weight is also an objective finding that can be used to note nutritional status. Newborns may be fussy and still be receiving adequate nutrition. Although breast milk is

potentially the perfect food for the newborn, not everyones breast milk has nutrient quality, so recording of weight gain and output measurements (wet diapers and stool production) confirm

nutritional status. Providing the mother with educational pamphlets may be advisable but does

not address the immediate problem.

PTS: 1 DIF: Cognitive Level: Application REF: 448

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OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn

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Care

28. A breastfeeding mother asks the postpartum nurse if any supplementation is necessary once

her breast milk comes in. What is the nurses best response?

a. Are you concerned about your ability to adequately nurse your baby? b. Do you eat a well-balanced diet, high in protein and carbohydrates? c. Breast milk is low in vitamin D and supplementation with 400 IU is recommended. d. Your breast milk has all the vitamins and will adequately meet your babys needs. ANS: C

Generally, nutrients provided in breast milk are present in amounts and proportions needed by the infant. However, recent studies have shown that the vitamin D content of breast milk is low, and daily supplementation with 400 IU of vitamin D is recommended within the first few days of life. Breastfeeding infants who are not exposed to the sun and those with dark skin are particularly at risk for insufficient vitamin D. Formula-fed infants who drink less than 1 quart of vitamin Dfortified milk per day should also be supplemented. Although the fatty acid content of breast milk is influenced by the mothers diet, malnourished mothers milk has about the same proportions of total fat, protein, carbohydrates, and most minerals as milk from those who are well nourished. Levels of water-soluble vitamins in breast milk are affected by the mothers intake and stores. It is important for breastfeeding women to eat a well-balanced diet to maintain

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 437

their own health and energy levels.

MSC: Client Needs: Health Promotion and Maintenance

29. A new mother is preparing for discharge. She plans on bottle feeding her baby. Which

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statement indicates to the nurse that the mom needs more information about bottle feeding?

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a. I should encourage my baby to consume the entire amount of formula prepared for each feeding. b. I can make up a 24-hour supply of formula and refrigerate the bottles so I am ready to feed my baby.

c. I will hold my baby in a cradle hold and alternate sides from left to right when I feed my baby. d. I will generally feed my baby every 3 to 4 hours or more as signs of hunger are displayed. ANS: A Infants will stop suckling when they are full. Encouraging them to overeat may lead to problems with regurgitation and possible aspiration. The mother can prepare a single bottle or a 24-hour supply if adequate refrigeration is available. Show the parents how to position the infant in a semiupright position, such as the cradle hold. This allows them to hold the infant close in a

faceto-face position. The bottle is held with the nipple kept full of formula to prevent excessive swallowing of air. Placing the infant in the opposite arm for each feeding provides varied visual stimulation during feedings. Feed the infant every 3 to 4 hours but avoid rigid scheduling and take cues from the infant. PTS: 1 DIF: Cognitive Level: Analysis REF: 458 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 30. A client who is receiving a pitocin (Oxytocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which

intervention would be a priority? a. Increase the rate of pitocin infusion to help spread out the contraction pattern.

b. Place oxygen on the client at 8 to 10 L/min via face mask and turn the client to her left side.

c. Stop the pitocin infusion.

d. Call the physician to obtain an order for the initiation of magnesium sulfate.

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ANS: C

The client is exhibiting uterine tachysystole (uterine tetany). The priority intervention is to stop

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the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician

may be contacted for additional orders.

Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy MULTIPLE CHOICE 1. A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a: a. diuretic. b. tocolytic.

c. anticonvulsant. d. antihypertensive. ANS: C Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate.

PTS: 1 DIF: Cognitive Level: Understanding REF: 523

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

b. Delivery of the fetus

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c. Antihypertensive medications

a. Magnesium sulfate

2. Which is the only known cure for preeclampsia?

ANS: B

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d. Administration of aspirin (ASA) every day of the pregnancy

If the fetus is viable and near term, birth is the only known cure for preeclampsia. Magnesium

sulfate is one of the medications used to treat but not cure preeclampsia. Antihypertensive

medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of aspirin (60 to 80 mg) have been administered to women at high risk for developing preeclampsia. PTS: 1 DIF: Cognitive Level: Understanding REF: 519 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia? a. Edema b. Proteinuria c. Glucosuria d. Hypertension ANS: C Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign

noted by the pregnant client is rapid weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension. The first indication of preeclampsia is

usually an increase in the maternal blood pressure.

PTS: 1 DIF: Cognitive Level: Application REF: 521

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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4. Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome?

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a. Abdominal palpation

b. Venous sample of blood

c. Checking deep tendon reflexes

d. Auscultation of the heart and lungs ANS: A

Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated. Venous blood is checked frequently to observe for thrombocytopenia. PTS: 1 DIF: Cognitive Level: Application REF: 529

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 5. A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area? a. +1 b. +2 c. +3

d. +4

ANS: C

Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is +2

edema. Generalized massive edema (+4) includes the accumulation of fluid in the peritoneal

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cavity.

PTS: 1 DIF: Cognitive Level: Application REF: 526

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

6. A client is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. Which potential problem should be investigated? a. Placenta previa b. Hydatidiform mole c. Abruptio placentae d. Disseminated intravascular coagulation (DIC) ANS: B

Gestational trophoblastic disease (hydatidiform mole) is usually detected in the first trimester of pregnancy. The frequency of this condition is highest at both ends of a womans reproductive life. Placenta previa usually occurs in the third trimester. Painless uterine bleeding is the classic symptom. Abruptio placentae usually occurs in the third trimester. Painful uterine bleeding is the classic symptom. DIC is a life-threatening complication of abruptio placentae, in which procoagulation and anticoagulation factors are simultaneously activated. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

7. Which maternal condition always necessitates birth by cesarean section? a. Partial abruptio placentae

b. Total placenta previa

c. Ectopic pregnancy

d. Eclampsia

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ANS: B

In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a

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vaginal birth occurred. If the client has stable vital signs and the fetus is alive, a vaginal birth can be attempted. If the fetus has died, a vaginal birth is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor

can be safely induced if the eclampsia is under control.

PTS: 1 DIF: Cognitive Level: Understanding REF: 512 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Spontaneous termination of a pregnancy is considered to be an abortion if: a. the pregnancy is less than 20 weeks. b. the fetus weighs less than 1000 g. c. the products of conception are passed intact.

d. there is no evidence of intrauterine infection. ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some fetuses of an older age may have a low birth weight. A spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection. PTS: 1 DIF: Cognitive Level: Understanding REF: 505

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. An abortion when the fetus dies but is retained in the uterus is called:

a. inevitable.

b. missed. c. incomplete.

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d. threatened. ANS: B

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A missed abortion refers to a dead fetus being retained in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all the products of conception were expelled. With a threatened abortion, the client has cramping

and bleeding but not cervical dilation. PTS: 1 DIF: Cognitive Level: Understanding REF: 506 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 10. A placenta previa when the placental edge just reaches the internal os is called: a. total. b. partial.

c. low-lying. d. marginal. ANS: D A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. With a partial previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete previa is termed total. The placenta completely covers the internal cervical os.

PTS: 1 DIF: Cognitive Level: Understanding REF: 513 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. Which would indicate concealed hemorrhage in abruptio placentae?

a. Bradycardia

c. Decrease in fundal height

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d. Decrease in abdominal pain

b. Hard boardlike abdomen

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ANS: B

Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle

results in a very firm, boardlike abdomen. The client will have shock symptoms that include

tachycardia. The fundal height will increase as bleeding occurs. Abdominal pain may increase. PTS: 1 DIF: Cognitive Level: Analysis REF: 516 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 12. The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to:

a. monitor uterine contractions. b. assess fetal heart rate and maternal vital signs. c. place clean disposable pads to collect any drainage. d. perform a venipuncture for hemoglobin and hematocrit levels. ANS: B Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus. Monitoring uterine contractions is important, but not the top priority. It is important to assess future bleeding, but the top priority is client and fetal well-being. The most important assessment is to check client and

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 516

fetal well-being. The blood levels can be obtained later.

MSC: Client Needs: Physiologic Integrity

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13. A primigravida of 28 years of age is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following?

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a. She should be isolated from her family.

b. This condition is caused by psychogenic factors.

c. The treatment is similar to that for morning sickness.

d. She should be assessed for signs of dehydration and starvation. ANS: D

The cause of hyperemesis gravidarum is unknown, but dehydration and starvation are the major complications. Emotional support is essential to the care of this client. She needs the opportunity to express how it feels to live with constant nausea. The cause is unknown. The first attempts to control the nausea are to treat it like morning sickness, but if treatment is not successful, further care is needed.

PTS: 1 DIF: Cognitive Level: Application REF: 518 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 14. A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to: a. advise her to cut down on fast foods that are high in fat. b. caution her to avoid salty foods and to return in 2 weeks. c. assess weight gain, location of edema, and urine for protein.

d. recommend she stay home from school for a few days to reduce stress. ANS: C

The nurse should further assess the client for hypertension, generalized edema, and proteinuria,

which are classic signs of pregnancy-induced hypertension. Cutting down on fast foods will not relieve the symptoms of pregnancy-induced hypertension. She is at risk for pregnancy-induced

hypertension and should be evaluated at this visit. Rest may be the treatment at first, but she

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needs further assessment to determine if pregnancy-induced hypertension is the problem. PTS: 1 DIF: Cognitive Level: Application REF: 526

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

15. A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate: a. gastrointestinal upset. b. effects of magnesium sulfate. c. anxiety caused by hospitalization. d. worsening disease and impending convulsion. ANS: D

Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. Gastrointestinal upset is not an indication as severe as the headache and visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe anxiety. PTS: 1 DIF: Cognitive Level: Analysis REF: 520 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 16. Rh incompatibility can occur if the client is Rh-negative and the:

a. fetus is Rh-negative.

c. father is Rh-positive.

d. father and fetus are both Rh-negative.

b. fetus is Rh-positive.

ANS: B

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For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive. If the fetus is Rh-negative, the blood types are compatible and no problems should occur. The fathers

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Rh factor is a concern only as it relates to the possible Rh factor of the fetus. If the fetus is Rhnegative, the blood type with the mother is compatible. The fathers blood type does not enter into the problem.

PTS: 1 DIF: Cognitive Level: Understanding REF: 530 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 17. In which situation would a dilation and curettage (D&C) be indicated? a. Complete abortion at 8 weeks b. Incomplete abortion at 16 weeks c. Threatened abortion at 6 weeks d. Incomplete abortion at 10 weeks

ANS: D D&C is carried out to remove the products of conception from the uterus and can be done safely until week 14 of gestation. If all the products of conception have been passed (complete abortion), a D&C is not done. If the pregnancy is still viable (threatened abortion), a D&C is not done. PTS: 1 DIF: Cognitive Level: Understanding REF: 506 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

18. Which orders should the nurse expect for a client admitted with a threatened abortion? a. NPO

b. Pad count

d. Meperidine (Demerol), 50 mg now

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ANS: B

c. Ritodrine IV

A client admitted with a threatened abortion should be instructed to count the number of perineal pads used and to note the quantity and color of blood on the pads. Ritodrine is not the first drug

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of choice for tocolytic medications. There is no reason for having the client NPO. At times, dehydration may produce contractions, so hydration is important. Demerol will not decrease the

contractions but may mask the severity of the contractions.

PTS: 1 DIF: Cognitive Level: Application REF: 505 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 19. Which data found on a clients health history would place her at risk for an ectopic pregnancy? a. Ovarian cyst 2 years ago b. Recurrent pelvic infections

c. Use of oral contraceptives for 5 years d. Heavy menstrual flow of 4 days duration ANS: B Infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for implantation. Ovarian cysts do not cause scarring of the fallopian tubes. Oral contraceptives do not increase the risk for ectopic pregnancies. Heavy menstrual flow of 4 days duration will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnancies.

PTS: 1 DIF: Cognitive Level: Understanding REF: 508

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

a. Blood pressure of 120/80 mm Hg

b. Complaint of frequent mild nausea

20. Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?

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c. Fundal height measurement of 18 cm

ANS: C

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d. History of bright red spotting for 1 day weeks ago

The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis

of the duration of the pregnancy. A client with a molar pregnancy may have early-onset,

pregnancy-induced hypertension. Nausea increases in a molar pregnancy because of the increased production of human chorionic gonadotropin (hCG). The history of bleeding is normally described as being of a brownish color. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa? a. Determining cervical dilation and effacement b. Monitoring FHR and maternal vital signs c. Observing vaginal bleeding or leakage of amniotic fluid d. Determining frequency, duration, and intensity of contractions ANS: A Vaginal examination of the cervix may result in perforation of the placenta and subsequent

hemorrhage. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this client. Monitoring for bleeding and rupture of membranes is not contraindicated with this

client. Monitoring contractions is not contraindicated with this client.

PTS: 1 DIF: Cognitive Level: Analysis REF: 512

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

is:

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a. vaginal bleeding.

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22. The primary symptom present in abruptio placentae that distinguishes it from placenta previa

b. rupture of membranes.

c. presence of abdominal pain.

d. changes in maternal vital signs. ANS: C

Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding. Both abruptio placentae and placenta previa may have vaginal bleeding. Rupture of membranes may occur with both conditions. Maternal vital signs may change with both if bleeding is pronounced. PTS: 1 DIF: Cognitive Level: Understanding REF: 515

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 23. A laboratory finding indicative of DIC is: a. decreased fibrinogen. b. increased platelets. c. increased hematocrit. d. decreased thromboplastin time. ANS: A

DIC develops when the blood-clotting factor thromboplastin is released into the maternal bloodstream as a result of placental bleeding. Thromboplastin activates widespread clotting, which uses the available fibrinogen, resulting in a decreased fibrinogen level. The platelet count

will decrease. The hematocrit may decrease if bleeding is pronounced. The thromboplastin time

is prolonged.

PTS: 1 DIF: Cognitive Level: Analysis REF: 507

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 24. Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate

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would indicate a therapeutic level of medication? a. Drowsiness

b. Urinary output of 20 mL/hr

c. Normal deep tendon reflexes d. Respiratory rate of 10 to 12 breaths/min ANS: C Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium

toxicity. A urinary output of 20 mL/hr is not adequate output. A respiratory rate of 10 to 12 breaths/min is too slow and could be indicative of magnesium toxicity. PTS: 1 DIF: Cognitive Level: Analysis REF: 525 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 25. A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take? a. Increase the clients IV fluids.

b. Administer calcium gluconate. c. Vigorously stimulate the client.

d. Instruct the client to take deep breaths.

ANS: B

Calcium gluconate reverses the effects of magnesium sulfate. Increasing the clients IV fluids will

not reverse the effects of the medication. Stimulation will not increase the respirations. Deep

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breaths will not be successful in reversing the effects of the magnesium sulfate.

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PTS: 1 DIF: Cognitive Level: Application REF: 525 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following? a. Hemorrhage is the major concern. b. She will be unable to conceive in the future. c. Bed rest and analgesics are the recommended treatment. d. A D&C will be performed to remove the products of conception.

ANS: A Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, her fertility will decrease but she will not be infertile. The recommended treatment is to remove the pregnancy before hemorrhaging. A D&C is done on the inside of the uterine cavity. The ectopic is located within the tubes. PTS: 1 DIF: Cognitive Level: Understanding REF: 507, 508 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 27. You are taking care of a client who had a therapeutic abortion following an episode of

vaginal bleeding and ultrasound confirmation of a blighted ovum. Lab work is ordered 2 weeks postprocedure as a follow-up to medical care. Which result indicates that additional intervention

is needed?

a. Hemoglobin, 13.2 mg/dL

c. Beta-hCG detected in serum

b. White blood cell count, 10,000 mm3

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d. Fasting blood glucose level, 80 mg/dL

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ANS: C

The presence of beta-hCG in serum 2 weeks after the procedure is clinically significant and indicates the possibility that there may have been a molar pregnancy (hydatidiform). Thus,

further examination is required. None of the other lab results warrant intervention because they

are within normal limits. PTS: 1 DIF: Cognitive Level: Analysis REF: 509 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 28. A female client presents to the emergency room complaining of lower abdominal cramping with scant bleeding of approximately 2 days duration. This morning, the quality and location of

the pain changed and she is now experiencing pain in her shoulder. The clients last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days. Which clinical diagnosis does the nurse suspect? a. Ectopic pregnancy b. Appendicitis c. Food poisoning d. Gastroenteritis ANS: A

Even though the clients menstrual cycle has variability, all women are considered to be pregnant until proven otherwise. The clients presenting symptoms are typical for ectopic pregnancy, so the

client should be monitored for the possible complication of rupture and shock.

PTS: 1 DIF: Cognitive Level: Application REF: 507, 508

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

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29. A client who was pregnant had a spontaneous abortion at approximately 4 weeks gestation. At the time of the miscarriage, it was thought that all products of conception were expelled. Two

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weeks later, the client presents at the clinic office complaining of crampy abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100 F, with blood pressure of 100/60 mm Hg,

irregular pulse 88 beats/min (bpm), and respirations, 20 breaths/min. Based on these assessment

data, what does the nurse anticipate as a clinical diagnosis? a. Ectopic pregnancy b. Uterine infection c. Gestational trophoblastic disease d. Endometriosis ANS: B

The client is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and blood pressure and pulse manifesting as shock-trended vitals. Because the pregnancy test is negative, an undiagnosed ectopic pregnancy and gestational trophoblastic disease are ruled out. There is no supportive evidence to indicate a clinical diagnosis of endometriosis at this time; however, it is more likely that this is an infectious process that must be aggressively treated. PTS: 1 DIF: Cognitive Level: Analysis REF: 506 OBJ: Nursing Process Step: Diagnosis

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 30. A client with no prenatal care delivers a healthy male infant via the vaginal route, with

minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of

heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6-

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client is exhibiting?

week checkup and is found to be hypertensive. Which type of hypertension do you think the

a. Pregnancy-induced hypertension (PIH)

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b. Gestational hypertension

c. Preeclampsia superimposed on chronic hypertension

ANS: D

d. Undiagnosed chronic hypertension

Even though the client has no documented prenatal care or medical history, she does relate a family history that is positive for heart disease. Additionally, the clients blood pressure increased following birth and was treated in the hospital and resolved. Now the client appears at the 6week checkup with hypertension. Typically, gestational hypertension resolves by the end of the 6-week postpartum period. The fact that this has not resolved is suspicious for undiagnosed chronic hypertension. There is no evidence to suggest that the client was preeclamptic prior to the birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 31. A high-risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean section. Which finding in the immediate postoperative period indicates that the client is at risk of developing HELLP syndrome? a. Platelet count of 50,000/ L

b. Liver enzyme levels within normal range c. Negative for edema

d. No evidence of nausea or vomiting

ANS: A

HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels, and a low platelet

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count. A platelet count of 50,000/ L indicates thrombocytopenia. PTS: 1 DIF: Cognitive Level: Analysis REF: 529

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OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Pathophysiology 32. As the triage nurse in the emergency room, you are reviewing results for the high- risk

obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that: a. immediate birth is required. b. the client should be transferred to the critical care unit for closer observation. c. RhoGAM should be administered. d. a tetanus shot should be administered.

ANS: A A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and, because the client is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore, the client should be delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered, because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time because there is no evidence of penetrating trauma. The client should be transferred to the obstetric area for birth, not the critical care unit setting.

PTS: 1 DIF: Cognitive Level: Analysis REF: 516 OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity: Medical Emergencies

33. A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and

birth nurse performs the following assessments. The vaginal exam is deferred until the physician

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is in attendance. The client is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does

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not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and

no fetal heart tones are observed. What does the nurse suspect is occurring?

a. Placental previa

b. Active labor has started c. Placental abruption d. Hidden placental abruption ANS: D

The clients signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention and imminent birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity: Medical Emergencies 34. The most appropriate nursing action for the client complaining of continuous headache 24

hours postpartum after a normal vaginal birth is to: a. encourage bed rest.

b. administer analgesic. c. assess blood pressure.

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ANS: C

d. assess for pitting edema.

The first indication of preeclampsia is usually hypertension. Continuous headache indicates poor cerebral perfusion and may be a precursor of seizures; encouraging bed rest, administering an headache.

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analgesic, and assessing for edema are not interventions to determine the source of the clients

PTS: 1 DIF: Cognitive Level: Application REF: 521 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 35. Which assessment finding indicates an adverse response to magnesium sulfate? a. Urine output of 30 mL/hr b. Respiratory rate of 11 breaths/min

c. Hypoactive patellar reflex d. Blood pressure reading of 110/80 mm Hg ANS: B A respiratory rate less than 12 breaths/min indicates magnesium toxicity and requires immediate intervention. A urine output of 30 mL/hr is normal urinary output; a hypoactive patellar reflex and blood pressure reading of 110/80 mm Hg are normal findings in the client receiving magnesium sulfate.

PTS: 1 DIF: Cognitive Level: Analysis REF: 525 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

36. Which finding could cause the nurse to suspect gestational trophoblastic disease in a client at

b. Fundal height of 12 cm

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c. Nausea and vomiting

a. Blood pressure of 128/70 mm Hg

8 weeks gestation?

ANS: B

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d. Weight gain of 3 pounds

Gestational trophoblastic disease is characterized by proliferation and edema of the chorionic

villi. The fluid-filled villi form grapelike clusters of tissue that can rapidly grow to fill the uterus

to the size of a more advanced pregnancy. Blood pressure of 128/70 mm Hg, nausea and vomiting, and weight gain of 3 pounds are all normal findings in the first trimester. PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 37. Which finding should be the nurses priority in a client suspected as having gestational trophoblastic disease?

a. Uterine contractions b. Nausea and vomiting c. Blood pressure of 130/80 mm Hg d. Increase discharge of vaginal mucus ANS: A Uterine contractions can cause trophoblastic tissue to be pulled into large venous sinusoids in the uterus, resulting in embolization of the tissue and respiratory distress. Nausea and vomiting and blood pressure of 130/80 mm Hg represent no immediate danger to the client and can be

addressed later. Increased discharge of vaginal mucus is a normal finding in pregnancy.

Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications

MULTIPLE CHOICE

pregnant client with diabetes?

1. Which factor is most important in diminishing maternal, fetal, and neonatal complications in a

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a. Evaluation of retinopathy by an ophthalmologist b. The clients stable emotional and psychological status

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c. Degree of glycemic control before and during the pregnancy

ANS: C

d. Total protein excretion and creatinine clearance within normal limits

The occurrence of complications can be greatly diminished by maintaining normal blood glucose levels before and during the pregnancy. Even nonpregnant diabetics should have an annual eye examination. Assessing a clients emotional status is helpful. Coping with a pregnancy superimposed on preexisting diabetes can be very difficult for the whole family. However, it is not the top priority. Baseline renal function is assessed with a 24-hour urine collection and does not diminish the clients risk for complications. PTS: 1 DIF: Cognitive Level: Understanding REF: 539

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. Which major neonatal complication is carefully monitored after the birth of the infant of a diabetic mother? a. Hypoglycemia b. Hypercalcemia c. Hypoinsulinemia d. Hypobilirubinemia

ANS: A The neonate is at highest risk for hypoglycemia because fetal insulin production is accelerated during pregnancy to metabolize excessive glucose from the mother. At birth, the maternal

glucose supply stops, and the neonatal insulin exceeds the available glucose, leading to

hypoglycemia. Hypocalcemia is associated with preterm birth, birth trauma, and asphyxia, all common problems of the infant of a diabetic mother. Because fetal insulin production is

accelerated during pregnancy, the neonate shows hyperinsulinemia. Excess erythrocytes are

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broken down after birth, releasing large amounts of bilirubin into the neonates circulation, which results in hyperbilirubinemia.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 539 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

3. Which factor is known to increase the risk of gestational diabetes mellitus? a. Previous birth of large infant b. Maternal age younger than 25 years c. Underweight prior to pregnancy d. Previous diagnosis of type 2 diabetes mellitus ANS: A

Prior birth of a large infant suggests gestational diabetes mellitus. A client younger than 25 is not at risk for gestational diabetes mellitus. Obesity (>90 kg [198 lb]) creates a higher risk for gestational diabetes. The person with type 2 diabetes mellitus already is a diabetic and will continue to be so after pregnancy. Insulin may be required during pregnancy because oral hypoglycemia drugs are contraindicated during pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 541 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 4. Which disease process improves during pregnancy?

a. Epilepsy

c. Rheumatoid arthritis

d. Systemic lupus erythematosus (SLE)

b. Bells palsy

ANS: C

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Although the reason is unclear, marked improvement is seen with rheumatoid arthritis in pregnancy. Most women relapse 6 weeks to 6 months postpartum. With epilepsy, the effect of

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pregnancy is variable and unpredictable. Seizures may increase, decrease, or remain the same. Bells palsy was thought to be caused by a virus three times more common during pregnancy and generally occurring in the third trimester. The client with SLE can have a normal pregnancy but

must be treated as high risk because 50% of all births will be premature. Pregnancy can

exacerbate SLE.

PTS: 1 DIF: Cognitive Level: Understanding REF: 555 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 5. When a pregnant client with diabetes experiences hypoglycemia while hospitalized, which should the nurse have the client do? a. Eat a candy bar.

b. Eat six saltine crackers or drink 8 oz of milk. c. Drink 4 oz of orange juice followed by 8 oz of milk. d. Drink 8 oz of orange juice with 2 teaspoons of sugar added. ANS: B Crackers provide carbohydrates in the form of polysaccharides. A candy bar provides only monosaccharides. Milk is a disaccharide and orange juice is a monosaccharide. This will help increase the blood sugar level but will not sustain it. Orange juice and sugar will increase the

PTS: 1 DIF: Cognitive Level: Application REF: 545

MSC: Client Needs: Physiologic Integrity

OBJ: Nursing Process Step: Implementation

blood sugar level but will not provide a slow-burning carbohydrate to sustain it.

6. Nursing intervention for pregnant clients with diabetes is based on the knowledge that the

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need for insulin is:

a. varied depending on the stage of gestation. b. increased throughout pregnancy and the postpartum period.

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c. decreased throughout pregnancy and the postpartum period.

ANS: A

d. should not change because the fetus produces its own insulin.

Insulin needs decrease during the first trimester, when nausea, vomiting, and anorexia are a factor. Insulin needs increase during the second and third trimesters, when the hormones of pregnancy create insulin resistance in maternal cells. Insulin needs change during pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 540 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 7. Which form of heart disease in women of childbearing years usually has a benign effect on pregnancy? a. Cardiomyopathy b. Mitral valve prolapse c. Rheumatic heart disease d. Congenital heart disease

ANS: B Mitral valve prolapse is a benign condition that is usually asymptomatic. Cardiomyopathy produces congestive heart failure during pregnancy. Rheumatic heart disease can lead to heart

or endocarditis during pregnancy.

failure during pregnancy. Some congenital heart diseases will produce pulmonary hypertension

PTS: 1 DIF: Cognitive Level: Understanding REF: 548

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which instructions should the nurse include when teaching a pregnant client with Class II

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heart disease?

a. Advise her to gain at least 30 pounds.

b. Instruct her to avoid strenuous activity.

c. Inform her of the need to limit fluid intake. d. Explain the importance of a diet high in calcium. ANS: B Activity may need to be limited so that cardiac demand does not exceed cardiac capacity. Weight gain should be kept at a minimum with heart disease. Iron and folic acid are important to prevent anemia. Fluid intake is necessary to prevent fluid deficits. Fluid intake should not be limited during pregnancy. The client may also be put on a diuretic.

PTS: 1 DIF: Cognitive Level: Understanding REF: 548 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 9. The most important instruction to include in a teaching plan for a client in early pregnancy who has Class I heart disease is she: a. must report any nausea or vomiting. b. may experience mild fatigue in early pregnancy.

c. must report any chest discomfort or productive cough. d. should plan to increase her daily exercise gradually throughout pregnancy.

ANS: C

Angina or a productive cough may signal congestive heart failure or pulmonary edema. Nausea and vomiting are expected in early pregnancy. Mild fatigue is expected in early pregnancy.

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Depending on the severity of the heart disease, the client may need to limit physical activity. PTS: 1 DIF: Cognitive Level: Understanding REF: 548

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 10. Antiinfective prophylaxis is indicated for a pregnant client with a history of mitral valve

stenosis related to rheumatic heart disease because the client is at risk of developing: a. hypertension. b. postpartum infection. c. bacterial endocarditis. d. upper respiratory infections. ANS: C

Because of vegetations on the leaflets of the mitral valve and the increased demands of pregnancy, the client is at greater risk of bacterial endocarditis. Pulmonary hypertension may occur with mitral valve stenosis, but antiinfective medications will not prevent it from occurring. Women with cardiac problems must be observed for possible infections during the postpartum period but are not given prophylactic antibiotics to prevent them. Women are not put on prophylactic antibiotics to prevent upper respiratory infections. PTS: 1 DIF: Cognitive Level: Understanding REF: 549 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

11. When planning intrapartum care for a client with heart disease, the nurse should include: a. taking vital signs according to standard protocols.

b. continuously monitoring cardiac rhythm with telemetry.

c. massaging the uterus to hasten birth of the placenta.

d. maintaining the infusion of intravenous fluids to avoid dehydration.

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ANS: B

A client with heart disease should have a cardiac monitor and possibly an arterial line for

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continuous blood pressure monitoring, as well as hemodynamic monitoring. Vital signs may need to be taken more frequently because of the extra workload on the heart. The uterus should not be massaged to hasten the birth of the placenta because this could cause undue overload on

the heart. Circulatory overload can occur, so IV fluids may not be used or may be used

minimally.

PTS: 1 DIF: Cognitive Level: Application REF: 549 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 12. For which of the following infectious diseases can a woman be immunized?

a. Rubella b. Toxoplasmosis c. Cytomegalovirus d. Herpesvirus type 2 ANS: A Rubella is the only infectious disease for which a vaccine is available. There are no vaccines available for toxoplasmosis, cytomegalovirus, or herpesvirus type 2.

PTS: 1 DIF: Cognitive Level: Understanding REF: 556 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

13. A client, who delivered her third child yesterday, has just learned that her two school-age

children have contracted chickenpox. What should the nurse tell her?

a. Her two children should be treated with acyclovir before she goes home from the hospital.

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b. The baby will acquire immunity from her and will not be susceptible to chickenpox.

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c. The children can visit their mother and baby in the hospital as planned but must wear gowns and masks.

ANS: D

d. She must make arrangements to stay somewhere other than her home until the children are no longer contagious.

Varicella (chickenpox) is highly contagious. Although the baby inherits immunity from the mother, it would not be safe to expose either the mother or the baby. Acyclovir is used to treat varicella pneumonia. The baby is already born and has received the immunity. If the mother never had chickenpox, she cannot transmit the immunity to the baby. Varicella infection occurring in a newborn may be life threatening. PTS: 1 DIF: Cognitive Level: Application REF: 557

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 14. A client has a history of drug use and is screened for hepatitis B during the first trimester. Which action is appropriate? a. Practice respiratory isolation. b. Plan for retesting during the third trimester. c. Discuss the recommendation to bottle feed her baby.

d. Anticipate administering the vaccination for hepatitis B as soon as possible. ANS: B

A person who has a history of high-risk behaviors should be rescreened during the third

trimester. Hepatitis B is transmitted through blood. The first trimester is too early to discuss feeding methods with a woman in the high-risk category. The vaccine may not have time to

affect a person with high-risk behaviors.

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PTS: 1 DIF: Cognitive Level: Application REF: 560

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OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 15. A client has tested HIV-positive and has now discovered that she is pregnant. Which

statement indicates that she understands the risks of this diagnosis?

a. I know I will need to have an abortion as soon as possible. b. Even though my test is positive, my baby might not be affected. c. My baby is certain to have AIDS and die within the first year of life. d. This pregnancy will probably decrease the chance that I will develop AIDS. ANS: B The fetus is likely to test positive for HIV in the first 6 months, until the inherited immunity from the mother wears off. Many of these babies will convert to HIV-negative status. With the newer

drugs, the risk for infection of the fetus has decreased. Also, the life span of an infected newborn has increased. The pregnancy will increase the chance of converting. PTS: 1 DIF: Cognitive Level: Analysis REF: 562 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 16. A client who has type 2 diabetes is pregnant with her second child. She was not diagnosed with diabetes until after her first pregnancy. Past obstetric history is unremarkablespontaneous vaginal birth of a male weighing 7 pounds, 15 ounces. The client is now concerned over what will happen during this subsequent pregnancy as a result of her disease process. What impact

could the disease process have on her upcoming birth? a. Client will not be able to receive an epidural for pain management.

b. Client will not be able to have a vaginal birth.

c. A planned birth will be instituted by her health care provider.

d. It is likely that she will deliver a fetus who is small for gestational age (SGA).

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ANS: C

Because of the presence of diabetes as a concurrent disease, the client will be closely monitored

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and a planned birth will be instituted to improve health outcomes for mother and fetus. Epidurals can be administered to obstetric clients who are diabetics. Although there is an increased risk for macrosomia and dystocia, the client will be prospectively managed and may still be able to have

a vaginal birth. Because of the presence of diabetes as a concurrent disease, it is more likely that

she will deliver a macrosomic infant who would be large for gestational age (LGA). PTS: 1 DIF: Cognitive Level: Analysis REF: 541 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 17. Which client teaching instructions are necessary for a pregnant client who is to undergo a glucose challenge test (GCT) as part of a routine pregnancy treatment plan?

a. Consume a low-fat diet for 48 hours prior to testing. b. Fast for 12 hours prior to testing. c. There are no dietary restrictions prior to testing. d. Consume a consistent carbohydrate diet (60 g) prior to testing. ANS: C For a GCT, there are no dietary restrictions and fasting is not required. Testing is done from 24 to 28 weeks for the general pregnant population.

PTS: 1 DIF: Cognitive Level: Application REF: 541 OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

18. Examination of a newborn in the birth room reveals bilateral cataracts. Which disease

process in the maternal history would likely cause this abnormality?

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a. Rubella b. Cytomegalovirus (CMV)

d. HIV

ANS: A

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c. Syphilis

Transmission of congenital rubella causes serious complications in the fetus that may manifest as cataracts, cardiac defects, microcephaly, deafness, intrauterine growth restriction (IUGR), and developmental delays. PTS: 1 DIF: Cognitive Level: Application REF: 556 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

19. Which postpartum client requires further assessment? a. G4 P4 who has had four saturated pads during the last 12 hours b. G1 P1 with Class II heart disease who complains of frequent coughing c. G2 P2 with gestational diabetes whose fasting blood sugar level is 100 mg/dL d. G3 P2 postcesarean client who has active herpes lesions on the labia ANS: B Frequent coughing may be a sign of congestive heart failure in the postpartum client with heart disease. Four saturated pads in a 4-hour period is acceptable postpartum blood loss, a fasting assessment.

PTS: 1 DIF: Cognitive Level: Analysis REF: 550

blood sugar is a normal value, and the client with identified active herpes does not require further

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

20. The labor nurse is providing care to a patient at 37 weeks gestation who is an insulin-

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dependent diabetic. The health care provider prescribes an infusion of insulin throughout her induction to be titrated to keep her blood glucose levels below 110 mg/dL. What type of insulin

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will the nurse select to prepare the infusion? a. NPH insulin

b. Regular insulin

c. Lispro (Humalog) d. Aspart (Novolog) ANS: B Continuous infusion of a regular insulin solution combined with a separate intravenous solution containing glucose, such as 5% dextrose in Ringers lactate, allows titration to maintain blood glucose levels between 80 and 110 mg/dL, or as designated by facility policy. The insulin

solution is raised, lowered, or discontinued to maintain euglycemia based on hourly capillary blood glucose levels. PTS: 1 DIF: Cognitive Level: Understanding REF: 540 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 21. The nurse is reviewing the instructions given to a patient at 24 weeks gestation for a glucose tolerance test (GCT). The nurse determines that the patient understands the teaching when she makes which statement? a. I have to fast the night before the test.

b. I will drink a sugary solution containing 100 grams of glucose.

c. I will have blood drawn at 1 hour after I drink the glucose solution.

d. I should keep track of my babys movements between now and the test. ANS: C

A GCT is administered between 24 and 28 weeks of gestation, often to low- and high-risk

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antepartum patients. Fasting is not necessary for a GCT, and the woman is not required to follow any pretest dietary instructions. The woman should ingest 50 g of oral glucose solution, and 1

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hour later a blood sample is taken. Fetal surveillance with kick counts is an ongoing evaluation for pregnant women; they should contact their health care provider if there is a noticeable decrease in fetal movement.

PTS: 1 DIF: Cognitive Level: Application REF: 541 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 22. The results of a pregnant patients glucose tolerance test (GTT) were 158 mg/dL. What is the next test that the nurse will include in the patients teaching plan? a. Urinalysis b. Amniocentesis c. Nonstress test

d. Oral glucose tolerance test (OGTT) ANS: D If the blood glucose concentration for a GTT is 140 mg/dL or greater, a 3-hour oral glucose tolerance test is recommended. The woman must fast from midnight on the day of the test. After a fasting plasma glucose level is determined, the woman should ingest 100 g of oral glucose solution. Plasma glucose levels are then determined at 1, 2, and 3 hours. Gestational diabetes is the diagnosis if the fasting blood glucose level is abnormal. PTS: 1 DIF: Cognitive Level: Understanding REF: 541

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

23. The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum.

What is the nurses next action?

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a. Ask the patient when she last had anything to eat or drink. b. Take a culture of the lesions to verify the involved organism.

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c. Ask the patient if she has had unprotected sex since her outbreak.

ANS: A

d. Use electronic fetal surveillance to determine a baseline fetal heart rate.

A cesarean birth is recommended for women with active lesions in the genital area, whether recurrent or primary, at the time of labor. The patients dietary intake is needed to prepare for surgery. This patient is in active labor and the fetus is at risk for infection if the membranes rupture. The health care provider needs to be notified, and a cesarean section needs to be performed as soon as possible. There is no need to validate the infection because the patient is well aware of the symptoms of an active infection. Although transmission to sexual partners is valid information, it is not necessary information in an urgent situation such as depicted in this scenario. Electronic fetal surveillance is the standard of care.

PTS: 1 DIF: Cognitive Level: Synthesis REF: 557 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. A pregnant patient with acquired immunodeficiency syndrome (AIDS) is reviewing infant care instructions with the prenatal nurse. Which patient statement indicates to the nurse that the teaching was effective? a. I will bathe my baby twice a day. b. I will use premixed formula to feed my baby. c. I will use gloves to change my babys diapers.

d. I will use alcohol wipes six times a day on the babys cord until it falls off.

ANS: B

Breast milk or prechewed food from an infected person can cause infant infection, so the patient with AIDS should bottle feed her baby. The infant does not require additional bathing. The

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drying and irritating to the skin.

patient has AIDS and transmission from the infants urine or stool is not an issue. Alcohol can be

PTS: 1 DIF: Cognitive Level: Application REF: 561

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

25. An infant of a diabetic mom arrives in the nursery unit for observation. The infant is term at 38 weeks gestation and weighs 10 pounds. The maternal hemoglobin A1c level is noted at 10%. Which findings would the nurse suspect as being present? (Select all that apply.) a. Fetus is jittery, temperature is decreased b. Nasal flaring and retractions c. Slight jaundice noted on blanching of nose d. Calcium level of 10 mg/dL

ANS: A, B, C The most common complications with regard to fetal presentation in the context of maternal preexisting diabetes are hypoglycemia, hypokalemia, hyperbilirubinemia, and respiratory distress syndrome. Maternal hemoglobin A1c levels indicate that glycemic control has not been maintained, so the fetus is at risk to develop complications.

Chapter 18: Labor at Risk MULTIPLE CHOICE

1. Which pelvic shape is most conducive to vaginal labor and birth?

a. Android b.Gynecoid c. Platypelloid d.Anthropoid

ANS: B

The gynecoid pelvis is round and cylinder-shaped, with a wide pubic arch. The prognosis for a

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vaginal birth is good. Only 30% of women have an android-shaped pelvis, which has a poor prognosis for vaginal birth. The anthropoid pelvis is a long narrow oval, with a narrow pubic

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arch. It is more favorable than the android or platypelloid pelvic shape. The platypelloid pelvis is flat, wide, short, and oval and has a very poor prognosis for vaginal birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 574

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. Which action by the nurse prevents infection in the labor and birth area? a. Using clean techniques for all procedures b.Keeping underpads and linens as dry as possible c. Cleaning secretions from the vaginal area by using a back to front motion d.Performing vaginal examinations every hour while the client is in active labor ANS: B

Bacterial growth prefers a moist, warm environment. Use an aseptic technique if membranes are not ruptured; use a sterile technique if membranes are ruptured. Vaginal drainage should be removed with a front to back motion to decrease fecal contamination. Vaginal examinations should be limited to decrease transmission of vaginal organisms into the uterine cavity. PTS: 1 DIF: Cognitive Level: Application REF: 576 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 3. A pregnant client with premature rupture of membranes is at higher risk for postpartum

infection. Which assessment data indicate a potential infection?

a. Fetal heart rate, 150 beats/min b.Maternal temperature, 99 F c. Cloudy amniotic fluid, with strong odor d.Lowered maternal pulse and decreased respiratory rates

ANS: C

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Amniotic fluid should be clear and have a mild odor, if any. Fetal tachycardia of greater than 160 beats/min is often the first sign of intrauterine infection. A temperature of 100.4 F or higher is a

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classic symptom of infection. Vital signs should be assessed hourly to identify tachycardia or tachypnea, which often accompany temperature elevation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 576

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 4. A client in labor at 34 weeks of gestation is hospitalized and treated with intravenous magnesium sulfate for 18 to 20 hours. When the magnesium sulfate is discontinued, which oral drug will be prescribed for at-home continuation of the tocolytic effect? a. Buccal oxytocin (Pitocin) b.Terbutaline sulfate (Brethine) c. Calcium gluconate (Calgonate) d.Magnesium sulfate

ANS: B The client receiving decreasing doses of magnesium sulfate is often switched to oral terbutaline to maintain tocolysis. Pitocin increases the strength of contractions and is used to augment or stimulate labor. Buccal Pitocin dosing is uncontrollable. Calcium gluconate reverses magnesium sulfate toxicity. The drug should be available for complications of magnesium sulfate therapy. Magnesium sulfate is usually given intravenously or intramuscularly. The patient must be hospitalized for magnesium therapy because of the serious side effects of this drug. PTS: 1 DIF: Cognitive Level: Application REF: 585

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 5. A client with polyhydramnios was admitted to a labor-birth-recovery-postpartum (LDRP)

suite. Her membranes rupture and the fluid is clear and odorless, but the fetal heart monitor

indicates bradycardia and variable decelerations. Which action should be taken next?

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a. Perform Leopold maneuvers. b.Perform a vaginal examination. c. Apply warm saline soaks to the vagina. d.Place the client in a high Fowler position.

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ANS: B

A prolapsed cord may not be visible but may be palpated on vaginal examination. The priority is to relieve pressure on the umbilical cord. Leopold maneuvers are not an appropriate action at this

time. Moist towels retard cooling and drying of the prolapsed cord, but it is hoped the fetus will be delivered before this occurs. The high Fowler position will increase cord compression and

decrease fetal oxygenation. PTS: 1 DIF: Cognitive Level: Application REF: 591 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity 6. Which technique is least effective for the client with persistent occiput posterior position?

a. Squatting b.Lying supine and relaxing c. Sitting or kneeling, leaning forward with support d.Rocking the pelvis back and forth while on hands and knees ANS: B Lying supine increases the discomfort of back labor. Squatting aids rotation and fetal descent. A sitting or kneeling position may help the fetal head to rotate to occiput anterior. Rocking the pelvis encourages rotation from occiput posterior to occiput anterior. PTS: 1 DIF: Cognitive Level: Application REF: 572

OBJ:Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

7. Birth for the nulliparous client with a fetus in a breech presentation is usually:

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a. cesarean section. b.vaginal birth. c. vacuumed extraction. d.forceps-assisted birth.

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ANS: A

Birth for the nulliparous client with a fetus in breech presentation is almost always cesarean section. The greatest fetal risk in the vaginal birth of breech presentation is that the head (largest

part of the fetus) is the last to be delivered. The birth of the rest of the baby must be quick so the

infant can breathe. Serious trauma to maternal or fetal tissues is likely if the vacuum extractor birth is difficult. Most breech births are difficult. The health care provider may assist rotation of the head with forceps. A cesarean birth may be required. PTS: 1 DIF: Cognitive Level: Understanding REF: 572 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which client situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor?

a. A primigravida who is 17 years old b.A 22-year-old multiparous client with ruptured membranes c. A primigravida who has requested no analgesia during her labor d.A multiparous client at 39 weeks of gestation who is expecting twins ANS: D Overdistention of the uterus in a multiple pregnancy is associated with hypotonic dysfunction because the stretched uterine muscle contracts poorly. A young primigravida usually will have good muscle tone in the uterus. This prevents hypotonic dysfunction. There is no indication that this clients uterus is overdistended, which is the main cause of hypotonic dysfunction. A primigravida usually will have good uterine muscle tone, and there is no indication of an

PTS: 1 DIF: Cognitive Level: Analysis REF: 569

overdistended uterus.

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 9. Which factor is most likely to result in fetal hypoxia during a dysfunctional labor?

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ANS: A

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a. Incomplete uterine relaxation b.Maternal fatigue and exhaustion c. Maternal sedation with narcotics d.Administration of tocolytic drugs

A high uterine resting tone, with inadequate relaxation between contractions, reduces maternal

blood flow to the placenta and decreases the fetal oxygen supply. Maternal fatigue usually does

not decrease uterine blood flow. Maternal sedation will sedate the fetus but should not decrease blood flow. Tocolytic drugs decrease contractions. This will increase uterine blood flow. PTS: 1 DIF: Cognitive Level: Understanding REF: 573 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 10. After a birth complicated by a shoulder dystocia, the infants Apgar scores were 7 at 1 minute and 9 at 5 minutes. The infant is now crying vigorously. The nurse in the birthing room should:

a. palpate the infants clavicles. b.encourage the parents to hold the infant. c. perform a complete newborn assessment. d.give supplemental oxygen with a small face mask. ANS: A Because of the shoulder dystocia, the infants clavicles may have been fractured. Palpation is a simple assessment to identify crepitus or deformity that requires follow-up. The infant needs to be assessed for clavicle fractures before excessive movement. A complete newborn assessment is necessary for all newborns, but assessment of the clavicle is top priority for this infant. The Apgar indicates that no respiratory interventions are needed.

PTS: 1 DIF: Cognitive Level: Understanding REF: 570, 571

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

11. A laboring client in the latent phase is experiencing uncoordinated irregular contractions of low intensity. How should the nurse respond to complaints of constant cramping pain?

ANS: D

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a. You are only 2 cm dilated, so you should rest and save your energy for when the contractions get stronger. b.Let me take off the monitor belts and help you get into a more comfortable position. c. You must breathe more slowly and deeply so there is greater oxygen supply for your uterus. That will decrease the pain. d.I have notified the doctor that you are having a lot of discomfort. Let me rub your back and see if that helps.

Intervention is needed to manage the dysfunctional pattern. Offering support and comfort is important to help the client cope with the situation, no matter at what stage. It is important to get her into a more comfortable position, but fetal monitoring should continue. Breathing will not decrease the pain. PTS: 1 DIF: Cognitive Level: Application REF: 570 OBJ:Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance 12. Which nursing action should be initiated first when there is evidence of prolapsed cord? a. Notify the health care provider. b.Apply a scalp electrode. c. Prepare the mother for an emergency cesarean birth. d.Reposition the mother with her hips higher than her head. ANS: D The priority is to relieve pressure on the cord. Changing the maternal position will shift the position of the fetus so that the cord is not compressed. Notifying the health care provider is a

priority but not the first action. It would not be appropriate to apply a scalp electrode at this time. Preparing the mother for a cesarean birth would not be the first priority.

PTS: 1 DIF: Cognitive Level: Application REF: 591 OBJ:Nursing Process Step: Implementation

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MSC:Client Needs: Physiologic Integrity

13. A client who has had two previous cesarean births is in active labor when she suddenly

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complains of pain between her scapulae. Which should be the nurses priority action?

ANS: A

a. Notify the health care provider promptly. b.Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d.Reposition the client with her hips slightly elevated.

Pain between the scapulae may occur when the uterus ruptures because blood accumulates under the diaphragm. This is an emergency that requires medical intervention. Observing for high uterine resting tones should have been done before the sudden pain. High uterine resting tones put the client at high risk for uterine rupture. The client is now at high risk for shock. Nonadditive intravenous fluids should be increased. Repositioning the client with her hips

slightly elevated is the treatment for a prolapsed cord. That position in this scenario would cause respiratory difficulties. PTS: 1 DIF: Cognitive Level: Application REF: 592 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Physiologic Integrity 14. Which factor should alert the nurse to the potential for a prolapsed umbilical cord?

a. Oligohydramnios b.Pregnancy at 38 weeks of gestation c. Presenting part at a station of 3 d.Meconium-stained amniotic fluid

ANS: C

Because the fetal presenting part is positioned high in the pelvis and is not well applied to the cervix, a prolapsed cord could occur if the membranes rupture. Hydramnios puts the client at

high risk for a prolapsed umbilical cord. A very small fetus, normally preterm, puts the client at

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risk for a prolapsed umbilical cord. Meconium-stained amniotic fluid shows that the fetus already has been compromised but does not increase the chance of a prolapsed cord.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 590

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. The fetus in a breech presentation is often born by cesarean birth because: a. the buttocks are much larger than the head. b.compression of the umbilical cord is more likely. c. internal rotation cannot occur if the fetus is breech. d.postpartum hemorrhage is more likely if the client delivers vaginally. ANS: B After the fetal legs and trunk emerge from the clients vagina, the umbilical cord can be compressed between the maternal pelvis and the fetal head if a delay occurs in the birth of the

head. The head is the largest part of a fetus. Internal rotation can occur with a breech. There is no relationship between breech presentation and postpartum hemorrhage. PTS: 1 DIF: Cognitive Level: Understanding REF: 590 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 16. A client who is 32 weeks pregnant telephones the nurse at her obstetricians office and complains of constant backache. She asks what pain reliever is safe for her to take. The best nursing response is:

a. You should come into the office and let the doctor check you. b.Acetaminophen is acceptable during pregnancy. You should not take aspirin, however. c. Back pain is common at this time during pregnancy because you tend to stand with a sway back. d.Avoid medication because you are pregnant. Try soaking in a warm bath or using a heating pad on low before taking any medication.

ANS: A

A prolonged backache is one of the subtle symptoms of preterm labor. Early intervention may

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prevent preterm birth. The client needs to be assessed for preterm labor before providing pain relief.

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PTS: 1 DIF: Cognitive Level: Application REF: 580

OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity 17. Which is (are) the priority nursing assessment(s) for the client having tocolytic therapy with terbutaline (Brethine)? a. Intake and output b.Maternal blood glucose level c. Internal temperature and odor of amniotic fluid d.Fetal heart rate, maternal pulse, and blood pressure ANS: D

All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured, but these are not relevant to the medication. PTS: 1 DIF: Cognitive Level: Application REF: 576 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 18. Which assessment finding indicates uterine rupture?

a. Fetal tachycardia occurs. b.The client becomes dyspneic. c. Labor progresses unusually quickly. d.Contractions abruptly stop during labor.

ANS: D

A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an

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early sign of a rupture. Contractions will stop with a rupture.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 582 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

19. Which intervention should be incorporated in a plan of care for a labor client who is

experiencing hypertonic labor? Vaginal exam is unchanged from prior exam3 cm, 80% effaced, and 0 station presenting part vertex. a. Augmentation of labor with oxytocin (Pitocin) b.AROM c. Performing a vaginal exam to denote progress d.Preparing the client for epidural administration as ordered by the physician ANS: D

The administration of an epidural may help relieve increased uterine resting tone by decreasing maternal pain sensation. Hypertonic labor pattern indicates increased uterine resting tone; therefore, augmentation would not be advised as this time because it would cause further uterine irritation in the form of contractions. Rupture of membranes would not be warranted at this time because the critical issue is to resolve the increased uterine resting tone. There is no indication that a vaginal exam is required at this time based on the information provided. PTS: 1 DIF: Cognitive Level: Analysis REF: 570 OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation 20. During the course of the birth process, the physician suspects that a shoulder dystocia is

occurring and asks the nurse for assistance. Which priority action should be taken by the nurse in

response to this request?

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a. Put pressure on the fundus. b.Ask the physician if he or she would like you to prepare for a surgical method of birth. c. Tell the client not to push until you prepare vacuum extraction device for physician. d.Reposition the client to facilitate birth.

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ANS: B

In the presence of a suspected shoulder dystocia, a surgical birth method is typically indicated to avoid complications from this type of abnormal presentation. Fundal pressure is no longer

recommended as a treatment strategy because it can cause additional problems. Vacuum extraction will not help solve this birth issue and may lead to further complications.

Repositioning of the client may not be effective to relieve this condition and facilitate birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 570, 571 OBJ:Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

21. A pregnant client who has had a prior obstetric history of preterm labors is pregnant with her third child. The physician has ordered an fFN (fetal fibronectin) test. Which instructions should be given to the client related to this clinical test? a. Client must be NPO prior to testing. b.Blood work will be drawn every week to help confirm the start of preterm labor. c. Client should refrain from sexual activity prior to testing. d.A urine specimen will be collected for testing. ANS: C Fetal fibronectin testing has a predictive value relative to the onset of preterm labor. A specimen is collected from the vaginal area. False-positive results can occur in response to excessive

OBJ:Nursing Process Step: Planning

PTS: 1 DIF: Cognitive Level: Application REF: 581

cervical manipulation, in the presence of bleeding, and as a result of sexual activity.

MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

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22. An obstetric client has been identified as being high risk and so has had activities restrictions (placed on bed rest) placed on her until the end of the pregnancy. Currently, she is at 32 weeks

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gestation and has two other children at home, ages 3 and 6. The clients husband works at home. A nursing diagnosis of Impaired home maintenance is noted. Which statement potentially identifies a long-term goal?

a. The client and husband will be able to adapt their schedules accordingly to meet activities of daily living until the clients next scheduled antepartum visit the following week. b.The client and husband will hire a nanny to act as an additional caregiver for the next month. c. The client will continue to take care of her children at home, taking frequent rest periods. d.The client and husband will make arrangements for child care routine activity assistance for the rest of the pregnancy. ANS: D A long-term goal is based on acknowledgment of prescribed clinical treatment conditions for the specified time frame. Planning for caregiving for the next week or month provide evidence of short-term goals. It is not realistic for the client to take care of her children at home with rest

period because the client will not be maintaining the prescribed therapy regimen and thus may be at risk to further develop complications. PTS: 1 DIF: Cognitive Level: Analysis REF: 580 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 23. A labor client has been diagnosed with cephalopelvic disproportion (CPD) following attempts at pushing for 2 hours with no progress. Based on this information, what birth method is available?

a. Vaginal birth with vacuum extraction b.Augmentation of labor with oxytocin (Pitocin) to improve contraction pattern and strengthen contractions c. Cesarean section d.Insertion of Foley catheter into empty bladder to provide more room for fetal descent

ANS: C

The presence of CPD is a contraindication for vaginal birth. To prevent further complications,

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the client should be prepped for a cesarean section. PTS: 1 DIF: Cognitive Level: Analysis REF: 570

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OBJ:Nursing Process Step: Evaluation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency 24. A client is diagnosed with anaphylactoid syndrome. Which therapeutic intervention does the

nurse suspect will be included in the plan of care? a. Normal amniotic fluid b.Initiation of CPR and other life support measures c. Respiratory treatments with nebulizers d.Internal fetal monitoring ANS: B

Anaphylactoid syndrome was previously known as amniotic fluid embolism. This is a rare complication that results in a medical emergency in which CPR measures are initiated and mechanical ventilation, correction of shock and hypotension, and blood component therapy are also begun. Meconium-stained fluid is associated with particulate matter that may be found in the maternal circulation. Internal fetal monitoring may provide a potential source of entry because it is an invasive procedure. The use of nebulizers is not indicated. PTS: 1 DIF: Cognitive Level: Analysis REF: 593 OBJ:Nursing Process Step: Implementation

MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency 25. A 20-year-old gravida 1, para 0, is determined to be at 42 weeks gestation on admission to

the labor and birth unit. The client is not in labor at the current time but has been sent over by her physician to be admitted for the induction of labor. The client indicates to you that she would

rather go home and wait for natural labor to start. How should the nurse respond to the clients

request?

ANS: B

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a. There is no way to tell if any complications would arise. Because the client is not presenting with any problems, the nurse should call the health care provider and inform her or him of the clients decision to go home and wait. b.Inform the client that there are a number of serious concerns related to a postdate pregnancy and that she would be better off to be monitored in a clinical setting. c. Tell the client that an assessment will be done and if there are no findings indicating that an induction of labor would be favorable, the client will be sent home. d.Tell the client that confirmation of a due date can be off by 2 weeks and possibly be even later than 42 weeks, so it is better to follow the physicians directions.

The most serious concern related to a postdate pregnancy is that of fetal compromise based on the fact that the placenta function deteriorates. Although one can appreciate that the client wants to have a natural labor experience, some women do not go into labor for various physiologic reasons. Therefore, it is best for the client to remain in a supervised clinical setting. Indicating that the client could possibly go home would place the client at risk and the nurse at risk for practicing outside of his or her scope of practice. Even though there can be a difference in the calculated due date, it is highly unlikely that the pregnancy has gone longer than 42 weeks.

PTS: 1 DIF: Cognitive Level: Analysis REF: 590 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency 26. Which presentation is least likely to occur with a hypotonic labor pattern? a. Prolonged labor duration b.Fetal distress c. Maternal comfort during labor d.Irregular labor contraction pattern

ANS: B A hypotonic labor pattern indicates that uterine contractions are variable in nature and weak and

thus do not affect cervical change in a timely manner. Labor patterns are prolonged in duration

and clients are typically comfortable but can become easily tired and frustrated because of the inability of their labor to progress to conclusion. The least likely occurrence is that of fetal

distress, because the uterine contraction pattern is not coordinated and/or strong enough to exert

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pressure.

PTS: 1 DIF: Cognitive Level: Application REF: 569

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Pathophysiologic Integrity 27. Which finding by the nurse on a vaginal exam would be a concern if a spontaneous rupture

of the membranes occurred?

a. Cephalic presentation b.Left occiput position c. Dilation 2 cm d.Presenting part at 3 station ANS: D If membranes rupture while the presenting part is at a high station, prolapse of the umbilical cord is more likely; a cephalic presentation, left occiput position, and dilation of 2 cm are normal findings.

PTS: 1 DIF: Cognitive Level: Analysis REF: 590 OBJ:Nursing Process Step: Analysis MSC: Client Needs: Safe and Effective Care Environment/Management of Care 28. Which intervention would be most effective if the fetal heart rate drops following a spontaneous rupture of the membranes?

a. Apply oxygen at 8 to 10 L/min. b.Stop the Pitocin infusion. c. Position the client in the knee-chest position. d.Increase the main line infusion to 150 mL/hr. ANS: C

A drop in the fetal heart rate following rupture of the membranes indicates a compressed or

prolapsed umbilical cord. Immediate action is necessary to relieve pressure on the cord. The knee-chest position uses gravity to shift the fetus out of the pelvis and relieves pressure on the

umbilical cord, applying oxygen will not be effective until compression is relieved, and stopping

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the Pitocin infusion and increasing the main line fluid do not directly affect cord compression. PTS: 1 DIF: Cognitive Level: Application REF: 591

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OBJ:Nursing Process Step: Analysis

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

29. When increasing the IV infusion rate of terbutaline (Brethine) 0.01 mg/min every 30 minutes, the nurse knows to stop increasing the rate when the: a. maximum dose of 0.1 mg/min is reached. b.systolic blood pressure falls below 110 mm Hg. c. contractions are less than two in a 10-minute period. d.maternal heart rate remains over 120 beats/min. ANS: D

The infusion rate is not increased or may be decreased if the maternal pulse rate remains over 120 beats/min (bpm). A maximum dose of 0.1 mg is above the recommended maximum rate, systolic blood pressure below 110 mm Hg may be a normal finding for this client, and the medication should continue to be increased until the maximum level is reached or contractions stop. PTS: 1 DIF: Cognitive Level: Application REF: 584 OBJ:Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

a. Fetal heart rate (FHR) of 134 bpm b.Heart rate of 122 bpm c. Two episodes of diarrhea d.Fasting blood glucose level of 100 mg/dL

30. Which finding would indicate an adverse response to terbutaline (Brethine)?

ANS: B

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Terbutaline (Brethine) stimulates beta-adrenergic receptors of the sympathetic system. This action results primarily in bronchodilation, inhibition of uterine muscle activity, increased pulse

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rate, and widening of pulse pressure. An FHR of 134 bpm and fasting blood glucose level of 100 mg/dL are normal findings, and diarrhea is not a side effect associated with this medication.

PTS: 1 DIF: Cognitive Level: Analysis REF: 584

OBJ:Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies 31. A dose of dexamethasone 12 mg was administered to a client in preterm labor at 8:30 AM on March 12. The nurse knows that the next dose must be scheduled for: a. 2:30 PM on March 12. b.8:30 PM on March 12. c. 8:30 AM on March 13. d.2:30 PM on March 13.

ANS: C The current recommendation for betamethasone for threatened preterm birth is two doses of 12 mg 24 hours apart; 2:30 PM on March 12, 8:30 PM on March 12, and 2:30 PM on March 13 do not fall within this recommendation. PTS: 1 DIF: Cognitive Level: Application REF: 586 OBJ:Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

32. When reviewing the prenatal record of a client at 42 weeks gestation, the nurse recognizes that induction of labor is indicated based on the finding of:

a. reduced amniotic fluid volume. b.cervix 2 cm at last prenatal visit. c. fundal height measured at the xyphoid process. d.1-pound weight gain at each of the last two weekly visits.

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ANS: A

Reduced amniotic fluid volume (oligohydramnios) often accompanies placental insufficiency and can result in fetal hypoxia. Lack of adequate amniotic fluid can result in umbilical cord

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compression; cervix 2 cm at last prenatal visit, fundal height measured at the xyphoid process, and 1-pound weight gain at each of the last two weekly visits are normal prenatal findings for a

42-week gestation.

PTS: 1 DIF: Cognitive Level: Analysis REF: 589 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 33. Which assessment finding in the postpartum client following a uterine inversion indicates normovolemia? a. Blood pressure of 100/60 mm Hg b.Urine output >30 mL/hr c. Rebound skin turgor <5 seconds d.Pulse rate <120 beats/min

ANS: B In the presence of normal volume, urinary output will be equal to or greater than 30 mL/hr; blood pressure of 100/60 mm Hg, rebound skin turgor <5 seconds, and pulse rate <120 beats/min may be indications of hypovolemia. PTS: 1 DIF: Cognitive Level: Analysis REF: 593 OBJ:Nursing Process Step: Assessment MSC:Client Needs: Physiologic Integrity/Physiologic Adaptation

34. Which assessment finding indicates a complication in the client attempting a vaginal birth after cesarean (VBAC)?

a. Complaint of pain between the scapulae b.Change in fetal baseline from 128 to 132 bpm c. Contractions every 3 minutes lasting 70 seconds d.Pain level of 6 on scale of 0 to 10 during acme of contraction

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ANS: A

A client attempting a VBAC is at greater risk for uterine rupture. As blood leaks into the abdomen, pain occurs between the scapulae or in the chest because of irritation from blood

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below the diaphragm; a change in the fetal baseline from 128 to 132 bpm, contractions every 3 minutes lasting 70 seconds, and a pain level of 6 on a scale of 0 to 10 during the acme of

contraction would be normal findings during labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 592 OBJ:Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment/Management of Care 35. The labor nurse is providing care to a multigravida with moderate to strong contractions every 2 to 3 minutes, duration 45 to 60 seconds. On admission, her cervical assessment was 5 cm, 80%, and 2. An epidural was administered shortly thereafter. Two hours after admission, her

contraction pattern remains the same and her cervical assessment is 5 cm, 90%, and 2. What is the nurses next action? a. Palpate the patients bladder for fullness. b.Contact the health care provider for a prescription to augment the labor. c. Obtain an order for an internal pressure catheter. d.Reassure the patient that she is making adequate progress. ANS: A The fetal presenting part is expected to descend at a minimal rate of 1 cm/hr in the nullipara and 2 cm/hr in the parous woman. Despite an active labor pattern, cervical dilation and descent have not occurred for 2 hours. The nurse must consider the possibility of an obstruction. During labor,

a full bladder is a common soft tissue obstruction. Bladder distention reduces available space in the pelvis and intensifies maternal discomfort. The woman should be assessed for bladder

distention regularly and encouraged to void every 1 to 2 hours. Catheterization may be needed if she cannot urinate or if epidural analgesia depresses her urge to void. Even with a catheter, the

nurse must assess for flow of urine and a distended bladder.

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PTS: 1 DIF: Cognitive Level: Synthesis REF: 575

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

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MULTIPLE RESPONSE

36. Emergency measures used in the treatment of a prolapsed cord include which of the

following? (Select all that apply.)

a. Administration of oxygen via face mask at 8 to 10 L/min b.Maternal change of position to knee-chest c. Administration of tocolytic agent d.Administration of oxytocin (Pitocin) e. Vaginal elevation f. Insertion of cord back into vaginal area ANS: A, B, C, E Prolapsed cord is a medical emergency. Oxygen should be administered to the mother to increase perfusion from mother to fetus. The maternal position change to knee-chest or Trendelenburg to

offset pressure on the presenting cord should be done. A tocolytic drug such as terbutaline inhibits contractions, increasing placental blood flow and reducing intermittent pressure of the fetus against the pelvis and cord. Vaginal elevation should be done to offset pressure on the presenting cord. Pitocin and manipulation of the cord by reinsertion are contraindicated. PTS: 1 DIF: Cognitive Level: Analysis REF: 591 OBJ:Nursing Process Step: Implementation MSC:Client Needs: Pathophysiologic Integrity/Medical Emergency 37. Which presentation is most likely to occur with a hypertonic labor pattern? (Select all that

.c ab

a. Increased risk for placenta previa b.Painful uterine contractions c. Increased resting tone d.Uterine vasodilation e. Increased uterine pressure f. Effective uterine contraction

apply.)

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ANS: B, C, E

Hypertonic labor patterns indicate increased uterine pressure and resting tone. Uterine ischemia

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occurs, leading to vasoconstriction and constant cramplike abdominal pain. Thus, there is an increased risk for placental abruption as compared with placenta previa, which is based on malpresentation of the placental attachment. The contractions are painful but not effective for

progression of labor.

Chapter 19: Postpartum Woman at Risk MULTIPLE CHOICE 1. Which statement by a postpartum client indicates that further teaching is not needed regarding thrombus formation? a. Ill keep my legs elevated with pillows.

b. Ill sit in my rocking chair most of the time. c. Ill stay in bed for the first 3 days after my baby is born. d. Ill put my support stockings on every morning before rising. ANS: D Venous congestion begins as soon as the client stands up. The stockings should be applied before she rises from the bed in the morning. The client should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities. As soon as possible, the client should ambulate

PTS: 1 DIF: Cognitive Level: Application REF: 607

frequently.

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 2. The nurse knows that late postpartum hemorrhage can be prevented by:

a. manually removing the placenta.

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b. inspecting the placenta after birth.

c. administering broad-spectrum antibiotics.

ANS: B

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d. pulling on the umbilical cord to hasten the birth of the placenta.

If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing

fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30 minutes after birth of the baby without pulling on the cord. That can cause uterine inversion. PTS: 1 DIF: Cognitive Level: Application REF: 602 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 3. A multiparous client is admitted to the postpartum unit after a rapid labor and birth of a 4000g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the client void and massages her fundus, but the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next? a. Recheck vital signs. b. Insert a Foley catheter. c. Notify the health care provider.

d. Continue to massage the fundus. ANS: C

Treatment of excessive bleeding requires the collaboration of the health care provider and the

nurses. Do not leave the client alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The client has voided successfully, so a Foley catheter is not needed at

this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and

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rebound hemorrhage.

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PTS: 1 DIF: Cognitive Level: Application REF: 604 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

4. Early postpartum hemorrhage is defined as a blood loss greater than: a. 500 mL within 24 hours after a vaginal birth. b. 750 mL within 24 hours after a vaginal birth. c. 1000 mL within 48 hours after a cesarean birth. d. 1500 mL within 48 hours after a cesarean birth. ANS: B

The average amount of bleeding after a vaginal birth is 500 mL. Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean averages 1000 mL. Late postpartum hemorrhage is 48 hours and later. PTS: 1 DIF: Cognitive Level: Understanding REF: 598 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests: a. uterine atony.

b. perineal hematoma. c. infection of the uterus.

d. lacerations of the genital tract.

ANS: D

Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is

uncontrolled by uterine contraction. The fundus would not be firm with uterine atony. A

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hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding would not be. With an infection of the uterus, there would be an odor to the lochia and systemic

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symptoms such as fever and malaise.

PTS: 1 DIF: Cognitive Level: Understanding REF: 601

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 6. A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a(n):

a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor.

ANS: B A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction. Delivering a 5-lb, 2-oz infant with outlet forceps would put this client at risk for lacerations because of the forceps. A 7-lb infant after an 8-hour labor is a normal labor progression. Less than 3 hours is rapid and can produce uterine muscle exhaustion. An 8-lb infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid birth and can cause the uterine muscles not to contract. PTS: 1 DIF: Cognitive Level: Understanding REF: 605

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. Which instruction should be included in the discharge teaching plan to assist the client in

recognizing early signs of complications?

a. Palpate the fundus daily to ensure that it is soft.

b. Report any decrease in the amount of brownish red lochia.

c. The passage of clots as large as an orange can be expected.

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ANS: D

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d. Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding.

An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates

a complication. The fundus should stay firm. The lochia should decrease in amount. Large clots

after discharge are a sign of complications and should be reported. PTS: 1 DIF: Cognitive Level: Application REF: 599 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. The nurse should expect medical intervention for subinvolution to include:

a. oral fluids to 3000 mL/day. b. intravenous fluid and blood replacement. c. oxytocin intravenous infusion for 8 hours. d. oral methylergonovine maleate (Methergine) for 48 hours. ANS: D Methergine provides long-sustained contraction of the uterus. There is no correlation between dehydration and subinvolution. There is no indication that excessive blood loss has occurred. Oxytocin provides intermittent contractions.

PTS: 1 DIF: Cognitive Level: Understanding REF: 605

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

9. If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

c. Laparotomy

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b. Laparoscopy

a. Hysterectomy

ANS: D

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d. Dilation and curettage (D&C)

D&C allows examination of the uterine contents and removal of any retained placenta or

membranes. Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus. Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity. PTS: 1 DIF: Cognitive Level: Understanding REF: 602 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

10. A sign of thrombophlebitis is: a. visible varicose veins. b. positive Homans sign. c. pedal edema in the affected leg. d. local tenderness, heat, and swelling. ANS: D Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the client to thrombophlebitis, but are not a sign. A

positive Homans sign is indicative of deep vein thrombosis (DVT).

PTS: 1 DIF: Cognitive Level: Understanding REF: 606

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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period following a cesarean birth?

11. Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery

a. Limit the clients oral intake of fluids for the first 24 hours.

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b. Assist the client in performing leg exercises every 2 hours. c. Ambulate the client as soon as her vital signs are stable.

ANS: B

d. Roll a bath blanket and place it firmly behind the clients knees.

Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bed rest. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The client may not have full return of leg movements, and ambulating is contraindicated. The blanket behind the knees will cause pressure and decrease venous blood flow. PTS: 1 DIF: Cognitive Level: Application REF: 607

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. Which temperature indicates the presence of postpartum infection? a. 99.6 F in the first 48 hours b. 100 F for 2 days postpartum c. 100.4 F in the first 24 hours d. 100.8 F on the second and third postpartum days

ANS: D A temperature elevation to greater than 100.4 F on two postpartum days, not including the first

24 hours, indicates infection. 99.6 F in the first 48 hours is an expected finding because of

dehydration. To be classified as an infection, the temperature needs to be greater than 100.4 F. It is anticipated that women have an elevated temperature the first 24 hours.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 609

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

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13. A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates:

a. possible infection.

b. normal WBC limit. c. serious infection. d. suspicion of a sexually transmitted disease. ANS: A A WBC count in the upper ranges of normal (20,000 to 30,000 cells/mm3) may indicate an infection. An elevated WBC count is anticipated but becomes a concern as it hits the upper range. An elevated WBC count may be an indication of different types of infection.

PTS: 1 DIF: Cognitive Level: Understanding REF: 614 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 14. The client who is being treated for endometritis is placed in the Fowler position because it: a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.

ANS: B Lochia and infectious material are eliminated by gravity drainage. The Fowler position may not

be the position of comfort, but it does allow for drainage. Good hygiene practice aids in

preventing the spread of infection to the urinary tract. This position aids in the drainage of lochia and infectious material.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: 611 OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Physiologic Integrity

15. Nursing measures that help prevent postpartum urinary tract infection include: a. forcing fluids to at least 3000 mL/day.

b. promoting bed rest for 12 hours after birth. c. encouraging the intake of orange, grapefruit, or apple juice. d. discouraging voiding until the sensation of a full bladder is present. ANS: A Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products. The client should be encouraged to ambulate early. Juices such as cranberry juice can discourage

bacterial growth. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The client needs to be encouraged to void frequently. PTS: 1 DIF: Cognitive Level: Application REF: 612 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 16. Which measure may prevent mastitis in a breastfeeding client?

b. Applying ice packs prior to feeding c. Initiating early and frequent feedings

d. Nursing the infant for 5 minutes on each breast

a. Wearing a tight-fitting bra

ANS: C

Early and frequent feedings prevent stasis of milk, which contributes to engorgement and

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mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the milk. A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be

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bound. Warm packs before feeding will increase the flow of milk. PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 17. A client with mastitis is concerned about breastfeeding while she has an active infection. Which is an appropriate response by the nurse? a. Organisms will be inactivated by gastric acid. b. Organisms that cause mastitis are not passed to the milk. c. The infant is not susceptible to the organisms that cause mastitis.

d. The infant is protected from infection by immunoglobulins in the breast milk. ANS: B The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infants gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. The client is just producing the immunoglobulin from this infection, so it is not available for the infant. PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

18. The nurse expecting a uterine infection in a postpartum client should assess the:

a. episiotomy site.

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b. odor of the lochia. c. abdomen for distention.

ANS: B

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d. pulse and blood pressure.

An abnormal odor of the lochia indicates infection in the uterus. The infection may move to the

episiotomy site if proper hygiene is not followed. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and will be more specific. PTS: 1 DIF: Cognitive Level: Application REF: 615 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 19. Following a difficult vaginal birth of a singleton pregnancy, the client starts bleeding heavily. Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine

fundus is soft and displaced laterally from midline. Vital signs are 99.8 F, pulse 90 beats/min, respirations 20 breaths/min, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated? a. Oxytocin (Pitocin) to be administered in a piggyback solution b. Administration of methylergonovine (Methergine) c. Administration of prostaglandin analogue d. Increase in parenteral fluids ANS: C

Prostaglandin analogues can be administered intramuscularly to stop uterine bleeding. Although Pitocin may be indicated in an attempt to stop uterine bleeding, it is not administered in a

piggyback solution. Methergine is contraindicated in the presence of hypertension. Increasing

fluids will not stop uterine bleeding.

PTS: 1 DIF: Cognitive Level: Analysis REF: 600

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity/Pharmacologic Parental Therapies

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20. Following a vaginal birth, a client has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this

clinical diagnosis?

a. Decrease in blood pressure, with an increase in pulse pressure b. Compensatory response of tachycardia and decreased pulse pressure c. Decrease in heart rate and an increase in respiratory effort d. Flushed skin ANS: B Clinical signs consistent with the beginning of hypovolemic shock include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color.

PTS: 1 DIF: Cognitive Level: Application REF: 602 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 21. A client has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The client now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to:

a. evaluate intake and output of the past 12 hours following birth. b. initiate a rapid response intervention.

c. obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs).

d. reposition the client and reassess in 15 minutes. Initiate frequent vital sign assessments.

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ANS: B

Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent

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client history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the clients complaints of difficulty breathing suggest that the client is progressing to pulmonary edema. An appropriate intervention

is to initiate a rapid response intervention so that the client can be stabilized. Calling the

physician for a type and crossmatch order is not indicated. Repositioning the client, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time. PTS: 1 DIF: Cognitive Level: Analysis REF: 604 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

22. A postpartum client has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen? a. Fresh fruits b. Milk c. Lentils d. Soda ANS: C

Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.

OBJ: Nursing Process Step: Planning

PTS: 1 DIF: Cognitive Level: Application REF: 608

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MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies 23. The nurse recognizes that infection may be present in her postpartum client when the client

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exhibits a temperature of:

a. 100.0 F during the first 36 hours postpartum. b. 100.8 F twice in the first 24 hours postpartum.

c. 99.6 F on the first postpartum day and 100.4 on the second.

d. 100.4 F on the second postpartum day and 100.8 F on the fourth. ANS: D The definition of puerperal infection is a temperature of 100.4 F or higher after the first 24 hours, occurring on at least two of the first 10 days following childbirth. 100.8 F in the first 24 hours, 100.0 F in the first 36 hours, and 99.6 F on the first day and 100.4 F on the second day do not meet the definition of puerperal infection.

PTS: 1 DIF: Cognitive Level: Analysis REF: 609 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity 24. To determine an adverse response to carboprost tromethamine (Hemabate), the nurse should frequently assess: a. temperature. b. lochial flow. c. fundal height.

d. breath sounds. ANS: D

Pulmonary edema is a potential adverse effect of carboprost tromethamine (Hemabate).

Auscultation of breath sounds will identify pulmonary edema; temperature, lochial flow and fundal height are not affected by this medication.

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PTS: 1 DIF: Cognitive Level: Application REF: 601

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic integrity

hemorrhage?

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25. Which labor and birth information on the client would suggest an increased risk for

a. Precipitous birth after a 12-hour labor

b. Cesarean birth of an infant weighing 8 lb, 4 oz c. Vaginal birth of 7-lb infant after a 2-hour labor d. Vaginal birth of 6-lb infant after a 7-hour labor ANS: C Precipitous labor (<3 hours) is a risk for postpartum hemorrhage; precipitous birth following a normal duration of labor, cesarean birth of an 8-lb, 4-oz infant, and vaginal birth of a 6-lb infant after a 7-hour labor do not increase the risk of postpartum hemorrhage.

PTS: 1 DIF: Cognitive Level: Analysis REF: 598 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 26. If the nurse suspects a complication of a low forceps birth labor, she should immediately: a. administer a strong oral analgesic. b. assess the perineal and vaginal areas. c. assess the position of the uterine fundus. d. review the labor record for duration of second stage.

ANS: B A low forceps birth may result in significant vaginal trauma. Assessment will provide

information on the extent of trauma of the perineum and vagina. Administering an analgesic may

interfere with obtaining an accurate assessment of the problem, assessing the position of the uterine fundus will not provide any information on vaginal or perineal trauma, and reviewing the

labor record may support the suspicion that trauma has occurred but will not identify extent of

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trauma.

PTS: 1 DIF: Cognitive Level: Application REF: 604

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

27. Prior to ambulating the client to the bathroom whose admission hemoglobin level was 10.2 g/dL, the nurse should: a. request repeat hemoglobin and hematocrit. b. assess the resting pulse rate. c. dangle her on the side of the bed. d. administer the ordered oral analgesic. ANS: C

Clients with a low hemoglobin level prior to birth will most likely have a drop in the hemoglobin level following birth. A low hemoglobin level will result in dizziness and place the client at risk for fainting when first ambulating. Dangling the client on the side of the bed prior to standing will allow for the blood pressure to stabilize and prevent fainting. Requesting additional labs will delay ambulation at a time when the client needs to empty her bladder, assessing the resting pulse rate will not provide any information about the effect of ambulation on her cardiovascular system, and administering an ordered oral analgesic may contribute to feelings of faintness. PTS: 1 DIF: Cognitive Level: Application REF: 604

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic integrity

a. on the first postpartum day.

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c. during the third stage of labor.

b. during recovery phase of labor.

nurse recognizes that this hemorrhage occurred:

28. If a late postpartum hemorrhage is documented on a client who delivered 3 days ago, the

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d. on the second postpartum day. ANS: D

A late postpartum hemorrhage occurs after the first 24 hours and up to 12 weeks after birth. The

first postpartum day, during the recovery phase, and during the third stage are all within the first

24 hours after birth and would be classified as early postpartum hemorrhage. PTS: 1 DIF: Cognitive Level: Analysis REF: 612 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 29. Which client data received during report should the nurse recognize as being a postpartum risk factor?

a. Gravida 5, para 5 b. Labor duration of 4 hours c. Infant weight greater than 3800 g d. Epidural anesthesia for labor and birth ANS: A Multiparity (five or more deliveries) is a risk factor for postpartum uterine atony and hemorrhage. A labor duration of 4 hours is not a risk factor because it is not a precipitate labor and birth (less than 3 hours), infant weight of 3800 g is not a risk factor because the infant is not affect uterine contractions.

PTS: 1 DIF: Cognitive Level: Application REF: 599

macrosomic, and epidural anesthesia is not a risk factor because epidural anesthesia does not

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

b. blood pressure.

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a. color of the lochia.

30. Before administering methylergonovine (Methergine), the nurse checks the:

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c. location of the fundus.

ANS: B

d. last administration of analgesics.

Methylergonovine (Methergine) elevates the blood pressure and should not be given to a woman who is hypertensive. The color of the lochia, location of the fundus, and analgesics are not related to the administration of or contraindicated to this medication. PTS: 1 DIF: Cognitive Level: Application REF: 600 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies

31. To evaluate the desired response of methylergonovine (Methergine), the nurse would assess the clients: a. uterine tone. b. pain level. c. blood pressure. d. last voiding. ANS: A Methylergonovine (Methergine) simulates sustained contraction of the uterus as evidenced by effectiveness of the medication.

OBJ: Nursing Process Step: Evaluation

PTS: 1 DIF: Cognitive Level: Application REF: 600

the tone of the uterus. The pain level, blood pressure, and voiding patterns are not related to the

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MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies 32. Which data collected during your assessment may indicate a vaginal wall hematoma?

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a. Firm uterus at U-1

b. Pulse rate of 110 bpm

c. Moderate lochia

d. Soreness of perineum ANS: B

Trauma to the vaginal area from a forceps birth may result in significant blood loss from hematomas or lacerations. Tachycardia is an early sign of compensation for excessive blood loss. If vital signs suggest hemorrhage but excessive bleeding is not obvious, the cause may be concealed bleeding and the formation of a hematoma; a firm fundus, moderate lochia, and soreness of the perineum are normal findings.

PTS: 1 DIF: Cognitive Level: Analysis REF: 601 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 33. As you receive a report, which assessment finding should you recognize as indicative of a vaginal laceration? a. Fundus firm at the umbilicus b. Pulse of 90 bpm, blood pressure of 110/78 mm Hg

c. Bright red continuous trickle of blood from vagina d. Client requested pain medication twice during last shift

ANS: C

Lacerations of the birth canal should always be suspected if excessive bleeding continues when the fundus is firm. Bleeding from the genital tract often is bright red, in contrast to the darker red

color of lochia; a firm fundus, pulse of 90 bpm, blood pressure of 110/78 mm Hg, and being

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medicated twice in one shift are common findings in the postpartum client.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 601 OBJ: Nursing Process Step: Analysis

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

34. Which observation of your client as she ambulates could indicate development of a DVT (deep vein thrombosis)? a. Slow gait b. Shuffling gait c. Stiffness of right leg d. Leans on husband for support

ANS: C Deep vein thrombosis may cause pain on ambulation and stiffness of the affected leg. A slow gait, shuffling gait, and needing ambulatory support are common observations of the postpartum client because of weakness and discomfort of the perineum. PTS: 1 DIF: Cognitive Level: Analysis REF: 607 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

35. If a DVT (deep vein thrombosis) is suspected, the nurse should:

b. dorsiflex the foot of the affected leg.

c. palpate the affected leg for edema and pain.

a. perform a Homans sign on the affected leg.

d. place the client on bed rest, with the affected leg elevated.

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ANS: D

Initial treatment of DVT is bed rest with the leg elevated to decrease swelling and promote

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venous return. Performing a Homans sign, dorsiflexing the foot, and palpating the leg are contraindicated actions that may dislodge a DVT and result in a pulmonary embolism.

PTS: 1 DIF: Cognitive Level: Application REF: 607

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Management of Care 36. If the nurse suspects a pulmonary embolism in the client who suddenly complains of chest pain, she or he should immediately: a. assess for abnormal breath sounds. b. apply O2 via tight face mask at 8 to 10 L/min.

c. position the client in a supine position with the head of the bed flat. d. monitor pulse oximetry for decreased oxygen saturation. ANS: B Administration of oxygen will increase oxygen saturation and decrease hypoxia; assessing breath sounds and monitoring pulse oximetry provide assessment data but do not correct the problem. A supine position with the head of the bed flat is incorrect because the head of the bed should be elevated to facilitate respiratory function.

PTS: 1 DIF: Cognitive Level: Application REF: 609 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment/Management of Care

a. change the peripad once per shift.

37. To prevent infection of the reproductive tract, the nurse should instruct the client to:

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b. cleanse the perineum from front to back.

c. perform pericare at least twice during the shift.

ANS: B

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d. increase fluid intake to 2500 to 3000 mL/day.

Lack of knowledge of hygiene measures increases the risk of postpartum infection. Wiping the

perineum from front to back prevents introduction of infection into the reproductive tract from the anal area. Changing the peripad once per shift and performing pericare twice in a shift are incorrect because these interventions should be done at every voiding or bowel elimination, and increasing fluid intake does not prevent infection of the reproductive tract. PTS: 1 DIF: Cognitive Level: Application REF: 610 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

38. For the client diagnosed with endometritis, the nurse recognizes that the client should be positioned in the: a. prone position. b. side-lying position. c. Fowler position. d. supine position with the head flat. ANS: C The Fowler position promotes drainage of lochia from the reproductive tract. The prone position,

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 610

side-lying position, and supine position do not promote drainage from the reproductive tract.

MSC: Client Needs: Health Promotion and Maintenance

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39. To prevent infection of the urinary tract, the nurse should instruct the client to: a. include soft drinks in the total fluid intake.

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b. drink grapefruit juice several times a day. c. perform pericare at least twice during a shift.

ANS: D

d. increase fluid intake to 2500 to 3000 mL/day.

Drinking 2500 to 3000 mL of fluid each day will dilute the bacterial count and flush the infection from the bladder. Ingesting soft drinks and grapefruit juice increase urine alkalinity, which provides a medium for bacterial growth; pericare performed twice during a shift is not frequent enough to remove bacteria, and pericare should be done at each voiding or bowel movement. PTS: 1 DIF: Cognitive Level: Application REF: 612

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 40. What data in the clients history should the nurse recognize as being pertinent to a possible diagnosis of postpartum depression? a. Teenage depression episode b. Unexpected operative birth c. Ambivalence during the first trimester

d. Second pregnancy in a 3-year period ANS: A

A personal history of depression is a risk factor for postpartum depression. An operative birth,

ambivalence during the first trimester, and two pregnancies in 3 years are not risk factors for postpartum depression.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 614

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Psychosocial integrity

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41. The nurse notes that the fundus of a postpartum patient is boggy, shifted to the left of the midline, and 2 cm above the umbilicus. What is the nurses priority action?

a. Massage the fundus of the uterus.

b. Assist the patient out of bed to void. c. Increase the infusion of oxytocin (Pitocin). d. Ask another nurse to bring in a straight catheter tray. ANS: A If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. One hand is placed just above the symphysis pubis to support the lower uterine segment, while the other hand gently but firmly

massages the fundus in a circular motion. Clots that may have accumulated in the uterine cavity interfere with the ability of the uterus to contract effectively. They are expressed by applying firm but gentle pressure on the fundus in the direction of the vagina. If the uterus does not remain contracted as a result of uterine massage or if the fundus is displaced, the bladder may be distended. A full bladder lifts the uterus, moving it up and to the side, preventing effective contraction of the uterine muscles. Assist the mother to urinate or catheterize her to correct uterine atony caused by bladder distention. Note the urine output. When the fundus is boggy, begin uterine massage. Check the womans bladder for distention and have her empty it if necessary. If she is not able to void and the bladder is distended, catheterize the woman. Weigh blood-soaked pads.

PTS: 1 DIF: Cognitive Level: Applying REF: 599, 600

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

42. For the patient experiencing a postpartum hemorrhage, the health care provider prescribes

a. Heart rate

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b. Temperature

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this medication?

methylergonovine (Methergine). What assessment must the nurse perform prior to administering

c. Blood pressure

ANS: C

d. Respiratory rate

Methylergonovine (Methergine) may be given intramuscularly but it elevates blood pressure and should not be given to a woman who is hypertensive. PTS: 1 DIF: Cognitive Level: Understanding REF: 600 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE 43. Which information should the nurse recognize as contributing to mastitis in the breastfeeding mother? (Select all that apply.) a. Insufficient emptying b. Feeding every 2 hours c. Supplementing feedings d. Blisters on both nipples e. Alternating breastfeeding positions

ANS: A, C, D

Mastitis may develop because of stasis of milk, inadequate emptying of the breast, skipped feedings, and introduction of bacteria through injured areas of the nipple. Feeding every 2 hours

and alternating breastfeeding positions are both interventions that promote emptying of the

breasts and support successful breastfeeding.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 612 OBJ: Nursing Process Step: Analysis

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MSC: Client Needs: Safe Effective Care Environment/Management of Care 44. The visiting nurse must be aware that women who have had a postpartum hemorrhage are

subject to a variety of complications after discharge from the hospital. These include which of

the following? (Select all that apply.) a. Anemia

b. Dehydration c. Exhaustion d. Postpartum infection e. Failure to attach to her infant

ANS: A, C, D, E Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated. Exhaustion is common after hemorrhage. It may take the new client weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and the attachment processes. The client is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection. The excessive blood loss that this client has experienced is likely to lead to risk for infection rather than dehydration. It is important that all mothers be educated about adequate fluid intake after birth.

Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders MULTIPLE CHOICE

b. Adequate prenatal care

a. High socioeconomic status

1. Which is most helpful in preventing premature birth?

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c. Aid to Families with Dependent Children

ANS: B

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d. Women, Infants, and Children (WIC) nutritional program

Prenatal care is vital for identifying possible problems. People with higher socioeconomic status

are more likely to seek adequate prenatal care, which is the most helpful for prevention. Lower

socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC aid in the nutritional status of the pregnant woman, but the most helpful aid for the prevention of premature births is adequate prenatal care. PTS: 1 DIF: Cognitive Level: Understanding REF: 623 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 2. In comparison with the term infant, the preterm infant has:

a. More subcutaneous fat. b. Well-developed flexor muscles. c. Few blood vessels visible through the skin. d. Greater surface area in proportion to weight. ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are more

PTS: 1 DIF: Cognitive Level: Analysis REF: 623

characteristic of a term infant.

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. Decreased surfactant production in the preterm lung is a problem because: a. Surfactant keeps the alveoli open during expiration.

b. Surfactant causes increased permeability of the alveoli.

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c. Surfactant dilates the bronchioles, decreasing airway resistance.

ANS: A

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d. Surfactant provides transportation for oxygen to enter the blood supply.

Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the

work of breathing. It does not affect the bronchioles. By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose. PTS: 1 DIF: Cognitive Level: Understanding REF: 623 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 4. A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse?

a. Encourage the parents to touch their infant. b. Reassure the parents that the infant is progressing well. c. Discuss the care they will give their infant when the infant goes home. d. Suggest that the parents visit for only a short time to reduce their anxiety. ANS: A Touching the infant will increase the development of attachment. It is important to keep the parents informed about the infants progress, but the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching but is not the most encouraging the parents to spend time with the infant.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 641

important priority during the first visit. Bonding needs to occur, and this can be fostered by

MSC: Client Needs: Psychosocial Integrity

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5. Which preterm infant should receive gavage feedings instead of bottle feedings? a. Sucks on a pacifier during gavage feedings

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b. Sometimes gags when a feeding tube is inserted c. Has a sustained respiratory rate of 70 breaths/min

d. Has an axillary temperature of 98.4 F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min ANS: C

Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths/min. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle feeding. Axillary temperature of 98.4 F, an apical

pulse of 149 beats/min, and respirations of 54 breaths/min are within expected limits and an indication that the infant is not having respiratory problems at that time. PTS: 1 DIF: Cognitive Level: Analysis REF: 631 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 6. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest.

b. Keep charts on top of the incubator so the nurses can write on them there. c. While giving a report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation.

d. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.

ANS: D

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Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may understimulate the infant during those long periods and overtire the infant during the procedures. Keeping charts on the incubator and giving

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the report in front of the incubator may cause overstimulation.

PTS: 1 DIF: Cognitive Level: Application REF: 640

OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 7. A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is: a. Soft and supple skin. b. A hematocrit level of 55%. c. Lack of subcutaneous fat. d. An abundance of vernix caseosa.

ANS: C This post-term infant actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant. PTS: 1 DIF: Cognitive Level: Understanding REF: 646 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. In caring for the preterm infant, which complication is thought to be a result of high arterial

blood oxygen level? a. Necrotizing enterocolitis (NEC)

c. Intraventricular hemorrhage (IVH)

d. Bronchopulmonary dysplasia (BPD)

b. Retinopathy of prematurity (ROP)

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ANS: B

ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is

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caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.

PTS: 1 DIF: Cognitive Level: Analysis REF: 644 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 9. In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n): a. Hematocrit level of 58%. b. RBC count of 5 million/ L.

c. WBC count of 15,000 cells/mm3. d. Blood glucose level of 25 mg/dL. ANS: D Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3. RBC count ranges from 3.9 to 5.5 million/ L.

PTS: 1 DIF: Cognitive Level: Understanding REF: 622 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

a. They weigh less than 2500 g.

10. Which is true about newborns classified as small for gestational age (SGA)?

b. They are born before 38 weeks of gestation.

c. They are below the tenth percentile on gestational growth charts.

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d. Placental malfunction is the only recognized cause of this condition.

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ANS: C

SGA infants are defined as below the tenth percentile in growth when compared with other

infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks

are defined as preterm. There are many causes of SGA infants. PTS: 1 DIF: Cognitive Level: Understanding REF: 646 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. Which nursing action is especially important for an SGA newborn? a. Promote bonding. b. Observe for and prevent dehydration.

c. Observe for respiratory distress syndrome. d. Prevent hypoglycemia with early and frequent feedings. ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific for SGA infants. Dehydration is a concern for all infants and is not specific for SGA infants. Respiratory distress syndrome is seen in preterm infants.

PTS: 1 DIF: Cognitive Level: Understanding REF: 647 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

12. What will the nurse note when assessing an infant with asymmetric intrauterine growth

restriction?

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a. All body parts appear proportionate.

b. The extremities are disproportionate to the trunk. c. The head seems large compared with the rest of the body.

ANS: C

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d. One side of the body appears slightly smaller than the other.

In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infants body is long and thin because of lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected because of the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head. PTS: 1 DIF: Cognitive Level: Understanding REF: 647

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 13. Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infants weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. Three successive temperature measurements were 97, 96, and 97 F.

ANS: D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about

20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day. PTS: 1 DIF: Cognitive Level: Analysis REF: 624

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 14. Which statement is most true about large-for-gestational age (LGA) infants?

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a. They weigh more than 3500 g.

b. They are above the 80th percentile on gestational growth charts.

c. They are prone to hypoglycemia, polycythemia, and birth injuries.

d. Postmaturity syndrome and fractured clavicles are the most common complications. ANS: C Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

PTS: 1 DIF: Cognitive Level: Understanding REF: 647 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 15. Following the vaginal birth of a macrosomic infant, the nurse should assess the infant for: a. Hyperglycemia. b. Clavicle fractures. c. Hyperthermia. d. An increase in red blood cells.

ANS: B Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as

fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the

potential to be hypoglycemic. The macrosomic infant would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

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PTS: 1 DIF: Cognitive Level: Application REF: 647

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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16. An infant delivered preterm at 28 weeks gestation weighs 1200 g. Based on this information, the infant is designated as:

a. SGA.

b. VLBW. c. ELBW.

d. Low birth weight at term. ANS: B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely-low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. However,

this option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks gestation.

PTS: 1 DIF: Cognitive Level: Application REF: 622 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

17. A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infants

color and heart rate remain unchanged. The nurse suspects that the infant:

a. Is exhibiting signs of RDS.

b. Requires tactile stimulation around the clock to ensure that apneic periods do not progress further.

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c. Is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit.

ANS: C

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d. Requires the use of CPAP to promote airway expansion.

Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths/min).

It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells. PTS: 1 DIF: Cognitive Level: Application REF: 623 OBJ: Nursing Process Step: Planning

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 18. Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity related to diarrhea as a result of phototherapy c. Fluid volume deficit related to phototherapy treatment d. Knowledge deficit (parents) related to initiation of medical therapy

ANS: C

Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are

at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the

priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake.

Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take

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precedence.

PTS: 1 DIF: Cognitive Level: Analysis REF: 626

OBJ: Nursing Process Step: Nursing Diagnosis

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

19. An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of:

a. RDS. b. PIVH. c. BPD. d. ROP. ANS: B IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory

symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the

eyes. Other physical characteristics are reported as being normal.

OBJ: Nursing Process Step: Evaluation

PTS: 1 DIF: Cognitive Level: Analysis REF: 644

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MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 20. To determine a preterm infants readiness for nipple feeding, the nurse should assess the:

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a. Skin turgor.

b. Bowel sounds.

c. Current weight.

d. Respiratory rate. ANS: D

Coordination of suck, swallow, and breathing is a common task for preterm infants. The infant must have a respiratory rate less than 60 breaths/min before nipple feeding can be implemented; skin turgor, bowel sounds, and current weight are not indications for nipple feeding. PTS: 1 DIF: Cognitive Level: Application REF: 631

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 21. Following a traumatic birth of a 10-pound infant, the nurse should assess: a. gestational age status. b. flexion of both upper extremities. c. infants percentile on growth chart. d. blood sugar to detect hyperglycemia. ANS: B

Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Gestational age or the infants growth chart percentile will not provide data

about potential injuries from a traumatic birth. A large infant is at risk for hypoglycemia.

PTS: 1 DIF: Cognitive Level: Application REF: 647

OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Health Promotion and Maintenance

would be:

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22. A newborn assessment finding that would support the nursing diagnosis of postmaturity

a. loose skin.

b. ruddy skin color.

c. presence of vernix. d. absence of lanugo. ANS: A Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.

PTS: 1 DIF: Cognitive Level: Assessment REF: 646 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 23. Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.) a. Sepsis

b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress

e. Problems with thermoregulation

ANS: A, C, E

Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are

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related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. The Association of Womens Health, Obstetric and

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Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the problem and determine ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and

symptoms of these complications. These infants are at risk for respiratory distress and

hypoglycemia.

Chapter 21: The Newborn at Risk: Congenital Disorders MULTIPLE CHOICE 1. The infant of a diabetic mother is hypoglycemic. Which type of feeding should be instituted first? a. Glucose water

b. D5W intravenously c. Formula via nasogastric tube d. Small amount of glucose water followed by formula or breast milk ANS: D Glucose followed by formula or breast milk is metabolized more slowly and results in longer normal glucose levels. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines would be a later choice if the hypoglycemia continues. Formula results in longer normal glucose levels but would be

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 659

administered via bottle, not by tube feeding.

MSC: Client Needs: Physiologic Integrity

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2. Which defect is present with tetralogy of Fallot? a. Patent ductus arteriosus b. Coarctation of the aorta

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c. Hypertrophy of the right ventricle

ANS: C

d. Transposition of the great arteries

Tetralogy of Fallot has four characteristicsventricular septal defect, positioning of the aorta over the defect, pulmonary stenosis, and hypertrophy of the right ventricle. Patent ductus arteriosus is a result of the failure of the ductus arteriosus to close after birth. Blood flow is impeded, though this constricted area of the aorta is not a characteristic of tetralogy of Fallot. In transposition of the great arteries, the positions of the aorta and pulmonary artery are reversed. PTS: 1 DIF: Cognitive Level: Understanding REF: 674

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 3. The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula feedings or breastfeedings is to: a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.

ANS: B

Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the

excess bilirubin from the infants system. Feedings every 2 hours will help prevent hypoglycemia.

Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the

bowel. The feedings stimulate bowel movements and emptying of the bilirubin from the bowel.

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PTS: 1 DIF: Cognitive Level: Application REF: 658 OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Physiologic Integrity

4. An infant with severe meconium aspiration syndrome is not responding to conventional

infant?

treatment. Which method of treatment may be available at a level III facility for use with this

a. Insertion of an endotracheal tube b. Respiratory support with a ventilator c. Extracorporeal membrane oxygenation d. Insertion of a laryngoscope and suctioning of the trachea ANS: C

Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infants lungs to rest and recover. An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth, before the infant takes the first breath. PTS: 1 DIF: Cognitive Level: Understanding REF: 653 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 5. Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic

mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority?

a. Notify the clinician stat.

c. Start an intravenous line with D5W.

b. Test for the blood glucose level.

d. Document the event in the nurses notes.

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ANS: B

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These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will

last longer. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until

the infant has been tested and treated if a problem is present. PTS: 1 DIF: Cognitive Level: Application REF: 670 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

6. Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome? a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes c. A 36-week-gestation male baby born by cesarean birth to a mother with insulindependent diabetes d. A 35-week-gestation female baby born vaginally to a mother who has pregnancyinduced hypertension

ANS: C Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at

risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born

vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother

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who has pregnancy-induced hypertension is at risk for hypoxia. PTS: 1 DIF: Cognitive Level: Analysis REF: 651, 652

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

7. Transitory tachypnea of the newborn (TTN) is thought to occur as a result of: a. a lack of surfactant.

b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal birth associated with meconium-stained fluid. ANS: C Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant causes respiratory distress syndrome. A slow vaginal birth will help prevent TTN.

PTS: 1 DIF: Cognitive Level: Understanding REF: 653 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of: a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn.

d. left-to-right shunting of blood through the foramen ovale. ANS: A

Persistent pulmonary hypertension can result from the aspiration of meconium.

Bronchopulmonary dysplasia is caused by the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is caused by

delayed absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent

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ductus arteriosus, or atrioventricular canal defects.

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PTS: 1 DIF: Cognitive Level: Application REF: 655 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

9. The nurse present at the birth is reporting to the nurse who will be caring for the neonate after

birth. Which information should be included for an infant who had thick meconium in the amniotic fluid?

a. The parents spent an hour bonding with the baby after birth. b. An IV was started immediately after birth to treat dehydration. c. There was no meconium below the vocal cords when they were visualized. d. The infant needed vigorous stimulation immediately after birth to initiate crying. ANS: C

A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Bonding after birth is an expected occurrence. There is no relationship between dehydration and meconium fluid. Vigorous stimulation in the presence of meconium fluid is contraindicated to prevent aspiration. PTS: 1 DIF: Cognitive Level: Understanding REF: 653 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

10. Which intervention should make phototherapy most effective in reducing the indirect bilirubin in an affected newborn?

b. Place eye patches on the newborn.

a. Turn the infant every 2 hours.

c. Wrap the infant in triple blankets to prevent cold stress.

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d. Increase the oral intake of water between and before feedings. ANS: A

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Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective.

The infant should be uncovered and unclothed. It is important to increase oral feedings, but water

should not necessarily be given, which would not reduce the bilirubin. PTS: 1 DIF: Cognitive Level: Application REF: 660 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 11. A mother with diabetes has done some reading about the effects of her condition on a newborn. Which statement shows a misunderstanding that should be clarified by the nurse?

a. The red appearance of my babys skin is due to an excessive number of red blood cells. b. My baby will be watched closely for signs of low blood sugar, especially during the early days after birth. c. My babys pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy. d. Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be. ANS: C Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause

them to produce more insulin than they need. High hematocrit values in neonates of diabetic mothers cause them to have a have a ruddy look. Neonates of diabetic mothers are prone to

hypoglycemia. It is correct that some women with diabetes have very small babies because of

poor blood flow through the placenta.

PTS: 1 DIF: Cognitive Level: Analysis REF: 665

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OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 12. Newborns whose mothers are substance abusers frequently have which behaviors?

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a. Hypothermia, decreased muscle tone, and weak sucking reflex b. Excessive sleep, weak cry, and diminished grasp reflex

c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation

d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding ANS: D

Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. They will have hyperactive muscle tone, a high-pitched cry, and diarrhea, not constipation. PTS: 1 DIF: Cognitive Level: Understanding REF: 667

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 13. When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find: a. cyanosis. b. diuresis. c. signs of pulmonary congestion. d. increased oxygenation of the tissues.

ANS: C Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not

a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this

type of cardiac defect.

PTS: 1 DIF: Cognitive Level: Analysis REF: 673

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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14. In an infant with cyanotic cardiac anomaly, the nurse should expect to see: a. feedings taken eagerly.

b. a consistent and rapid weight gain.

c. a decrease in the heart rate with activity.

d. little to no improvement in color with oxygen administration. ANS: D With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity.

PTS: 1 DIF: Cognitive Level: Application REF: 665 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 15. The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice: a. usually results in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body.

d. results from the breakdown of excessive erythrocytes not needed after birth. ANS: B

Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice

appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Jaundice proceeds from the head down. Both jaundices are the

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such as Rh incompatibility.

result of the breakdown of erythrocytes. Pathologic jaundice is caused by a pathologic condition,

PTS: 1 DIF: Cognitive Level: Understanding REF: 673, 674

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. While caring for a post-term infant, the nurse recognizes that the elevated hematocrit level

most likely results from: a. hypoxia in utero.

b. underproduction of red blood cells. c. increased breakdown of red blood cells. d. the normal expected shift from fetal hemoglobin to normal hemoglobin. ANS: A

While in utero, the infant who is hypoxic will compensate by producing more red blood cells. An elevated hematocrit results from an overproduction of red blood cells. It would be seen with a decreased breakdown of red blood cells and is not a normal shift from fetal hemoglobin to normal hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: 657 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 17. Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit

(NICU) for closer observation, with a diagnosis of transient tachypnea (TTN). The parents are notified and become anxious because they have no idea what this means in terms of medical

condition. The best action that the nurse can take at this time is to: a. refer them to the neonatologist for more information.

b. tell them not to worry because their infant will be monitored closely by trained staff.

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c. explain to them that this often occurs following a birth but it will most likely resolve in the next 24 to 48 hours.

ANS: C

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d. tell them that they will be able to come and see their baby, which will help make them feel better.

The clinical diagnosis of TTN has been established, and the nurse should provide factual

information relative to the clinical condition. The RN should be able to provide information to clarify the parents concern. Telling someone not to worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction with the newborn and parents may help ease anxiety but does not address the parents knowledge deficit. PTS: 1 DIF: Cognitive Level: Analysis REF: 664 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

18. While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth? a. Risk for infection related to release of meconium b. Risk for injury related to high-risk birth interventions, such as amino infusion c. Risk for aspiration related to retained secretions d. Risk for thermoregulation because of high-risk labor status ANS: C Because the fetus has already passed meconium in utero, the labor and birth take on a high-risk

management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, so airway abnormalities take precedence in terms of nursing

diagnosis and medical management.

PTS: 1 DIF: Cognitive Level: Application REF: 653

OBJ: Nursing Process Step: Nursing Diagnosis

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MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

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19. Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample

c. Infant bilirubin level

d. Maternal blood type ANS: C The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infants bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice.

PTS: 1 DIF: Cognitive Level: Analysis REF: 657 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 20. Which of the following lab values indicates that an infant may have polycythemia? a. Hb 18 g/dL, Hct 50% b. Hb 25/dL, Hct 55% c. Hb 20/dL, Hct 65%

d. Hb 30 g/dL, Hct 70%

ANS: D

The presence of polycythemia in an infant is characterized by a hemoglobin level greater than 22

g/dL and a hematocrit value greater than 65%.

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PTS: 1 DIF: Cognitive Level: Application REF: 665 OBJ: Nursing Process Step: Assessment

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MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 21. The nurses immediate action after the birth of a post-term infant with meconium stained

amniotic fluid is to:

a. stimulate the infant to cry. b. suction the infants airways. c. complete the 1- and 5-minute Apgars. d. vigorously dry the infants head and trunk. ANS: B Meconium in the upper airways may be pulled deep into the respiratory passages when the infant takes the first breath after birth. Stimulating the infant to cry may cause aspiration of meconium

in the upper airways, completing the 1- and 5-minute Apgars would delay suctioning and allow initiation of respirations, and vigorously drying the infant would increase stimulation and crying. PTS: 1 DIF: Cognitive Level: Application REF: 653 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 22. The nurse notes that the infant has been feeding poorly over the last 24 hours. She should immediately assess for other signs of:

a. hyperglycemia. b. neonatal infection.

c. hemolytic anemia.

d. increased bilirubin levels.

ANS: B

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Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic

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anemia, and increased bilirubin levels are not associated with poor infant feeding. PTS: 1 DIF: Cognitive Level: Application REF: 662

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

23. The priority assessment for the Rh-positive infant whose mothers indirect Coombs test was positive at 36 weeks is: a. skin color. b. temperature. c. respiratory rate. d. blood glucose level.

ANS: A An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor because of erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated with erythroblastosis fetalis. PTS: 1 DIF: Cognitive Level: Application REF: 657 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

a. both mother and infant are O-positive.

b. mother is A-positive and infant is A-negative.

24. The nurse should be alert to a blood group incompatibility if:

c. mother is O-positive and infant is B-negative.

d. mother is B-positive and infant is O-negative.

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ANS: D

Blood group incompatibilities occur because O-positive mothers have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists.

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The mother with blood group B does not have any antibodies to group O.

Chapter 22: Principles of Growth and Development

MULTIPLE CHOICE 1. The husband of a laboring woman asks the nurse how he can help his wife throughout the first stage of labor. The nurse informs him that in addition to all that hes doing now, he could tell her when the contractions are: a. 2 minutes apart. b. at their acme. c. at their increment.

d. at their decrement. ANS: B When the contraction is most intense, the coach can tell the laboring woman that this contraction will be over soon to help her remain focused. Describing the frequency of the contractions is not usually helpful. The increment occurs as the contraction begins in the fundus and spreads through the uterus. Calling attention to this phase may cause the woman to become tense. The woman does not need anyone to tell her that the contraction is decreasing in intensity. PTS: 1 DIF: Cognitive Level: Understanding REF: 196, 197

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. The nurse is explaining to a group of nursing students what occurs during active labor as the products during a contraction?

a. Is not significantly affected

uterus contracts. Which statement explains the maternal-fetal exchange of oxygen and waste

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b. Increases as blood pressure decreases

c. Diminishes as the spiral arteries are compressed

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d. Continues except when placental functions are reduced ANS: C

During labor contractions, the maternal blood supply to the placenta gradually stops as the spiral

arteries supplying the intervillous space are compressed by the contracting uterine muscle. The exchange of oxygen and waste products is affected by contractions. The exchange of oxygen and waste products decreases. The maternal blood supply to the placenta gradually stops with contractions. PTS: 1 DIF: Cognitive Level: Application REF: 199 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity 3. The nurse is directing an unlicensed assistive personnel (UAP) to take maternal vital signs between contractions. Which statement is the best rationale for assessing maternal vital signs between contractions? a. Vital signs taken during contractions are not accurate. b. During a contraction, assessing fetal heart rate is the priority. c. Maternal blood flow to the heart is reduced during contractions. d. Maternal circulating blood volume increases temporarily during contractions.

ANS: D

During uterine contractions, blood flow to the placenta temporarily stops, causing a relative

increase in the mothers blood volume, which in turn temporarily increases blood pressure and

slows the pulse. Vital signs are altered by contractions but are considered accurate for a period of time. It is important to monitor the fetal response to contractions, but the question is concerned

with the maternal vital signs. Maternal blood flow is increased during a contraction.

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PTS: 1 DIF: Cognitive Level: Application REF: 198

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OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Safe and Effective Care Environment

4. Uncontrolled maternal hyperventilation during labor results in: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis. ANS: D

Rapid deep respirations cause the laboring woman to lose carbon dioxide through exhalation, resulting in respiratory alkalosis. Hyperventilation does not cause respiratory acidosis, metabolic acidosis, or metabolic alkalosis. PTS: 1 DIF: Cognitive Level: Understanding REF: 198 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. Which mechanism of labor occurs when the largest diameter of the fetal presenting part passes the pelvic inlet? a. Extension

b. Engagement c. Internal rotation

d. External rotation ANS: B

Engagement occurs when the presenting part fully enters the pelvic inlet. Extension occurs when

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the fetal head meets resistance from the tissues of the pelvic floor and the fetal neck stops under the symphysis. This causes the fetal head to extend. Internal rotation occurs when the fetus enters

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the pelvic inlet. The rotation allows the longest fetal head diameter to conform to the longest diameter of the maternal pelvis. External rotation occurs after the birth of the head. The head then turns to the side so the shoulders can internally rotate and are positioned with their

transverse diameter in the anteroposterior diameter of the pelvic outlet.

PTS: 1 DIF: Cognitive Level: Understanding REF: 209 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 6. The laboring client asks the nurse how the labor contractions work to dilate the cervix. The best response by the nurse is that labor contractions facilitate cervical dilation by: a. promoting blood flow to the cervix. b. contracting the lower uterine segment.

c. enlarging the internal size of the uterus. d. pulling the cervix over the fetus and amniotic sac. ANS: D Effective uterine contractions pull the cervix upward at the same time the fetus and amniotic sac are pushed downward. Blood flow decreases to the uterus during a contraction. The contractions are stronger at the fundus. The internal size becomes smaller with the contractions; this helps push the fetus down.

PTS: 1 DIF: Cognitive Level: Application REF: 198 OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

7. Pregnant clients can usually tolerate the normal blood loss associated with childbirth because

they have:

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a. a higher hematocrit. b. increased leukocytes.

c. increased blood volume.

ANS: C

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d. a lower fibrinogen level.

Women have a significant increase in blood volume during pregnancy. After birth, the additional circulating volume is no longer necessary. The hematocrit decreases with pregnancy because of the high fluid volume. Leukocyte levels increase during labor, but that is not the reason for the toleration of blood loss. Fibrinogen levels increase with pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 198 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. The nurse is assessing the duration of a clients labor contractions. Which action does the nurse implement to assess the duration of labor contractions? a. Assess the strongest intensity of each contraction. b. Assess uterine relaxation between two contractions. c. Assess from the beginning to the end of each contraction. d. Assess from the beginning of one contraction to the beginning of the next. ANS: C Duration of labor contractions is the average length of contractions from beginning to end.

Assessing the strongest intensity of each contraction assesses the strength or intensity of the contractions. Assessing uterine relaxation between two contractions is the interval of the

contraction phase. Assessing from the beginning of one contraction to the beginning of the next

is the frequency of the contractions.

PTS: 1 DIF: Cognitive Level: Application REF: 196, 197

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 9. Which event is the best indicator of true labor?

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a. Bloody show

b. Cervical dilation and effacement

c. Fetal descent into the pelvic inlet

d. Uterine contractions every 7 minutes ANS: B

The conclusive distinction between true and false labor is that contractions of true labor cause progressive change in the cervix. Bloody show can occur before true labor. Fetal descent can occur before true labor. False labor may have contractions that occur this frequently but is usually inconsistent. PTS: 1 DIF: Cognitive Level: Understanding REF: 198

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 10. Which factor ensures that the smallest anterior-posterior diameter of the fetal head enters the pelvis? a. Station b. Flexion c. Descent d. Engagement

ANS: B The anterior-posterior diameter of the head varies with how much it is flexed. In the most favorable situation, the head is fully flexed and the anterior-posterior diameter is the

suboccipitobregmatic, averaging 9.5 cm. The station is the relationship of the fetal presenting

part to the level of the ischial spine. Descent is the moving of the fetus through the birth canal. Engagement occurs when the largest diameter of the fetal presenting part has passed the pelvic

outlet.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 209

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OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. An increase in urinary frequency and leg cramps after the 36th week of pregnancy most

likely indicates:

a. lightening.

b. breech presentation. c. urinary tract infection. d. onset of Braxton-Hicks contractions. ANS: A As the fetus descends toward the pelvic inlet near the end of pregnancy, increased pelvic pressure occurs, resulting in greater urinary frequency and more leg cramps. Breech presentation

does not cause urinary frequency and leg cramps. A urinary tract infection may cause urinary frequency but with burning and would not cause leg cramps. Braxton-Hicks contractions are irregular and mild and occur throughout the pregnancy. PTS: 1 DIF: Cognitive Level: Understanding REF: 207 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 12. A nullipara client has progressed to the active phase of labor. The nurse understands that this phase of labor, on the average, for a nullipara will last how long? a. 50 minutes

b. hours c. 6 to 7 hours

d. 8 to 10 hours ANS: D

The active phase of labor for a nullipara lasts 8 to 10 hours. The second phase of labor lasts 50 of labor is 6 to 7 hours.

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minutes for a nullipara. The transition phase lasts hours for a nullipara. A multiparas active phase

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PTS: 1 DIF: Cognitive Level: Analysis REF: 208

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

13. A client just delivered a baby by the vaginal route. The client asks the nurse why the babys head is not round, but oval. Which explanation should the nurse give to the client? a. This results from molding. b. This results from lightening. c. This results from the fetal lie. d. This results from the fetal presentation. ANS: A

The sutures and fontanels allow the bones of the fetal head to move slightly, changing the shape of the fetal head so it can adapt to the size and shape of the pelvis. Lightening is the descent of the fetus toward the pelvic inlet before labor. Lie is the relationship of the long axis of the fetus to the long axis of the mother. Presentation is the fetal part that first enters the pelvic outlet. PTS: 1 DIF: Cognitive Level: Application REF: 201 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

14. A client whose cervix is dilated to 5 cm is considered to be in which phase of labor? a. Latent phase

b. Active phase c. Second stage

d. Third stage

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ANS: B

The active phase of labor is characterized by cervical dilation of 4 to 7 cm. The latent phase is from the beginning of true labor until 3 cm of cervical dilation. The second stage of labor begins

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when the cervix is completely dilated until the birth of the baby. The third stage of labor is from the birth of the baby until the expulsion of the placenta.

PTS: 1 DIF: Cognitive Level: Understanding REF: 212 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 15. The nurse is assessing a client in the active phase of labor. What should the nurse expect during this phase? a. The client is sociable and excited. b. The client is requesting pain medication. c. The client begins to experience the urge to push.

d. The client experiences loss of control and irritability. ANS: B During the active phase of labor, contraction intensity and discomfort increase to the point where women often request pain medication. Sociability and excitability occur during the latent phase. The urge to push occurs at the end of the transition phase or the second stage of labor. Loss of control and irritability occur during the transition phase of labor. PTS: 1 DIF: Cognitive Level: Application REF: 212

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 16. A laboring client asks the nurse how she will know that the contraction is at its peak. The

nurse explains that the contraction peaks during which stage of measurement?

a. The acme b. The interval

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ANS: A

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d. The decrement

c. The increment

The acme is the peak or period of greatest strength during the middle of a contraction cycle. The interval is the period between the end of the contraction and the beginning of the next. The

increment is the beginning of the contraction until it reaches the peak. The decrement occurs

after the peak until the contraction ends. PTS: 1 DIF: Cognitive Level: Application REF: 196, 197 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. A client in labor presents with a breech presentation. The nurse understands that a breech presentation is associated with:

a. more rapid labor. b. a high risk of infection. c. maternal perineal trauma. d. umbilical cord compression. ANS: D The umbilical cord can compress between the fetal body and maternal pelvis when the body has been born but the head remains within the pelvis. Breech presentation is not associated with a more rapid labor. There is no higher risk of infection with a breech birth. There is no higher risk

for perineal trauma with a breech birth. PTS: 1 DIF: Cognitive Level: Understanding REF: 202, 203

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

a. total duration of labor.

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b. level of pain experienced.

18. The primary difference between the labor of a nullipara and that of a multipara is:

c. amount of cervical dilation.

ANS: A

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d. sequence of labor mechanisms.

Multiparas usually labor more quickly than nulliparas, making the total duration of their labor

shorter. The level of pain is individual to the woman, not the number of labors she has experienced. Cervical dilation is the same for all labors. The sequence of labor mechanisms is the same with all labors. PTS: 1 DIF: Cognitive Level: Analysis REF: 214 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 19. Which maternal factor may inhibit fetal descent?

a. A full bladder b. Decreased peristalsis c. Rupture of membranes d. Reduction in internal uterine size ANS: A A full bladder may inhibit fetal descent because it occupies space in the pelvis needed by the fetal presenting part. Peristalsis does not influence fetal descent. Rupture of membranes will assist in the fetal descent. Contractions will reduce the internal uterine size to assist fetal descent.

PTS: 1 DIF: Cognitive Level: Understanding REF: 198

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

20. Which assessment finding would cause a concern for a client who had delivered vaginally? a. Estimated blood loss (EBL) of 500 mL during the birth process

b. White blood cell count of 28,000 mm3 postbirth

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c. Client complains of fingers tingling

ANS: C

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d. Client complains of thirst

A clients complaint of fingers tingling may represent respiratory alkalosis due to

hyperventilation breathing patterns during labor. As such it requires intervention by the nurse to have the client slow breathing down and restore normal carbon dioxide levels. PTS: 1 DIF: Cognitive Level: Application REF: 198 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

21. Which clinical findings would be considered to be normal for a preterm fetus during the labor period? a. Baseline tachycardia b. Baseline bradycardia c. Fetal anemia d. Acidosis ANS: A Because the nervous system is immature, it is expected that the preterm fetus will have a baseline

tachycardia because of stimulation of the sympathetic nervous system. Baseline bradycardia, fetal anemia, and acidosis would indicate abnormal findings and fetal compromise.

OBJ: Nursing Process Step: Assessment

PTS: 1 DIF: Cognitive Level: Application REF: 199

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MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 22. On admission to the labor and birth unit, a 38-year-old female, gravida 4, para 3, at term in early labor is found to have a transverse lie on vaginal examination. What is the priority

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intervention at this time?

a. Perform a vaginal exam to denote progress.

b. Notify the health care provider.

c. Initiate parenteral therapy. d. Apply oxygen via nasal cannula at 8 L/min. ANS: B A transverse lie is considered to be an abnormal presentation so the physician should be notified and the process of a C section as the birth method should be initiated. The information provided relative to transverse lie was found on vaginal exam. At this point, the priority is to prepare for a surgical birth because assessment data also indicate that the client is in early labor; thus, a

vaginal birth is not imminent. Although initiating parenteral therapy will be required, it is not the priority at this time. Application of oxygen is not required because there is no evidence of fetal or maternal distress. PTS: 1 DIF: Cognitive Level: Analysis REF: 202 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 23. An assessment finding that would indicate to the nurse that cervical dilation and/or

effacement has occurred is: a. onset of irregular contractions.

c. bloody mucus drainage from vagina.

b. cephalic presentation at 0 station.

d. fetal heart tones (FHTs) present in the lower right quadrant.

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ANS: C

Cervical dilation and/or effacement results in loss of the mucous plug as well as rupture of small capillaries in the cervix; irregular contractions, cephalic presentation, and FHTs in the lower

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right quadrant do not indicate the onset of cervical ripening.

PTS: 1 DIF: Cognitive Level: Analysis REF: 207

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 24. If a notation on the clients health record states that the fetal position is LSP, this means that the: a. head is in the right posterior quadrant of the pelvis. b. head is in the left anterior quadrant of the pelvis. c. buttocks are in the left posterior quadrant of the pelvis. d. buttocks are in the right upper quadrant of the abdomen.

ANS: C LSP explains the position of the fetus in the maternal pelvis. L = left side of the pelvis, S = sacrum (fetus is in breech presentation), P = posterior quadrants of the pelvis. When the head is in the right posterior quadrant of the pelvis, the position is ROP. When the head is in the left anterior quadrant of the pelvis, the position is ROA. When the buttocks are in the upper quadrant of the abdomen, the position would be ROA, ROP, LOA, LOP, LOT, or ROT. PTS: 1 DIF: Cognitive Level: Analysis REF: 204 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

25. The assessment finding which indicates that the client is in the active phase of the first stage of labor is:

a. 80% effacement.

b. dilation of 5 cm. c. presence of bloody show.

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d. regular contraction every 3 to 4 minutes. ANS: B

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The active phase of labor is defined by cervical dilation between 4 to 7 cm. Effacement, bloody show, and regular contractions are not parameters whereby the phases of labor are defined.

PTS: 1 DIF: Cognitive Level: Analysis REF: 212 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 26. To determine if the client is in true labor, the nurse would assess for changes in: a. cervical dilation. b. amount of bloody show. c. fetal position and station. d. pattern of uterine contractions.

ANS: A Cervical changes are the only indication of true labor and are used to determine true and false labor. Changes in the amount of bloody show, fetal position and station, and pattern of uterine contractions are unreliable indicators of true labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 208 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

27. The health care provider for a laboring patient makes the following entry into the patients record: 3/50%/1. What instruction will the nurse implement with the patient?

a. You will need to remain in bed attached to the electronic fetal monitor.

b. Breathe with me slowly, in through your nose and out through your mouth.

c. I will begin the administration of 1000 mL of IV fluid so you can have an epidural.

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d. Your partner will need to change into scrub attire to attend the imminent birth.

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ANS: B

This client is in the latent phase of the first stage of labor. Use slow, deep chest breathing patterns early in labor to conserve energy for the upcoming process. There is no mention in the

stem that the membranes are ruptured, which may prohibit the patient from ambulating.

Ambulating during early labor uses gravity to facilitate fetal descent. This is desired because the head is at 1 station. Epidural placement during early labor may slow down the labor process. There is no indication that birth is imminent because the patient is 3 cm dilated. PTS: 1 DIF: Cognitive Level: Analysis REF: 212 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

28. The examiner indicates to the labor nurse that the fetus is in the left occiput anterior (LOA) position. To facilitate the labor process, how will the nurse position the laboring patient? a. On her back b. On her left side c. On her right side d. On her hands and knees ANS: B LOA is the desired fetal position for the birthing process. Positioning the patient on her left side

will accomplish two objectives: (1) by the use of gravity, the fetus will most likely stay in the LOA position; and (2) increase perfusion of the placenta and increase oxygen to the fetus.

Positioning the patient on her back decreases placental perfusion. Positioning on her right may facilitate internal rotation and move the fetus out of the LOA position. The hands and knees

position is reserved to decrease cord compression, facilitate the fetus out of a posterior position, or increase oxygenation in the presence of hypoxia. Because none of these conditions are

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present, there is no need to implement this position. PTS: 1 DIF: Cognitive Level: Analysis REF: 204

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OBJ: Nursing Process Step: Implementation

29.

MSC: Client Needs: Health Promotion and Maintenance

The primipara at 39 weeks gestation states to the nurse, I can breathe easier now. What is the nurses best response? a. You labor will start any day now since the baby has dropped. b. That process is called lightening. Do you have to urinate more frequently? c. Contact your health care provider when your contractions are every 5 minutes for 1 hour.

d. You will likely not feel you babys movements as much now, so do not be concerned. ANS: B As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patients statement of being able

to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

OBJ: Nursing Process Step: Implementation

PTS: 1 DIF: Cognitive Level: Application REF: 207

MSC: Client Needs: Health Promotion and Maintenance

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30. The nurse assess a laboring patients contraction pattern and notes the frequency at every 3 to 4 minutes, duration 50 to 60 sections, and the intensity is moderate by palpation. What is the

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most accurate documentation for this contraction pattern? a. Stage 1, latent phase

b. Stage 2, latent phase

c. Stage 1, active phase d. Stage 2, active phase ANS: C In the active phase of stage 1, contractions are about 2 to 5 minutes apart, with a duration of about 40 to 60 seconds and an intensity that ranges from moderate to strong. During the latent phase of stage 1, the interval between contractions shortens until contractions are about 5 minutes apart. Duration increases to 30 to 40 seconds by the end of the latent phase. During stage

2, latent phase, the woman is resting and preparing to push; she likely has not experienced the Ferguson reflex. She is actively bearing down during the active phase of the second stage. PTS: 1 DIF: Cognitive Level: Understanding REF: 212 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 31. A laboring patient states to the nurse, I have to push! What is the next nursing action? a. Contact the health care provider. b. Examine the patients cervix for dilation.

c. Review with her how to bear down with contractions. d. Ask her partner to support her head with each push.

ANS: B

When the cervix is completely dilated, the head can descend through the pelvis and stimulate the Ferguson, or pushing, reflex. Cervical dilation must first be confirmed because premature

pushing efforts may result in cervical edema and corresponding delay in dilation. Once complete

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dilation has been confirmed, the nurse can notify the health care provider. Teaching positioning and pushing efforts is accomplished once complete dilation has been confirmed.

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PTS: 1 DIF: Cognitive Level: Application REF: 199

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

32. After birth of the placenta the patient states, All of a sudden I feel very cold. What is the best nursing action in response to this statement? a. Place a warm blanket over the patient. b. Place the baby on the patients abdomen. c. Tell the patient that chills are expected after birth. d. What do you mean by your words very cold? ANS: A

Many women are chilled after birth. The cause of this reaction is unknown but probably relates to the sudden decrease in effort, loss of the heat produced by the fetus, decrease in intraabdominal pressure, and fetal blood cells entering the maternal circulation. The chill lasts for about 20 minutes and subsides spontaneously. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Placing the baby on her abdomen may result in transfer of heat and make her feel even colder. Reassurance is appropriate after the blanket is provided. Validation of an expected physical response to the birthing process results in a delay of care and is unnecessary. PTS: 1 DIF: Cognitive Level: Application REF: 214

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

MULTIPLE RESPONSE

33. A 28-year-old gravida 1, para 0 client who is at term calls the labor and birth unit stating that

she thinks she is in labor. She states that she does have some vaginal discharge and feels wet but

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it is not bloody in nature. She relates a contraction pattern that is irregular, ranging from 5 to 7 minutes and lasting 30 seconds. What questions would be used during the process of phone

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triage by the nurse? (Select all that apply.)

a. Ask her if her if she thinks that her membranes have ruptured. b. Ask her if she has any evidence of bloody show.

c. Have her keep monitoring her contraction pattern and call you back if they become more regular. d. Ask her when her she has her next scheduled visit with her health care provider. e. Tell her to come into the hospital for evaluation. ANS: A, E The cornerstone of obstetric triage is reassurance of maternal-fetal well-being. Thus, in view of the assessment data that the client provided, the nurse should ascertain membrane status and ask the client to come in for evaluation. The client has already indicated that the vaginal discharge

was not bloody in nature. Having the client continue to monitor at home would not provide assurance of maternal-fetal well-being. Asking the client about the next scheduled physician visit does not address current health concerns of impending labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 208 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 34. A client asks the nurse how she can tell if labor is real? What should the nurse give as an

explanation? (Select all that apply.) a. In true labor, the cervix begins to dilate.

b. In true labor, the contractions are felt in the abdomen and groin.

c. In true labor, contractions often resemble menstrual cramps during early labor.

d. In true labor, contractions are inconsistent in frequency, duration, and intensity in the early stages.

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ANS: A, C, E

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e. In true labor your contractions tend to increase in frequency, duration, and intensity with walking.

In true labor, the cervix begins to dilate, contractions often resemble menstrual cramps in the early stage, and labor contractions increase in frequency, duration, and intensity with walking.

False labor contractions are felt in the abdomen and groin and the contractions are inconsistent in

frequency, duration, and intensity. PTS: 1 DIF: Cognitive Level: Application REF: 208 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 35. The nurse who elects to practice in the area of obstetrics often hears discussion regarding the four Ps. What are the four Ps that interact during childbirth? (Select all that apply.)

a. Powers b. Passage c. Position d. Passenger e. Psyche ANS: A, B, D, E Powers: The two powers of labor are uterine contractions and pushing efforts. During the first stage of labor, through full cervical dilation, uterine contractions are the primary force moving

the fetus through the maternal pelvis. At some point after full dilation, the woman adds her voluntary pushing efforts to propel the fetus through the pelvis.

Passage: The passage for birth of the fetus consists of the maternal pelvis and its soft tissues. The bony pelvis is more important to the successful outcome of labor because bones and joints

do not yield as readily to the forces of labor.

Passenger: This is the fetus plus the membranes and placenta. Fetal lie, attitude, presentation,

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and position are all factors that affect the fetus as passenger. Psyche: The psyche is a crucial part of childbirth. Marked anxiety, fear, or fatigue decreases the

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womans ability to cope.

Position is not one of the four Ps.

PTS: 1 DIF: Cognitive Level: Analysis REF: 199 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 36. The nurse is planning care for a client during the fourth stage of labor. Which interventions should the nurse plan to implement? (Select all that apply.) a. Offer the client a warm blanket. b. Place an ice pack on the perineum. c. Massage the uterus if it is boggy.

d. Delay breastfeeding until the client is rested. e. Explain to the client that the lochia will be light pink in color. ANS: A, B, C The fourth stage of labor lasts from the birth of the placenta through the first 1 to 4 hours after birth. Many women are chilled after birth. A warm blanket, hot drink, or soup may help relieve the chill and make the woman more comfortable. Localized discomfort from birth trauma such as lacerations, episiotomy, edema, or hematoma is evident as the effects of local and regional anesthetics diminish. Ice packs on the perineum limit this edema and hematoma formation. A soft (boggy) uterus and increasing uterine size are associated with postpartum hemorrhage

because large blood vessels at the placenta site are not compressed. The uterus should be massaged if it is not firm. The fourth stage is the best time to initiate breastfeeding if maternal

and infant problems are absent. The vaginal drainage after childbirth is called lochia. The three stages are lochia rubra, lochia serosa, and lochia alba. Lochia rubra, consisting mostly of blood,

is present in the fourth stage of labor. The color of the lochia will be bright red not pink.

PTS: 1 DIF: Cognitive Level: Application REF: 214

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OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

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37. Which should the nurse expect to assess in the third stage of labor that indicates the placenta has separated from the uterine wall? (Select all that apply.) a. A gush of blood appears.

b. The uterus rises upward in the abdomen.

c. The fundus descends below the umbilicus. d. The cord descends further from the vagina. e. The uterus becomes boggy and soft, with an elongated shape. ANS: A, B, D Four signs suggest placenta separation. The uterus has a spherical shape. The uterus rises upward in the abdomen as the placenta descends into the vagina and pushes the fundus upward. The cord

descends further from the vagina. A gush of blood appears as blood trapped behind the placenta is released. The fundus rises upward above the umbilicus. A boggy uterus with an elongated shape would not be expected. PTS: 1 DIF: Cognitive Level: Analysis REF: 214 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 38. The nurse is teaching a group of nursing students about factors that have a role in starting labor. Which should the nurse include in the teaching session? (Select all that apply.) a. Progesterone levels become higher than estrogen levels.

b. Natural oxytocin in conjunction with other substances plays a role.

c. Stretching, pressure, and irritation of the uterus and cervix increase.

d. The secretion of prostaglandins from the fetal membranes decreases. ANS: B, C

Factors that appear to have a role in starting labor include the following: (1) natural oxytocin

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plays a part in labors initiation in conjunction with other substances; and (2) stretching, pressure, and irritation of the uterus and cervix increase as the fetus reaches term size. The progesterone

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levels drop and estrogen levels increase. There is an increase in the secretion of prostaglandins from the fetal membranes.

Chapter 23:Growth and Development of the Infant: 28 Days to 1 Year

MULTIPLE CHOICE 1. A mother calls the pediatricians office because her infant is colicky. The helpful measure the nurse would suggest to the parent is: a. Sing songs to the infant in a soft voice. b. Place the infant in a well-lit room. c. Walk around and massage the infants back.

d. Rock the fussy infant slowly and gently. ANS: D One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements. DIF: Cognitive Level: Application REF: Text Reference: 390 OBJ: Objective: 11 TOP: Topic: Health Maintenance

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. The nurse is aware that the age at which the posterior fontanelle closes is:

a. 2 to 3 months

b. 3 to 6 months

d. 9 to 12 months

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ANS: A

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c. 6 to 9 months

The posterior fontanel closes between 2 and 3 months of age.

DIF: Cognitive Level: Knowledge REF: Text Reference: 384, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse knows that an infants birthweight should be tripled by: a. 9 months

b. 1 year c. 18 months d. 2 years ANS: B The infant usually triples his or her birth weight by about 12 months of age. DIF: Cognitive Level: Knowledge REF: Text Reference: 386, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

4. The nurse is aware that the age at which an infant is able to sit steadily alone is:

a. 4 months

c. 8 months

ANS: C

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d. 15 months

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b. 5 months

The infant can sit alone without support at about 8 months of age. DIF: Cognitive Level: Knowledge REF: Text Reference: 382, Figure 16-3 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The infant should be able to walk independently by the age of:

a. 8-10 months b. 12-15 months c. 15-18 months d. 18-21 months ANS: B For the majority of children, the milestone of walking alone is achieved between 12 and 15 months.

DIF: Cognitive Level: Knowledge REF: Text Reference: 383, Table 16-3

KEY: Nursing Process Step: Assessment

OBJ: Objective: 2 TOP: Topic: Development and Care

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

6. The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin

a. 5 months

c. 1 year

ANS: A

d. 2 years

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b. 9 months

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drinking from a cup? The nurse would reply:

The infant can usually drink from a cup when it is offered at about 5 months. DIF: Cognitive Level: Comprehension REF: Text Reference: 386, Table 16-1 OBJ: Objective: 7 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The nurse would expect a 4-month-old to be able to: a. Hold a cup b. Stand with assistance c. Lift head and shoulders d. Sit with back straight ANS: C

Because development is cephalocaudal, of these choices, sitting is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at

about 8 months.

DIF: Cognitive Level: Analysis REF: Text Reference: 381, Table 16-1

OBJ: Objective: 2 TOP: Topic: Development and Care

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KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The abnormal finding in an evaluation of growth and development for a 6-month-old infant

would be:

a. Weight gain of 4-7 ounces per week

b. Length increase of 1 inch in 2 months c. Head lag present d. Can sit alone for a few seconds ANS: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.

DIF: Cognitive Level: Analysis REF: Text Reference: 386, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A parent brings a 6-month-old infant to the pediatric clinic for her well-child examination. Her birthweight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least:

a. 12 pounds b. 16 pounds

c. 20 pounds

d. 24 pounds

ANS: B

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Birth weight is usually doubled by 6 months of age.

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DIF: Cognitive Level: Application REF: Text Reference: 386, Table 16-1 OBJ: Objective: 8 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The nurse would advise a parent when introducing solid foods to: a. Begin with one tablespoon of the food. b. Mix foods together. c. Eliminate a refused food from the diet. d. Introduce each new food 4 to 7 days apart.

ANS: D Only one new food is offered in a 4- to 7-day period to determine tolerance. DIF: Cognitive Level: Comprehension REF: Text Reference: 394 OBJ: Objective: 5 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

11. When talking with a parent about tooth eruption, the nurse explains that the first deciduous teeth to erupt are the:

a. Lower central incisors

c. Lower lateral incisors

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d. Upper lateral incisors

b. Upper central incisors

ANS: A

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The first teeth to erupt, usually at about 7 months, are the lower central incisors. DIF: Cognitive Level: Knowledge REF: Text Reference: 387, Table 16-1

OBJ: Objective: 8 TOP: Topic: Development and Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. When assessing development in a 9-month-old infant, the nurse would expect to observe the infant: a. Sitting if supported

b. Grasping objects with the palm c. Imitating sounds such as da-da d. Beginning to use a spoon rather sloppily ANS: C The 9-month-old tries to imitate sounds such as da-da or ba-ba. DIF: Cognitive Level: Analysis REF: Text Reference: 388, Table 16-1 OBJ: Objective: 2 TOP: Topic: Development and Care

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

13. The statement made by a parent that indicates correct understanding of infant feeding is:

a. Ive been mixing rice cereal and formula in the babys bottle.

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b. I switched the baby to low-fat milk at 9 months. c. The baby really likes little pieces of chocolate.

ANS: D

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d. I give the baby any new foods before he takes his bottle.

New solid foods should be introduced before formula or breast milk to encourage the infant to

try new foods.

DIF: Cognitive Level: Analysis REF: Text Reference: 394 OBJ: Objective: 5 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

14. The nurse would advise a mother who is concerned because her 10-month-old is lethargic, to: a. Keep the babys room well-lit. b. Rub the babys soles vigorously. c. Offer the baby a pacifier. d. Handle the infant slowly and gently. ANS: D Some infants respond to stimulating environments by shutting down. Move and handle infants

slowly and gently. DIF: Cognitive Level: Application REF: Text Reference: 390

KEY: Nursing Process Step: Implementation

OBJ: Objective: 11, 14 TOP: Topic: Health Maintenance

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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. The nurse discusses safety-proofing the home with the mother of a 9-month-old. The

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statement made by the mother that indicates an unsafe behavior is: a. I put covers on all of the electrical outlets. b. In the car, she rides in a front-facing car seat.

c. There are locks on all of the cabinets in the house.

d. I have a gate at the top and bottom of the stairs. ANS: B A rear-facing infant car seat should be used for infants under 1 year of age. DIF: Cognitive Level: Analysis REF: Text Reference: 396 OBJ: Objective: 13 TOP: Topic: Infant Safety

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. The nurse observes a 10-month-old infant using her index finger and thumb to pick up Cheerios. This behavior is evidence that the infant has developed the: a. Pincer grasp b. Grasp reflex c. Prehension ability

d. Parachute reflex ANS: A

By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

DIF: Cognitive Level: Analysis REF: Text Reference: 382, Figure16-3

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OBJ: Objective: 2 TOP: Topic: General Characteristics KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A parent is concerned because her infant has a diaper rash. The nurse would advise the parent

to:

a. Use commercial diaper wipes to clean the area. b. Apply a protective ointment on the area. c. Change the babys diaper less frequently. d. Keep the diaper area covered all of the time. ANS: B A protective ointment can be applied when the skin in the diaper area appears pink and irritated.

DIF: Cognitive Level: Application: Basic Care and Comfort REF: Text Reference: 390 OBJ: Objective: 10 TOP: Topic: Community-Based Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The mother of an infant born prematurely tells the nurse, The baby is irritable. He cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe him? The most appropriate recommendation to help this parent would be:

a. Play the radio or TV while you feed the baby. b. Put the baby in a room with sunlight.

c. Cover the baby snugly when you hold him.

d. Change the babys position quickly.

ANS: C

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A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face.

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DIF: Cognitive Level: Application REF: Text Reference: 383

OBJ: Objective: 11 TOP: Topic: Community-Based Care

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. The most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old would be: a. Ride a tricycle. b. Spend time in an infant swing. c. Play with push-pull toys.

d. Read large picture books. ANS: C Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child. DIF: Cognitive Level: Analysis REF: Text Reference: 397, Table 16-4 OBJ: Objective: 12 TOP: Topic: Infant Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The statement that indicates the mother of an 8-month-old understands infant sleep patterns

is:

a. I put the baby in my bed until she falls asleep, then I put her in her crib.

b. I let the baby skip an afternoon nap so she will fall asleep earlier. c. I put the pacifier in the crib so she can find it when she wakes up.

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d. I rock the baby back to sleep if she wakes up at night.

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ANS: C

The parent should assist the infant to develop self-soothing behaviors so the infant can get back

to sleep on her own.

DIF: Cognitive Level: Analysis REF: Text Reference: 390 OBJ: Objective: 14 TOP: Topic: Health Maintenance KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE

1. The nurse is aware that the 7-month-old can signal feeding readiness by: Select all that apply. a. Pulling spoon toward mouth b. Biting at spoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement at sight of food e. Manipulating finger foods

ANS: A, E The 7-month-old pulls the spoon toward its mouth, and can manipulate finger foods. The 7-

month-old does not have upper incisors and has not developed adequately to recognize the food

container or exhibit excitement related to the sight of food.

DIF: Cognitive Level: Analysis REF: Text Reference: 395, Table 16-4

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OBJ: Objective: 2 TOP: Topic: Feeding Skills KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

COMPLETION

1. The nurse reminds the parents that the first DPT, oral polio, and flu immunizations should be

given when the child is ____________________ months old. ANS: 2 DIF: Cognitive Level: Comprehension REF: Text Reference: 384, Table 16-1 OBJ: Objective: 2 TOP: Topic: Immunizations KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: The first DPT, polio, and flu immunizations are given at the age of 2 months. 2. The nurse explains the second process of self-mobility a baby learns is seen at the age of 9 months, when the baby begins to ____________________. ANS: creep DIF: Cognitive Level: Application REF: Text Reference: 388, Table 16-1

OBJ: Objective: 2 TOP: Topic: Creeping KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

NOT: Rationale: At 7 months the baby begins to crawl, using arms and dragging trunk and legs. At 9 months the baby begins to creep, holding its trunk above the floor. The next self-mobility

activity is cruising, where the child walks from one piece of furniture to the next before it begins

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to walk independently.

3. The nurse cautions parents to place their baby in the ____________________ or

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____________________ positions, rather than on its stomach, to reduce the risk of sudden infant death syndrome (SIDS).

ANS: supine or side-lying

DIF: Cognitive Level: Application REF: Text Reference: 390 OBJ: Objective: 10 TOP: Topic: Positions for Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

NOT: Rationale: The supine or side-lying position has been found to reduce possible aspiration, and is believed to reduce the risk of SIDS. OTHER 1. The nurse explains that a babys prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex. a. Hands held open most of the time b. Grasps with thumb on one side and three fingers on the other

c. Picks up toy with squeeze action

d. Thumb and forefinger hold object

e. Hands held closed most of the time

ANS:

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E, A, C, B, D

The development advances from the newborns closed hands to the open star hands of the older

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infant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger.

Chapter 24:Growth and Development of the Toddler: 1 to 3 Years MULTIPLE CHOICE 1. Which of these behaviors reported by a parent of an 18-month-old toddler would the nurse report to the pediatrician as a cause for concern? a. The child has temper tantrums. b. The child feeds himself sloppily. c. The child walks by holding onto furniture.

d. The child speaks in short sentences. ANS: C By 18 months, a toddler should have been walking alone for several months. The toddler who walks holding onto furniture should be evaluated by a developmental specialist. DIF: Cognitive Level: Analysis REF: Text Reference: 400, Table 17-1 OBJ: Objective: 2 TOP: Topic: Development

KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

a. That the child jumps with both feet

2. The nurse assessing growth and development of a 2-year-old child would expect to find:

b. That 20 deciduous teeth have erupted c. That the child can hop on one foot

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d. A vocabulary of 900 words

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ANS: A

The 2-year-old can jump with both feet. The remaining achievements occur after 2 years of age.

DIF: Cognitive Level: Analysis REF: Text Reference: 400, Table 17-1 OBJ: Objective: 2 TOP: Topic: Physical Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A parent remarks, My 18-month-old daughter carries her blanket around everywhere. Is this normal? The nurse who has an understanding of toddler development might explain that:

a. She carries her blanket because she is ritualistic. b. Carrying her favorite blanket is self-consoling behavior. c. This behavior can be discouraged by offering new toys to the child. d. This could be indicative of emotional distress. ANS: B Favorite possessions and repetitive rituals are self-consoling behaviors for the toddler. DIF: Cognitive Level: Application REF: Text Reference: 403

OBJ: Objective: 6 TOP: Topic: Guidance and Discipline

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse observed three toddlers playing side by side with dolls. Closer observation revealed

that the children were not interacting with one another. This type of play would be characterized

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as:

b. Parallel

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a. Solitary

c. Associative

ANS: B

d. Cooperative

Toddlers engage in parallel play. Children play next to, but not with, each other. DIF: Cognitive Level: Analysis REF: Text Reference: 411 OBJ: Objective: 9 TOP: Topic: Play KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse planning anticipatory guidance for parents of a toddler would include which of the following instructions? a. Adhere to a rigid schedule because the toddler is ritualistic. b. Limit setting should include praise. c. Shoes should fit snugly at the toe and arch. d. Dress the toddler in pants with a zipper so he or she can learn to zip and unzip clothes.

ANS: B

Limit-setting should include praise as well as disapproval for undesired behavior.

DIF: Cognitive Level: Application REF: Text Reference: 403

OBJ: Objective: 2 TOP: Topic: Daily Care

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KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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6. The best advice the nurse can offer a parent who is concerned because her 2-year-old is very active and does not eat much is:

a. Insist that the child eat one food on the plate.

b. Help the child to wind down with a quiet activity before mealtime. c. Maintain a consistent eating schedule for the family. d. Serve the meal with a variety of interesting plates, cups, and utensils. ANS: B Quiet time before meals provides an opportunity for the active toddler to wind down. DIF: Cognitive Level: Application REF: Text Reference: 406

OBJ: Objective: 11 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. How would the nurse advise a parent who states, I never know how much food to feed my child? a. Serving sizes should not exceed 1 teaspoon of each type of food. b. Food quantities must be carefully measured to avoid overfeeding.

c. Use 1 tablespoon of each food for each year of age as a guideline. d. A toddler should eat three balanced meals. Snacks are not necessary.

ANS: C

A tablespoon of each type of food for each year of age is a good guideline to follow when

determining serving sizes.

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DIF: Cognitive Level: Application REF: Text Reference: 406

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OBJ: Objective: 11 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

8. The nurse discussing toilet training with parents would identify which of the following as an indicator of readiness? The child is: a. Willing to sit on the potty for 15 to 20 minutes b. Dry in the daytime for 4-hour periods c. Able to communicate that he or she is wet d. Curious about bathroom activities ANS: C

Children are ready for toilet training when they can communicate in some fashion that they are wet or need to urinate or defecate. DIF: Cognitive Level: Comprehension REF: Text Reference: 405 OBJ: Objective: 7 TOP: Topic: Toilet Independence KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

9. The nurse selects the most appropriate toy for a normal 2-year-old child, which is: a. A bicycle with training wheels b. A dump truck

c. Wind-up toys

d. Legos

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ANS: B

The 2-year-old enjoys playing with objects that can be pushed or pulled.

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DIF: Cognitive Level: Application REF: Text Reference: 410 OBJ: Objective: 9 TOP: Topic: Toys and Play

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. To encourage a toddler to practice independence, the nurse would recommend that the childs mother: a. Offer a variety of items to choose from to stimulate his mind. b. Allow the child to determine his own daily routine. c. Offer him a choice between two items.

d. Set the routine herself, but discuss with her toddler how he or she would have done it differently. ANS: C The toddler can be allowed to make choices as the situation warrants, but the number of choices should be limited because too many confuse the toddler. DIF: Cognitive Level: Application REF: Text Reference: 399 OBJ: Objective: 3 TOP: Topic: General Characteristics

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. On a home visit, the nurse notes each of the following. The observation that requires teaching

a. The fireplace has a screen.

intervention to protect the 15-month-old child who lives there is:

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b. The dining room table has a tablecloth on it. c. There are paintings on the wall.

ANS: B

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d. The kitchen floor is clean but not shiny.

A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it. The

toddler could be injured if items on the table are moved when the tablecloth is pulled. DIF: Cognitive Level: Analysis REF: Text Reference: 409, Table 17-6 OBJ: Objective: 8 TOP: Topic: Injury Prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

12. The nurse considers the appropriate snack for a 2-year-old child would be: a. Hot dog sections b. Grapes c. Popcorn d. Applesauce ANS: D Applesauce is a healthy and safe snack food for the toddler. The toddler risks choking on such

foods as grapes, hot dogs, and popcorn. DIF: Cognitive Level: Analysis REF: Text Reference: 407

KEY: Nursing Process Step: Planning

OBJ: Objective: 8 TOP: Topic: Injury Prevention

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. The nurse assessing vital signs on a 2-year-old would be concerned about the finding of:

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a. Temperature 98.8 F b. Pulse 100 beats/min

c. Respirations 36 breaths/min

d. Blood pressure 90/60 mm Hg ANS: C

In the toddler period, the respiratory rate decreases to 25 breaths per minute. DIF: Cognitive Level: Analysis REF: Text Reference: 400 OBJ: Objective: 2 TOP: Topic: Physical Development KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. When assessing language development in a 2-year-old, an expected finding would be: a. A 900-word vocabulary b. Use of two-word sentences c. Use of pronouns and prepositions d. 100% of speech is understandable ANS: B

The 2-year-old should be using two-word sentences.

DIF: Cognitive Level: Analysis REF: Text Reference: 403

OBJ: Objective: 5 TOP: Topic: Speech Development

KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse has explained the use of time-outs to the parent of a 3-year-old. The nurse time-out is:

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determines the parent understands the information when she states an appropriate period for a

a. 3 minutes

b. 6 minutes

c. 10 minutes d. 15 minutes ANS: A

Timing for time out is usually based on 1 minute per year of age. DIF: Cognitive Level: Application REF: Text Reference: 403

OBJ: Objective: 10 TOP: Topic: Guidance and Discipline KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The parent of a toddler tells the nurse, My daughters appetite has decreased. Thank goodness she loves to drink milk. The most appropriate response for the nurse to make is: a. Has your daughter been sick recently? b. How much milk does she drink in a day?

c. Has she become a fussy eater, too? d. Have you tried offering her finger foods?

ANS: B

Milk should be limited to 24 ounces a day. Too few solid foods can lead to dietary deficiencies

of iron.

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DIF: Cognitive Level: Analysis REF: Text Reference: 406

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OBJ: Objective: 11 TOP: Topic: Nutrition Counseling KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

hours.

17. The nurse suggests that bladder training should start when the toddler can stay dry for _____

a. 1 b. 2 c. 3 d. 4

ANS: B If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective.

DIF: Cognitive Level: Application REF: Text Reference: 406 OBJ: Objective: 2 TOP: Topic: Bladder Training KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse explains to frustrated parents that a toddler will test their own power with: a. Negativism b. Dawdling

c. Tantrums

d. Food fads

ANS: A

By refusing to eat, dress, sleep, or anything else by saying NO, the toddler tests his own power to

control. Because toddlers are also egocentric, they come to believe that their negativism is

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absolute. This is especially true if the adults give into it

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DIF: Cognitive Level: Comprehension REF: Text Reference: 399 OBJ: Objective: 2 TOP: Topic: Negativism

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. The nurse points out physiological changes that occur in the toddler, which serve as a protection against disease, such as: Select all that apply. a. Toughening of the skin

b. Increased capillary response for thermoregulation c. Stabilization of body temperature d. Elevation in white blood cell count e. Enlarged adenoids and tonsils ANS: A, B, C, E With the exception of an increased WBC count, which is always pathological, the other options are all maturing changes that equip the toddler better to fight disease.

DIF: Cognitive Level: Application REF: Text Reference: 400

KEY: Nursing Process Step: Implementation

OBJ: Objective: 2 TOP: Topic: Physiological Changes

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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COMPLETION

1. The nurse assessing a 2-year-old is satisfied to see that the present weight of the child has

ANS: tripled

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____________________ the birthweight.

DIF: Cognitive Level: Comprehension REF: Text Reference: 399

OBJ: Objective: 2 TOP: Topic: Tripled Birthweight KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: The birth weight has usually tripled by the time the child is 2 years of age. 2. The nurse explains that with the completion of myelination, the toddler will have the neuromuscular maturity to attain ____________________ or ____________________ control.

ANS: bowel, bladder DIF: Cognitive Level: Application REF: Text Reference: 400 OBJ: Objective: 2 TOP: Topic: Myelination KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: With the mature myelin, the toddler is able to translate neural impulses and respond in a significant manner. With myelination, the toddler can now translate the feeling of a

full bladder or bowel and respond by defecating or urinating at willhopefully in the bathroom. 3. The nurse recognizes that when the toddler claims everything in the environment as mine, it is

an example of the toddler trait of ____________________. ANS: egocentrism

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DIF: Cognitive Level: Application REF: Text Reference: 400, Table 17-1 OBJ: Objective: 2 TOP: Topic: Egocentrism

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KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

NOT: Rationale: Toddlers are egocentric in that they perceive their world only as it applies to

themMY mommy, MY dog, MY car, MY house, My street. As they mature and have more experience with the world, they come to a more realistic viewpoint. 4. When the previously potty-trained 3-year-old wets the bed after admission to the hospital, the nurse assesses this event is caused by a ____________________ related to the new environment. ANS: regression

Chapter 25:Growth and Development of the Preschool Child: 3 to 6 Years

MULTIPLE CHOICE 1. Which of the following statements best describes the 3-year-old child? a. Boisterous, tattles on others b. Aggressive, shows off c. Helpful, wants to assist with chores d. Talkative, inquisitive about the environment ANS: C

Three-year-old children are helpful and can assist in simple household chores.

OBJ: Objective: 3 TOP: Topic: Development

DIF: Cognitive Level: Analysis REF: Text Reference: 418

KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The parents of a 4-year-old boy are concerned because they have noticed him frequently

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touching his penis. The nurse would base a response on the knowledge that: a. This behavior indicates a normal curiosity about sexuality.

b. Masturbation suggests the boy has an excessive fear of castration.

c. It is usually a result of discomfort from a penile rash or irritation. d. The behavior is abnormal and the child should be referred for counseling. ANS: A Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality. DIF: Cognitive Level: Comprehension REF: Text Reference: 418

OBJ: Objective: 17 TOP: Topic: Guidance KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A preschool-age child is asked, Why do trees have leaves? Which of the following responses would be an example of animism? a. So I can have shade over my sandbox. b. Because God made them that way.

c. To hide behind when they are scared. d. For the squirrels to play in.

ANS: C

Animism describes the tendency of preschool children to attribute human characteristics to

nonhuman objects.

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DIF: Cognitive Level: Comprehension REF: Text Reference: 415

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OBJ: Objective: 4 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

4. The tasks that would be appropriate to expect of a 5-year-old would be: a. Setting the table with paper plates b. Washing the dirty knives c. Carrying glasses from the table to the sink d. Scrubbing out the sink with cleanser ANS: A

Parents must consider developmental level and safety when asking the 5-year-old child to help with chores. DIF: Cognitive Level: Analysis REF: Text Reference: 419 OBJ: Objective: 3 TOP: Topic: Development-Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A 3-year-old child, while playing with her favorite toy in the playroom of the pediatric unit, is

approached by another child who also wants to play with the same toy. The nurse anticipates that

a. Play well with the other child

b. Give the toy up and then not play any more

the 3-year-old will:

c. Become angry and a physical response might ensue

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d. Ignore the toy and go on to something else ANS: C

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The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her possessions.

DIF: Cognitive Level: Analysis REF: Text Reference: 419

OBJ: Objective: 6 TOP: Topic: Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. A parent is concerned about her childrens reaction should their grandmother die. In planning a response, the nurse is guided by the understanding that: a. Children are unlikely to notice their grandmothers absence if no one reminds them.

b. Young children often understand that other people die, but do not equate it with themselves. c. The childrens response will depend entirely on whether they have been acquainted with death before this. d. Children can understand the concept of a higher being much like adults can. ANS: B Between 3 and 4 years of age, the child becomes curious about death and dying. They may realize that others die, but they do not relate death to themselves.

OBJ: Objective: 13 TOP: Topic: Concept of Death

KEY: Nursing Process Step: Planning

DIF: Cognitive Level: Comprehension REF: Text Reference: 419

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. The intervention that is most effective in dealing with occasional aggression in a 4-year-old

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child is:

a. Have the child take a time-out in the corner for 4 minutes.

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b. Spank the child at the time of the incident. c. Take away television privileges for the day.

d. Send the child to his room for 30 minutes. ANS: A

Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique. DIF: Cognitive Level: Application REF: Text Reference: 420 OBJ: Objective: 9 TOP: Topic: Discipline and Limit Setting

KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. A parent is concerned about how to make his preschool-age child stop sucking his thumb and asks the nurse for suggestions. The nurses most helpful response would be: a. Most children will stop thumb-sucking naturally by school age. b. Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice. c. Consistently touching the childs fingers whenever he sucks his thumb is most effective.

d. Thumb-sucking is detrimental to the eruption of the childs teeth and must be stopped as soon as possible.

ANS: A

Most children give up the habit of thumb-sucking by the time they reach school.

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DIF: Cognitive Level: Comprehension REF: Text Reference: 422 OBJ: Objective: 12 TOP: Topic: Thumb-Sucking

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KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

9. The nurse characterizes the play of 5-year-old children as: a. Rough and tumble play b. Well-organized games c. Following rules d. Prefer inside activities ANS: C

The 5-year-old wants to play by the rules but cannot accept losing. The rules may be very strict or change as the game progresses. DIF: Cognitive Level: Comprehension REF: Text Reference: 419 OBJ: Objective: 6 TOP: Topic: Play KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. When discussing preschoolers sexual curiosity with the parent, the nurse determines that the parent understands the information when she states she would:

a. Make up funny words for body parts. b. Distract my child with a toy if she asks about sex.

c. Answer her questions when she asks.

d. Tell her to ask me again when she is 6 years old.

ANS: C

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Parents should provide sex education at the time the child asks about sex.

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DIF: Cognitive Level: Analysis REF: Text Reference: 426 OBJ: Objective: 12 TOP: Topic: Sexual Curiosity

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance 11. In planning care for a moderately retarded child, the type of play most appropriate is: a. Play should exercise leg and arm muscles. b. Play should be educationally oriented to make up for lost time. c. Play should be adjusted to her mental age rather than her chronological age. d. Play is not a necessary component of the care of a mentally retarded child.

ANS: C The nurse must consider the childs mental age rather than her chronological age when selecting toys for play. DIF: Cognitive Level: Analysis REF: Text Reference: 425 OBJ: Objective: 6 TOP: Topic: Play KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

12. The nurses best advice to a parent about a preschoolers imaginary friend would be that: a. Imaginary friends is a sign that the child has a low self-esteem. b. It is common for preschoolers to have imaginary friends.

c. The preschooler invents an imaginary friend when he feels overwhelmed.

d. The best approach to dealing with an imaginary friend is to ignore them.

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ANS: B

Imaginary friends are common and normal during the preschool period and serve many purposes,

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such as relief from loneliness, mastery of feats, and scapegoat. DIF: Cognitive Level: Comprehension REF: Text Reference: 418

OBJ: Objective: 3 TOP: Topic: Play KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. The nurse suggests measures that might be helpful for the child with enuresis, such as: a. Apply an electric pad that gently shocks the child. b. Wake the child several times during the night to urinate. c. Decrease fluid intake after the evening meal. d. Increase dietary fiber intake.

ANS: C If a child is experiencing enuresis, liquids after dinner should be limited and the child should routinely void before going to bed. DIF: Cognitive Level: Application REF: Text Reference: 413 OBJ: Objective: 12 TOP: Topic: Enuresis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. The nurse suggests that the most appropriate toy choice for a 3-year-old would be:

a. A board game

b. A small pet, such as a goldfish c. A large construction set

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d. Push-pull toys ANS: C

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Large construction sets are suitable toys for the preschool-age child. DIF: Cognitive Level: Application REF: Text Reference: 425

OBJ: Objective: 12 TOP: Topic: Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The parent of a 3-year-old child tells the nurse, My daughter points whenever she wants me to get something for her but she understands me when I ask her to do something. Based on the parents comment, the nurse recognizes that: a. The childs language development is age-appropriate.

b. The child may have expressive language delay. c. The child has a receptive language delay. d. The child should have her hearing tested. ANS: B An expressive language delay is suspected when the child understands spoken language but is not talking. DIF: Cognitive Level: Analysis REF: Text Reference: 416, Table 18-1

OBJ: Objective: 3 TOP: Topic: Language Development

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The parent of a 4-year-old child tells the nurse, Bedtime is difficult. I cant get my child to

bed at night. The nurse and the childs mother discuss options and decide that the best choice

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would be to:

a. Allow the child to put himself to bed when he is tired.

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b. Let the child read in his room until he falls asleep. c. Establish a bedtime routine and use it consistently.

ANS: C

d. Tire him out with physical activity before bedtime.

Parents should engage the child in quiet activities before bedtime and establish a ritual that signals readiness for bedtime. DIF: Cognitive Level: Application REF: Text Reference: 418 OBJ: Objective: 11 TOP: Topic: Bedtime Habits KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse understands that a fear unique to the preschool period is: a. Fear of water b. Fear of animals c. Fear of bodily harm d. Fear of death ANS: C

The fear of bodily harm, particularly the loss of body parts, is unique to this stage.

OBJ: Objective: 3 TOP: Topic: Development

DIF: Cognitive Level: Knowledge REF: Text Reference: 419

KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. A 4-year-old child tells the nurse that he will not eat peas because they are green. This is an

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example of: a. Egocentrism

b. Artificialism

c. Animism

d. Centering ANS: D

The tendency to concentrate on a single outstanding characteristic of an object while excluding other features is known as centering. DIF: Cognitive Level: Application REF: Text Reference: 415

OBJ: Objective: 4 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. A 4-year-old child insists that he has more money with a nickel than his father has with a dime. The nurse is aware that this perception is described in Piagets theory as: a. Egocentrism b. Artificialism

c. Animism d. Centering

ANS: D

The intuitive stage, as described by Piaget, is prelogical thinking that is based on the outside

appearance of objects. A nickel is larger than a dime, and therefore more valuable

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DIF: Cognitive Level: Application REF: Text Reference: 415

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OBJ: Objective: 4 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

MULTIPLE RESPONSE 1. The nurse suggests that bedtime preparation be preceded by rituals, such as: Select all that apply. a. Telling a story b. Placing a favorite toy in bed c. Placing a glass of water at the bedside

d. Turning on a night light e. Playing energetically ANS: A, B, C, D All options are soothing and bedtime suggestive rituals except energetic playing, which would be stimulating and counterproductive to sleep. DIF: Cognitive Level: Comprehension REF: Text Reference: 418 OBJ: Objective: 11 TOP: Topic: Bedtime Habits

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

2. The nurse planning a seminar on safety for the preschooler will focus on:

Select all that apply.

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a. Poison b. Burns

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c. Falls d. Abduction

e. Car-pedestrian

ANS: A, B, C, D, E

All of the options are significant safety threats to the preschooler because of their developmental characteristics of playing boisterously, imitating their parents using matches, and drinking from bottles or taking pills. Their egocentrism does not make them suspicious of strangers. DIF: Cognitive Level: Comprehension REF: Text Reference: 423 OBJ: Objective: 10 TOP: Topic: Accident Prevention

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse points out that among the advantages of a nursery school experience are: Select all that apply. a. Increasing self-confidence b. Fostering group cooperation c. Detecting adjustment problems

d. Enhancing social skills e. Playing experiences with other children

ANS: A, B, C, D, E

Nursery school increases self-confidence, group cooperation, social skills, and cooperative play.

Objective observations by a nursery school instructor can detect early adjustment problems.

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DIF: Cognitive Level: Comprehension REF: Text Reference: 423

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OBJ: Objective: 5 TOP: Topic: Advantages of Nursery School KEY: Nursing Process Step: Implementation

MSC: NCLEX: Promotion and Maintenance: Growth and Development

COMPLETION

1. When planning an activity for a 3-year-old, the nurse bases the plan on the average attention span of ____________________ minutes. ANS: 15 DIF: Cognitive Level: Application REF: Text Reference: 416, Table 18-1 OBJ: Objective: 4 TOP: Topic: Attention Span of Preschooler

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: The average attention span of the preschooler is about 15 minutes. 2. Play that is designed to retrain muscles or improve eye-hand coordination is considered ____________________ play. ANS: therapeutic

Chapter 26:Growth and Development of the School-Aged Child: 6 to 10 Years MULTIPLE CHOICE

a. Grow 3 to 6 inches/year

b. Gain 5 to 7 pounds/year

1. The nurse is aware that, in general, the school-age child will:

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c. Increase head circumference by 1 inch/year

ANS: B

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d. Reach a visual acuity of 20/20 by 9 years of age

During the school-age period, the average weight gain per year is generally 5.5 to 7 pounds.

DIF: Cognitive Level: Knowledge REF: Text Reference: 429 OBJ: Objective: 2 TOP: Topic: Physical Growth KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse, planning to teach a class on nutrition to fourth-grade students, would keep in mind that school-age children:

a. Can concentrate on only one aspect of a situation b. Can think abstractly c. Are egocentric in their thinking d. Think logically and concretely ANS: D Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and an understanding of cause and effect.

DIF: Cognitive Level: Analysis REF: Text Reference: 429 OBJ: Objective: 2 TOP: Topic: Cognitive Development

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

3. The nurse explains that the preferred social interaction for the school-age child is based on

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relationships that are: a. Heterosexual interest groups

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b. Association with one best friend

c. Organized groups like Boy Scouts

ANS: D

d. Same-sex peer groups

The preferred social interaction of the school-age child is in same-sex peer groups or cliques. DIF: Cognitive Level: Analysis REF: Text Reference: 429 OBJ: Objective: 2 TOP: Topic: Social Development, Play KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse advises the parents of a 10-year-old boy that, according to Eriksons theory, the most developmentally supportive experience for him would be: a. Constant variety of activities b. Successful performance in Little League c. Feeling healthy and strong d. Having a girl friend

ANS: B The child who is successful in activities will feel positively about himself or herself.

DIF: Cognitive Level: Analysis REF: Text Reference: 429

OBJ: Objective: 2 TOP: Topic: Psychosocial Development

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KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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5. The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent nightmares. The nurses most helpful response is to explain that nightmares are:

a. A normal extension of the childs fear of mutilation

b. An abnormal response to repressed feelings c. A common result of latent sexuality d. A side effect of overactivity and stimulation ANS: A The nightmares experienced by an 8-year-old are an extension of their characteristic fear of mutilation. DIF: Cognitive Level: Comprehension REF: Text Reference: 438, Table 19-3

OBJ: Objective: 2 TOP: Topic: Eight-Year-Old Nightmares KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. The nurse suggests an appropriate toy for a hospitalized 6-year-old boy would be a: a. Game Boy game b. Compact disc player c. Adventure book

d. Jigsaw puzzle

ANS: A

The 6-year-old child can perform numerous feats that require muscle coordination. At this age,

the Gameboy toy will offer nonaggressive competition.

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DIF: Cognitive Level: Analysis REF: Text Reference: 433 OBJ: Objective: 2 TOP: Topic: Six-Year-Old

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KEY: Nursing Process Step: N/A

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon

be starting first grade. The nurse determines that the parents understood the information when the girls father states: a. We should put a stop to her thumb-sucking. b. Well have a talk about what school is like. c. We will let her walk to the bus stop by herself. d. Well have her meet some children who will be in her class. ANS: D

To prepare a child for school, parents can arrange for the child to meet other children who will be entering school with her. DIF: Cognitive Level: Application REF: Text Reference: 443, Box 19-2 OBJ: Objective: 3 TOP: Topic: Parental Guidance for Starting School KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. A 9-year-old boy is often cranky and irritable and his school performance has declined. All the

options are true about the child. The possible factor causing this behavior is that he:

a. Sleeps only 6 to 7 hours a night b. Eats eggs every day

c. Has a new dog

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d. Plays about 1 to 3 hours each evening

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ANS: A

The 9-year-old child requires about 10 hours of sleep per night.

DIF: Cognitive Level: Analysis REF: Text Reference: 436

OBJ: Objective: 2 TOP: Topic: Nine-Year-Old Child KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A parent asked the nurse, At what age are children capable of assuming more responsibility for personal belongings? Based on a knowledge of growth and development, the nurse would respond:

a. 6 years b. 7 years c. 9 years d. 12 years ANS: C The 9-year-old is dependable and assumes more responsibility for personal belongings. DIF: Cognitive Level: Comprehension REF: Text Reference: 436

OBJ: Objective: 2 TOP: Topic: Development

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The school nurse who is preserving a tooth that was knocked out on the school yard will be

especially careful to:

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a. Wrap the tooth loosely in a clean cloth. b. Rinse the tooth with alcohol.

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c. Handle the tooth only by the crown.

ANS: C

d. Place the tooth in a warm environment.

When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage to the root and placed in milk until the child can be examined by a dentist. DIF: Cognitive Level: Application REF: Text Reference: 431 OBJ: Objective: 6 TOP: Topic: Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A parent states, My 7-year-old really wants a dog. His 10-year-old brother has allergies to animal dander. I dont know what to do. The nurse could advise this parent to: a. Choose a small breed of dog because the large dogs produce more allergens. b. An older unneutered dog produces fewer allergens than a younger one. c. A cat may be a good choice since it requires less care and is less allergenic. d. Poodles do not shed, making this dog a good choice for people with allergies.

ANS: D The poodle breed of dog does not have a shed cycle and so it may be the least offensive pet for

the allergic child.

DIF: Cognitive Level: Analysis REF: Text Reference: 441

OBJ: Objective: 7 TOP: Topic: Pet Ownership

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KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. When asked about her activities, a 10-year-old girl responded, I like school. I play the flute in the school band and I take tennis lessons. The nurse knows these activities will help this child

develop a sense of:

a. Initiative b. Industry c. Identity d. Intimacy ANS: B

The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities facilitates the childs sense of industry. DIF: Cognitive Level: Analysis REF: Text Reference: 438, Table 19-3 OBJ: Objective: 2 TOP: Topic: Psychosocial Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. A mother reports that she has a new job and her 12-year-old child is home alone for a time

after school. The statement made by the parent, indicating a potentially unsafe situation for this child, is:

a. I told him that he could invite a few friends after school.

b. I put a list of emergency numbers next to the telephone. c. Last week we made a first aid kit together.

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d. There is a neighbor available in case of an emergency. ANS: A

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Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to be home alone in an unsupervised environment is an unsafe situation.

DIF: Cognitive Level: Analysis REF: Text Reference: 439

OBJ: Objective: 3 TOP: Topic: Latchkey Children KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A mother is concerned because her 9-year-old has developed the habit of twitching his eyes and flipping his hair while communicating with anyone. The best nursing response to this parent is:

a. This may indicate that he needs eyeglasses. b. Children sometimes do these things for attention. c. This behavior suggests low self-esteem. d. Tics appear when a child is under stress. ANS: D The child cannot help such actions and should not be scolded for them because they are mainly a result of tension.

KEY: Nursing Process Step: Implementation

OBJ: Objective: 2 TOP: Topic: Nine-Year-Old Child

DIF: Cognitive Level: Analysis REF: Text Reference: 436

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

15. A seventh-grade girl tells the school nurse that her art teacher, also a female, is her hero. The

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most appropriate interpretation of the girls comment is: a. The student may be exploring her career options.

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b. The comment is cause for concern about sexual abuse. c. The child may have difficulty interacting with her peers.

ANS: D

d. Hero worship is a normal phenomenon.

School-age children tend to admire their teachers and adult companions. For the 11- to 12-yearold, hero worship is a normal phenomenon. DIF: Cognitive Level: Analysis REF: Text Reference: 429 OBJ: Objective: 2 TOP: Topic: Social Development KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. According to Piaget, a 9-year-old child is in which stage of cognitive development? a. Formal operations b. Preoperational c. Concrete operations d. Sensorimotor ANS: C

School-age children are in the concrete operations stage of cognitive development.

DIF: Cognitive Level: Knowledge REF: Text Reference: 429

OBJ: Objective: 2 TOP: Topic: Cognitive Development

KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse assesses that the 11-year-old has moved from the mind set of egocentrism when he

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says:

a. I am a member of the best Cub Scout group in the world.

b. I must do my homework before I can play.

c. My dad can do anything! d. Im sorry. I bet that hurt your feelings. ANS: D The ability to see anothers point of view indicates moving away from egocentrism into a more altruistic mind set. DIF: Cognitive Level: Analysis REF: Text Reference: 429

OBJ: Objective: 5 TOP: Topic: Increasing Understanding KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. When the school-age child becomes frustrated with a school assignment and says, I cant do this!, the parent should: a. Ask, What is it that is so difficult? b. Allow the child to quit the effort.

c. Call in older siblings to help. d. Finish the project for him.

ANS: A

Helping the child focus on the problem that is keeping him from mastery can limit frustration.

Quitting or having someone else finish is detrimental to the development of industry.

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DIF: Cognitive Level: Analysis REF: Text Reference: 429

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OBJ: Objective: 2 TOP: Topic: Industry KEY: Nursing Process Step: N/A

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

MULTIPLE RESPONSE 1. The nurse, in attempting to help a 7-year-old girl express her feelings about being in a new school, would prompt the child with basic feeling words, such as: Select all that apply. a. Mad b. Glad

c. Sad d. Scared e. Jealous ANS: A, B, C, D The words mad, glad, sad, and scared are basic feeling words that can prompt a young child to better express his or her feelings. DIF: Cognitive Level: Application REF: Text Reference: 440

OBJ: Objective: 2 TOP: Topic: Expression of Feelings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

COMPLETION

1. The nurse advises the parents of a 6-year-old to try and ensure at least

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____________________ hours of sleep daily.

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ANS: 11

DIF: Cognitive Level: Comprehension REF: Text Reference: 434

OBJ: Objective: 2 TOP: Topic: Sleep Needs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: The 6-year-old school-age child needs at least 11 hours of sleep. 2. The nurse reminds the parents who are trying to select a dog for their allergic child that the best selection would be a female dog that is ____________________ and ____________________.

ANS: young, neutered DIF: Cognitive Level: Comprehension REF: Text Reference: 441 OBJ: Objective: 7 TOP: Topic: Pet Selection for Allergic Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: Young, neutered female dogs produced less allergens.

3. When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse cautioned the teacher to be alert for symptoms of ____________________ that can be

carried by the reptiles.

ANS: Salmonella

DIF: Cognitive Level: Comprehension REF: Text Reference: 440, Table 19-14

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OBJ: Objective: 7 TOP: Topic: Salmonella

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KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease NOT: Rationale: Geckos can infect humans with Salmonella.

4. The pediatric nurse assesses the child who has been diagnosed with diabetes to ensure that he

does to come to believe that his disease is a form of ____________________. ANS: punishment

Chapter 27:Growth and Development of the Adolescent: 11 to 18 Years MULTIPLE CHOICE

1. When assessing a 13-year-old boy, the nurse would keep in mind physical changes in the pubertal male, beginning with: a. Development of axillary and facial hair b. Enlargement of pectoral muscles c. Enlargement of testicles d. Voice changes ANS: C

In boys, pubertal changes begin with enlargement of the testicles and internal structures. DIF: Cognitive Level: Comprehension REF: Text Reference: 447

KEY: Nursing Process Step: Assessment

OBJ: Objective: 4 TOP: Topic: Physical Development

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A 13-year-old boy states, The girls in my class tower over me. The nurses most informative

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response would be:

a. It may seem that way because girls have a growth spurt 2 years earlier than boys. b. Perhaps your parents are not exceptionally tall.

c. Boys usually experience a growth spurt 1 year earlier than girls.

d. You may feel short, but you are actually average height for your age. ANS: A Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlier for girls than for boys. DIF: Cognitive Level: Application REF: Text Reference: 445 OBJ: Objective: 4 TOP: Topic: Physical Development

KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A parent comments that her adolescent daughter seems to be daydreaming a lot these days. The nurse understands that this behavior indicates she is: a. Bored b. Not getting enough rest c. Trying to block out stress and anxiety

d. Mentally preparing for real situations ANS: D

Daydreaming allows adolescents to act out in their imaginations what will be said or done in

certain situations. This helps them to prepare for and cope with interactions with others.

DIF: Cognitive Level: Analysis REF: Text Reference: 453

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OBJ: Objective: 4 TOP: Topic: Development-Daydreams

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KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

4. The nurse planning a safety program for high school students should understand that most

accidental deaths in adolescence are related to: a. Firearms

b. Automobiles c. Drowning d. Diving injuries ANS: B The chief safety hazard for the adolescent is automobiles.

DIF: Cognitive Level: Knowledge REF: Text Reference: 458 OBJ: Objective: 11 TOP: Topic: Safety KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A 16-year-old excitedly tells his parents that he was offered a part-time job. Which response represents an effective problem-solving approach for his parents? a. Your studies are too important for you to have a part-time job.

b. When we went to high school, academics were the teenagers priority. c. We want you to put your earnings in a savings account.

d. How do you think you will manage your school work and a job?

ANS: D

An effective approach to help adolescents learn to solve problems is for parents to guide them in

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exploring alternatives.

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DIF: Cognitive Level: Application REF: Text Reference: 454 OBJ: Objective: 11 TOP: Topic: Parenting

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. One psychosocial task of adolescence on which the nurse must focus when planning care, is the development of a sense of: a. Initiative b. Industry c. Identity d. Involvement

ANS: C Psychosocial milestones that must be accomplished during adolescence include the five Isimage of self, identity, independence, interpersonal relationships, and intellectual maturity. DIF: Cognitive Level: Knowledge REF: Text Reference: 445, Box 20-1 OBJ: Objective: 2 TOP: Topic: Psychosocial Development KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. A 13-year-old female tells the school nurse that she is getting fat, especially in her hips and

legs. The understanding by the nurse that would best guide the response is:

a. Many teenagers are unaware of proper nutrition.

b. Teenagers of this age become less active and should eat fewer calories.

c. Puberty is often preceded by fat deposits in these areas.

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d. As soon as menarche occurs, she will lose this excess weight.

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ANS: C

Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips,

thighs, and breasts, causing them to enlarge.

DIF: Cognitive Level: Analysis REF: Text Reference: 449, Box 20-2 OBJ: Objective: 4 TOP: Topic: Physical Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The school nurse is planning a program for girls about the physical changes of puberty; this program should be directed to girls of the age:

a. 16 years b. 14 years c. 12 years d. 10 years ANS: D Because puberty can occur in girls as early as age 10 years, instruction must be given by that age. DIF: Cognitive Level: Comprehension REF: Text Reference: 454

OBJ: Objective: 4 TOP: Topic: Physical Development

KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. The statement made by a parent indicating understanding about helping a 13-year-old manage

allowance money is:

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a. I set amounts he can earn for particular chores.

b. I give him a certain amount of money for each day.

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c. I put money into his bank account each month.

ANS: A

d. I told him to ask me when he needs money.

If money is simply handed out as requested, it is difficult to develop responsibility for finances and money management. The older adolescent is able to get a job. The younger teen can earn money by doing particular chores. DIF: Cognitive Level: Application REF: Text Reference: 453 OBJ: Objective: 4 TOP: Topic: Development-Responsibility KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The nurse suggests a good dietary source of zinc for an adolescent who is a vegetarian would be: a. Green, leafy vegetables b. Citrus fruits c. Nuts d. Enriched breads

ANS: C Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources

include nuts, legumes, and wheat germ.

DIF: Cognitive Level: Comprehension REF: Text Reference: 457

OBJ: Objective: 9 TOP: Topic: Nutrition

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KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. An adolescents parent comments, My son seems so preoccupied with his appearance these

days. Is this normal? The nurses best response would be: a. It is his attempt to express his individualism.

b. His preoccupation with his looks is quite normal. c. He is probably troubled with his physical changes. d. This shows that he has a positive self-image. ANS: B Preoccupation with self-image is normal and accounts for the constant primping of teenagers. DIF: Cognitive Level: Application REF: Text Reference: 445

OBJ: Objective: 4 TOP: Topic: Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. Foods that would be a healthy choice for an adolescent who just finished playing in a strenuous game would be: a. Cheeseburger and soda b. Hot fudge sundae

c. Two Egg McMuffins and orange juice d. Bagel and skim milk

ANS: D

release of carbohydrates to the muscles.

A bagel provides a rapid supply of carbohydrates to the muscles, and skim milk provides a slow

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DIF: Cognitive Level: Application REF: Text Reference: 457

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OBJ: Objective: 9 TOP: Topic: Nutrition KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

13. When planning to answer a 16-year-old girls questions about menstruation, the nurse must consider cognitive development. According to Piaget, the cognitive aspect that is developed during adolescence is the ability to: a. View a situation from multiple perspectives b. Focus more on the past than present situations c. Exercise concrete reasoning d. Consider hypothetical situations

ANS: D According to Piaget, in the formal operations stage adolescents have the ability to think abstractly. DIF: Cognitive Level: Comprehension REF: Text Reference: 445, Box 20-1 OBJ: Objective: 4 TOP: Topic: Cognitive Development KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A girl tells the nurse that she and her best friend belong to the popular clique. She states, I love Britney Spears and I want to be a singer. The nurse recognizes the girls statement as

a. Early adolescence

characteristic of peer relationships in:

b. Middle adolescence

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c. Late adolescence

ANS: A

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d. Entire adolescent period

Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early

adolescent.

DIF: Cognitive Level: Comprehension REF: Text Reference: 452 OBJ: Objective: 4 TOP: Topic: Social Development KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

15. The nurse is leading a discussion group with parents of adolescents. One parent comments, My son cant do anything without checking with his friends first. My opinion doesnt count anymore. The nurse would formulate a response on the knowledge that this behavior is: a. Unusual for adolescent boys b. Often more apparent in boys than girls c. A normal phenomenon during adolescence d. Suggestive of feelings of low self-worth ANS: A

Parents may need help understanding that the teenagers exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family.

DIF: Cognitive Level: Application REF: Text Reference: 452 OBJ: Objective: 4 TOP: Topic: Peer Relationships

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KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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16. The nurse points out to a group of parents that the most positive developmental significance of a peer group to the adolescent is that the group serves as:

a. A social outlet

b. An association to blur personal identity c. A platform for group think d. An initial separation from family ANS: D Being a member of a peer group and communicating with and seeking approval from this group are the first separation from the family.

DIF: Cognitive Level: Analysis REF: Text Reference: 461 OBJ: Objective: 10 TOP: Topic: Peer Groups KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse understands that the adolescents avid sexual orientation to be based on Freuds theory, which describes adolescence as the _____ stage. a. Conceptual

b. Genital c. Glandular

d. Pubertal

ANS: B

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Freud describes the adolescent period as genital.

DIF: Cognitive Level: Knowledge REF: Text Reference: 445, Box 20-1

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OBJ: Objective: 3 TOP: Topic: Freud

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse using the PACE interview guide for persons at risk for substance abuse arrives at a score of 2 for an adolescent patient. The nurse should assess this score as: a. Nonindicative of potential substance abuse b. Normal experimentation of the adolescent c. Need to schedule another PACE interview in 3 months d. Indication for referral for counseling

ANS: D The PACE guide recommends that a score of 2 or higher would suggest the need for a referral for counseling about substance abuse. DIF: Cognitive Level: Knowledge REF: Text Reference: 445 OBJ: Objective: 4 TOP: Topic: PACE Interview KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE

1. The nurse explains that the restlessness seen in the adolescent is, in part, attributable to:

Select all that apply.

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b. Surge for independence

a. Drive to be accepted by society as an individual

c. Establishment of a personal identity

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d. Intense libido e. Rapid body changes

ANS: A, B, C, D, E

All the options listed are sources of stress to the adolescent and are stimulants to restlessness. DIF: Cognitive Level: Comprehension REF: Text Reference: 444 OBJ: Objective: 2 TOP: Topic: Sources of Stress for the Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

2. The nurse teaching a seminar on teen pregnancy tells the parents that they should be alert for indications of a child concealing a pregnancy with such behaviors as: Select all that apply. a. Wearing baggy clothes b. Wearing excessive makeup c. Dieting to lose weight d. Seeking privacy e. Ostentatiously purchasing tampons

ANS: A, C, E

Wearing of concealing clothing, dieting to lose weight, and conspicuous advertising of a menstrual period are indicators of a hidden pregnancy. Wearing of excessive makeup and

seeking privacy are normal adolescent behaviors.

DIF: Cognitive Level: Analysis REF: Text Reference: 460, Box 20-5

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OBJ: Objective: 12 TOP: Topic: Signals of Concealed Pregnancy

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KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

3. The nurse considers the rites of passage that are valued by the adolescent in American society,

which are:

Select all that apply. a. Attaining legal drinking age b. Selection of a career c. Religious affiliation d. Obtaining a drivers license e. High school graduation

ANS: A, D, E Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, drivers license, and matriculation through high school are such signals. Religious affiliation and selection of a career path do not necessarily signal adulthood. DIF: Cognitive Level: Analysis REF: Text Reference: 459 OBJ: Objective: 2 TOP: Topic: Rites of Passage KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

COMPLETION

1. The nurse is amused, but understands that as adolescents strive for individuality, the strongest need of any adolescent in society is that of ____________________.

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ANS: conformity

DIF: Cognitive Level: Analysis REF: Text Reference: 445

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OBJ: Objective: 10 TOP: Topic: Conformity KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NOT: Rationale: For all of the stress from coming of age as an individual in his own right, the adolescent also has an equal drive for conformity. 2. The nurse knows that an adolescent may find making a career choice difficult because there is less clarity in ____________________ roles. ANS: gender

Chapter 28: Data Collection (Assessment) for the Child MULTIPLE CHOICE 1. A 5-year-old child is in the clinic for a checkup. The nurse would expect him to: a. Need to be held on his mothers lap. b. Be able to sit on the examination table. c. Be able to stand on the floor for the examination. d. Be able to remain alone in the examination room.

ANS: B

At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and

young children aged 6 months to 2 or 3 years should be positioned in the parents lap.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 794

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MSC: Client Needs: Safe and Effective Care Environment: Management of Care 2. Which statement is true regarding the recording of data from the history and physical

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examination?

a. Use long, descriptive sentences to document findings.

b. Record the data as soon as possible after the interview and physical examination.

c. If the information is not documented, then it can be assumed that it was done as a standard of care. d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient. ANS: B The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes

should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions. DIF: Cognitive Level: Applying (Application) REF: p. 784 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 3. When assessing the neonate, the nurse should test for hip stability with which method? a. Eliciting the Moro reflex b. Performing the Romberg test

c. Checking for the Ortolani sign d. Assessing the stepping reflex

ANS: C

The nurse should test for hip stability in the neonate by testing for the Ortolani sign. The other

tests are not appropriate for testing hip stability.

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DIF: Cognitive Level: Applying (Application) REF: p. 791

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MSC: Client Needs: Health Promotion and Maintenance 4. A female patient tells the nurse that she has four children and has had three pregnancies. How

should the nurse document this? a. Gravida 3, para 4

b. Gravida 4, para 3

c. This information cannot be documented using the terms gravida and para. d. The patient seems to be confused about how many times she has been pregnant. ANS: A Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins.

DIF: Cognitive Level: Applying (Application) REF: p. 807 MSC: Client Needs: Safe and Effective Care Environment: Management of Care 5. The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate: a. Epigastric hernia. b. Pyloric obstruction. c. Hypoactive bowel sounds.

d. Hyperactive bowel sounds.

ANS: D

A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the

stomach as observed with pyloric obstruction or large hiatus hernia (see Chapter 21).

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DIF: Cognitive Level: Analyzing (Analysis) REF: p. 572

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MSC: Client Needs: Safe and Effective Care Environment: Management of Care 6. Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child

checkup?

a. Testing for Ortolani sign b. Assessment for stereognosis c. Blood pressure measurement d. Assessment for the presence of the startle reflex ANS: A

Until the age of 12 months, the infant should be assessed for Ortolani sign. If Ortolani sign is present, then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child

Chapter 29: Care of the Hospitalized Child MULTIPLE CHOICE 1. Which child would have the most difficulty in coping with separation from parents because of hospitalization?

a. The 3-month-old child b. The 16-month-old child

c. The 4-year-old child

d. The 7-year-old child

ANS: B

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Separation anxiety occurs after age 6 months and is most pronounced in the toddler. DIF: Cognitive Level: Comprehension REF: 466-467 OBJ: 2

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TOP: Separation Anxiety KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

2. A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago. The nurse understands that this behavior suggests: a. The toddler feels abandoned by his mother. b. The child still has not adjusted to his hospitalization. c. The child is not separated from his mother often. d. A poor mother-child bond exists. ANS: A

Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization are obvious. DIF: Cognitive Level: Analysis REF: 465-466 OBJ: 2 TOP: Separation Anxiety KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The statement that best corresponds to a preschoolers understanding of hospitalization is:

b. I got sick because I was mad at my brother. c. My tonsils are sick and they have to come out.

d. I have a cast because I broke my leg.

a. A germ made me get sick.

ANS: B

The preschooler may feel guilty, particularly if an accident happens as a result of mischief on his

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or her part.

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DIF: Cognitive Level: Application REF: 476 OBJ: 6 TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

4. The parents of a hospitalized toddler are upset because she seems more interested in her toys when they come to visit her. The toddler is most likely in which stage of separation anxiety? a. Protest b. Despair c. Denial d. Attachment ANS: C

In the stage of denial or detachment, the child appears to deny the need for the parents and becomes uninterested in their visits. DIF: Cognitive Level: Comprehension REF: 465-466 OBJ: 2 TOP: Separation Anxiety KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nurse must make a room assignment for a 16-year-old teenager with cystic fibrosis. An optimal roommate might be:

a. A 4-year-old child who had an appendectomy b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis

d. To assign the adolescent to a private room

c. A 15-year-old teenager with type 1 diabetes mellitus

ANS: C

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Adolescents usually do better in rooms with one or more roommates than in single rooms. The adolescent would do best with a roommate who is closest to his or her age and also lives with a

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chronic illness.

DIF: Cognitive Level: Application REF: 477 OBJ: 8

TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his younger sibling. The nurse understands that: a. Most facilities do not allow visitors under age 12 years for infection control purposes. b. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided.

c. The sibling could view the infant from the doorway but not enter the room to prevent the spread of microorganisms. d. The preschooler needs to visit his infant sister to reassure himself that she is all right. ANS: D Siblings are affected by a childs hospitalization. Their ability to cope is influenced by their age, experience, and intactness of the family.

TOP: Siblings-Parents Reaction to Hospitalization

KEY: Nursing Process Step: Assessment

DIF: Cognitive Level: Analysis REF: 474 OBJ: 3

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. A hospitalized toddler was drinking from a cup at home, but now refuses to drink from

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anything except his favorite bottle. This is because the toddler is: a. Dealing with the anxiety of hospitalization by regressing

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b. Demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital c. Attempting to refocus the attention of the adults around him to avoid further painful procedures

d. Exhibiting normal behavior for his age, as children often stop new behaviors after they feel they have mastered them ANS: A

Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital. DIF: Cognitive Level: Comprehension REF: 468 OBJ: 4

TOP: Regression KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 8. A nurse encourages a school-age child to draw a picture after a painful procedure. The best rationale for this intervention is that the nurse is: a. Attempting to reestablish rapport b. Providing a way for the child to express his feelings c. Encouraging quiet play

d. Distracting the child from thinking about the pain ANS: B

or to act out their feelings through puppet play.

Following treatments, the nurse should encourage children to draw and talk about their drawings

DIF: Cognitive Level: Comprehension REF: 490 OBJ: 7

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TOP: The Hospitalized School-Age Child

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KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

9. The nurse suggests that the best time for parents to begin to prepare a 5-year-old for surgery

and hospitalization is:

a. As soon as the surgery is scheduled b. About 2 weeks before surgery c. About 4 days before surgery d. On the night before admission to the hospital ANS: C Parents should prepare children for procedures and hospitalization a few days in advance.

DIF: Cognitive Level: Application REF: 471 OBJ: 4, 6 TOP: The Nurses Role in Hospital Admission-Preparing the Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around 12:00 PM. The next morning, the child asks the nurse, When is my mommy coming? The best response for the nurse to make is:

b. Your mommy will be here when you have lunch.

d. Your mommy is coming in 4 hours.

c. Mommy will be here very soon.

a. Your mommy will be here around noon.

ANS: B

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The toddler and preschooler do not understand time yet. They understand time relationships through activities in their experience, such as naptime and mealtimes.

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DIF: Cognitive Level: Application REF: 476 OBJ: 6

TOP: The Hospitalized Toddler/Preschooler

KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. A 13-year-old girl has been hospitalized for the past week. When discussing the girls feelings about her illness, the nurse would expect the girl to express the most concern about: a. Invasive procedures b. Loss of control c. Appearance

d. Separation from her boyfriend ANS: C Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image. DIF: Cognitive Level: Comprehension REF: 477 OBJ: 8 TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

12. The nurse notices that the mother of a child with cerebral palsy corrects and redoes many of the things the nurse does for her child. The most appropriate response to this mother would be:

a. Would you like to do all of your childs care?

b. Im doing the very best job that I can with your child.

c. Why dont you go have a cup of coffee. You are going to be exhausted if you dont take a break.

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d. Id be happy if you would share with me some of the special things you do for your child.

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ANS: D

The person who cares daily for the child with a chronic illness can provide information that will

best guarantee continuity of care between the home and the hospital.

DIF: Cognitive Level: Application REF: 472 OBJ: 4 TOP: The Parents Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The mother of a hospitalized toddler states, He cries when I visit. Maybe I should just stay away. The nurses best response would be: a. Perhaps you are right. He only gets upset when you have to leave.

b. It is important that you are here. This is a common reaction in children when they are separated from their parents. c. It might be easier for your child if you would stay with him, but this decision is up to you. d. We take good care of him and he seems fine when you are not here. ANS: B During the second stage of separation anxiety (despair), the child is quiet, is not crying, and is sad and depressed. The child will revert to protest when the parent arrives for a visit.

DIF: Cognitive Level: Application REF: 466 OBJ: 3 TOP: Separation Anxiety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

14. The nurse, preparing to collect an admission history from parents who have recently

immigrated from Russia, would keep in mind that:

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a. Eye-to-eye contact is considered disrespectful.

b. Touching the childs head means the nurse is superior.

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c. Smiling is inappropriate in a serious situation.

ANS: C

d. Staring is a sign of the nurses rudeness.

In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation. DIF: Cognitive Level: Analysis REF: 468 OBJ: 4 TOP: Fostering Intercultural Communication KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

15. The nursing action that would facilitate rapport with a child and the childs parents during the admission process is: a. Direct the parents to undress the child. b. Answer questions in a calm and matter-of-fact way. c. Perform assessments and ask questions as quickly as possible. d. Express concern about the seriousness of the childs condition. ANS: B

the childs condition.

TOP: Nurses Role in Hospital Admission

DIF: Cognitive Level: Application REF: 474 OBJ: 4

The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless of

KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 16. When a 2-year-old returns to her hospital room following a diagnostic procedure, her parents

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are not available and the child is crying loudly. The technique that is most appropriate to alleviate the childs distress is:

a. Rock the child gently to sleep.

b. Play with the child using pop-up toys. c. Role play with the child to act out her feelings. d. Ask the child to draw a picture about her feelings. ANS: B Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help reduce anxiety and pain.

DIF: Cognitive Level: Analysis REF: 474 OBJ: 10 TOP: The Hospitalized Toddler KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 17. A 4-year-old begins to cry when his mother tells him it is time for his operation. The nurse understands this is an expected reaction because the preschooler is particularly fearful of: a. Loss of control b. Restricted mobility

c. Unfamiliar routines d. Invasive procedures

ANS: D

The preschool-age child is afraid of bodily harm, particularly invasive procedures.

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DIF: Cognitive Level: Knowledge REF: 476 OBJ: 6

TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 18. The nurse determines a parent understands a hospitalized toddlers need for transitional

objects when the parent states:

a. This stuffed animal makes him feel secure. b. He insisted on bringing this dirty old blanket with him. c. Im going to buy him a big stuffed animal from the gift shop. d. Id like to get him some toys from the playroom. ANS: A The use of a transitional object such as a blanket or a favorite toy promotes security.

DIF: Cognitive Level: Comprehension REF: 475 OBJ: 10 TOP: The Hospitalized Toddler KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 19. An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a fractured femur. In planning care for the child, the nurse realizes immobilization in this age group can generate feelings of: a. Loss of control

b. Altered body image c. Shame and guilt

d. Fear of bodily harm

ANS: A

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control and loss of security.

Forced dependency in the hospital, such as immobilization, can result in a feeling of loss of

DIF: Cognitive Level: Analysis REF: 477 OBJ: 10

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TOP: The Hospitalized School-Age Child

KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. The nurse explains the use of fentanyl has the advantages of: a. Being specifically designed for children b. Rapid onset c. Nonaddicting d. Long duration ANS: B

Fentanyl is a drug useful for all ages because of its rapid onset and brief duration. DIF: Cognitive Level: Application REF: 467 OBJ: 5 TOP: Fentanyl KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 1. The nurse suggests to parents that they avail themselves of the outpatient surgical center for

their childs upcoming surgery because the surgical center has the advantages of: Select all that apply.

b. Less incidence of nosocomial infections

a. Lower cost

c. Reduction of parent-child separation

d. Recuperation at home

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ANS: A, B, C, D, E

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e. Decreased emotional impact of illness

All options listed are advantages of outpatient services.

DIF: Cognitive Level: Application REF: 463 OBJ: 4

TOP: Use of Outpatient Facilities KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse understands that no matter the reason for the young child being hospitalized, the basic fears are: Select all that apply.

a. Separation b. Permanent scarring c. Pain d. Cost e. Body intrusion ANS: A, C, E Small children all share the same basic fears relative to hospitalization, which are separation from family, pain, and body intrusion or mutilation.

DIF: Cognitive Level: Comprehension REF: 465 OBJ: 2

TOP: Basic Fear KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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Select all that apply.

3. The nurse taking a developmental history will include information relative to:

a. Previous experience with hospitalization

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b. Cultural needs

c. History of illness

d. Allergies

e. Childs nickname ANS: A, B, E

The developmental history has information about the child and the childs developmental and cultural needs and personal preferences. The information relative to history of illness or allergies would be covered in the medical history. DIF: Cognitive Level: Application REF: 475 OBJ: 4

TOP: Developmental History KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation COMPLETION 1. When the preschooler who is hospitalized for surgery to correct a poorly healed fracture says, My doctor is going to unscrew my bent arm and screw on a new one, the nurse should ____________________ this misconception. ANS: correct

Chapter 30: Procedures and Treatments

MULTIPLE CHOICE

1. Which is the most appropriate statement for the nurse to make to a 5-year-old child who is to

have a venipuncture?

a. You must hold still or Ill have someone hold you down. This is not going to hurt.

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b. This will hurt like a pinch. Ill get someone to help you hold your arm still so it will be over fast and hurt less.

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c. Be a big boy and hold still. This will be over in just a second.

ANS: B

d. Im sending your mother out so she wont be scared. You are big, so hold still and this will be over soon.

Honesty is the best approach and a venipuncture may hurt. Children should be told what sensation they will feel during a procedure. A 5-year-old child should not be expected to hold still, and assistance ensures safety to everyone. The nurse should not tell the child to a be a big boy and hold still or that it will be over in just a second as this is not supportive or honest. Parents should be encouraged to remain with the child unless they are extremely uncomfortable doing so. DIF: Cognitive Level: Application REF: p. 269

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 2. The nurse should obtain informed consent for which situation? a. For any procedure that will be performed on a child b. For any invasive procedure involving a risk to a child c. Only if the child is not able to give consent d. Only if the parents are not present ANS: B

Informed consent is required for invasive procedures that involve a risk to a child, such as lumbar puncture, chest tube insertion, and bone marrow aspirations. Informed consent is not required for procedures that are covered under the general consent to treat that is signed at

admission by a parent or a guardian. Agreement with the procedure is obtained from children

older than 7 years of age but does not preclude the need for informed consent from a parent. If a parent is not present and an emergency procedure requiring informed consent is needed,

administrative consent must be obtained.

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DIF: Cognitive Level: Application REF: pp. 270-271

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OBJ: Nursing Process Step: Implementation MSC: Safe and Effective Care Environment

3. Which nursing diagnosis is appropriate for a 5-year-old child in isolation because of

immunosuppression?

a. Spiritual distress b. Social isolation c. Diversional activity deficit d. Sleep disturbance ANS: C

Children in isolation need extra attention to avoid boredom. A 5-year-old child is not developmentally advanced enough to feel spiritual distress. The main social system for a 5-yearold child is the family, who should be allowed liberal visitation. Sleep disturbances may occur during hospitalization but are not specific to isolation. DIF: Cognitive Level: Comprehension REF: p. 273 OBJ: Nursing Process Step: Nursing Diagnosis MSC: Safe and Effective Care Environment

4. Which nursing action is most appropriate when giving a child a sponge bath to decrease fever? a. Use alcohol in the bath water to lower the childs temperature rapidly.

b. Use cold water to hasten the procedure.

c. Stop the sponge bath immediately if the child starts to shiver.

d. Bathe the child for 45 to 60 minutes.

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ANS: C

The procedure should be stopped immediately if the child begins to shiver. Shivering will increase the childs temperature. Alcohol is contraindicated because of skin irritation, the risk of

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neurological depression from the fumes or absorption through the skin, and shivering, which results from rapid cooling. Cold water can lead to rapid cooling. Tepid water should be used for a sponge bath to reduce fever. The procedure should be stopped immediately if the child begins

to shiver. Shivering will increase the childs temperature. DIF: Cognitive Level: Application REF: p. 279 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 5. Which action is appropriate when the nurse is bathing a small child? a. Test the water on the inside of the wrist or elbow for comfort. b. Allow children older than 2 years to bathe themselves.

c. Check that the water temperature does not exceed 120 F. d. Step out of the room to give the child privacy while bathing. ANS: A Bath water should be warm, not hot. Water temperature can be tested on the inside of the wrist or elbow. Young children can assist with bathing but cannot bathe independently. The temperature of the water should be less than 100 F. The nurse should never leave an infant or small child unattended in the bath.

DIF: Cognitive Level: Application REF: pp. 273-274 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

6. Which is the best response for a nurse to make to a parent who has asked, When should I start

dental care for my child?

a. The recommendation is for children to have a dental examination no later than 2 1/2 years.

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b. Children should see a dentist at least one time before kindergarten. c. The recommendation is for children to have a dental examination before first grade.

ANS: A

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d. A dental examination by 1 year of age is the current recommendation.

Children should be examined by a dentist between the time the first teeth erupt and primary dentition is complete at 2 1/2 years of age. Children require regular dental examinations well before kindergarten. Six years of age is too late to begin regular dental examinations. One year of age is too young, since many children have only a few teeth at this age. DIF: Cognitive Level: Application REF: p. 275 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 7. Which action is appropriate to promote a toddlers nutrition during hospitalization?

a. Allow the child to walk around during meals. b. Require the child to empty his or her plate. c. Ask the childs parents to bring a cup and utensils from home. d. Select new foods for the child from the menu. ANS: C Using familiar items during mealtimes increases the toddlers sense of security and control. For safety reasons, roaming while eating should not be permitted. The child should be seated during meals. Toddlers often use food as a source of control. Forcing a toddler to eat only increases the childs sense of powerlessness. Toddlers also experience food jags, a normal phenomenon during

is not the time to introduce the child to new foods.

which they will eat only certain foods. Hospitalization is a stressful experience for the toddler. It

DIF: Cognitive Level: Application REF: pp. 275-276

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

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8. Which concept is important for the nurse to know when taking a childs temperature? a. The method used should be consistent.

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b. Rectal temperatures should always be taken on infants. c. Oral temperatures can be taken on all children older than 5 years of age.

ANS: A

d. Axillary temperatures should be taken at night.

The method that is determined most appropriate for the child should be used consistentlythe same site and device to maintain consistency and allow reliable comparison and tracking of temperatures over time. Because of the risk of rectal perforation and the intrusive nature of the procedure, rectal temperatures are measured only when no other route can be used or when it is necessary to obtain a core body temperature. Oral temperatures can be used on most children older than 6 years of age but may be inaccurate because of oral intake, oral surgery, oxygen

therapy, nebulizer treatments, or crying. The method of measuring temperature should be consistent, including at night. DIF: Cognitive Level: Application REF: p. 276 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 9. A parent calls the pediatricians office because her 1-year-old child has a 100 F temperature. What would be the most appropriate initial nursing response to make to the parent? a. Did you feel your childs forehead?

b. Tell me about the childs behavior. c. Has anyone in your home been sick lately?

d. There is no need for concern if the childs temperature is less than 101 F.

ANS: B

In general, the height of the fever is not an indication of the seriousness of the illness. It is more

important to note changes in the childs behavior. If a child has a low-grade temperature and acts

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sick, he or she should be assessed further. Feeling a childs forehead can give clues related to whether the childs temperature should be measured; if it has already been measured, this would

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be unnecessary because it does not give accurate information about the childs body temperature. Learning of other sick persons in the home will yield relevant information for the nurse to use in advising the parent, but it is not the best initial response. Although the height of the temperature

is not an indication of the seriousness of the childs illness, it is incorrect to tell a parent to be

unconcerned about temperatures less than 101 F. DIF: Cognitive Level: Application REF: p. 279 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 10. Which nursing action is appropriate for specimen collection? a. Follow sterile techniques for specimen collection. b. Sterile gloves are worn if the nurse plans to touch the specimen.

c. Use standard precautions when handling body fluids. d. Avoid wearing gloves in front of the child and family. ANS: C Standard precautions should always be used when handling body fluids. Specimen collection is not always a sterile procedure. Gloves should be worn if there is a chance the nurse will be contaminated. The choice of sterile or clean gloves will vary according to the procedure or specimen. The child and family should be educated in the purpose of glove use, including the fact that gloves are used with every patient, so they will not be offended or frightened.

DIF: Cognitive Level: Application REF: p. 280

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

gastrostomy tube at home?

a. Never turn the gastrostomy button.

11. What information should the nurse include in teaching parents to care for a childs

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b. Clean around the insertion site daily.

c. Expect some leakage around the button.

ANS: B

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d. Remove the tube for cleaning once a week.

The skin around the tube insertion site should be cleaned with soap and water once or twice

daily. The gastrostomy button should be rotated in a full circle during cleaning. Leakage around the tube should be reported to the physician. A gastrostomy tube is placed surgically. It is not removed for cleaning. DIF: Cognitive Level: Comprehension REF: pp. 289-290 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

12. Which nursing action is the most appropriate when applying a face mask for oxygen therapy to a child? a. The oxygen flow rate should be less than 6 liters per minute. b. Make sure the mask fits properly. c. Keep the child warm. d. Remove the mask for 5 minutes every hour. ANS: B A properly fitting face mask is essential for adequate oxygen delivery. The oxygen flow rate

should be greater than 6 liters per minute to prevent rebreathing of exhaled carbon dioxide. Oxygen delivery through a face mask does not affect body temperature. A face mask used for

DIF: Cognitive Level: Application REF: p. 291

oxygen therapy is not routinely removed.

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

tracheostomy?

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13. Which information is appropriate to include in the care plan for a family of a child with a

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a. Suction of the tracheostomy every 2 to 4 hours or as needed b. Application of powder around the stoma to decrease irritation

c. Suction catheter insertion limited to less than 30 seconds

d. Hygiene that includes showers, not baths ANS: A

To maintain a patent airway in a child with a tracheostomy, assessing respiratory status and suctioning every 2 to 4 hours or as needed using standard precautions are important interventions to teach families. Talc powder should be avoided because of the risk of inhalation injury from breathing the powder particles. Catheter insertion for suctioning should be less than 5 seconds to

prevent hypoxia. The family should be taught to avoid getting water in the tracheostomy during bath time. Showers should be discouraged. DIF: Cognitive Level: Application REF: pp. 293-294 OBJ: Nursing Process Step: Planning MSC: Physiological Integrity 14. Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler? a. Measuring oral temperature for 5 minutes

c. Observing chest movement for respiratory rate

d. Recording blood pressure as P/80

b. Counting apical heart rate for 60 seconds

ANS: B

Apical pulse measurement when the child is quiet for 1 full minute is the preferred method for

measuring vital signs in infants and children ages 2 years and younger. A child younger than 6

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years may not be able to hold a thermometer under the tongue. The respiratory rate in infants and young children can be measured by watching abdominal movement. It may be difficult to

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auscultate blood pressure in infants and toddlers. Systolic pressure can be palpated and should be recorded as systolic pressure over pulse (e.g., 80/P).

DIF: Cognitive Level: Analysis REF: p. 277

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 15. Which action by a nurse is appropriate when preparing a child for a procedure? a. Discourage the child from crying during the procedure. b. Use professional terms so the child will understand what is happening. c. Give the child choices whenever possible. d. Discourage the parents from staying in the room during the procedure.

ANS: C Allowing children to make choices gives them a sense of control. Children (and adults) should be given permission to cry. Age-appropriate language should always be used. Parents should be encouraged to stay in the room and give support to the child. DIF: Cognitive Level: Comprehension REF: p. 270 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 16. Which is the most reliable method that indicates the end of a nasogastric tube is correctly

placed? a. Swallowing, coughing, and gagging reflex are intact.

c. The fluid has a grassy green appearance.

b. The pH of aspirated fluid is 5 or lower.

d. Insufflation of air is auscultated over the epigastrium.

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ANS: B

The pH of fluid aspirated from the stomach should be 5 or lower. This is the most reliable method for indicating that a nasogastric tube is properly placed. Intact swallowing, coughing,

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and gagging reflexes should not be used in the determination of nasogastric tube placement. Fluid aspirated from the stomach can have a grassy green, brown, or clear, mucoid-flecked appearance, but this is not the most reliable way to determine correct placement. A whooshing or

gurgling sound can be heard as air injected into the tube enters the stomach, but this is not the

most reliable method for determining tube placement. DIF: Cognitive Level: Analysis REF: p. 288 OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity 17. Which is critical for the nurse to know when using restraints on children? a. Use the least restrictive type of restraint.

b. Tie knots securely so they cannot be untied easily. c. Secure the ties to the mattress or side rails. d. Remove restraints every 4 hours to assess skin. ANS: A When restraints are necessary, the nurse should institute the least restrictive type of restraint. Knots must be tied so that they can be easily undone for quick access to the child. The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. Restraints are removed every 2 hours to allow for range of motion, position changes, and

assessment of skin integrity. DIF: Cognitive Level: Comprehension REF: pp. 271-272

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

a. Second right intercostal space

18. Where would the nurse locate the apical pulse on a 6-year-old child?

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b. Second intercostal space at the sternal border

c. Fourth intercostal space lateral to the midclavicular line

ANS: C

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d. Fifth intercostal space at the midclavicular line

In children younger than 7 years of age, the apical pulse is located at the fourth intercostal space,

lateral to the midclavicular line. The tricuspid valve is auscultated at the second right intercostal space. The pulmonic valve can be auscultated at the second intercostal space at the left sternal border. The apical pulse in a child older than 7 years of age is located at the fifth intercostal space in the midclavicular line. DIF: Cognitive Level: Comprehension REF: p. 277 OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

SHORT ANSWER 1. A nurse is totaling the intake of a child who is on oral feedings, enteral feedings, and parenteral IV fluids. During the 8 hour shift the child took 4 ounces of formula, by mouth. The child also had a supplemental feeding per gastrostomy tube that ran at 20 mL per hour for 4 hours. The childs IV ran continuously at 25 mL per hour for the whole 8 hours. What is the childs total intake for the 8 hour shift? ANS: 400

Keeping accurate intake and output (I&O) measurements may be necessary for some children. Measure and record all intake: oral, enteral, and parenteral. The 4 ounces of formula = 120, the 4

hours of enteral feeding at 20 mL per hour = 80, the parenteral IV intake at 25 mL per hour for 8

hours = 200. 120 + 80 + 200 = 400 total intake for the 8 hours.

DIF: Cognitive Level: Application REF: pp. 285-286

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OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity OTHER

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1. A nurse is collecting a nasopharyngeal culture on a school-age child. Place the steps in order from the first step the nurse should take to the last step.

a. Dip the swab tip into saline.

b. Place the swab in an appropriate culture medium. c. Ask the child to look up. d. Gently insert the tip of the swab into one nostril. e. Label the specimen. ANS:

C, A, D, B, E To obtain a nasopharyngeal culture on a school-age child the first step is to ask the child to look up. Bend the wire so that when the swab is inserted, the tip will go beyond the back of the nares and into the pharyngeal area. Dip the swab tip into saline and gently insert it into one nostril, down to the posterior nasopharynx. Leave it in place for several seconds and then remove it. After the specimen is obtained, place the swabs in the appropriate culture media. Remove gloves and perform hand hygiene. Label the specimen with the infant/childs name, birth date, medical record number, and the time and date of collection. Place it in a biohazard bag and send it to the laboratory with the requisition form for the test(s) to be performed.

Chapter 31: Medication Administration and Intravenous Therapy

MULTIPLE CHOICE

a. Calibrated syringe b. Paper measuring cup

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c. Plastic measuring cup

1. Which should the nurse use to prepare liquid medication in volumes less than 5 milliliters?

ANS: A

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d. Household teaspoon

To ensure accuracy, a calibrated syringe without a needle should be used to prepare a liquid

dosage less than 5 milliliters. Paper and plastic measuring cups are not calibrated for liquid volumes less than 5 milliliters. A household teaspoon is not accurate enough to measure small amounts of medication. DIF: Cognitive Level: Application REF: p. 303 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 2. Which food choice is appropriate to mix with medication?

a. Formula or milk b. Applesauce c. Syrup d. Orange juice ANS: B To prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications. Formula and milk are essential foods in a childs diet. Medications may alter their flavor and cause the child to avoid them in the future. Syrup is not used to mix with medications because of its high sugar content.

Orange juice is considered an essential food; therefore, the nurse should not mix medications

DIF: Cognitive Level: Application REF: p. 303

with it.

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

to a 3-month-old infant?

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3. Which physiological difference would affect the absorption of oral medications administered

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a. More rapid peristaltic activity

b. More acidic gastric secretions

c. Usually more rapid gastric emptying

d. Variable pancreatic enzyme activity ANS: D

Pancreatic enzyme activity is variable in infants for the first 3 months of life as the gastrointestinal system matures. Medications that require specific enzymes for dissolution and absorption might not be digested to a form suitable for intestinal action. Infants up to 8 months of age tend to have prolonged motility. The longer the intestinal transit time, the more medication is absorbed. The gastric secretions of infants are less acidic than in older children or adults. Gastric emptying is usually slower in infants.

DIF: Cognitive Level: Comprehension REF: p. 300 OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity 4. Which factor should the nurse remember when administering topical medication to an infant? a. Infants require a larger dosage because of a greater body surface area. b. Infants have a thinner stratum corneum that absorbs more medication. c. Infants have a smaller percentage of muscle mass compared with adults. d. The skin of infants is less sensitive to allergic reactions.

ANS: B Infants and young children have a thinner outer skin layer (stratum corneum), which increases

the absorption of topical medication. A similar dose of a topical medication administered to an

infant compared with an adult is approximately three times greater in the infant because of the greater body surface area. The smaller muscle mass in infants affects site selection for injected

medications. The young childs skin is more prone to irritation, making contact dermatitis and

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other allergic reactions more common.

DIF: Cognitive Level: Application REF: p. 300

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OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 5. What is the appropriate nursing response to a parent who asks, What should I do if my child

cannot take a tablet?

a. You can crush the tablet and put it in some food. b. Find out if the medication is available in a liquid form. c. If the child cant swallow the tablet, tell the child to chew it. d. Let me show you how to get your child to swallow tablets. ANS: B

A tablet should not be crushed without knowing whether it will alter the absorption, effectiveness, release time, or taste. Therefore telling the parent to find out whether the medication is available in liquid form is the most appropriate response. A chewed tablet may have an offensive taste, and chewing it may alter its absorption, effectiveness, or release time. Forcing a child, or anyone, to swallow a tablet is not acceptable and may be dangerous. DIF: Cognitive Level: Application REF: p. 303 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 6. What is the maximum safe volume that an infant (aged 1 to 12 months) can receive in an

intramuscular injection? a. 0.25 milliliter

b. 0.5 milliliter

c. 1 milliliter

d. 1.5 milliliters

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ANS: C

The maximum volume of medication for an intramuscular injection to an infant is 1 mL. The

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neonate should receive no more than 0.5 mL per intramuscular injection. 1.5 milliliters is not appropriate for an infant. It is appropriate for an intramuscular injection to a child 3 to 14 years of age.

DIF: Cognitive Level: Comprehension REF: p. 306 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 7. Which muscle would the nurse select to give a 6-month-old infant an intramuscular injection? a. Deltoid b. Ventrogluteal c. Dorsogluteal d. Vastus lateralis

ANS: D The vastus lateralis is not located near any vital nerves or blood vessels. It is the best choice for intramuscular injections for children younger than 3 years of age. The deltoid muscle is not used for intramuscular injections in young children. The ventrogluteal muscle is safe for intramuscular injections for children older than 18 months. The dorsogluteal muscle does not develop until a child has been walking for at least 1 year. DIF: Cognitive Level: Comprehension REF: pp. 305-306 OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

8. The nurse is planning to administer an intramuscular injection to a 13-year-old child. What is the maximum volume of medication that can be injected into the ventrogluteal site?

a. 0.5 to 1 milliliter

b. 1 to 1.5 milliliters c. 1.5 to 2 milliliters

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d. 2 to 2.5 milliliters ANS: C

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The maximum volume of medication for an intramuscular injection to an older child (6 to 14 years) is 1.5 to 2.0 milliliters. 0.5 to 1.4 milliliters are acceptable volumes to inject, but they are not the maximum. 2 to 2.5 milliliters exceeds the amount that can be safely injected into one site

for a 13-year-old child.

DIF: Cognitive Level: Comprehension REF: pp. 305-306 OBJ: Nursing Process Step: Planning MSC: Physiological Integrity 9. Which parameter should guide the nurse when administering a subcutaneous injection? a. Do not give injections in edematous areas. b. Attach a clean 1-inch needle to the syringe.

c. The maximum volume injected into one site is 2 milliliters. d. Do not pinch up tissue before inserting the needle. ANS: A Subcutaneous injections should never be given in areas of edema because absorption is unreliable. A short (no more than 5/8 inch) needle should be used to deposit medication into subcutaneous tissue. Volumes for subcutaneous injections are small, usually averaging 0.5 milliliters. The skin is pinched up for a subcutaneous injection to raise the fatty tissue away from the muscle.

DIF: Cognitive Level: Application REF: p. 306

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

10. Which action is correct when administering ear drops to a 2-year-old child? a. Administer the ear drops straight from the refrigerator.

b. Pull the pinna of the ear back and down.

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c. Massage the pinna after administering the medication.

ANS: B

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d. Pull the pinna of the ear back and up.

For children younger than 3 years, the pinna, or lower lobe, of the ear should be pulled back and

down to straighten the ear canal. Medication should be at room temperature because cold

solutions in the ear will cause pain. The tragus of the ear should be massaged to ensure the drops reach the tympanic membrane. For a child 3 years or older, the pinna is pulled up and back. DIF: Cognitive Level: Application REF: p. 309 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

11. A nurse is preparing to start a continuous IV infusion on a child. The nurse selects a Buretrol (volume-control) attachment as part of the IV tubing set-up. The main purpose for selecting a Buretrol attachment is to: a. avoid fluid overload. b. aid in measuring intake. c. administer antibiotics. d. ensure adequate intravenous fluid intake. ANS: A

A volume-control device such as a Buretrol or an infusion pump allows the nurse to set a specific volume of fluid to be given in a specific period of time (usually 1 hour) and decreases the risk of

inadvertently administering a large amount of fluid. Although the use of a volume-control device allows for accurate measurement of intake, the primary purpose for using this equipment is to

prevent fluid overload. Medications such as antibiotics can be administered with a volume-

control device; however, this is not the primary purpose.

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DIF: Cognitive Level: Application REF: pp. 312-313

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OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 12. Which is the most important nursing action before discharge for a mother who is apprehensive about giving her child insulin?

a. Review the side effects of insulin with the mother.

b. Have the mother verbalize that she knows the importance of follow-up care. c. Observe the mother while she administers an insulin injection. d. Help the mother devise a rotation schedule for injections. ANS: C It is important that the nurse evaluate the mothers ability to give the insulin injection prior to discharge. Watching her give the injection to the child will give the nurse an opportunity to offer

assistance and correct any errors. Although reviewing side effects is important, this could be done over the phone or by the pharmacist when the medication is picked up. Having the mother verbalize her knowledge of the importance of follow-up care is important but not directly relevant to the mothers concern. Helping the mother devise a rotation schedule for injections is important but not as important as having the mother demonstrate the procedure. DIF: Cognitive Level: Application REF: p. 315 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 13. A nurse has just initiated an intravenous piggyback of gentamicin (Garamycin). What is the

best time for a trough serum level to be measured? a. Just before the next dose

b. When the infusion is finished

d. Depends on the specific medication

c. One hour after the medication is administered

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ANS: A

The medication trough is the level at which the serum concentration is lowest. Trough levels are

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usually obtained just before the next medication dose. The serum concentration would be increasing as the infusion finishes. This is not the concentration trough. The peak concentration, or the concentration after the medication has been distributed, varies according to the specific

medication. Trough is always the lowest just before the next medication dose.

DIF: Cognitive Level: Application REF: p. 300 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 14. A nurse should routinely ask a colleague to double-check a medication calculation and the actual medication before administering which medications? a. Antibiotics b. Acetaminophen

c. Anticonvulsants d. Anticoagulants ANS: D The nurse should ask another nurse to check the dosage calculation and the medication before administering anticoagulants. The nurse always double-checks a dosage calculation, but it is not necessary to have a second nurse check the medication before administering antibiotics, acetaminophen, or anticonvulsant medications.

DIF: Cognitive Level: Comprehension REF: p. 302 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

15. Which nursing action is correct when administering heparin subcutaneously?

a. Insert the needle with the bevel up at a 15-degree angle. b. Insert the needle into the skin at a 45-degree angle.

c. Inject the needle into the tissue on the upper back.

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d. Massage the injection site when the injection is complete.

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ANS: B

For a subcutaneous injection, the nurse would pinch the skin and inject at a 45-degree angle. Inserting the needle with the bevel up at a 15-degree angle is the technique used for an

intradermal injection. The upper back is used for intradermal injections. The nurse would not

massage the site after administering heparin. DIF: Cognitive Level: Application REF: p. 306 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 16. Which indicates that a school-age child is using a metered-dose inhaler correctly? a. The child uses his inhaled steroid before the bronchodilator.

b. The child exhales forcefully as he squeezes the inhaler. c. The child holds his breath for 10 seconds after the first puff. d. The child waits 10 minutes before taking a second puff. ANS: C After a puff, the child should hold his breath for about 10 seconds or until he counts slowly to 5. If one of the childs medications is an inhaled steroid, it should be administered last. The child should inhale slowly as the inhaler is squeezed or depressed. The child does not need to wait this long to take a second puff of medication. He can take a second puff after holding his breath for

10 seconds. DIF: Cognitive Level: Analysis REF: p. 310

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

17. Which step is appropriate when using EMLA cream before intravenous catheter insertion?

a. Rub a liberal amount of cream into the skin thoroughly.

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b. Cover the skin with a gauze dressing after applying the cream. c. Leave the cream on the skin for 1 to 2 hours before the procedure.

ANS: C

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d. Use the smallest amount of cream necessary to numb the skin surface.

The cream should be left in place for a minimum of 1 hour and up to 2 hours. The EMLA cream

should not be rubbed into the skin. After the cream is applied to the skin surface, it is covered with a transparent occlusive dressing. The nurse would use a liberal amount of EMLA cream. DIF: Cognitive Level: Application REF: p. 311 OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity 18. A child is receiving intravenous fluids. How frequently should the nurse assess and document the condition of the childs intravenous site?

a. Every hour b. Every 2 hours c. Every 4 hours d. Every shift ANS: A The nurse assesses and documents an IV site at least every hour for signs and symptoms of infiltration and phlebitis. The nurse should assess a childs IV site more frequently than every 2 to 4 hours or every shift. Serious complications could occur during this time interval.

DIF: Cognitive Level: Application REF: p. 312

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

19. What is the hourly maintenance fluid rate for an intravenous infusion in a child weighing 19.3 kilograms?

c. 61 milliliters

ANS: C

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d. 95 milliliters

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b. 45 milliliters

a. 19 milliliters

The formula for calculating daily fluid requirements is 0 to 10 kg: 100 mL/kg/day; 10 to 20 kg:

1000 mL for the first 10 kg of body weight plus 50 mL/kg/day for each kg between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. DIF: Cognitive Level: Application REF: p. 313 OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity 20. The nurse administering an IV piggyback medication to a preschool child should take which action?

a. Dilute the medication in at least 20 milliliters and infuse over at least 15 minutes. b. Flush the IV tubing before and after the infusion with normal saline solution. c. Inject the medication into the IV catheter using the port closest to the child. d. Inject the medication into the IV tubing in the direction away from the child. ANS: A Medications given by IV piggyback are diluted in at least 20 milliliters of IV solution and administered over at least 15 minutes. When administering medications by IV piggyback, the nurse flushes the tubing after the medication has infused, usually with 16 to 20 milliliters of IV solution. The nurse is using the IV push method when injecting medication into the IV tubing

using the port closest to the child. The IV retrograde method involves clamping the IV tubing below the injection port and injecting medication into the tubing in a direction away from the

child, causing it to flow into the tubing above the injection port.

Chapter 32: The Child with a Chronic Health Problem

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MULTIPLE CHOICE

1. A family has just learned their child has cystic fibrosis. They told the nurse this wont change anything, our child is not that sick. The nurse recognizes that the family is in which stage of the

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grieving process?

a. Anger and resentment

b. Sorrow and depression

c. Shock and disbelief d. Acceptance and adjustment ANS: C According to Kbler-Ross, denial is the initial stage of the grieving process when an individual reacts with shock and disbelief to the diagnosis of a chronic illness. Feelings of anger, resentment, sadness, and depression are part of the grieving process, after the initial response of shock and disbelief. Acceptance is the final stage of the grieving process.

DIF: Cognitive Level: Comprehension REF: p. 252 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 2. A nurse is planning care for a dying child. Which priority intervention is planned to address the primary concern parents have for the dying child? a. Pain b. Safety c. Food intake

d. Fluid intake ANS: A

The primary concern of all parents of dying children is the possibility of their child feeling pain.

Although safety, eating, and hydration are important, they are not the priority concern.

DIF: Cognitive Level: Application REF: p. 264

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OBJ: Nursing Process Step: Planning MSC: Physiological Integrity 3. A parent of an infant states that she will room-in while her child is hospitalized. The nurse are:

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supports her decision knowing that the major fears of infants during illness and hospitalization

a. bodily injury and pain.

b. separation from caregivers and fear of strangers. c. loss of control and altered body image. d. the unknown and being left alone. ANS: B The major fear of infants during illness and hospitalization are separation from caregivers and fear of strangers. Bodily injury and pain are fears of preschool and school-age children. Loss of

control is a fear of children from the preschool period through adolescence. Altered body image applies to adolescents. Fear of the unknown and being left alone are applicable to preschoolers. DIF: Cognitive Level: Comprehension REF: p. 254 OBJ: Nursing Process Step: Evaluation MSC: Psychosocial Integrity 4. A nurse has just completed a teaching session for parents about childrens understanding of death. Parents of a 5-year-old child understood the teaching if they indicate which corresponds to their childs understanding of death? a. Loss of a caretaker

b. Reversible and temporary c. Permanent

d. Inevitable ANS: B

Children in early childhood (2 to 7 years old) view death as reversible and temporary. Toddlers

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view death as loss of a caretaker. The school-age child and adolescent understand death is permanent. The adolescent understands death not only as permanent, but also inevitable.

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DIF: Cognitive Level: Application REF: p. 260

OBJ: Nursing Process Step: Evaluation MSC: Psychosocial Integrity

5. A nurse plans to include family in the aspects of care for a dying 12-month-old child. The nurse bases this plan on the understanding that death for an infant is understood as: a. temporary. b. permanent. c. loss of caretaker. d. punishment. ANS: C

Infants and toddlers view death as loss of a caretaker. The preschool-age child views death as temporary. The school-age child and adolescent understand the permanence of death. The preschool-age child facing impending death may view his or her condition as punishment for behaviors or thoughts. DIF: Cognitive Level: Comprehension REF: p. 260 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 6. Which activity should the nurse implement for the toddler hospitalized with a chronic illness to promote autonomy?

a. Playing with a push-pull toy. b. Putting a puzzle together.

c. Playing a simple card game.

d. Watching cartoons on TV.

ANS: A

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Chronic illness may interfere in the development of autonomy, which is the major psychosocial task of the toddler. The developmentally appropriate activity for the hospitalized toddler is to

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play with a push-pull toy. Putting a puzzle together and playing a simple card game could frustrate the toddler and are appropriate for a preschool or school-age child. Watching cartoons on TV is passive and will not promote autonomy.

DIF: Cognitive Level: Application REF: p. 254 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 7. How can chronic illness and frequent hospitalization affect the psychosocial development of an adolescent? a. They can lead to feelings of inadequacy. b. They can interfere with parental attachment. c. They can block the development of identity.

d. They can prevent the development of imagination. ANS: C Development of identity is the task of the adolescent. Inadequacy and inferiority refer to the school-age period. Parental attachment is a task of the infant. Development of imagination occurs in the preschool period. DIF: Cognitive Level: Comprehension REF: p. 254 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

8. Which is an important focus of nursing care for the dying child and his or her family? a. Nursing care should be organized to minimize contact with the child.

b. Adequate oral intake is crucial to the dying child.

c. Families should be made aware that hearing is the last sense to stop functioning before death.

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d. It is best for the family if nursing care takes place during periods when the child is alert.

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ANS: C

Families should be encouraged to talk to the child because verbal communication and physical touch are important both for the family and child. Nursing care should minimize disruptions but

not contact. When a child is dying, fluids should be based on the childs requests, with a focus on comfort and preventing a dry mouth. The times when the child is alert should be devoted to

family contacts.

DIF: Cognitive Level: Application REF: p. 265 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity 9. What is the most appropriate response to a school-age child who asks if she can talk to her dying sister?

a. You need to talk loudly so she can hear you. b. Holding her hand would be better because at this point she cant hear you. c. Although she cant hear you, she can feel your presence so sit close to her. d. Even though she will probably not answer you, she can still hear what you say to her. ANS: D Hearing is the last sense to cease before death. Talking to the dying child is important both for the child and the family. The sibling should be encouraged to speak to the child as well as hold

the childs hand. DIF: Cognitive Level: Application REF: p. 265

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

10. The nurse recognizes that the priority goal for the child with a chronic illness is to:

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b. eliminate all stressors.

a. maintain the intactness of the family.

c. achieve complete wellness.

ANS: D

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d. obtain the highest level of wellness.

To obtain the highest level of health and function possible is the priority goal of nursing of

children. Maintaining the intactness of the family is a goal for the family, not specifically the child. It is not a realistic goal to eliminate all stressors because life will continue to present stressors. It is also unrealistic to achieve complete wellness because chronic illness by definition is a long-term condition either without a cure or with residual limitations. DIF: Cognitive Level: Comprehension REF: pp. 253-254 OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

11. Which is the predominant trait of the resilient family associated with chronic illness? a. Social separation b. Family flexibility c. Family cohesiveness d. Clear family boundaries ANS: C Family cohesiveness is the predominant trait of the resilient family. Maintaining social integration is one of the traits of a resilient family system. Family flexibility and clear family

backgrounds are traits of the resilient family, but not the predominant one.

DIF: Cognitive Level: Knowledge REF: p. 251

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 12. Parents express recurrent feelings of grief, loss, and fear related to their childs chronic

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condition. The nurse understands that this is: a. anticipatory grieving.

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b. chronic sorrow. c. bereavement.

ANS: B

d. illness trajectory.

The stated recurrent feelings define chronic sorrow, which is considered a normal process involving grief that may never be resolved. Anticipatory grieving is the process of mourning, coping, interacting, planning, and psychosocial reorganization that is begun as a response to the impending loss of a loved one. Bereavement is defined as the objective condition or state of loss. Illness trajectory is defined as the impact of the disease or condition on all family members, physiological unfolding of the disease, and work organization done by the family to cope. DIF: Cognitive Level: Comprehension REF: p. 252

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 13. Which would be a priority nursing diagnosis for the child with chronic illness? a. Risk for delayed development related to chronic illness or disability b. Chronic pain related to frequent injections c. Anticipatory grieving related to impending death d. Anxiety related to frequent hospitalizations ANS: A

Risk for delayed development related to chronic illness or disability is the priority nursing diagnosis that would be appropriate for the majority of children with chronic illnesses. Pain is not associated with the majority of chronic illnesses. A chronic illness is one that does not have a

cure. It does not mean the child will die prematurely. Frequent hospitalizations are not required

for all chronic illnesses.

DIF: Cognitive Level: Application REF: p. 253

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OBJ: Nursing Process Step: Nursing Diagnosis

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MSC: Health Promotion and Maintenance

14. Which is the most appropriate response for the nurse when parents say that living with this

disease our child has is really hard; its not fair?

a. Tell me about what is hard for you. b. I know exactly how you must feel. c. I know a local support group for families. d. I am going to ask the grief counselor to meet with you. ANS: A The first step in supporting families and helping them deal with chronic sorrow is to listen to and recognize their pain. Telling the parents that you know how they must be feeling would not

encourage parents to talk about their feelings. Each individuals perception of a situation is different. A nurse can never know exactly how parents feel about having a child with a chronic illness. I know a local support group for families and I am going to ask the grief counselor to meet with you do not address the parents immediate feelings. DIF: Cognitive Level: Application REF: p. 252 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 15. Which is the most appropriate response to a parent who tells the nurse, I dont want my child to know she is dying?

a. I shall respect your decision. I wont say anything to your child. b. Dont you think she has a right to know about her condition?

c. Would you like me to arrange for the physician to speak with your child?

d. Ill answer any questions she asks me as honestly as I can.

ANS: D

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Nurses can inform parents that they will not initiate any discussion with the child but that they intend to respond openly and honestly if and when the child initiates such a discussion. As the

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caregiver and advocate, the nurse should first meet the childs needs. Would you like me to arrange for the physician to speak with your child does not address the parents wishes.

DIF: Cognitive Level: Application REF: p. 263

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity MULTIPLE RESPONSE 1. Which indicators of imminent death in a child should the nurse expect to assess? Select all that apply. a. Heart rate increases. b. Blood pressure increases.

c. Respirations become rapid and shallow. d. The extremities become warm. e. Peripheral pulses become stronger. ANS: A, C Indicators of imminent death include the heart rate increasing, with a concomitant decrease in the strength and quality of peripheral pulses; respiratory effort declines, as evidenced by rapid, shallow respirations; and extremities are cool and cyanotic.

DIF: Cognitive Level: Comprehension REF: p. 252 OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

OTHER

1. Place the stages of grieving in order starting with the initial stage and ending with the final

stage.

c. Denial

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b. Depression

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a. Anger

d. Acceptance

e. Bargaining ANS:

C, A, E, B, D The stages of grieving, in order, include denial, anger, bargaining, depression, and acceptance.

Chapter 33: Abuse in the Family and Community

MULTIPLE CHOICE 1. A nurse is assessing a child with a depressive disorder. Which symptom is likely to be manifested by the child? a. Increased nighttime waking b. Impulsivity and distractibility c. Carelessness and inattention to details d. Refusal to leave the house

ANS: A Sleep pattern disturbances are often associated with depression. These include insomnia or hypersomnia. Impulsivity and distractibility are manifestations of attention-deficit hyperactivity

disorder (ADHD). A diminished ability to think or concentrate, carelessness, and inattention to

details are clinical manifestations of a depressive disorder. A refusal to leave the house, even to

play with friends, is characteristic of separation anxiety disorder.

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DIF: Cognitive Level: Application REF: p. 775

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

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2. A nurse is teaching parents about symptoms associated with suicide. Which statement about suicide should the nurse include in the teaching plan?

a. Children younger than 10 years of age do not attempt suicide.

b. A child who attempts suicide is usually depressed and has low self-esteem. c. Suicide is usually an isolated event in a school community. d. The suicide rate among females is higher than among males. ANS: B Poor self-concept and depression contribute significantly to suicidal behaviors. Children as young as 3 years of age who have attempted suicide have been evaluated and found to be

cognizant of their actions. It is common for suicide to occur in a cluster within a community (e.g., schools). Males have a higher incidence of both suicide attempts and completed suicides. DIF: Cognitive Level: Application REF: p. 776 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 3. What is the best response for the nurse to make to an adolescent who states, I am very sad. I wish I wasnt alive.? a. Everyone feels sad once in a while.

b. You are just trying to escape your problems. c. Have you told your parents how you feel?

d. Have you thought about hurting yourself?

ANS: D

Have you thought about hurting yourself? acknowledges the adolescents suicide gesture and

further assesses the adolescents condition. Everyone feels sad once in a while is a judgmental

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response that ignores the adolescents obvious statement indicating a need for professional help. The parents should be made aware of an adolescents precarious mental state; however, Have you

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told your parents how you feel? does not address the adolescents statement. DIF: Cognitive Level: Application REF: pp. 777-778

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 4. A nurse is teaching parents about family relationship patterns associated with eating disorders. Which family relationship pattern should the nurse teach that is consistent for an adolescent female diagnosed with an eating disorder? a. The adolescent is viewed as an extension of the parent. b. There is an overprotective mother and an emotionally distant father. c. The mother is domineering and the father is passive. d. The adolescent is the youngest child or is an only child.

ANS: A One of the most salient factors associated with eating disorders is enmeshed family relationships in which the child is considered to be an extension of the parent or is viewed as a means of meeting the parents needs. The family dynamics for males with anorexia are reported to include a mother who is overinvolved with the child and a father who typifies a strong, cultural image. A domineering mother and passive father are not characteristic of the family dynamics associated with eating disorders. Birth order and number of children in the family were not identified as factors in enmeshed family relationships.

DIF: Cognitive Level: Application REF: p. 781 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

a. managing the effects of malnutrition.

5. The long-term treatment plan for an adolescent with an eating disorder focuses on:

c. improving family dynamics.

b. establishing sufficient caloric intake.

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d. restructuring the perception of body image.

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ANS: D

The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individuals body image. The treatment of eating disorders is

initially focused on reestablishing physiological homeostasis. Once body systems are stabilized,

the next goal of treatment for eating disorders is maintaining adequate caloric intake. Although family therapy is indicated when dysfunctional family relationships exist, the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues. DIF: Cognitive Level: Comprehension REF: p. 782 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

6. A parent of a child with a psychosocial disorder states, I dont know how my child developed this problem. The nurse should base a response on which information? a. Neurobiological, family, and sociocultural factors can contribute to the development of psychosocial disorders in children. b. Like many conditions affecting children, the etiology of psychosocial disorders is unknown. c. The majority of psychosocial disorders have a clear pattern of genetic inheritance. d. Dysfunctional family patterns are usually identified as the cause of a psychosocial disorder.

ANS: A Psychosocial disorders are responses to stress and may be manifested as disturbances in feeling,

body functions, behavior, or performance. The etiology of many psychosocial disorders in children can be identified. Some psychosocial disorders are inheritable disorders. Others have

been identified as having a familial predisposition. Research consistently shows that psychosocial disorders are caused by a combination of predisposing or inherent factors and

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environmental or interactional factors.

DIF: Cognitive Level: Comprehension REF: p. 769

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OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 7. A nurse is caring for a child admitted for substance abuse. The nurse plans care with the

recognition that substance abuse primarily affects which organ of the body?

a. Heart b. Liver

c. Brain d. Lungs ANS: C

The primary affect of substance abuse is on the brain and residually on the rest of the body. Although an excessive amount of a chemical can cause cardiac abnormalities, the brain is the most commonly affected organ. Long-term alcohol use is known to impair the liver; however, brain function is decreased by any amount of alcohol intake. The pulmonary system is not the primary target; however, one commonly abused drug known to cause pulmonary problems is tobacco. DIF: Cognitive Level: Implementation REF: p. 785 OBJ: Nursing Process Step: Planning MSC: Psychosocial Integrity

8. A 14-year-old child admits to using marijuana every day. Which phase of substance abuse should the nurse assess for?

a. Experimentation

c. True drug addiction

d. Severe drug addiction

b. Early drug use

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ANS: C

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True drug addiction is identified as regular use of drugs. Physical dependence may be present. Social functioning has a drug focus. With experimentation, the individual tries the drug to see what it is like or to satisfy peers. Early drug use is identified as using drugs with some degree of

regularity for their desirable effects. In severe drug addiction, the physical condition of the

individual deteriorates and all activities are related to drug use. DIF: Cognitive Level: Comprehension REF: p. 784 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 9. The school nurse observes an unkempt child dressed in inappropriate clothing who repeatedly asks for food. The nurse is concerned about which problem? a. Physical abuse

b. Physical neglect c. Emotional abuse d. Sexual abuse ANS: B These physical and behavioral indicators suggest that parental attention is not being given to the childs physical needs. The child is being neglected. There are no physical indicators of actual abuse in this description. Behavioral indicators of physical abuse reflect an impaired relationship with parents and other adults. Emotional abuse is manifested by developmental problems or maladaptive behaviors. Physical indicators of sexual abuse are focused on the genitourinary sleeping disturbances.

DIF: Cognitive Level: Comprehension REF: p. 788

system. A variety of behavioral indicators range from bizarre sexual behavior to eating and

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 10. Which should be the most appropriate nursing intervention for the infant who is not gaining

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weight?

a. Instruct the primary caregiver on proper feeding techniques.

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b. Observe and document the parentinfant interaction. c. Assign different nurses to care for the infant.

d. Feed the infant on a predetermined schedule. ANS: B

Observation and documentation of the parentinfant interaction may offer insight into the cause of malnutrition. Instruction alone is not the best teaching strategy. Role modeling and supervised practice along with parental instruction will facilitate the parents learning to feed the infant. A consistent caregiver will facilitate trust in the infant. The infants caloric intake is increased by feeding the infant on demand rather than on a schedule. DIF: Cognitive Level: Application REF: p. 788

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 11. Which statement made by a parent of a toddler who is not gaining weight indicates the need for education about feeding small children? a. He doesnt want to eat, so I put the cereal in his bottle. b. I put him in a high chair for meals and snacks. c. I turn off the television and we eat together for every meal. d. I try to feed him at the same times every day.

ANS: A Large quantities of cereal or baby food in bottles do not provide sufficient nutritional intake for the small child. The young child should be placed in a high chair for feeding. Distraction during

feedings, such as watching television, is identified as a reason for inadequate nutritional intake in

young children. Having the parents or others eat with the child makes meals and snacks a

pleasant time. A regular pattern or schedule for meals facilitates nutritional intake.

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DIF: Cognitive Level: Comprehension REF: p. 791

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

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12. Which intervention should the nurse teach parents about caring for an infant experiencing drug withdrawal?

a. Keep rooms in the home well lighted.

b. Play music or the television continuously. c. Organize care to minimize disruptions. d. Let the infant calm himself if irritable. ANS: C The infants care should be coordinated to limit the number of times the infant is disturbed. Light levels should be maintained at the minimum necessary level. Sound levels should be kept to the

minimum necessary level. Comfort measures should be provided immediately when the infant exhibits irritability. DIF: Cognitive Level: Application REF: pp. 786-787 OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 13. A child who has symptoms of irritable mood and changes in sleep and appetite patterns lasting 3 weeks meets the criteria for which depressive disorder? a. Major depressive disorder

b. Dysthymic disorder c. Cyclothymic disorder

d. Panic disorder

ANS: A

A 2-week (or longer) episode of depressed or irritable mood in addition to disturbances in

appetite, sleep, energy, or self-esteem meets the criteria for a major depressive disorder. A

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dysthymic disorder is associated with a depressed or irritable mood for at least a year. A cyclothymic or bipolar mood disorder is characterized by chronic, fluctuating mood disturbances

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between depressive lows and highs for a year. A panic disorder is a type of anxiety disorder. DIF: Cognitive Level: Comprehension REF: p. 773

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 14. What is the goal of therapeutic management for a child diagnosed with attention-deficit hyperactivity (ADHD) disorder? a. Administer stimulant medications. b. Assess the child for other psychosocial disorders. c. Correct nutritional imbalances. d. Reduce the frequency and intensity of unsocialized behaviors.

ANS: D The primary goal of therapeutic management for the child with ADHD is to reduce the intensity and frequency of unsocialized behaviors. Although medications are effective in managing behaviors associated with ADHD, all families do not choose to give their child medication. Administering medication is not the primary goal. Children with ADHD may have other psychosocial or learning problems; however, diagnosing these is not the primary goal. Interventions to correct nutritional imbalances are the primary focus of care for eating disorders. DIF: Cognitive Level: Comprehension REF: p. 779

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity 15. Which behavior demonstrated by an adolescent should alert the school nurse to a problem of

a. States feelings of worthlessness

substance abuse?

b. Increased desire for social conformity

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ANS: D

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d. Rebellious behavior

c. Does not feel the need for peer approval

Rebellious or aggressive behavior is a behavior that may indicate substance abuse. Feelings of worthlessness are suggestive of a depressive disorder. An adolescent with a substance abuse

problem may be depressed, but this behavior is not a manifestation of substance abuse. The

clinical manifestations of substance abuse are marked by an increase in antisocial behavior as the desire for social conformity decreases and the need for the substance increases. The adolescent with a substance abuse problem may demonstrate an excessive dependence on peer influence. DIF: Cognitive Level: Comprehension REF: p. 785 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

16. A nurse is caring for an infant with neonatal abstinence syndrome. Which manifestation should the nurse expect to assess? a. Weight gain b. Respiratory acidosis c. High-pitched persistent cry d. Hypotonus ANS: C A high-pitched persistent cry is one of the many manifestations of infant drug withdrawal. The

infant undergoing drug withdrawal may lose weight or fail to gain weight. Respiratory alkalosis and respiratory distress are manifestations of withdrawal. An infant undergoing drug withdrawal

DIF: Cognitive Level: Analysis REF: p. 786

would have hypertonus, hyperreflexia, and hyperactivity.

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

sexually abused?

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17. Which finding noted by the nurse on a physical assessment may suggest that a child has been

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a. Swelling of the genitalia and pain on urination b. Smooth philtrum and thin upper lip

c. Speech and physical development delays

d. History of constipation, drowsiness, and constricted pupils ANS: A

Physical indicators of sexual abuse may include swelling or itching of the genitalia and pain on urination. Other indicators may include bruises, bleeding, or lacerations of the external genitalia, vagina, or anal area. The infant with fetal alcohol syndrome may have microphthalmia or abnormally small eyes or short palpebral fissures, a thin upper lip, and a poorly developed philtrum. Children who have been emotionally abused may exhibit speech disorders, lags in

physical development, failure to thrive, or hyperactive and disruptive behaviors. Opiates can cause these behaviors: detachment and apathy, drowsiness, constricted pupils, constipation, slurred speech, and impaired judgment. DIF: Cognitive Level: Comprehension REF: p. 789 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity 18. A nurse is assessing a child with attention-deficit hyperactivity disorder (ADHD). Which manifestation should the nurse not expect to assess? a. Talking incessantly

b. Blurting out the answers to questions before the questions have been completed c. Acting withdrawn in social situations

d. Fidgeting with hands or feet ANS: C

The child with ADHD tends to be talkative, often interrupting conversations, rather than

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withdrawn in social situations. Talking excessively is a characteristic of impulsivity/hyperactivity. Blurting out the answers to questions before the questions have been

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completed is an indication of the impulse control that is often lacking in children with ADHD. The child with ADHD tends to be talkative, often interrupting conversations, rather than withdrawn in social situations.

DIF: Cognitive Level: Analysis REF: p. 778 OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse working on the pediatric unit should be aware that children admitted with which assessment findings are suggestive of physical child abuse? Select all that apply. a. Bruises in various stages of healing

b. Bruises over the shins or bony prominences c. Burns on the palms of the hands d. A fracture of the right wrist from a sports accident e. Rib fractures in an infant ANS: A, C, E Bruises in various stages of healing and burns on the palms of the hand may be indicative of physical abuse. Rib fractures in an infant are another indicator of physical abuse. Bruises over the shins or bony prominences are seen in children beginning to walk. A fracture of the right

wrist can occur as the child begins to participate in sports activities. DIF: Cognitive Level: Analysis REF: p. 788

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

2. The nurse is aware that suicide risk increases if the child displays which characteristics? Select

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a. Previous suicide attempt

all that apply.

b. No previous exposure to violence in the home

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c. Recent loss

d. Effective social network

e. History of physical abuse

ANS: A, C, E

The risk of suicide increases if the child has had a previous suicide attempt, a recent loss, or a history of physical abuse. No previous violence in the home or having an effective social network decreases the risk of suicide.

Chapter 34: The Dying Child MULTIPLE CHOICE

1.Which of the following are the two major factors in childrens reaction to loss? a. number of siblings and birth orderc. caregiver emotions and reactions b.self-esteem and body image d.age and cognitive development ANS: D

Feedback AIncorrect. The number of siblings and birth order are not the two major factors in childrens reaction to loss. B Incorrect. The self-esteem and body image are not the two major factors in childrens reaction to loss. CIncorrect. The caregiver emotions and reactions are not the two major factors in childrens reaction to loss. DCorrect. Two major factors in childrens reaction to loss are age and cognitive development.

PTS: 1 REF: p. 630 Situations Leading to Loss OBJ: Cognitive Level: Knowledge 2.Young children experience loss, separation, or bereavement in a myriad of situations. These

early experiences:

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a. are almost always totally repressed and of little help to a person b.help shape an individuals ability to cope with loss later in adult life c. determine to a large extent whether a person will experience situational depression later d.cloud ones ability to think clearly and logically about similar experiences as an adult

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ANS: B

Feedback AIncorrect. Childrens early experiences with loss, separation, or bereavement are not always totally repressed and of little help to a person as they age. B Correct. On average, children experience loss, separation, or bereavement through a myriad of situations that are not related to the death of a person. These early experiences are important and help shape an individuals ability to cope with loss later in adult life. CIncorrect. Childrens early experiences with loss, separation, or bereavement do not have to determine to a large extent whether a person will experience situational depression later. DIncorrect. Childrens early experiences with loss, separation, or bereavement do not have to cloud ones ability to think clearly and logically about similar experiences as an adult. PTS: 1 REF: p. 630 Situations Leading to Loss OBJ: Cognitive Level: Knowledge 3.Caregivers may be excited about the family relocating to another city so they can have better jobs and a bigger home. After the move, however, the children will most likely:

a. reflect the excitement modeled by the caregivers and suffer little emotional upset b.do better emotionally than the caregivers, as the children will acclimate to their new surroundings with greater ease c. grieve for the loss of comfortable and familiar people, surroundings, and things left behind d.appreciate the better surroundings and seek new friendships in the neighborhood ANS: C

OBJ: Cognitive Level: Comprehension

PTS:1REF:p. 630 Situations Leading to Loss

Feedback AIncorrect. After relocating to another city, the children will not most likely reflect the excitement modeled by the caregivers and suffer little emotional upset. B Incorrect. After relocating to another city, the children will not most likely do better emotionally than the caregivers, as the children will acclimate to their new surroundings with greater ease. CCorrect. For children, the relocating to another city so they can have better jobs and a bigger home may be seen as a loss of comfortable and familiar things, people and surroundings; moving to a new school or even starting a new grade may trigger feelings of anxiety and loss. DIncorrect. After relocating to another city, the children will not most likely appreciate the better surroundings and seek new friendships in the neighborhood.

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4.Most preschoolers have a favorite toy or belonging that goes with them to the babysitter, the day care, or the health care provider. When the caregivers fail to bring that toy or belonging

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along on an outing, the child will most likely:

a. start to learn how to rely on people for security rather than on objects b.suffer feelings of anxiety associated with loss and separation issues c. be angry with the caregivers for several days or weeks d.reject the toy or belonging then it is next presented ANS: B

Feedback AIncorrect. When the caregivers fail to bring a toy or belonging along on an outing, the child will not start to learn how to rely on people for security rather than on objects, in fact, may feel unable to trust others. B Correct. Children at an early age develop attachments to objects such as a toy and items of clothing. When the caregivers fail to bring that toy or belonging along on an outing, the child will most likely suffer feelings of anxiety associated with loss and separation issues. CIncorrect. When the caregivers fail to bring a toy or belonging along on an outing, the child may not even know they are angry and may not express anger, they may only feel anxious.

DIncorrect. Upon rejoining the toy or belonging, the child will not very likely reject the toy or belonging then it is next presented, instead will be gleefully reunited. PTS:1REF:p. 630 Situations Leading to Loss OBJ: Cognitive Level: Comprehension 5.When a child loses a pet, the way the child feels about the loss will: a. greatly depend on whether the pet died or was lost due to other causes b.depend on the age of the pet and how close the pet was to dying of natural causes c. be associated with how well-liked the pet was by the rest of the family d.be much the same, regardless of how the loss came about or other factors

ANS: D

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Feedback AIncorrect. When a child loses a pet, the way the child feels about the loss will not greatly depend on whether the pet died or was lost due to other causes. B Incorrect. When a child loses a pet, the way the child feels about the loss will not depend on the age of the pet and how close the pet was to dying of natural causes. CIncorrect. When a child loses a pet, the way the child feels about the loss will not be associated with how well-liked the pet was by the rest of the family. DCorrect. Regardless of the cause of the loss of a pet, the way the child feels about the loss will be much the same, no matter how the loss came about or any other factors

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PTS:1REF:p. 631 Situations Leading to Loss OBJ: Cognitive Level: Comprehension

6.A leading cause of separation in families is:

a. military assignmentc. temporary separation b.divorce d.jail or prison time ANS: B Feedback AIncorrect. A military assignment is not a leading cause of separation in families. B Correct. Divorce, an extremely stressful event in the life of a family, is a leading cause of separation experienced by families and children. CIncorrect. A temporary separation is not a leading cause of separation in families. DIncorrect. Jail or prison time is not a leading cause of separation in families.

PTS: 1 REF: p. 631 Situations Leading to Loss OBJ: Cognitive Level: Knowledge 7.A mother shares with the pediatric nurse that her 3-year-old has started thumb sucking and bed-wetting again after about a year of not engaging in these behaviors. The pediatric nurse notices the child clinging to the mother. Based on the childs behaviors, the pediatric nurse would in the assessment phase most need to ask the mother: a. Has there been any loss or change in your lives such as separation, divorce, or relocation? b.Are you rewarding your child whenever she urinates in the potty or does not suck her thumb? c. Has your child been sick or had a contagious disease, fever, diarrhea, or vomiting? d.Has your child been getting enough attention from you in the past few weeks?

ANS: A

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Feedback ACorrect. In regards to divorce, preschoolers sensing conflict tend to feel confused and bewildered. They perceive divorce as one parent leaving. They often assume that this is their fault. They next fear abandonment by the remaining parent, leading to becoming clinging. They may lose any independence recently acquired, may regress to wetting the bed, thumb sucking, even bottle feeding. B Incorrect. Hearing from a mother that her 3-year-old has started thumb sucking and bedwetting again after about a year of not engaging in these behaviors, the pediatric nurse would not most need to ask the mother: Are you rewarding your child whenever she urinates in the potty or does not suck her thumb? CIncorrect. Hearing from a mother that her 3-year-old has started thumb sucking and bedwetting again after about a year of not engaging in these behaviors, the pediatric nurse would not most need to ask the mother: Has your child been sick or had a contagious disease, fever, diarrhea, or vomiting? DIncorrect. Hearing from a mother that her 3-year-old has started thumb sucking and bedwetting again after about a year of not engaging in these behaviors, the pediatric nurse would not most need to ask the mother: Has your child been getting enough attention from you in the past few weeks? PTS:1REF:p. 631 Situations Leading to Loss OBJ: Cognitive Level: Application 8.The nurse is working with a custodial father of a preschooler who has become more aggressive in his play. This preschoolers increase in aggression occurred about the time the caregivers divorced. The nurse will talk to the father about the most probable cause of the escalation in violence, which is:

a. watching more television after the divorce b.a decrease in the gentle influence of the mother c. confusion and acting out feelings of confusion d.an increase in the more masculine influence of the father ANS: C

Feedback AIncorrect. Asking about the preschoolers increase in aggression, the nurse would not most likely talk to the father about linking the escalation in violence to watching more television after the divorce. B Incorrect. Asking about the preschoolers increase in aggression, the nurse would not most likely talk to the father about linking the escalation in violence to a decrease in the gentle influence of the mother. CCorrect. Preschoolers may experience nightmares or sleep disturbances and their play may become more aggressive as they attempt to act out their feelings of confusion during the time of a divorce. DIncorrect. Asking about the preschoolers increase in aggression, the nurse would not most likely talk to the father about linking the escalation in violence to an increase in the more masculine influence of the father.

PTS:1REF:p. 632 Situations Leading to Loss

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OBJ: Cognitive Level: Comprehension

9.A mother is talking with the school nurse about her school-aged child, who thinks up reasons for her mother to meet with her ex-husband, the childs father. The child even acts out then

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visiting with the father so the mother will come and talk with the father. When something breaks in the mothers home, the child says, Dad could fix this. The nurse talks to the mother about a

common theme with school-aged children, which is:

a. the mother will be carried away by an evil person and the child needs help to keep her b.a fantasy that the caregivers will reunite and efforts to make this fantasy come true c. only the biological parents can fulfill the emotional needs of the children d.the mother is sad and only the father can fix the sadness that the mother is experiencing ANS: B Feedback AIncorrect. Discussing the school-aged child of a divorce with the mother, the nurse will not identify as a common theme that the mother will be carried away by an evil person and the child needs help to keep her.

B Correct. The school-aged child may have fantasies of reunification of parents and family, and may lie in an attempt to make this fantasy come true. CIncorrect. Discussing the school-aged child of a divorce with the mother, the nurse will not identify as a common theme that only the biological parents can fulfill the emotional needs of the children. DIncorrect. Discussing the school-aged child of a divorce with the mother, the nurse will not identify as a common theme that the mother is sad and only the father can fix the sadness that the mother is experiencing. PTS:1REF:p. 632 Situations Leading to Loss OBJ: Cognitive Level: Comprehension

10.Which of the following best describes the term parentification?

a. raising the caregivers up onto a pedestal b.assuming the caregiver (parental) role c. believing ones caregivers can do nothing right d.holding onto caregivers out of a fear of abandonment ANS: B

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Feedback AIncorrect. Parentification is not best described as raising the caregivers up onto a pedestal. B Correct. Parentification, the role of assuming the caregiver (parent) role, is common among older school-age children (9-12 years). These children of divorce may experience conflicts with loyalty and also exhibit outbursts of anger toward either or both parents. Parentification is also common in the adolescent group. CIncorrect. Parentification is not best described as believing ones caregivers can do nothing right. DIncorrect. Parentification is not best described as holding onto caregivers out of a fear of abandonment.

PTS:1REF:p. 632 Childrens Awareness of Death OBJ: Cognitive Level: Knowledge 11.The school nurse is working with a group of school-aged children whose caregivers are in the process of divorcing or who have recently divorced. Which of the following topics will be most important for this age group to explore? a. which of their caregivers is at fault in the breakdown of relationships in the family b.how they would like the custody battles to be resolved and who they would like to live with

c. the impact of the divorce on understanding the day-to-day schoolwork d.feelings of guilt, believing their caregivers emotional distress is related to how they behaved ANS: D

Feedback AIncorrect. Working with a group of school-aged children whose caregivers are in the process of divorcing or who have recently divorced, the school nurse would not select as the most important topic for this age group to explore: which of their caregivers is at fault in the breakdown of relationships in the family. B Incorrect. Working with a group of school-aged children whose caregivers are in the process of divorcing or who have recently divorced, the school nurse would not select as the most important topic for this age group to explore: how they would like the custody battles to be resolved and who they would like to live with. CIncorrect. Working with a group of school-aged children whose caregivers are in the process of divorcing or who have recently divorced, the school nurse would not select as the most important topic for this age group to explore: the impact of the divorce on understanding the day-to-day schoolwork. DCorrect. School-age children (9-12 years) may believe their parents emotional distress is related to how they have been behaving and can perceive the divorce as a rejection of themselves, resulting in feelings of guilt.

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PTS:1REF:p. 632 Loss and Bereavement

12.Parentification is common in children and adolescents who are 9 years old or older and is

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especially common in which of the following circumstances?

a. then daily activities of the home are neglected b.then the caregivers are very authoritarian c. during the holiday season d.then there are several older siblings ANS: A

Feedback ACorrect. Parentification is common in children and adolescents who are 9 years old or older and is especially common then daily activities of the home are neglected. B Incorrect. Parentification is common in children and adolescents who are 9 years old or older but does not become more or less common then the caregivers are very authoritarian. CIncorrect. Parentification is common in children and adolescents who are 9 years old or older but is not especially common during the holiday season, it is not seasonal.

DIncorrect. Parentification is common in children and adolescents who are 9 years old or older but not especially common then there are several older siblings. PTS:1REF:p. 632 Situations Leading to Loss OBJ: Cognitive Level: Comprehension 13.A school nurse notices that one of the adolescents has begun spending a lot of time and energy at school, volunteering for projects and doing extra work. The nurse knows that often then adolescents begin to spend all their energies in school activities, they are doing so because they want to:

a. get good recommendations from teachers for entering college b.avoid thinking about a difficult or troubling situation at home c. get praise from teachers and peers for a job well done d.do things for others in an altruistic period of their life

ANS: B

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Feedback AIncorrect. The nurse knows that often then adolescents begin to spend all their energies in school activities, they are not doing so simply because they want to get good recommendations from teachers for entering college. B Correct. For some adolescents, school may become a refuge from turmoil at home, and they spend all their energies in school activities to avoid thinking about the situation at home. CIncorrect. The nurse knows that often then adolescents begin to spend all their energies in school activities, they are not doing so simply because they want to get praise from teachers and peers for a job well done. DIncorrect. The nurse knows that often then adolescents begin to spend all their energies in school activities, they are not doing so simply because they want to do things for others in an altruistic period of their life.

PTS:1REF:p. 632 Childrens Awareness of Death OBJ: Cognitive Level: Comprehension 14.You are the nurse working with a 4-year-old child who was injured in an automobile accident in which the childs mother was killed. From your knowledge of children and how they view death, you will suspect that this child will view the death of the mother from which of the following ideas of death?

a. universal c. nonfunctional b.temporaryd.causal ANS: B

Feedback AIncorrect. Working with a 4-year-old child who was injured in an automobile accident in which the childs mother was killed, you will suspect that this child will view the death of the mother as temporary and reversible. A 4-year-old child lives in a concrete world view, and cannot comprehend an abstraction such as the universality of death. B Correct. Younger children are more likely than older children to state death is not universal, is avoidable, and occurs in the remote future. In essence, death is temporary and reversible. CIncorrect. Working with a 4-year-old child who was injured in an automobile accident in which the childs mother was killed, you will suspect that this child will view the death of the mother as temporary and reversible. A 4-year-old child lives in a concrete world view, and cannot comprehend an abstraction such as nonfunctionality. DIncorrect. Working with a 4-year-old child who was injured in an automobile accident in which the childs mother was killed, you will suspect that this child will view the death of the mother as temporary and reversible. A 4-year-old child lives in a concrete world view, and cannot comprehend an abstraction such as the causality of death.

PTS:1REF:p. 632 Childrens Awareness of Death

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OBJ: Cognitive Level: Comprehension

15.A caregiver asks the nurse for advice on how to explain the death of a grandfather to a 5-yearold child. The nurse shares with the caregiver that children of this age look at death differently

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than adults do and that children would best understand and benefit from the explanation:

ANS: C

a. Your grandfather has gone to rest. c. His body and his heart fore out. b.Your grandfather worked too hard.d.He has gone to a much better place.

Feedback AIncorrect. Providing advice to a caregiver about how best to explain the death of a grandfather to a 5-year-old child, the nurse shares with the caregiver that children of this age look at death differently than adults do, and would suggest the avoidance of abstractions such as: Your grandfather has gone to rest. So then is the nap over. B Incorrect. Providing advice to a caregiver about how best to explain the death of a grandfather to a 5-year-old child, the nurse shares with the caregiver that children of this age look at death differently than adults do, and would suggest the avoidance of abstractions such as: Your grandfather worked too hard.

CCorrect. By the age of 5, childrens definition of death is more focused on function. People die then they are unable to breathe, eat, talk, and walk. This reflects Piagets second stage of cognitive development, or the preoperational stage, and reflects egocentricity and tangible, concrete thinking. The grandfather died because he could not breathe, eat, talk and walk. DIncorrect. Providing advice to a caregiver about how best to explain the death of a grandfather to a 5-year-old child, the nurse shares with the caregiver that children of this age look at death differently than adults do, and would suggest the avoidance of abstractions such as: He has gone to a much better place. PTS:1REF:p. 632 Childrens Awareness of Death OBJ: Cognitive Level: Application 16.A father is concerned that his 14-year-old son is engaging in high-risk behavior by inline-

skating in traffic. He is afraid the son will kill himself accidentally. The nurse explains that this behavior in adolescents is believed to be due to which of the following attitudes?

a. underlying suicidal wishc. belief that death wont happen to me b.need for attention d.need to excel in some skill or activity

ANS: C

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Feedback AIncorrect. Explaining the high-risk behavior of inline-skating in traffic to the father of a 14year-old son, the nurse does not explain that this behavior in adolescents is believed to be due to an underlying suicidal wish. B Incorrect. Explaining the high-risk behavior of inline-skating in traffic to the father of a 14year-old son, the nurse does not explain that this behavior in adolescents is believed to be due to a need for attention. CCorrect. Although the adolescent is capable of understanding and conceptualizing death as permanent and universal, often there is an exclusion of the self from this concept. In other words, there is the notion it wont happen to me. DIncorrect. Explaining the high-risk behavior of inline-skating in traffic to the father of a 14year-old son, the nurse does not explain that this behavior in adolescents is believed to be due to a need to excel in some skill or activity. PTS:1REF:p. 633 Childrens Awareness of Death OBJ: Cognitive Level: Application

17.The school nurse becomes aware that a student has experienced the loss of a family member and is returning to school after a few days absence. The best action on the part of the nurse is to plan with other members of the school team for: a. opportunities for this student to talk about her feelings and to have supportive counseling b.making sure the student gets to spend lots of time with peers at school and out of school c. psychological testing of the student to see what impact the death had on her d.the teachers to reduce the homework assignments to about half that of other students ANS: A

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Feedback ACorrect. Becoming aware that a student has experienced the loss of a family member and is returning to school after a few days absence, the best action on the part of the school nurse is to plan with other members of the school team to provide opportunities for this student to talk about her feelings and to have supportive counseling. B Incorrect. Becoming aware that a student has experienced the loss of a family member and is returning to school after a few days absence, the best action on the part of the school nurse is not to make sure the student gets to spend lots of time with peers at school and out of school. CIncorrect. Becoming aware that a student has experienced the loss of a family member and is returning to school after a few days absence, the best action on the part of the school nurse is not to make available psychological testing of the student to see what impact the death had on her. DIncorrect. Becoming aware that a student has experienced the loss of a family member and is returning to school after a few days absence, the best action on the part of the school nurse is to not to make sure the teachers reduce the homework assignments to about half that of other students. PTS:1REF:p. 632 Childrens Awareness of Death

OBJ: Cognitive Level: Application

18.In working with children and families who have experienced a loss of a family member, the nurse keeps in mind: a. people experiencing a loss follow a predictable pattern in terms of grief and bereavement b.individuals who have a mental illness themselves, or in the family, will grieve differently c. each persons response to a loss is different and each persons bereavement is different d.people who are close to the grieving person can often predict their grieving pattern ANS: C Feedback

AIncorrect. In working with children and families who have experienced a loss of a family member, the nurse realizes that people experiencing a loss do not follow a predictable pattern in terms of grief and bereavement. B Incorrect. In working with children and families who have experienced a loss of a family member, the nurse is not most attuned to mental illness and the grieving process. CCorrect. One can describe grief as the reaction an individual has to a loss, and bereavement as the behaviors one exhibits after the loss. Each persons response is different; therefore, each persons bereavement will be different. DIncorrect. In working with children and families who have experienced a loss of a family member, the nurse keeps in mind that grief and bereavement is individual and largely unpredictable. PTS:1REF:p. 634 Childrens Awareness of Death

OBJ: Cognitive Level: Comprehension

a. an individuals reaction to a loss b.an adaptation to a loss c. the process from the loss to the adaptation d.a time of shock and disbelief

19.Which of the following best defines the term grieving?

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ANS: A

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Feedback ACorrect. An individuals reaction to a loss best defines the term grieving. B Incorrect. An adaptation to a loss does not best define the term grieving. CIncorrect. The process from the loss to the adaptation does not best define the term grieving. DIncorrect. A time of shock and disbelief does not best define the term grieving.

PTS:1REF:p. 634 Childrens Awareness of Death OBJ: Cognitive Level: Knowledge 20.According to Kubler-Ross, the first stage of the grieving process is: a. denialc. bargaining b.anger d.depression ANS: A Feedback

ACorrect. Kubler-Ross identified five distinct stages of the grieving process: 1) denial; 2) anger; 3) bargaining; 4) depression; 5) acceptance. The first stage is denial. B Incorrect. Anger is Kubler-Rosss second stage of the grieving process. CIncorrect. Bargaining is Kubler-Rosss third stage of the grieving process. DIncorrect. Depression is Kubler-Rosss fourth stage of the grieving process. PTS:1REF:p. 634 Childrens Awareness of Death OBJ: Cognitive Level: Knowledge 21.According to Kubler-Ross, the last stage of the grieving process is called:

a. anger resolutionc. acceptance b.mood norming d.final peace ANS: C

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Feedback AIncorrect. According to Kubler-Ross, the last stage of the grieving process is not called anger resolution. B Incorrect. According to Kubler-Ross, the last stage of the grieving process is not called mood norming. CCorrect. According to Kubler-Ross, the last stage of the grieving process is called acceptance. DIncorrect. According to Kubler-Ross, the last stage of the grieving process is not called final peace.

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PTS: 1 REF: p. 634 Grief and Bereavement OBJ: Cognitive Level: Knowledge 22.The nurse is working with a family going through a divorce. The mother tells the nurse how good her young son has been in washing windows and doing household chores. The nurse

realizes that this child is most likely:

a. in denial c. depressed b.bargainingd.angry ANS: B Feedback AIncorrect. Working with a family going through a divorce, the nurse realizes that the young son who has been washing windows and doing household chores is not most likely in denial. B Correct. Bargaining is seen at a time then there is an impending loss, such as death, loss of good health, an appendage, even a way of life. Bargaining is an attempt to postpone the occurrence of the event, in this case by being extra good to his mom.

CIncorrect. Working with a family going through a divorce, the nurse realizes that the young son who has been washing windows and doing household chores is not most likely depressed. DIncorrect. Working with a family going through a divorce, the nurse realizes that the young son who has been washing windows and doing household chores is not most likely angry. PTS:1REF:p. 634 Grief and Bereavement OBJ: Cognitive Level: Application 23.Which of the following statements by a child would indicate her acceptance of a mothers death?

a. She is taking a long nap. c. God is not very loving. b.I am going to be a good girl. d.My mother is in heaven. ANS: D

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Feedback AIncorrect. She is taking a long nap indicates denial, early in the grieving process, and a long way from acceptance. B Incorrect. I am going to be a good girl indicates bargaining, a hope to change the outcome, on the path to acceptance. CIncorrect. God is not very loving indicates a residual anger, on the path to acceptance. DCorrect. My mother is in heaven indicates complete acceptance of a mothers death by a child. It indicates the griever is consciously aware of what has happened and the finality of death.

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PTS:1REF:p. 632 Loss and Bereavement OBJ: Cognitive Level: Application

must:

24.According to Wordens four tasks of mourning, before children can deal with the loss, they

a. be at least 6 years old b.be able to do abstract thinking c. have at least one close relative, adult, or friend to talk to d.believe the deceased person is dead and will not return to life ANS: D Feedback

AIncorrect. According to Wordens four tasks of mourning, before children can deal with the loss, they must be told about the death in appropriate age-related language, and does not say they must be at least 6 years old. B Incorrect. According to Wordens four tasks of mourning, before children can deal with the loss, they must be told about the death in appropriate age-related language, and does not say they must be able to do abstract thinking. CIncorrect. According to Wordens four tasks of mourning, before children can deal with the loss, they must be told about the death in appropriate age-related language, and does not say they must have at least one close relative, adult, or friend to talk to. DCorrect. Worden suggests that before children can deal with the loss of a death, they must believe the deceased is dead and will not return to life. PTS:1REF:p. 634 Grief and Bereavement

OBJ: Cognitive Level: Comprehension

a. the childs intelligence quotient b.how verbal the child is c. observations of the adults experiences of loss d.emotional maturity

25.A childs ability to process the pain of loss will depend most on:

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ANS: C

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Feedback AIncorrect. Worden does not conclude that a childs ability to process the pain of loss will depend most on the childs intelligence quotient. B Incorrect. Worden does not conclude that a childs ability to process the pain of loss will depend most on how verbal the child is. CCorrect. Wordens second task of mourning, to experience the pain or emotional aspects of the loss, requires to behaviors and feelings of the child to be recognized and acknowledged. A childs ability to process the pain of loss will be influenced by observing an adults experience of the loss. DIncorrect. Worden does not conclude that a childs ability to process the pain of loss will depend most on emotional maturity. PTS:1REF:p. 634 Childrens Responses to Death OBJ: Cognitive Level: Comprehension

26.You are the nurse working with a child whose grandparent died. When the child has completed the first three tasks of mourning according to Worden and is ready to work on the fourth task, you would most help him by: a. keeping the child busy so he doesnt have time to think about his loss b.reminding the child that the grandparent is not returning to life c. keeping the child focused on the family members he has left in his life d.helping the child make a scrapbook or write a poem about the grandparent ANS: D

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Feedback AIncorrect. Working with a child whose grandparent has died, then the child has completed the first three tasks of mourning according to Worden and is ready to work on the fourth task, you would not most help him by keeping the child busy so he doesnt have time to think about his loss. B Incorrect. Working with a child whose grandparent has died, then the child has completed the first three tasks of mourning according to Worden and is ready to work on the fourth task, you would not most help him reminding the child that the grandparent is not returning to life. CIncorrect. Working with a child whose grandparent has died, then the child has completed the first three tasks of mourning according to Worden and is ready to work on the fourth task, you would not most help him by keeping the child focused on the family members he has left in his life. DCorrect. Working with a child whose grandparent has died, then the child has completed the first three tasks of mourning according to Worden and is ready to work on the fourth task, you would most help him by helping the child make a scrapbook or write a poem about the grandparent. The fourth task of mourning involves finding a new and appropriate place for the deceased in ones emotional life, i.e., finding ways to memorialize the person. PTS:1REF:p. 635 Childrens Responses to Death

OBJ: Cognitive Level: Application 27.Caregivers share with the school nurse that their child, who was so depressed and upset for a month by the death of a grandparent, is now engaging in all his old activities, laughing and enjoying life, and acting as if nothing ever happened. The nurse will tell the caregivers that the most likely explanation for this change in behavior is that: a. Children do not grieve the same as adults, and this is probably normal. b.The child received a lot of attention for the depressed behavior and has gotten enough attention. c. Children are very resilient, and your child is more so than most.

d.Your child is just in an emotional plateau and resting from the depression. ANS: A

Feedback ACorrect. Children may have long periods then they are overcome with grief which is then followed by an interval then they do not seem to be affected by the loss. Nurses must help grieving caregivers understand the childs behavior is a normal process of grieving since children do not grieve the same as adults. B Incorrect. In explaining to the caregiver the deep depression followed by a return to life as if no death had occurred, the nurse will not tell the parent that the child was only seeking attention, but that this is normal for children. CIncorrect. In explaining to the caregiver the deep depression followed by a return to life as if no death had occurred, the nurse will not tell the parent that children are resilient as though they do not grieve, but that this is normal for children. DIncorrect. In explaining to the caregiver the deep depression followed by a return to life as if no death had occurred, the nurse will not tell the parent that the child is just in an emotional plateau and resting from the depression, but that this is normal for children.

OBJ: Cognitive Level: Application

PTS:1REF:p. 635 Childrens Responses to Death

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28.A school-aged child reacted very little to the death of an older brother who had lived away from the family for several years and yet seemed overcome with grief at the death of an elderly lady who was her babysitter. The most logical and likely explanation for this difference in the

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amount of observable grief is which of the following?

a. She is hiding the grief for her brother because it is so painful. b.There was a closer relationship with the babysitter than with the brother. c. This child values the elderly more than she does younger people. d.She was mad at her brother for being so uncaring as to die. ANS: B

Feedback AIncorrect. Having been overcome with grief at the death of an elderly lady who was her babysitter, the most likely explanation for reacting very little to the death of an older brother is not that she is hiding the grief for her brother because it is so painful. B Correct. A major factor influencing how children react to grief is the relationship with the deceased. For example, a child may have little reaction to the death of an older sibling where there has been little contact or interaction, yet may react significantly to the loss of the afterschool care provider.

CIncorrect. Having been overcome with grief at the death of an elderly lady who was her babysitter, the most likely explanation for reacting very little to the death of an older brother is not that this child values the elderly more than she does younger people. DIncorrect. Having been overcome with grief at the death of an elderly lady who was her babysitter, the most likely explanation for reacting very little to the death of an older brother is not that she was mad at her brother for being so uncaring as to die. PTS:1 REF: p. 635 Reactions of Family to a Child with a Life-Threatening or Terminal Illness OBJ: Cognitive Level: Application

29.A school-aged childs great-uncle dies, and the child expresses a desire to go to the funeral. The best action on the part of the caregivers is most often to:

a. have the child stay at home with a relative b.send the child to school as usual c. include the child in appropriate activities related to the funeral and burial d.call all the other caregivers and see if anyone else is taking their child

ANS: C

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Feedback AIncorrect. The school-aged child having expressed a desire to go to the funeral, the best action on the part of the caregivers is not to have the child stay at home with a relative. B Incorrect. The school-aged child having expressed a desire to go to the funeral, the best action on the part of the caregivers is not to send the child to school as usual. CCorrect. Children should be included in activities related to funeral and burial rites then appropriate. DIncorrect. The school-aged child having expressed a desire to go to the funeral, the best action on the part of the caregivers is not to call all the other caregivers and see if anyone else is taking their child. PTS:1REF:p. 638 Disasters or Traumatic Events OBJ: Cognitive Level: Application 30.A caregiver talks with the nurse about how badly her surviving child has behaved after the death of a sibling. Which of the following statements by the nurse would most likely be true? a. When children have a tendency to misbehave, it gets worse during a crisis.

b.Children always misbehave to an extreme degree after the death of a sibling. c. The closer the relationship was between siblings before the death of one, the more behavior problems the surviving siblings demonstrate afterward. d.You probably were distracted by all that was going on during this crisis and did not discipline this child as much as you normally would have, so the child misbehaved. ANS: C

Feedback AIncorrect. After a caregiver tells the nurse about how badly her surviving child has behaved after the death of a sibling, the nurse would not most likely state as absolutely true: When children have a tendency to misbehave, it gets worse during a crisis. B Incorrect. After a caregiver tells the nurse about how badly her surviving child has behaved after the death of a sibling, the nurse would not most likely state as absolutely true: Children always misbehave to an extreme degree after the death of a sibling. CCorrect. The closer the relationship was before death, the more behavior problems the surviving siblings demonstrate afterward. DIncorrect. After a caregiver tells the nurse about how badly her surviving child has behaved after the death of a sibling, the nurse would not most likely state as absolutely true: You probably were distracted by all that was going on during this crisis and did not discipline this child as much as you normally would have, so the child misbehaved.

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PTS:1REF:p. 638 Childrens Responses to Death

31.When a child in a family dies, the most neglected member of the family during the grieving

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process is usually the:

ANS: D

a. motherc. grandparents b.father d.siblings

Feedback AIncorrect. When a child in a family dies, the most neglected member of the family during the grieving process is not usually the mother. B Incorrect. When a child in a family dies, the most neglected member of the family during the grieving process is not usually the father. CIncorrect. When a child in a family dies, the most neglected member of the family during the grieving process is not usually the grandparents. DCorrect. It is important for nurses to understand because grieving parents may be emotionally unavailable to surviving children and because support is generally directed toward parents, siblings are often the most neglected family members then a child dies.

PTS:1 REF: p. 638 Reactions of Family to a Child with a Life-Threatening or Terminal Illness OBJ: Cognitive Level: Comprehension 32.You are assigned to care for a young adolescent who is in the terminal stage of an illness. This early adolescent says to you: I dont want to die. What would be your best response?

a. You may not die, as miracles do sometimes happen. b.Tell me more about what you are thinking. c. I dont want you to die either. d.Why do you think you might die? ANS: B

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Feedback AIncorrect. In response to the youths comment, You may not die, as miracles do sometimes happen, trivializes his heartfelt expression, and would not be your best response. B Correct. Do not trivialize the youths comment, or deflect it, instead engage the issue in a matter of fact way. The best response would be something along the lines of, Tell me more about what you are thinking. CIncorrect. In response to the youths comment, I dont want you to die either, is already taken for granted, but does not engage the adolescents heartfelt expression. DIncorrect. In response to the youths comment, Why do you think you might die? is better than some responses, but engages indirectly the adolescents heartfelt expression.

REF: p. 644 Reactions of Family to a Child with a Life-Threatening or Terminal Illness

Chapter 35: The Child with a Sensory/Neurologic Disorder MULTIPLE CHOICE 1. A parent comments that her infant has had several ear infections in the past few months. The nurse understands that infants are more susceptible to otitis media because: a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure.

c. They have increased susceptibility to upper respiratory tract infections. d. The eustachian tube is short, straight, and wide. ANS: D An infants eustachian tubes are shorter, wider, and straighter, allowing microorganisms easy access to the middle ear. DIF: Cognitive Level: Knowledge REF: 511 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse determines a mother understands instructions about administering an oral antibiotic

for otitis media when the mother verbalizes that she will:

a. Continue using the medication until symptoms are relieved.

b. Share the medicine with siblings if their symptoms are the same.

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c. Give the medication with a glass of milk.

ANS: D

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d. Administer prescribed doses until all the medication is used.

Antibiotic therapy for otitis media is continued until the prescribed amount has been completed,

even if symptoms are alleviated.

DIF: Cognitive Level: Application REF: 522 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. The situation in which the nurse would be suspicious about a hearing impairment is: a. A 3-month-old infant with a positive Moro reflex

b. A 15-month-old toddler who is babbling c. An 18-month-old toddler who is speaking one-syllable words d. A 24-month-old toddler who communicates by pointing ANS: D The child who is not making verbal attempts by 18 months should undergo a complete physical examination. DIF: Cognitive Level: Analysis REF: 523 OBJ: 3

TOP: Hearing Impairment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The best way for the nurse to communicate with a 10-year-old child who has a hearing

impairment would be to:

a. Use gestures and signs as much as possible.

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b. Let the childs parents communicate for her.

c. Face the child and speak clearly in short sentences.

ANS: C

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d. Recognize that the childs ability to communicate will be on a 6-year-old level.

The nurse who faces the child and speaks clearly will help the hearing-impaired child in the

hospital to develop a healthy personality. DIF: Cognitive Level: Application REF: 523 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. The nurse planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes would include:

a. Keep the infant flat after feeding. b. Give over-the-counter anticongestants. c. Avoid getting water in the ears. d. Clean the ear canal with cotton-tipped applicators. ANS: C Following a tympanostomy, care should be taken to avoid getting water in the ears. DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2

TOP: Postoperative Care of Tympanostomy

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk

6. The school nurse would suspect amblyopia when the child:

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a. Has a reddened sclera in one eye

b. Covers one eye to read the board c. Complains of a headache

ANS: B

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d. Has copious tears while watching TV

Indicators of amblyopia include covering one eye to see, tilting the head to see, missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, it is too vague to point suspicion to any disorder. DIF: Cognitive Level: Analysis REF: 526 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. The nurse explains that a common treatment for amblyopia is: a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractory muscles to rest c. Using glasses that will slightly blur the image for the good eye d. Using corticosteroids to treat inflammation of the optic nerve ANS: A Early detection and treatment are essential for the child with amblyopia. Treatment includes

DIF: Cognitive Level: Knowledge REF: 526 OBJ: 4

TOP: Amblyopia KEY: Nursing Process Step: N/A

patching the good eye and using glasses to correct refractive errors.

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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a. Opacity of the lens

8. The school nurse recognizes the cardinal sign of a hyphema when she assesses:

b. A yellow-white reflex on the pupil

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c. A dark-red spot in front of the iris

ANS: C

d. Inflamed mucous membranes of the eyelids

A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury. DIF: Cognitive Level: Knowledge REF: 527 OBJ: N/A TOP: Retinoblastoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parents to have their children immunized against Reyes syndrome. c. Avoid giving salicylate-containing medications to a child who has viral symptoms. d. Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy.

ANS: C Prevention of Reyes syndrome includes educating parents not to give aspirin-containing

medication to children with viral symptoms.

DIF: Cognitive Level: Application REF: 529 OBJ: 11

TOP: Reyes Syndrome KEY: Nursing Process Step: Planning

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The nurse caring for a 5-month-old with viral influenza suspects the development of Reyes

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syndrome when the child:

a. Has respirations drop from 18 to 14 breaths/min

b. Goes to sleep after feeding

c. Suddenly vomits

d. Develops a macular rash ANS: C A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in LOC. A 5-month-old child that sleeps after eating is normal. DIF: Cognitive Level: Application REF: 529 OBJ: 11

TOP: Reyes Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. The nurse explains that febrile seizures: a. Occur when the body temperature exceeds 103F b. Can be prevented by anticonvulsant medication c. Usually lead to the development of epilepsy d. Occur when the temperature rises quickly

ANS: D

Febrile seizures occur in response to a rapid rise in temperature, often above 102F (38.8C).

DIF: Cognitive Level: Comprehension REF: 533 OBJ: 9

TOP: Febrile Seizures KEY: Nursing Process Step: N/A

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A parent reports that her child experiences episodes where he appears to be staring into

a. Absence

b. Akinetic

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space. This behavior is characteristic of which type of seizure?

c. Myoclonic

d. Complex partial ANS: A Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and which may last only a few seconds. DIF: Cognitive Level: Analysis REF: 534, Table 23-2

OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. An adolescent has just had a generalized seizure lasting 1 minute. Following the seizure, the nurse should: a. Help the patient to sit upright b. Turn on the side c. Offer ice chips

d. Assist to ambulate ANS: B

During the tonic phase of a generalized seizure, the head, legs, and back stiffen.

DIF: Cognitive Level: Analysis REF: 534, Table 23-2

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OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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14. When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing action would be to:

a. Guide the child to the floor if the child is standing, and then go for help.

b. Move objects out of the childs immediate area. c. Stick a padded tongue blade between the childs teeth. d. Manually restrain the child. ANS: B During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury. DIF: Cognitive Level: Application REF: 534, Table 23-2

OBJ: 9 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 15. A child had a generalized tonic-clonic seizure that lasted 90 seconds. After a generalized tonic-clonic seizure, the nurse would expect that the child might be: a. Restless b. Sleepy c. Nauseated

d. Anxious ANS: B

Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep

for a time (postictal lethargy) and then return to full consciousness.

DIF: Cognitive Level: Analysis REF: 535 OBJ: 9

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TOP: Epilepsy KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The nurse would include in a teaching plan pertinent to the long-term administration of

Dilantin that:

a. The medication should be given with food to reduce gastrointestinal distress.

b. Behavioral changes are a possible side effect. c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored. ANS: C Dilantin can cause gum overgrowth, which can be minimized by regular massaging. DIF: Cognitive Level: Application REF: 536 OBJ: 9

TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic

d. Mixed

ANS: C

Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

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DIF: Cognitive Level: Analysis REF: 536 OBJ: 10

TOP: Cerebral Palsy KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The assessment finding that should be reported immediately if observed in a child with

meningitis is:

a. Irregular respirations b. Tachycardia

c. Slight drop in blood pressure d. Elevated temperature ANS: A

Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure. DIF: Cognitive Level: Analysis REF: 530 OBJ: 15 TOP: Meningitis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. The nurse recognizes this posture as:

a. Correct anatomical position b. Decorticate

c. Decerebrate

d. Opisthotonos

ANS: C

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In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.

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DIF: Cognitive Level: Analysis REF: 542 OBJ: 14

TOP: Posturing KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse giving instructions for acute conjunctivitis would teach parents to: a. Apply cool compresses to the affected eye several times a day. b. Instill topical steroid eye drops for 1 week. c. Clear away drainage from the inner to the outer aspect of the eye. d. Keep the eye patched until the inflammation resolves. ANS: C

Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction). DIF: Cognitive Level: Application REF: 526 OBJ: N/A TOP: Conjunctivitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. A child is brought to the emergency department after he fell and hit his head on the ground. The nursing assessment that suggests the child has a concussion is:

a. Sleepy but easily arousable b. Complaining of a stiff neck

c. Cannot remember what happened to him

d. Pupils react sluggishly to light

ANS: C

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A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred

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immediately before, during, or after the injury. DIF: Cognitive Level: Analysis REF: 543 OBJ: N/A

TOP: Head Injury KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches that are worse in the morning with vomiting. The nurse would suspect: a. Meningitis b. Reyes syndrome

c. Brain tumor d. Encephalitis ANS: C The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased ICP with the hallmark symptoms of headache, vomiting, drowsiness, and seizures. DIF: Cognitive Level: Analysis REF: 532 OBJ: 15 TOP: Brain Tumor KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

1. The pediatric nurse is alerted to the probability of an ear infection in a 6-month-old child when

the baby:

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Select all that apply. a. Is hypersensitive to noise

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b. Is irritable

c. Has a reddened ear canal

d. Rolls head from side to side

e. Spikes a temperature of 103F ANS: B, D, E

Infants signal ear infections by being irritable, spiking a temperature, rolling their heads from side to side, and pulling at or rubbing their ears. DIF: Cognitive Level: Application REF: 521 OBJ: 2 TOP: Indications of Ear Infection KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse cautions parents that hearing impairment can affect the childs: Select all that apply. a. Speech clarity b. Language development c. Emotional stability d. Personality development

e. Academic achievement ANS: A, B, C, D, E

All the options are areas in which a hearing impairment could interfere with normal

development.

DIF: Cognitive Level: Comprehension REF: 522 OBJ: 2

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TOP: Hearing Impairment KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse, preparing air travel instructions to prevent barotraumas in infants, would include:

Select all that apply.

a. Using ear plugs during takeoff b. Holding baby upright during flight c. Omitting the meal just before takeoff d. Letting the baby nurse during descent e. Applying ear drops before takeoff ANS: D

Encouraging an infant to swallow reduces the pressure in the ears during descent. DIF: Cognitive Level: Comprehension REF: 524 OBJ: 2 TOP: Barotrauma KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse caring for a child with infectious meningitis, would include in the care: Select all that apply.

b. Provision of dimly lit room

c. Observation for increasing intracranial pressure d. Preparation for spinal tap

e. Seizure precautions

a. Isolation precautions

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ANS: A, B, C, D, E

All elements of nursing care listed in the options would be part of comprehensive care of a child

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with meningitis.

Chapter 36: The Child with a Respiratory Disorder

MULTIPLE CHOICE

1. The nurse tells the parents of a child who has a positive throat culture for group A hemolytic streptococcus that the treatment most likely will be: a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until his sore throat is gone d. Streptococcus immunization

ANS: B When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished. DIF: Cognitive Level: Application REF: 575 OBJ: 27 TOP: Acute Pharyngitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. The initial intervention that the nurse would suggest to the parents of a child experiencing

laryngeal spasm is to: a. Take the child outside in the cool air.

b. Bring the child directly to the emergency department.

c. Put the child in the bathroom with a hot shower running.

d. Have the child drink plenty of fluids.

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ANS: C

The child experiencing laryngeal spasm should be placed in a high-humidity environment such

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as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.

DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 576

OBJ: 8 TOP: Croup Syndromes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse would observe a child for frequent swallowing following a tonsillectomy and adenoidectomy (T & A) because this is indicative of: a. Bleeding from the surgical site

b. Pain at the incision area c. Sore throat from postnasal drip d. Potential vomiting ANS: A Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing. DIF: Cognitive Level: Comprehension REF: 579 OBJ: 19

TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk

4. The best choice for fluid replacement that the nurse can offer a child who has just had a

tonsillectomy is:

a. Popsicle

c. Orange juice

ANS: A

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d. Cola drink

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b. Chocolate milk

Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as

irritating as natural juices. A popsicle is usually well-tolerated. DIF: Cognitive Level: Analysis REF: 581 OBJ: 19 TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. The 4-month-old child in the emergency department shows extreme dyspnea, a croaking inspiration, and excessive drooling. Based on these observations alone, the nurses initial intervention would be to: a. Sit the child upright and notify the physician. b. Start oxygen by mask and keep the child flat. c. Apply a cold compress to the throat. d. Assess the back of the throat for obstruction. ANS: A

These are the classic signs of epiglottitis. If epiglottitis is suspected, the nurse should not examine the back of the throat because laryngospasm may occur followed by respiratory arrest.

The child should be made as comfortable as possible and the physician should be summoned.

Epiglottitis is a medical emergency.

DIF: Cognitive Level: Analysis REF: 576 OBJ: 12

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TOP: Epiglottitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

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6. The nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, would expect to find:

a. Fine crackles

b. Coarse rhonchi

c. Expiratory wheezing d. Decreased breath sounds at lung bases ANS: C The child experiencing an acute asthma attack will wheeze as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced.

DIF: Cognitive Level: Knowledge REF: 582 OBJ: 13, 14 TOP: Asthma KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse caring for a child experiencing an acute asthma attack would include: a. Offering plenty of fluids, particularly carbonated beverages b. Placing the child in a humidified cool mist tent with oxygen c. Administering sedatives as ordered to decrease anxiety

d. Positioning the child with arms resting on the overbed table

ANS: D

This position is comfortable and allows maximum use of the accessory muscles for breathing.

Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are

contraindicated in persons with dyspnea.

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DIF: Cognitive Level: Comprehension REF: 583 OBJ: 14

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TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. The nurse explains to the parent of a child with exercise-induced asthma that Cromolyn, an

antiinflammatory drug, should be inhaled: a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day ANS: A

Antiinflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the attack in progress. They are meant to be used as prophylactic therapies. DIF: Cognitive Level: Analysis REF: 584 OBJ: 14, 15 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in their families has CF. The nurses response is based on the

understanding that with CF: a. Only one parent carries the CF gene.

c. The inheritance pattern is multifactorial.

d. The result is probably a genetic mutation.

b. Both parents are carriers of the CF gene.

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ANS: B

Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child

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to have the disease.

DIF: Cognitive Level: Analysis REF: 587 OBJ: 20

TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The statement indicating that the childs parents understand how to perform respiratory therapy is: a. We do her postural drainage before the aerosol therapy. b. We give her respiratory treatments when she is coughing a lot. c. We give the aerosol followed by postural drainage before meals.

d. She needs respiratory therapy everyday when she has an infection. ANS: C Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting. DIF: Cognitive Level: Analysis REF: 589 OBJ: 20 TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. To facilitate digestion and absorption of nutrients, the nurse teaches the child with cystic

fibrosis that she needs to take:

b. Water-soluble minerals

c. Fat-soluble vitamins

a. Pancreatic enzymes

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d. Salt supplements

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ANS: A

An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the

pancreatic enzymes that the childs body cannot produce.

DIF: Cognitive Level: Knowledge REF: 594 OBJ: 20 TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The nurse would advise a mother to clear the nostrils when her infant has a cold by: a. Clearing the nasal passages after the infant has a feeding b. Using over-the-counter nose drops to clear passages

c. Removing nasal secretions with a bulb syringe d. Instilling saline nose drops after clearing away secretions ANS: C The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe. DIF: Cognitive Level: Application REF: 574 OBJ: N/A TOP: Nasopharyngitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. The nurse offers a variety of fluids to compensate for the fluid loss through dyspnea.

a. Room temperature water

b. Carbonated beverages

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ANS: A

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c. Iced fruit juice d. Cold milk

Appropriate fluids would be:

Room temperature fluids are the best. Carbonated and iced beverages increase spasm Milk

stimulates mucus production.

DIF: Cognitive Level: Analysis REF: 585 OBJ: 14 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. The asthmatic child who has been taking theophylline complains of stomach ache and tachycardia and is sweating profusely. The nurse recognizes these symptoms as:

a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity ANS: D The symptoms described are the signs of theophylline toxicity. DIF: Cognitive Level: Analysis REF: 584 OBJ: 13

TOP: Asthma KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

15. The nurse is planning to teach parents about preventing sudden infant death syndrome

(SIDS). Significant information would be to:

a. Wrap the infant snugly for rest periods.

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b. Position the infant prone for sleep. c. Sit the baby up in an infant seat.

ANS: D

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d. Place infants on their back or side for sleep.

The American Academy of Pediatrics recommends that all healthy infants be placed in the

supine or side-lying position on a firm mattress to prevent SIDS. DIF: Cognitive Level: Application REF: 595 OBJ: 16 TOP: Sudden Infant Death Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16. An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is:

a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk for fluid volume deficit related to tachypnea and decreased oral intake d. Fear/anxiety related to dyspnea and hospitalization ANS: B An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.

DIF: Cognitive Level: Analysis REF: 577 OBJ: 9

MSC: NCLEX: Physiological Integrity

KEY: Nursing Process Step: Nursing Diagnosis

TOP: Respiratory Syncytial Virus

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17. The nurse explains that a ventricular septal defect will:

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a. Allow blood to shunt left to right, causing increased pulmonary flow and no cyanosis b. Allow right-to-left shunt, causing decreased pulmonary flow and cyanosis c. Allow no shunting because of high pressure in the left ventricle

d. Allow increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume ANS: A

Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis. DIF: Cognitive Level: Analysis REF: 598 OBJ: 22

TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect, is: a. A loud, harsh murmur with a systolic tremor b. Cyanosis when crying c. Blood pressure higher in the arms than in the legs

d. A machinery-like murmur ANS: A

A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal

defect.

DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 599

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OBJ: 22 TOP: Congenital Heart Disease

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KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

19. The finding the nurse would expect when measuring blood pressure on all four extremities of

a child with coarctation of the aorta is: a. Blood pressure is higher on the right side. b. Blood pressure is higher on the left side. c. Blood pressure is lower in the arms than in the legs. d. Blood pressure is lower in the legs than in the arms. ANS: D

The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation. DIF: Cognitive Level: Analysis REF: 599 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse is caring for a toddler with acute laryngotracheobronchitis. The assessment finding

that would indicate the child is experiencing increased respiratory obstruction is: a. Restlessness

b. Tachycardia c. Brassy cough

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ANS: C

d. Expiratory wheezing

Restlessness is a primary sign of increased respiratory obstruction.

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DIF: Cognitive Level: Analysis REF: 576 OBJ: 5

TOP: Acute Croup KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting: a. Increases the return of venous blood back to the heart b. Decreases arterial blood flow away from the heart c. Is a common resting position when a child is tachycardic d. Increases the workload of the heart

ANS: A The squatting position allows the child to breathe more easily because systemic venous return is increased. DIF: Cognitive Level: Analysis REF: 600 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). The nurse

understands dyspnea occurs because:

a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion.

b. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia. c. Blood is shunted past cardiac arteries, causing myocardial hypoxia.

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d. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart. ANS: A

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When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.

DIF: Cognitive Level: Analysis: Physiological Adaptation REF: 599 OBJ: 22 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. An appropriate nursing action related to the administration of Lanoxin to an infant would be: a. Counting the apical rate for 30 seconds before administering the medication

b. Withholding a dose if the apical heart rate is less than 100 beats/min c. Repeating a dose if the child vomits within 30 minutes of the previous dose d. Checking respiratory rate and blood pressure before each dose ANS: B As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified. DIF: Cognitive Level: Application REF: 603 OBJ: 23

TOP: Congestive Heart Failure KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

24. A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart

affected by carditis are:

a. The coronary arteries

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b. The heart muscle and the mitral valve c. The aortic and pulmonic valves

ANS: B

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d. The contractility of the ventricles

The tissues that cover the heart and heart valves are affected. The heart muscle may be involved

and the mitral valve is frequently involved. DIF: Cognitive Level: Knowledge REF: 604 OBJ: 26 TOP: Rheumatic Fever KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is:

a. He is always hungry. b. He tires out during feedings. c. He is fussy for several hours every day. d. He sleeps all the time. ANS: B Fatigue during feeding or activity is common to most infants with congenital cardiac problems. DIF: Cognitive Level: Analysis REF: 596 OBJ: 23

TOP: Congenital Heart Disease KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks

the nurse, How does Kawasaki disease affect my childs heart and blood vessels? The nurses

response is based on the understanding that:

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a. Inflammation weakens blood vessels, leading to aneurism. b. Increased lipid levels lead to the development of atherosclerosis.

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c. Untreated disease causes mitral valve stenosis. d. Altered blood flow increases cardiac workload with resulting heart failure.

ANS: A

Inflammation of vessels weakens the walls of the vessels and often results in aneurysm. DIF: Cognitive Level: Analysis REF: 607 OBJ: N/A TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the parent understood the instructions when he states: a. If the baby turns blue, I will hold him over my shoulder with his knees bent up toward his chest. b. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body. c. If the baby turns blue, I will immediately put the baby upright in an infant seat. d. If the baby turns blue, I will put the baby in a squatting position.

ANS: A In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-

chest position.

DIF: Cognitive Level: Application REF: 600 OBJ: 22

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TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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28. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? The nurse bases a response on the understanding that clubbing occurs as

a result of:

a. Untreated congestive heart failure

b. A left-to-right shunting of blood c. Decreased cardiac output d. Chronic hypoxia ANS: D Clubbing of the fingers develops in response to chronic hypoxia. DIF: Cognitive Level: Analysis REF: 604 OBJ: 22

TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints and carditis c. Erythema marginatum and arthralgia

d. Chorea and elevated sedimentation rate ANS: B

The presence of two major Jones criteria would indicate a high probability of rheumatic fever.

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OBJ: 26 TOP: Rheumatic Fever

DIF: Cognitive Level: Analysis REF: 604, Box 25-3

KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 30. An infant with congestive heart failure is receiving Lanoxin. The nurse recognizes signs of

digoxin toxicity, which are:

a. Restlessness

b. Decreased respiratory rate c. Increased urinary output d. Vomiting ANS: D Symptoms of digoxin toxicity include the following: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

DIF: Cognitive Level: Analysis REF: 604 OBJ: 23 TOP: Congestive Heart Failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse describes the allergic salute as a cluster of signs related to chronic allergy, which are:

Select all that apply. a. Mouth breathing b. Transverse nasal crease

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ANS: A, B, C, E

e. Reddened conjunctiva

d. Productive cough

c. Dark circles under the eyes

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The allergic salute does not include a productive cough. DIF: Cognitive Level: Comprehension REF: 582 OBJ: 10

TOP: Allergic Salute KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse would suggest to the parents of an asthmatic child to encourage participation in such activities as: Select all that apply. a. Swimming b. Gymnastics

c. Baseball d. Basketball e. Tennis ANS: A, B, C Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion. DIF: Cognitive Level: Application REF: 585 OBJ: 13

TOP: Sports Activities Suitable for Asthmatics

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. The nurse explains that the ____________________ can sense the oxygen concentration in the

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ANS: chemoreceptors

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blood and can signal the brainstem to increase respiration.

DIF: Cognitive Level: Comprehension REF: 573 OBJ: 3

TOP: Chemoreceptors KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: Chemoreceptors can sense the oxygen concentration of the blood and can signal the brainstem to increase and deepen respirations in order to keep an adequate supply of oxygen in the circulating volume. 2. After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the nurse explains that routine immunizations will need to be delayed for ____________________ months.

ANS: 9 DIF: Cognitive Level: Application REF: 578 OBJ: 9 TOP: Syncytial Virus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT: Rationale: After a protocol of antiviral medications, the routine immunizations should be delayed because the antiviral medications affect the integrity of the immunizations. 3. The nurse reviews for the client drugs such Accolate and Zyflo, which are _______________

_______________; they are capable of blocking the inflammatory response as well as providing bronchodilation.

ANS: leukotriene modifiers

Chapter 37: The Child with a Cardiovascular/Hematologic Disorder

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MULTIPLE CHOICE

a. 4c. 12 b.8d.16

ANS: B

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1.Cardiac development is fairly complete by how many weeks of gestation?

Feedback AIncorrect. Cardiac development is nearly complete by 8 weeks of gestation. B Correct. Cardiac development is nearly complete by 8 weeks of gestation. CIncorrect. Cardiac development is nearly complete by 8 weeks of gestation. DIncorrect. Cardiac development is nearly complete by 8 weeks of gestation. PTS: 1 REF: p. 847 Anatomy and Physiology OBJ: Cognitive Level: Knowledge 2.What is the purpose of the ductus arteriosus while the fetus is developing in utero? a. to divert blood from the fetal lungs to the fetal aorta

b.to circulate blood throughout the fetal body and back to the placenta c. to move blood between the various chambers of the fetal heart d.to direct blood immediately to the fetal liver ANS: A

Feedback ACorrect. The ductus arteriosus (a blood vessel connecting the aorta with the pulmonary artery) is used to divert blood from the fetal lungs to the fetal aorta as the lungs do not participate in gas exchange in utero. This structure usually closes after birth. B Incorrect. The ductus arteriosus does not circulate blood throughout the fetal body and back to the placenta. This is the role of the umbilical cord. CIncorrect. The ductus arteriosus does not move blood between the various chambers of the fetal heart. DIncorrect. The ductus arteriosus does not direct blood immediately to the fetal liver. PTS:1REF:p. 861 Congestive Heart Failure

OBJ: Cognitive Level: Comprehension

3.Cardiac abnormalities account for what percentage of all congenital malformations?

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a. 5% c. 20% b.10%d.25% ANS: D

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Feedback AIncorrect. Cardiac abnormalities do not account for 5% of all congenital malformations. B Incorrect. Cardiac abnormalities do not account for 10% of all congenital malformations. CIncorrect. Cardiac abnormalities do not account for 20% of all congenital malformations. DCorrect. Cardiac abnormalities account for 25% of all congenital malformations. PTS: 1 REF: p. 847 Anatomy and Physiology OBJ: Cognitive Level: Knowledge 4.Heart size has a correlation that continues into adulthood. The heart is the size of the: a. ear c. knee b.fistd.elbow ANS: B Feedback

AIncorrect. The heart is not the size of the ear. B Correct. Heart size corresponds with the size of the childs fist; this correlation continues into adulthood. CIncorrect. The heart is not the size of the knee. DIncorrect. The heart is not the size of the elbow. PTS:1REF:p. 847 Anatomy and Physiology OBJ: Cognitive Level: Comprehension 5.After birth the pulmonary artery is the only artery in the body that:

a. has a high concentration of hemoglobinc. carries deoxygenated blood b.has a high-pressure vascular bed d.returns blood to the heart ANS: C

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Feedback AIncorrect. The pulmonary artery carries deoxygenated blood. Since most oxygen carried in the blood is bound to hemoglobin and the pulmonary artery carries deoxygenated blood, it does not have a high concentration of hemoglobin. B Incorrect. The pulmonary vascular bed is a low-pressure vascular bed. CCorrect. After birth the pulmonary artery is the only artery in the body that carries deoxygenated blood. All other arteries including the aorta carry oxygenated blood. DIncorrect. The pulmonary artery carries blood from the right ventricle to the lungs for oxygenation. It does not return blood to the heart.

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PTS:1REF:p. 847 Anatomy and Physiology

OBJ: Cognitive Level: Comprehension

6.Which of the following calculations determines cardiac output? a. heart rate times stroke volume b.systolic blood pressure minus the apical heart rate c. heart rate at exercise minus heart rate at rest d.apical heart rate minus rate of pedal pulse ANS: A Feedback ACorrect. Cardiac output is calculated by multiplying the heart rate by the stroke volume (CO=HR X SV)

B Incorrect. Cardiac output is not calculated by subtracting the apical heart rate from the systolic blood pressure. CIncorrect. Cardiac output is not calculated by subtracting the heart rate at rest from the heart rate at exercise. DIncorrect. Cardiac output is not calculated by subtracting the pedal pulse from the apical heart rate. PTS:1REF:p. 848 Anatomy and Physiology OBJ: Cognitive Level: Application

a. size of the heart and size of the heart valves b.age of the person and the condition of the heart c. preload, afterload, and contractility d.blood pressure and hormonal influences

7.Which of the following factors determines stroke volume?

ANS: C

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Feedback AIncorrect. The size of the heart and size of the heart valves are not factors in determining stroke volume. B Incorrect. The age of the person and the condition of the heart are not factors in determining stroke volume. CCorrect. The determinants of stroke volume are preload, afterload, and contractility. DIncorrect. Blood pressure and hormonal influences are not factors in determining stroke volume.

PTS:1REF:p. 848 Anatomy and Physiology

OBJ: Cognitive Level: Comprehension 8.Which of the following indicates the flow of blood in the human body? a. flows from an area of lower pressure to an area of higher pressure b.takes the path of most resistance and flows from the area of highest pressure to an area of low pressure c. goes from higher to lower pressure and takes the path of most resistance d.flows from an area of high pressure to an area of low pressure and takes the path of least resistance ANS: D

Feedback AIncorrect. Blood flows in the human body from an area of high pressure to an area of low pressure. B Incorrect. Blood flow will take the path of least resistance, not most resistance. It is correct that blood flows from the area of highest pressure to an area of low pressure. CIncorrect. Blood flow does go from higher to lower pressure, but it takes the path of least resistance. DCorrect. Blood flows in the human body from an area of high pressure to an area of low pressure (flowing down hill) and takes the path of least resistance. PTS:1REF:p. 848 Anatomy and Physiology OBJ: Cognitive Level: Application

9.The nurse assessing an infant will be most concerned about which of the following findings?

a. peripheral cyanosis of the hands c. cyanosis of the lips or tongue b.perioral cyanosis d.cyanosis of the feet

ANS: C

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Feedback AIncorrect. Peripheral cyanosis of the hands is usually caused by instability of the peripheral circulation system typically seen in the young infant and is not a concern. This is called acrocyanosis. B Incorrect. The nurse will not be most concerned about perioral cyanosis (cyanosis of the skin around the lips). CCorrect. The nurse will be most concerned about cyanosis of the lips or tongue. This finding may indicate a cardiovascular alteration. Cyanosis appears when hemoglobin, approximately 5g/dl of blood, circulates unbound to oxygen and the measured oxygen saturation drops below 85%. DIncorrect. Cyanosis of the feet is usually caused by instability of the peripheral circulation system typically seen in the young infant and is not a concern. This is called acrocyanosis. PTS:1REF:p. 849 Anatomy and Physiology OBJ: Cognitive Level: Application 10.Which of the following terms describes the nurses finding that the angle between the nail and the nail bed of a child has been lost and the fingertips are wider and rounder? a. moon nailsc. notching b.angle nails d.clubbing

ANS: D Feedback AIncorrect. This is not a description of moon nails. B Incorrect. This is not a description of angle nails. CIncorrect. This is not a description of notching. DCorrect. Clubbing is a result of chronic cyanosis with the subsequent development of the loss of the angle between the nail and nailbed. The fingertips eventually become wider and rounder. PTS: 1 REF: p. 850 Assessment of the Child with a Cardiovascular Alteration OBJ: Cognitive Level: Comprehension

a. between the first and second heart sounds b.in the right chest at the fourth intercostal space c. at the sternal border d.at the base of the heart

11.Systolic murmurs are heard best in which of the following locations?

ANS: A

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Feedback ACorrect. Systolic murmurs are heard best between the first and second heart sounds. B Incorrect. Systolic murmurs are not heard best in the right chest at the fourth intercostal space. CIncorrect. Systolic murmurs are not heard best at the sternal border. DIncorrect. Systolic murmurs are not heard best at the base of the heart. The second heart sound is heard best at the base of the heart.

PTS: 1 REF: p. 850 Assessment of the Child with a Cardiovascular Alteration

OBJ: Cognitive Level: Application 12.Systolic murmurs are considered abnormal if they are: a. grade I c. grade III or greater b.grade IId.grade 0 ANS: C Feedback AIncorrect. A heart murmur of grade III or less is considered an innocent murmur and is not abnormal.

B Incorrect. A heart murmur of grade III or less is considered an innocent murmur and is not abnormal CCorrect. Systolic murmurs are considered abnormal if they are loud and grade III or greater. A grade III is loud but not accompanied by a thrill. DIncorrect. A systolic murmur is considered abnormal at grade III or greater. Murmurs are graded based on their intensity from grade I to grade VI, with VI being the most severe. There is not a grade 0. PTS: 1 REF: p. 850 Assessment of the Child with a Cardiovascular Alteration OBJ: Cognitive Level: Comprehension 13.Which of the following best describes the quality of an innocent murmur?

a. bowing and hissing following the second heart sound b.soft, short, systolic, and vibratory c. high pitched, diastolic, and organic d.to and fro, continuous, musical

ANS: B

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Feedback AIncorrect. Bowing and hissing following the second heart sound are not a description of an innocent murmur. B Correct. An innocent murmur is described as soft, short, systolic, and vibratory, indicating there is no structural or functional heart disease. Over 80% of children have innocent murmurs sometime during childhood, most commonly beginning at age 3 or 4 years. Innocent murmurs are accentuated in high output states, especially with fever and anemia. CIncorrect. High pitched, diastolic, and organic are not a description of an innocent murmur. DIncorrect. To and fro, continuous, musical are not a description of an innocent murmur.

PTS: 1 REF: p. 850 Assessment of the Child with a Cardiovascular Alteration OBJ: Cognitive Level: Comprehension 14.Which of the following actions would the nurse take when finding an innocent murmur while listening to a childs heart? a. Refer the child and mother to a cardiologist. b.Advise the caregiver(s) to restrict the childs activity. c. Teach the family that this murmur needs no intervention. d.Get an order for oxygen, and administer it as soon as possible.

ANS: C Feedback AIncorrect. The nurse would not refer the child and mother to a cardiologist. B Incorrect. The nurse would not advise the caregiver(s) to restrict the childs activity. CCorrect. The nurse would teach the family that this murmur needs no intervention and is not pathological, indicating no structural or functional heart disease. DIncorrect. The nurse would not get an order for oxygen, and administer it as soon as possible. PTS: 1 REF: p. 851 Assessment of the Child with a Cardiovascular Alteration OBJ: Cognitive Level: Application

15.While assessing a child the nurse finds hepatomegaly. The nurse is aware that this condition

a. congestive heart failure c. maternal alcoholism b.congenital heart defectsd.prematurity

is most associated with which of the following?

ANS: A

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Feedback ACorrect. Hepatomegaly is most often associated with congestive heart failure. Inadequate emptying of the heart caused by volume overload or poor contractility results in cardiac failure. This generates an increase in venous volume with a subsequent increase in venous congestion. Systemic venous congestion results in liver engorgement and hepatomegaly. B Incorrect. Hepatomegaly is not associated with congenital heart defects. CIncorrect. Hepatomegaly is not associated with maternal alcoholism. DIncorrect. Hepatomegaly is not associated with prematurity.

PTS: 1 REF: p. 851 Assessment of the Child with a Cardiovascular Alteration

OBJ: Cognitive Level: Comprehension 16.When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is greater than that found in the childs leg. The nurse reacts to these findings in which of the following ways? a. charts the findings and realizes they are normal b.suspects the child may have coarctation of the aorta c. places the child in the Trendelenburg position d.notifies the physician and alerts the surgery team

ANS: B Feedback AIncorrect. Theses findings are not normal. B Correct. A right arm BP greater than a leg BP is indicative of coarctation of the aorta. Normally lower extremity BP is equal to or greater than arm BP. CIncorrect. The definitive treatment for coarctation of the aorta is relief of the obstruction by either surgery or balloon dilation. Placing the child in the Trendelenburg position in an incorrect nursing action. DIncorrect. The nurse should notify the physician of the BP findings but would not alert the surgery team since this is not an emergency situation. Treatment of the symptomatic newborn depends on the severity of the coarctation, symptomatology, degree of congestive heart failure, and systemic circulation.

PTS: 1 REF: p. 851 Assessment of the Child with a Cardiovascular Alteration

OBJ: Cognitive Level: Application

17.The nurse is assigned to care for a child who is scheduled for a catheterization for balloon

dilation of narrow heart valves. Which of the following is most important for the nurse to do?

ANS: C

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a. Listen to the parents or caregivers fears and concerns and allay fears. b.Make certain the child has had nothing to eat or drink for 12 or more hours preceding the surgery. c. Ask about any latex allergy the child might have, and notify surgery immediately if there is a latex allergy. d.Take a last-minute set of vital signs before the surgery stretcher and staff members come for the child.

Feedback AIncorrect. While listening to the parents or caregivers fears and concerns and allaying fears is important, it is not the most important nursing action prior to the catheterization. B Incorrect. The child should be NPO for 4 to 6 hours prior to the procedure, but this is not the most important consideration before the procedure. CCorrect. It is most important for the nurse to ask about any latex allergy the child might have, and notify surgery immediately if such an allergy exists. Some catheters used in the catheterization laboratory have latex balloons. If the child has a latex allergy, use of such a balloon can precipitate a life threatening reaction. DIncorrect. Taking a last-minute set of vital signs before the surgery stretcher and staff members come for the child is not the most important nursing action prior to the cath. PTS: 1 REF: p. 855 Assessment of the Child with a Cardiovascular Alteration

OBJ: Cognitive Level: Application 18.The nurse caring for a child who has had a heart catheterization is aware that the childs activity level is: a. unrestricted because this is a minor procedure b.restricted to being up and about with no exercise, lifting, or other activity, which would increase heart rate c. restricted to sitting in a chair for 4 hours after the procedure d.bed rest with the affected extremity straight for 4 to 8 hours, subject to hospital policy and physicians orders ANS: D

Feedback AIncorrect. The childs activity level is restricted. This is not a minor procedure. B Incorrect. The childs activity level is not restricted to being up and about with no exercise, lifting, or other activity, which would increase heart rate. CIncorrect. The child is not restricted to sitting in a chair for 4 hours after the procedure. DCorrect. After a heart catheterization the child should be kept in bed with the affected extremity straight for 4 to 8 hours, subject to hospital policy and physicians orders.

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PTS: 1 REF: p. 855 Assessment of the Child with a Cardiovascular Alteration OBJ: Cognitive Level: Application

infants?

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19.Which of the following conditions is the most common cause of congestive heart failure in

a. cardiomyopathyc. congenital heart disease b.endocarditis d.myocarditis ANS: C

Feedback AIncorrect. Cardiomyopathy is an acquired heart disease and is one of the most common causes of congestive heart failure in older children or adolescents. B Incorrect. Endocarditis is an acquired heart disease and is one of the most common causes of congestive heart failure in older children or adolescents. CCorrect. Congenital heart disease is the most common cause of congestive heart failure in infants. DIncorrect. Myocarditis is an acquired heart disease and is one of the most common causes of congestive heart failure in older children or adolescents.

PTS: 1 REF: p. 855 Assessment of the Child with a Cardiovascular Alteration OBJ: Cognitive Level: Comprehension 20.The most common cause of congestive heart failure (CHF) in older children is: a. acquired heart diseasec. aortic stenosis b.tetralogy of Fallot d.congenital valve problems ANS: A

Feedback ACorrect. The most common cause of congestive heart failure (CHF) in older children is acquired heart disease. B Incorrect. Tetralogy of Fallot is not the most common cause of congestive heart failure (CHF) in older children. CIncorrect. Aortic stenosis is not the most common cause of congestive heart failure (CHF) in older children. DIncorrect. Congenital valve problems are not the most common cause of congestive heart failure (CHF) in older children.

PTS: 1 REF: p. 855 Assessment of the Child with a Cardiovascular Alteration

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OBJ: Cognitive Level: Comprehension

21.The nurse is assessing an infant with congestive heart failure (CHF). The nurse hears rales

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and rhonchi, observes nasal flaring and restlessness, and finds that the oxygen saturation is falling. What does the nurse most suspect?

a. The infant has been over-medicated or undermedicated. b.There is an increase in lung fluid or a congenital heart defect. c. The infant has experienced a spontaneous pneumothorax. d.There is an electrolyte imbalance and probably respiratory acidosis. ANS: B Feedback AIncorrect. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation do not indicate that the infant has been over-medicated or undermedicated. B Correct. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation indicate pulmonary congestion or a congenital heart defect. As pulmonary congestion worsens, there is leaking of fluid into the alveoli and interstitium of the lung leading to pulmonary edema.

CIncorrect. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation do not indicate that the infant has experienced a spontaneous pneumothorax. DIncorrect. Rales and rhonchi, nasal flaring, restlessness, and falling oxygen saturation do not indicate that there is an electrolyte imbalance and probably respiratory acidosis. PTS:1REF:p. 857 Congestive Heart Failure OBJ: Cognitive Level: Application 22.The nurse is assessing an infant with congestive heart failure (CHF). Which of the following symptoms would the nurse most likely find in this infant?

a. jugular vein distentionc. greatly elevated blood pressure b.peripheral edema d.diaphoresis during feeding ANS: D

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Feedback AIncorrect. Jugular vein distention cannot be observed in infants with CHF because of their short necks. B Incorrect. Peripheral edema is a rare finding in infants with CHF, but when present, it is usually localized to the periorbital area. CIncorrect. The blood pressure is usually maintained in infants with CHF. Hypotension, rather than hypertension, is a late and ominous sign. DCorrect. An infant with congestive heart failure exhibits diaphoresis during feeding caused by sympathetic stimulation.

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PTS:1REF:p. 857 Congestive Heart Failure

OBJ: Cognitive Level: Application

23.Which of the following symptoms would the nurse most likely find in assessing a child with right ventricular failure? a. rales and rhonchi, falling oxygen saturation, and labored breathing b.falling blood pressure, falling pulse rate, and increased respirations c. diaphoresis, nausea and vomiting, and tingling in extremities d.hepatomegaly, jugular venous distention, and peripheral edema ANS: D Feedback

AIncorrect. Rales and rhonchi, falling oxygen saturation, and labored breathing indicate pulmonary congestion. B Incorrect. Falling blood pressure, falling pulse rate, and increased respirations are not symptoms of right ventricular failure. CIncorrect. Diaphoresis, nausea and vomiting, and tingling in extremities are not symptoms of right ventricular failure. DCorrect. Systemic venous congestion indicates right ventricular failure with symptoms of hepatomegaly, jugular venous distention, and peripheral edema. PTS:1REF:p. 857 Congestive Heart Failure OBJ: Cognitive Level: Comprehension

24.Which of the following positions is used to evaluate jugular vein distention in older children?

a. sitting c. lying flat b.standingd.head slightly elevated

ANS: A

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Feedback ACorrect. In the older child jugular vein distention is evaluated when the child is sitting. B Incorrect. In the older child jugular vein distention is not evaluated when the child is standing. CIncorrect. Jugular vein distention is not evaluated when the child is lying flat. DIncorrect. Jugular vein distention is not evaluated with the childs head slightly elevated.

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PTS:1REF:p. 857 Congestive Heart Failure OBJ: Cognitive Level: Application

25.Which of the following medications is the primary diuretic used in children to treat volume

overload?

a. furosemide (Lasix) c. bumetanide (Bumex) b.spironolactone (Aldactone)d.chlorothiazide (Diuril) ANS: A Feedback ACorrect. Furosemide (Lasix), a potent loop diuretic, is the primary diuretic used in children to treat volume overload.

B Incorrect. Spironolactone (Aldactone), a potassium sparing diuretic, is a weak diuretic. It is not the primary diuretic used in children to treat volume overload. This class of diuretics may be given with loop diuretics or thiazides to decrease the potential for hypokalemia. CIncorrect. Although bumetanide (Bumex) is also a loop diuretic like Lasix, it is not the primary diuretic used in children to treat volume overload. DIncorrect. Chlorothiazide (Diuril) is not the primary diuretic used in children to treat volume overload. Thiazides act at the distal renal tubules and are loss potent than loop diuretics such as Lasix. They also cause the kidneys to waste potassium, placing the child at risk for hypokalemia. PTS:1REF:p. 858 Congestive Heart Failure OBJ: Cognitive Level: Comprehension

26.The three primary treatments for congestive heart failure are diuretics, afterload-reducing agents, and:

a. analgesics c. inotropes b.antibioticsd.cortisone ANS: C

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Feedback AIncorrect. The three primary treatments for congestive heart failure are diuretics, afterloadreducing agents, but not analgesics. B Incorrect. The three primary treatments for congestive heart failure are diuretics, afterloadreducing agents, but not antibiotics. CCorrect. The three primary treatments for congestive heart failure are diuretics, afterloadreducing agents, and inotropes. DIncorrect. The three primary treatments for congestive heart failure are diuretics, afterloadreducing agents, but not cortisone.

PTS: 1 REF: p. 858 Congestive Heart Failure OBJ: Cognitive Level: Knowledge 27.You are the nurse preparing to give a child a dose of digoxin. Before giving the digoxin, you would first check the apical pulse, and you would also be most interested in making sure which of the following levels were within normal? a. red blood cell countc. potassium levels b.chloride levels d.platelet ANS: C

Feedback AIncorrect. Before giving digoxin, you would first check the apical pulse. However, the red blood cell count would not be relevant. B Incorrect. Before giving digoxin, you would first check the apical pulse. However, the chloride level would not be relevant. CCorrect. Before giving digoxin, you would first check the apical pulse and serum potassium level which should be normal. Hypokalemia in combination with digoxin can result in ventricular arrhythmias and can enhance digoxin toxicity. DIncorrect. Before giving digoxin, you would first check the apical pulse. However, the platelet levels would not be relevant. PTS:1REF:p. 858 Congestive Heart Failure

OBJ: Cognitive Level: Application 28.You are caring for a child who is on a diuretic and digoxin. Prior to giving the medications, you assess this child and find that the child has a bradycardia, has a ventricular arrhythmia, and

is nauseated and wanting to vomit. What is the most likely explanation for these signs and

symptoms?

a. hyperkalemia c. digitalis toxicity b.drug incompatibilityd.dehydration

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ANS: C

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Feedback AIncorrect. These signs and symptoms do not indicate hyperkalemia. B Incorrect. These signs and symptoms do not indicate an incompatibility between a diuretic and digoxin. CCorrect. The most likely explanation for these signs and symptoms is digitalis toxicity. DIncorrect. These signs and symptoms do not indicate dehydration.

PTS:1REF:p. 858 Congestive Heart Failure OBJ: Cognitive Level: Application 29.The nurse planning nutritional interventions for an infant with congestive heart failure who has a nursing diagnosis of Imbalanced nutrition: Less than body requirements related to poor caloric intake and increased metabolic demands as evidenced by poor weight gain and weight loss would most likely include in the nursing care plan which of the following interventions?

a. Increase calorie density slowly by adding less water when mixing formula or powdered formula to expressed breast milk. b.Quickly increase the calorie density by adding less water when mixing formula or powdered formula to expressed breast milk. c. Administer bolus feedings via a nasogastric tube every 2 to 3 hours. d.Start rice cereal earlier than is normally recommended. ANS: A

Feedback ACorrect. The nursing care plan would most likely include interventions such as increasing calorie density slowly by adding less water when mixing formula or powdered formula to expressed breast milk. B Incorrect. The nursing care plan would not include quickly increasing the calorie density by adding less water when mixing formula or powdered formula to expressed breast milk. Increasing caloric density should be accomplished slowly over a number of days, as a sudden increase will increase the osmotic load in the gut, producing diarrhea. CIncorrect. The nursing care plan would not include administering bolus feedings via a nasogastric tube every 2 to 3 hours. DIncorrect. The nursing care plan would not include starting rice cereal earlier than is normally recommended.

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OBJ: Cognitive Level: Application

PTS:1REF:p. 861 Congestive Heart Failure

30.Which of the following outcome goals would be best for an adolescent male who has a

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nursing diagnosis of Imbalanced nutrition: Less than body requirements related to poor caloric intake and increased metabolic demands as evidenced by poor weight gain and weight loss?

a. The child will ingest the appropriate number of calories for his age (50 calories per kilogram per 24 hours). b.The child will take in three meals per day. c. There will be an improvement in appetite during the next 3 days. d.The dietary department will consult with the child and his family to ascertain likes and dislikes and will serve more likes. ANS: A Feedback ACorrect. The outcome goal that would be best for this adolescent male is: The child will ingest the appropriate number of calories for his age (50 calories per kilogram per 24 hours). This is an appropriate goal for this nursing diagnosis since the problem is poor caloric intake.

B Incorrect. The best outcome goal would not be that the child will take in three meals per day because there is no guarantee that the caloric intake will be increased. CIncorrect. The best outcome goal would not be that there will be an improvement in appetite during the next 3 days. Simply improving the childs appetite does not guarantee in increase in calories. DIncorrect. Although consultation with a dietician can assist in providing increased calories, this is not the best outcome goal. The child can be provided with more calorie dense foods, but he also must ingest them to prevent weight loss. PTS:1REF:p. 861 Congestive Heart Failure OBJ: Cognitive Level: Application 31.The nurse is feeding an infant who has congestive heart failure. The infant arches her back

and averts her eyes from the nurse. The nurse is aware that the infant is giving cues indicating a need or want to:

a. pass gas or be burped c. disengage and take a break b.have a bowel movement d.take a nap

ANS: C

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Feedback AIncorrect. The infant is not giving cues indicating a need to pass gas or be burped. B Incorrect. The infant is not giving cues indicating a need to have a bowel movement. CCorrect. The infant is giving cues indicating a need or want to disengage and take a break from feeding. DIncorrect. The infant is not giving cues indicating a need to take a nap.

PTS:1REF:p. 864 Congestive Heart Failure

OBJ: Cognitive Level: Application 32.Which of the following heart defects increases pulmonary blood flow? a. pulmonary stenosis c. pulmonary atresia b.patent ductus arteriosusd.tetralogy of Fallot ANS: B Feedback

AIncorrect. Pulmonary stenosis decreases pulmonary blood flow by shunting unoxygenated blood from the right side of the heart to the left. There is a mixing of oxygenated and unoxygenated blood in the systemic circulation. These infants are hypoxic and cyanotic. B Correct. Patent ductus arteriosus increases pulmonary blood flow. Defects that increase pulmonary blood flow are caused by a shunting of the blood from the left side of the heart to the right side through an abnormal connection (left to right shunt). These infants exhibit clinical manifestations of congestive heart failure. CIncorrect. Pulmonary atresia decreases pulmonary blood flow, resulting in unoxygenated blood from the right side of the heart to the left. There is a mixing of oxygenated and unoxygenated blood in the systemic circulation. These infants are hypoxic and cyanotic. DIncorrect. Tetralogy of Fallot decreases pulmonary blood flow, resulting in unoxygenated blood from the right side of the heart to the left. There is a mixing of oxygenated and unoxygenated blood in the systemic circulation. These infants are hypoxic and cyanotic.

PTS:1REF:p. 864 Congestive Heart Failure OBJ: Cognitive Level: Comprehension

33.The nurse is assessing a child and hears a widely split S2, which is not affected by the

respiratory pattern. The physician verifies the finding and orders a chest X-ray, which shows an enlarged heart. An echocardiogram is ordered, which shows the defect. The finding by the nurse

is a classic murmur found in which of the following cardiac defects?

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ANS: A

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a. atrial septal defectc. patent ductus arteriosus (PDA) b.tetralogy of Fallot d.transposition of the great arteries (TGA)

Feedback ACorrect. In atrial septal defect, the infant is generally asymptomatic. There is often a soft systolic murmur and more classically a widely split S2 unaffected by respiratory pattern. Chest X rays will usually demonstrate an increased heart size. B Incorrect. In tetralogy of Fallot there is a characteristic systolic murmur resulting from the right ventricular outflow tract obstruction and is generally moderate in severity. CIncorrect. The murmur of a PDA is often continuous, and a chest X ray is normal. DIncorrect. These findings are not indicative of TGA. TGA should be suspected in an otherwise healthy newborn with acute cyanosis that is not responsive to oxygen. Chest X ray may be within normal limits or show a mildly enlarged right heart. PTS:1REF:p. 864 Congestive Heart Failure OBJ: Cognitive Level: Application

34.If an atrial septal defect is detected early in life, it is usually not repaired until the preschool age period. Why is this defect not repaired sooner? a. The childs heart needs to strengthen and grow to survive the surgery. b.There is the possibility of a spontaneous closure in the first 2 years of life. c. Parental separation is traumatic for the child, potentially increasing the workload of the heart. d.This gives the parents time to adjust to the idea, and separation for the child is easier. ANS: B

Feedback AIncorrect. This defect is usually not repaired until the preschool age period, but not because the childs heart needs to strengthen and grow to survive the surgery. B Correct. If an atrial septal defect is detected early in life, it is usually not repaired until the preschool age period because there is the possibility of a spontaneous closure in the first 2 years of life, and the child is usually asymptomatic. CIncorrect. This defect is usually not repaired until the preschool age period, but not because parental separation is traumatic for the child, potentially increasing the workload of the heart. DIncorrect. This defect is usually not repaired until the preschool age period, but not because this gives the parents time to adjust to the idea, and separation for the child is easier.

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OBJ: Cognitive Level: Application

PTS:1REF:p. 864 Congestive Heart Failure

35.Which of the following is the most common congenital heart defect?

ANS: B

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a. transposition of the great arteries c. pulmonary atresia b.ventral septal defect d.atrial septal defect

Feedback AIncorrect. Transposition of the great arteries is not the most common congenital heart defect. B Correct. Ventral septal defect (VSD) is the most common congenital heart defect. Isolated VSDs and those VSDs associated with other congenital anomalies account for approximately 50% of infants with congenital heart disease. CIncorrect. Pulmonary atresia is not the most common congenital heart defect. DIncorrect. Atrial septal defect is not the most common congenital heart defect. PTS: 1 REF: p. 864 Congestive Heart Failure OBJ: Cognitive Level: Knowledge

36.The nurse is working with the parents of an infant who has a small ventricular septal defect. The mother asks if the child will have surgery and, if not, what will be done about this defect. The nurse knows and will share with the parents that small ventricular septal defects are usually treated by: a. immediate surgery b.surgery at age 3 c. waiting to see if it closes spontaneously in the first 2 years of life d.inserting an umbrella device or coil by catheterization to close off the defect ANS: C

Feedback AIncorrect. Small ventricular septal defects are not usually treated by immediate surgery. B Incorrect. Small ventricular septal defects are not usually treated by surgery at age 3. CCorrect. Small ventricular septal defects are usually treated by waiting to see if they close spontaneously, as 75-80% of these defects will close spontaneously. DIncorrect. Small ventricular septal defects are usually not treated by inserting an umbrella device or coil by catheterization to close off the defect.

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OBJ: Cognitive Level: Application

PTS:1REF:p. 866 Congenital Heart Defects

37.The ductus arteriosus in the full-term newborn begins to close within 12 hours after birth and

w .n

will normally be closed within what time frame?

ANS: D

a. 24 hoursc. 1 week b.48 hoursd.2 to 3 weeks

Feedback AIncorrect. The ductus arteriosus in the full-term newborn begins to close within 12 hours after birth but will not normally be closed within 24 hours. B Incorrect. The ductus arteriosus in the full-term newborn begins to close within 12 hours after birth but will not normally be closed within 48 hours. CIncorrect. The ductus arteriosus in the full-term newborn begins to close within 12 hours after birth but will not normally be closed within 1 week. DCorrect. The ductus arteriosus in the full-term newborn begins to close within 12 hours after birth and will normally be closed within 2 to 3 weeks.

PTS:1REF:p. 867 Congenital Heart Defects OBJ: Cognitive Level: Comprehension 38.When the nurse is listening to the chest of an infant who has a murmur associated with a patent ductus arteriosus (PDA), the murmur will best be heard in which of the following locations? a. at the apex of the heart c. at the fifth intercostal space b.just below the left clavicle d.over the mitral valve ANS: B

Feedback AIncorrect. The murmur associated with a patent ductus arteriosus (PDA) will not best be heard at the apex of the heart. B Correct. The murmur associated with a patent ductus arteriosus (PDA) will best be heard just below the left clavicle. CIncorrect. The murmur associated with a patent ductus arteriosus (PDA) will not best be heard at the fifth intercostal space. DIncorrect. The murmur associated with a patent ductus arteriosus (PDA) will not best be heard over the mitral valve.

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PTS:1REF:p. 867 Congenital Heart Defects

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OBJ: Cognitive Level: Application

39.The nurse is caring for a premature infant who is receiving an infusion of a substance in an attempt to close a patent ductus arteriosus. The nurse will explain to the mother that this

substance is:

a. indomethacin, which inhibits the synthesis of prostaglandin, the substance that maintains the patency of the ductus arteriosus b.a hypertonic saline solution that will draw the ductus into closure c. a cardiac stimulant, which increases the firing in the Purkinje fibers, thus causing a greater force for closing the ductus arteriosus d.an estrogen product, which will build up the tissue in the ductus arteriosus and cause an eventual closure ANS: A Feedback

ACorrect. The nurse will explain to the mother that indomethacin inhibits the synthesis of prostaglandin, the substance that maintains the patency of the ductus arteriosus. The ductus arteriosus is a direct connection between the main pulmonary artery and the aorta. It is necessary in the fetus for survival. In the premature infant the PDA does not close based on developmental immaturity; however, it does close in the full term infant. B Incorrect. Indomethacin is not a hypertonic saline solution that will draw the ductus into closure. CIncorrect. Indomethacin is not a cardiac stimulant, which increases the firing in the Purkinje fibers, thus causing a greater force for closing the ductus arteriosus. DIncorrect. Indomethacin is not an estrogen product, which will build up the tissue in the ductus arteriosus and cause an eventual closure.

Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder

MULTIPLE CHOICE

b. Choking on the first feeding

c. Palpable mass in the sternal area

a. Failure to pass meconium in 24 hours

1. The finding in a newborn assessment suggestive of tracheoesophageal fistula is:

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d. Visible peristalsis across abdomen

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ANS: B

After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first

feeding is introduced.

DIF: Cognitive Level: Analysis REF: 635 OBJ: 2 TOP: Esophageal Atresia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. An acid-base imbalance that the nurse would expect to occur from this persistent vomiting is: a. Hyperkalemia

b. Hypernatremia c. Acidosis d. Alkalosis ANS: D Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting. This results in alkalosis. DIF: Cognitive Level: Analysis REF: 641 OBJ: N/A

TOP: Vomiting KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. On the second day of hospitalization for a 3-month-old brought in for treatment for

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a. Weight loss of 4 ounces

that the treatment is not effective is:

gastroenteritis, the nurse makes all of the assessments listed below. The assessment that indicates

b. Dry mucous membranes

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c. Decreased skin turgor d. Depressed fontanelle

ANS: A

Weight loss is the most significant indicator of dehydration. DIF: Cognitive Level: Analysis REF: 647-648 OBJ: 5 TOP: Dehydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse is aware that rapid respirations are a possible cause of dehydration because they:

a. Prevent the child from drinking b. Increase circulation, thus increasing urine production c. Cause evaporation of fluid on the mucous membranes d. Often lead to vomiting ANS: C Rapid respirations cause increased insensible fluid loss. DIF: Cognitive Level: Comprehension REF: 647 OBJ: 5

TOP: Dehydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. An appropriate intervention for a 3-month-old infant who has gastroesophageal reflux is to: a. Position the infant in the crib on its abdomen, with the head elevated.

b. Administer medication as ordered to stimulate the pyloric sphincter.

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c. Give thin rice cereal with formula before feeding solid foods.

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d. Place the infant in an infant seat after feedings. ANS: A

After feedings, the infant is placed in a prone position to avoid increased intraabdominal

pressure.

DIF: Cognitive Level: Application REF: 642 OBJ: 3 TOP: Gastroesophageal Reflux KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse interviewing parents of an infant with pyloric stenosis would expect the parents to report the infant has had:

a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation ANS: B Vomiting is the outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting.

DIF: Cognitive Level: Application REF: 636 OBJ: 2 TOP: Pyloric Stenosis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. A parent reports that her child has been scratching the anal area and complaining of itching.

Based on this information, the nurse might suspect this child has:

b. Giardiasis

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c. Ringworm

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a. Pinworms

d. Roundworm

ANS: A

With pinworms, the nurse or parent may notice that the child scratches the anal area and complains of itchiness. The other choices do not cause this reaction. DIF: Cognitive Level: Analysis REF: 652 OBJ: 7 TOP: Worms KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. The nurse that is teaching a parent about pyrvinium (Povan) would include the information that the drug will cause: a. Diarrhea b. Skin rash c. Red stool d. Metallic taste ANS: B

DIF: Cognitive Level: Application REF: 652 OBJ: 7

The nurse should advise parents that Povan stains and turns stools red.

TOP: Worms KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

9. The instruction the nurse would give to parents about preventing the spread and reinfection of

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pinworms is: a. Keep childrens nails short

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b. Dress child in loose-fitting underwear

c. Clean the bathroom with bleach solution

ANS: A

d. Wash bed linens in cold water

One intervention to prevent the further spread of pinworms is to keep the childs fingernails short. Pinworms are not spread from person to person. DIF: Cognitive Level: Application REF: 653 OBJ: 7 TOP: Worms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. A parent reports that her 2-year-old child experiences constipation frequently. The nurse would recommend to the mother to include in the childs diet: a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt ANS: C Dietary modifications for constipation include eating more high-roughage foods such as whole-

grain breads and cereals.

DIF: Cognitive Level: Application REF: 643 OBJ: N/A

TOP: Constipation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

a. Currant jelly

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b. Black and tarry

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11. Intussusception would be suspected when parents describe the childs stools as:

c. Green liquid

ANS: A

d. Greasy and foul-smelling

Bowel movements of blood and mucus that contain no feces (currant jelly stools) are common about 12 hours after the onset of the obstruction. DIF: Cognitive Level: Comprehension REF: 640 OBJ: N/A TOP: Intussusception KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. The nurse explains that the treatment of choice for a child with intussusception is: a. A barium enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage ANS: A A barium enema is the treatment of choice for intussusception because the passage of the barium

frequently un-telescopes the bowel. Surgery is scheduled only if reduction is not achieved. DIF: Cognitive Level: Knowledge REF: 640 OBJ: N/A

MSC: NCLEX: Physiological Integrity

TOP: Intussusception KEY: Nursing Process Step: Implementation

13. Parents ask the nurse how their infant developed a Meckels diverticulum. The nurses

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response is based on the knowledge that this condition occurs when: a. The yolk sac remains connected to the intestine.

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b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear.

ANS: C

d. There is a weakness in the abdominal wall.

If the vitelline duct fails to disappear completely after birth, a blind pouch may form. DIF: Cognitive Level: Knowledge REF: 640 OBJ: 2 TOP: Meckels Diverticulum KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

14. An infant is admitted to the hospital with severe isotonic dehydration. In planning the infants care, the nurse is aware the infant is at risk for: a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock ANS: D

DIF: Cognitive Level: Analysis REF: 647 OBJ: 5

Shock is the greatest threat to life in isotonic dehydration.

TOP: Dehydration KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

15. A child is brought to the emergency department because he ingested an unknown quantity of

a. Activated charcoal

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b. N-Acetylcysteine

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Tylenol. After gastric lavage is completed, the nurse might expect this child to receive:

c. Vitamin K

ANS: B

d. Syrup of ipecac

Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen. DIF: Cognitive Level: Application REF: 654 OBJ: 10 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

16. The nurse, planning a parent education program about lead poisoning prevention, would include the information that the sources of lead in the community are most likely: a. Increased lead content of air b. Use of aluminum cookware c. Deteriorating paint in older buildings d. Inhaling smog ANS: C

DIF: Cognitive Level: Knowledge REF: 656 OBJ: 11

The primary source of lead is paint from old, deteriorating buildings.

MSC: NCLEX: Physiological Integrity

TOP: Lead Poisoning KEY: Nursing Process Step: Planning

17. A frightened mother calls a neighbor because her child swallowed dishwashing detergent.

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The most appropriate action that the neighbor can advise is: a. Induce vomiting by giving the child syrup of ipecac.

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b. Take the child to the local emergency department. c. Give the child activated charcoal mixed with juice.

ANS: B

d. Give the child milk to soothe affected mucous membranes.

Inducing vomiting is no longer recommended because it may pose additional problems. The child should be taken immediately to the nearest emergency department. DIF: Cognitive Level: Knowledge REF: 653 OBJ: 9 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

18. A child has been diagnosed with ascariasis (roundworm). The statement made by her mother that may suggest a cause for her condition is: a. Ive been airing out the house on these nice breezy days. b. My child often goes out to the garden and pulls up a carrot to eat. c. She runs barefoot so much I have to wash her feet at least twice a day. d. We just remodeled our bathroom at home. ANS: B

DIF: Cognitive Level: Analysis REF: 653 OBJ: N/A

The child can ingest roundworm eggs from contaminated soil.

TOP: Worms KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

b. Hard, constipated

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c. Bulky, frothy

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a. Ribbonlike

19. The nurse would expect the stools of a child with celiac disease to have which appearance?

ANS: C

d. Loose, foul-smelling

Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption. DIF: Cognitive Level: Analysis REF: 638 OBJ: N/A TOP: Celiac Disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. After reviewing dietary restrictions for celiac disease, the nurse determines that a parent understands the information when she states that a grain that can be eaten by a child with celiac disease is: a. Wheat b. Oats c. Barley d. Rice ANS: D

Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease.

DIF: Cognitive Level: Knowledge REF: 638 OBJ: N/A

TOP: Celiac Disease KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. The priority goal of the infants care is to prevent:

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a. Fluid and electrolyte imbalance b. Nutritional deficiency

c. Skin breakdown

d. Malabsorption ANS: A

The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance. DIF: Cognitive Level: Comprehension REF: 641 OBJ: N/A TOP: Gastroenteritis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. The nurse, speaking to the parent of a 3-year-old child who has mild diarrhea, would advise the dietary modification of: a. Soft diet with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution such as Pedialyte d. Chicken soup because it is high in sodium ANS: C

bowel movements.

DIF: Cognitive Level: Application REF: 663 OBJ: 6

An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent

TOP: Diarrhea KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

a. Cry to be picked up

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23. The nurse would expect a child admitted to the hospital for nonorganic failure to thrive to:

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b. Be limp like a rag doll

c. Be responsive to cuddling

ANS: B

d. Weigh in the 10th percentile for age

Some children with failure to thrive have rag-doll limpness (hypotonia) and appear wary of their caregivers. DIF: Cognitive Level: Analysis REF: 649 OBJ: N/A TOP: Failure to Thrive KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

24. Nursing interventions for the mother of a 10-month-old infant with nonorganic failure to thrive would include: a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative characteristics of the infant with the mother c. Having the nurse provide as much of the infants care as possible d. Teaching the mother about the developmental milestones to expect in the next few months

ANS: D The nurse can increase parents knowledge of growth and development by providing anticipatory

guidance about normal developmental milestones.

DIF: Cognitive Level: Application REF: 650 OBJ: N/A

TOP: Failure to Thrive KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 25. The statement by a mother that may indicate a cause of her sons vitamin C deficiency is:

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a. We get our fruits from homemade preserves. b. We use milk from our own goats.

c. We raise all our own vegetables.

d. Were not big meat eaters. ANS: A

Vitamin C is destroyed by heat. DIF: Cognitive Level: Analysis REF: 651 OBJ: N/A TOP: Scurvy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. The nurse instructing a mother how to administer oral nystatin suspension, prescribed to treat thrush, would teach to: a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa.

ANS: D

and then swab it on the inside of the mouth.

An appropriate way to administer nystatin is to moisten a sterile applicator with the medication

DIF: Cognitive Level: Application REF: 652 OBJ: N/A

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TOP: Thrush KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

that:

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27. One reason that infants are more vulnerable to fluid and electrolyte imbalances than adults is

a. They have a smaller surface area than adults in proportion to body weight.

b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water. ANS: C A greater percentage of body water is contained in the extracellular compartment of children under 2 years of age. DIF: Cognitive Level: Knowledge REF: 647 OBJ: 5

TOP: Dehydration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. An infant is admitted to the hospital with severe dehydration. Laboratory results show pH 7.32, PaCO2 40, HCO3 21. The nurse interprets these values as: a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis

d. Respiratory alkalosis ANS: A

A pH lower than 7.35 indicates acidosis. If the childs pH falls in the same line as the HCO 3-, the

problem is metabolic (see Table 27-4).

DIF: Cognitive Level: Application REF: 643 OBJ: N/A

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TOP: Fluid and Electrolyte Imbalance KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE

1. When feeding a child with pyloric stenosis, the nurse will:

Select all that apply.

a. Give a formula thinned with water. b. Burp the baby before and during feeding. c. Give the feeding slowly. d. Refeed if the baby vomits. e. Position baby on left side after feeding.

ANS: B, C, D Children with pyloric stenosis are given formula thickened with cereal; the baby is burped before and during feeding to get rid of any gas in the stomach; the baby is fed slowly and refed if vomiting occurs. The baby is positioned on the right side to allow the weight of the feeding to stay in the stomach against the pyloric valve. DIF: Cognitive Level: Application REF: 636 OBJ: 4 TOP: Pyloric Stenosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION

1. The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for a baby with

gastroenteritis, recognizes that this confirms the ____________________ process that is part of

this disease.

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ANS: inflammatory

DIF: Cognitive Level: Analysis REF: 633 OBJ: 6

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TOP: Gastroenteritis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

NOT: Rationale: The ESR elevates in the presence of an inflammatory response. 2. The nurse explains that because ____________________ drinks cause diuresis, they are not good choices for fluid replacement in a child who is dehydrated. ANS: cola caffeinated

DIF: Cognitive Level: Application REF: 643 OBJ: 6 TOP: Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort NOT: Rationale: Cola drinks or other caffeinated drinks cause diuresis and will further dehydrate an already dehydrated child. 3. The nurse explains that rickets, a deficiency disease that causes bony deformities, is caused by the inadequate supply of vitamin ____________________.

ANS: D

DIF: Cognitive Level: Knowledge REF: 651 OBJ: N/A

TOP: Rickets KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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NOT: Rationale: Rickets is caused by a deficiency of vitamin D. 4. The nurse reminds parents of a child allergic to cows milk that they should avoid foods that

ANS: casein

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list ____________________ as part of their contents.

Chapter 39: The Child with a Genitourinary Disorder MULTIPLE CHOICE 1. The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection in the child. The statement made by the parent indicating a need for further teaching is: a. My daughter should wash and wipe the perineal area from front to back. b. I am only going to have my daughter wear cotton underwear. c. It is acceptable to take frequent bubble baths.

d. She needs to drink lots of fluids and void frequently. ANS: C Oils in bubble bath and similar products are known to irritate the urethra. DIF: Cognitive Level: Application REF: Text Reference: 666, NCP 28-1 OBJ: Objective: N/A TOP: Topic: Acute Urinary Tract Infection KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 2. When asked about correcting the hypospadias of their newborn, the nurse explains that with

this condition:

a. No intervention is necessary as the defect will correct itself over time.

b. Surgical repair of the hypospadias is done before 18 months of age. c. Corrective surgery is usually delayed until the preschool period.

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d. Repairing the defect will increase the risk of testicular cancer.

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ANS: B

Treatment of hypospadias consists of surgical repair and is usually performed before 18 months

of age.

DIF: Cognitive Level: Comprehension REF: Text Reference: 662 OBJ: Objective: 8 TOP: Topic: Hypospadias KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The initial sign of nephrosis that the nurse might note in the child would be:

a. Raspberry-like rash b. Periorbital edema c. Temperature elevation d. Abdominal pain ANS: B The edema of nephrotic syndrome is generalized, and not readily noticed, even by the parents, but an early sign that can be assessed is periorbital edema.

KEY: Nursing Process Step: Assessment

OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome

DIF: Cognitive Level: Application REF: Text Reference: 662

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease

4. While a child is receiving prednisone to treat nephrotic syndrome, it is important for the nurse

a. Infection

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b. Urinary retention

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to assess the child for:

c. Easy bruising

ANS: A

d. Hypoglycemia

Prednisone depresses the immune response and increases susceptibility to infection. Because steroids mask signs of infection, the child must be assessed for more subtle symptoms of illness. DIF: Cognitive Level: Analysis REF: Text Reference: 663 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. During a physical assessment of a hospitalized 5-year-old, the nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. The nurse should: a. Forcibly push the foreskin down over the head of the penis. b. Place a warm compress on the penis. c. Notify the charge nurse. d. Wait a few hours and try again. ANS: C

Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the penis; this should be remedied immediately.

DIF: Cognitive Level: Application REF: Text Reference: 662 OBJ: Objective: 1 TOP: Topic: Paraphimosis

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KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

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6. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. An appropriate nursing intervention for this child would be:

a. Providing activities for the child on restricted activity

b. Feeding the child a protein-restricted diet c. Carefully handling edematous extremities d. Observing the child for evidence of hypotension ANS: A Although children may feel well, activity is limited until hematuria resolves. DIF: Cognitive Level: Application REF: Text Reference: 669

OBJ: Objective: 2 TOP: Topic: Acute Glomerulonephritis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 7. The nurse clarifies that the urinary diversion procedure that would be least damaging to the body image of the adolescent would be: a. Urostomy b. Ileal conduit

c. Nephrostomy d. Suprapubic placement

ANS: B

The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no

external appliance as is needed with the other diversion methods.

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DIF: Cognitive Level: Analysis REF: Text Reference: 664, Table 28-2

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OBJ: Objective: 8 TOP: Topic: Obstructive Uropathy-Urinary Diversions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he needs to get immunizations to enter kindergarten. The nurse clarifies that while on prednisone, immunizations: a. Can interfere with the treatment for nephrosis b. Require that the child have antibiotic coverage c. Can be given in smaller, divided doses d. Should be delayed

ANS: D No vaccinations or immunizations should be administered while the disease is active and during immunosuppressive therapy. DIF: Cognitive Level: Comprehension REF: Text Reference: 668 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk 9. When diuresis has not occurred after a month on corticosteroids, the nurse explains to the

b. Lasix, a diuretic c. Cipro, an antibiotic

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d. Cytoxan, an antisuppressant

a. Ibuprofen, an antiinflammatory agent

parents of a child with nephrotic syndrome that diuresis can be brought about by a protocol of:

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ANS: D

A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have

proven ineffective.

DIF: Cognitive Level: Analysis REF: Text Reference: 667 OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. Because of the hyperkalemia associated with acute glomerulonephritis, the nurse recommends that the child avoid such foods as:

a. Dairy products b. Whole-grain cereals c. Organ meats d. Bananas ANS: D Bananas are very high in potassium and should be avoided. DIF: Cognitive Level: Application REF: Text Reference: 669

OBJ: Objective: 2 TOP: Topic: AGN KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

11. The physical assessment that the nurse would omit in caring for a 2-year-old who has a

Wilms tumor is:

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b. Palpating the abdomen

a. Performing ROM on lower extremities

c. Assessing for bowel sounds

ANS: B

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d. Percussing ankle and knee reflexes

Palpation of the abdomen could disturb the tumor and cause spread of the malignancy. DIF: Cognitive Level: Application REF: Text Reference: 669 OBJ: Objective: 7 TOP: Topic: Wilms Tumor KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

12. Parents are speaking with the urologist about their sons undescended testicle. The nurse determines the childs father understands the information presented when he states: a. An undescended testicle can reduce fertility. b. The testicle usually descends spontaneously during the first month of life. c. Surgical correction reduces the risk for testicular tumors. d. The optimal time to surgically correct the condition is at diagnosis. ANS: A Although orchiopexy improves the condition, the fertility rate among patients may be reduced

even when only one testis is undescended.

KEY: Nursing Process Step: Evaluation

OBJ: Objective: 9 TOP: Topic: Cryptorchidism

DIF: Cognitive Level: Analysis REF: Text Reference: 672

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A parent tells the nurse her child is scheduled for an x-ray of the bladder and urethra that is

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done while the child is urinating. The nurse recognizes this description as a(n): a. Cystometrogram

b. Cystoscopy

c. Voiding cystourethrogram d. Intravenous pyelogram ANS: C An x-ray examination of the bladder and urethra before and during micturition is called a voiding cystourethrogram. DIF: Cognitive Level: Comprehension REF: Text Reference: 661

OBJ: Objective: 4 TOP: Topic: Diagnostic Procedures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. A 6-year-old child with daytime enuresis complains of dysuria and urgency; the nurse recognizes these as signs and symptoms of: a. Urinary tract infection b. Nephrotic syndrome c. Acute glomerulonephritis

d. Vesicoureteral reflux ANS: A

Urinary frequency and pain during micturition are symptoms of acute urinary tract infection.

DIF: Cognitive Level: Analysis REF: Text Reference: 665

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OBJ: Objective: N/A TOP: Topic: Acute Urinary Tract Infection KEY: Nursing Process Step: Assessment

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 15. An appropriate intervention for the child with minimal change nephrotic syndrome who is

edematous would be to:

a. Teach the child to minimize body movements. b. Change the childs position frequently. c. Keep the head of the childs bed flat. d. Keep edematous areas moist and covered. ANS: A The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate skin.

DIF: Cognitive Level: Analysis REF: Text Reference: 667 OBJ: Objective: 5 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. The statement made by a parent of a child with nephrotic syndrome indicating an understanding of discharge teaching is:

b. He can stop taking his medication next week.

a. I will make sure he gets his measles vaccine as soon as he gets home.

c. I should check his urine for protein when he goes to the bathroom.

d. He should eat a low-protein diet for the next few weeks.

ANS: C

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The parents should be instructed to keep a daily record of the childs urinary proteins. DIF: Cognitive Level: Analysis REF: Text Reference: 667

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OBJ: Objective: N/A TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the childs history, the nurse recognizes the probable cause of this condition as: a. Recovered from German measles 2 months ago b. Dysuria since the previous night c. A history of allergy d. A sore throat 2 weeks ago

ANS: D Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which causes an allergic-type response that alters the effectiveness of the glomeruli. DIF: Cognitive Level: Analysis REF: Text Reference: 668 OBJ: Objective: 2 TOP: Topic: Acute Glomerulonephritis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection. The nurse determines the adolescent understands the information when she says a good drink to

keep urine acidic is:

a. Milk

b. Grape juice

ANS: C

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d. Orange juice

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c. Apple juice

Juices such as apple or cranberry help maintain acidity of urine.

DIF: Cognitive Level: Analysis REF: Text Reference: 666, NCP 28-1 OBJ: Objective: N/A TOP: Topic: Acute Urinary Tract Infection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 19. The 6-year-old scheduled for an orchiopexy shyly asks the nurse, What are they going to do to me down there? The nurses best response would be:

a. They are going to fix you up down there b. They will move your testicle from your abdomen to your scrotum. c. What do you think your doctor is going to do? d. You shouldnt worry. Your doctor knows exactly what to do. ANS: C Encourage the patient to talk about what he knows and what feelings he has about the surgery. School-age children have a fear of bodily harm.

DIF: Cognitive Level: Analysis REF: Text Reference: 672

KEY: Nursing Process Step: Implementation

OBJ: Objective: 8 TOP: Topic: Orchipexy

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MULTIPLE RESPONSE

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

1. The nurse caring for a newborn with exstrophy of the bladder will include in the care:

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Select all that apply.

a. Diaper infant tightly.

b. Protect skin around bladder.

c. Position infant on back. d. Prepare for surgical closure. e. Cover exposed bladder with shield. ANS: B, C, D, E The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is constantly bathed with urine. These infants are diapered loosely, if at all. Surgical closure is done as quickly as possible.

DIF: Cognitive Level: Analysis REF: Text Reference: 663 OBJ: Objective: N/A TOP: Topic: Exstrophy of the Bladder KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse caring for a child with nephrotic syndrome is alert to the classic symptoms of this disorder, which are:

Select all that apply. a. Proteinuria b. Grossly bloody urine

c. Hyperalbuminemia

d. Fatigue

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ANS: A, B, D, E

e. Generalized edema

All options listed are those of nephrotic syndrome with the exception of hyperalbuminemia. The

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nephrotic child has hypoalbuminemia, as most of the protein has been spilled in the urine.

DIF: Cognitive Level: Analysis REF: Text Reference: 665-666

OBJ: Objective: 2 TOP: Topic: Nephrotic Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection COMPLETION 1. The nurse explains that the test that measures the pressure and volume of the urine stream is called the ____________________.

ANS: uroflowmeter DIF: Cognitive Level: Knowledge REF: Text Reference: 661 OBJ: Objective: 4 TOP: Topic: Uroflowmeter KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection NOT: Rationale: The test that specifically measures the dynamics of micturition is the

uroflowmeter 2. The nurse uses a diagram to show how the ____________________, the working unit of the

kidney, filters and regulates fluids.

ANS: nephron

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MULTIPLE CHOICE

Chapter 40: The Child with a Musculoskeletal Disorder

1. In planning teaching to parents of a child with Legg-Calv-Perthes disease about the long-term

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effects of this disease, the nurse would include that: a. There are no long-term effects.

b. The disease is self-limiting, resolving itself in a year.

c. Degenerative arthritis may develop later in life. d. There is risk of osteogenic sarcoma in adulthood. ANS: C Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life. DIF: Cognitive Level: Application REF: 560 OBJ: 9

TOP: Legg-Calv-Perthes Disease KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse caring for a child in Bucks skin traction will keep the: a. Child in high-Fowlers position b. Child pulled up in bed c. Childs heel on the bed surface d. Childs feet against the foot of the bed

ANS: B Bucks traction is a type of skin traction that relies on the childs weight as counter-balance The

child must be kept with head elevated no more than 20 degrees, pulled up in bed, and the feet

should not touch the bed surface or the foot of the bed.

DIF: Cognitive Level: Analysis REF: 553 OBJ: 7

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TOP: Bucks Traction KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. When caring for a child in Bucks extension, the nurse would include:

a. Positioning the child with hips flexed 90 at all times

b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule ANS: C The skin exposed to frequent friction may break down. DIF: Cognitive Level: Application REF: 553 OBJ: 7

TOP: Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse reviewing the characteristics of Ewings sarcoma would point out that with Ewings sarcoma: a. Amputation is the accepted treatment. b. The disease is sensitive to radiation and chemotherapy. c. Metastasis is rare.

d. The disease is more prevalent in toddlers and preschoolers. ANS: B

Ewings sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected

extremity is not recommended. This cancer occurs in school-age children and does metastasize.

DIF: Cognitive Level: Comprehension: Physiological Adaptation

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REF: 561 OBJ: N/A TOP: Ewings Sarcoma

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KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse caring for a child with Duchennes muscular dystrophy notes a characteristic

manifestation, which is that the child: a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development ANS: C Frequent falling and clumsiness are clinical manifestations of Duchennes muscular dystrophy.

DIF: Cognitive Level: Knowledge REF: 560 OBJ: 4 TOP: Duchennes Muscular Dystrophy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. This finding is suggestive of the _____ type of juvenile rheumatoid arthritis. a. Pauciarticular

b. Polyarticular c. Systemic

d. Acute febrile

ANS: A

The pauciarticular form of juvenile rheumatoid arthritis is limited to four joints or fewer.

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DIF: Cognitive Level: Analysis REF: 562 OBJ: 8

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TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse is providing instructions about how to treat a sprained ankle. The nurse will

recognize the need for additional teaching when the mother states: a. Apply warm compresses to the ankle for the first 24 hours. b. Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off. c. Wrap the ankle in an Ace bandage for support. d. Keep the leg elevated when sitting. ANS: A

Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation. DIF: Cognitive Level: Analysis REF: 552 OBJ: 12 TOP: Soft Tissue Injury KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse explains that Russell traction is a type of skin traction that: a. Subluxates the tibia

b. Does not interfere with range of motion c. Prevents the knee from flexing

d. Supplies continuous pull in two directions

ANS: D

Russell traction is skin traction, similar to Bucks traction, with a sling positioned under the knee,

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which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions.

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DIF: Cognitive Level: Application REF: 553 OBJ: 7

TOP: Russell Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse who is checking for capillary refill on a child in Bryants traction will record adequate perfusion if the toe regains color in _____ seconds a. 3 b. 4 c. 5 d. 6

ANS: A Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion. DIF: Cognitive Level: Analysis REF: 556 OBJ: 2 TOP: Fracture KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The parent of a child with osteomyelitis asks why his child is in so much pain. The nurses

response will be based on the understanding that the pain of osteomyelitis is caused by: a. The pressure of inelastic bone b. Purulent drainage in the bone marrow

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ANS: B

d. Circulatory congestion of the skin

c. The cast applied on the extremity

Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs,

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producing ischemia and pain.

DIF: Cognitive Level: Analysis REF: 556 OBJ: N/A

TOP: Osteomyelitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. The nurse responds that antibiotic therapy will probably last for: a. 2 weeks b. 6 weeks

c. 2 months d. 3 months ANS: B Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks. DIF: Cognitive Level: Application REF: 556 OBJ: 11 TOP: Osteomyelitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

12. The nurse, assessing the neurovascular status of a child in Russell traction, should report

a. Skin warm to the touch

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c. Ability to wiggle toes

b. Capillary refill less than 3 seconds

immediately the finding of:

ANS: D

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d. Bluish coloration of skin

Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.

DIF: Cognitive Level: Application REF: 556 OBJ: 11 TOP: Neurovascular Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. When a 13-year-old girl is diagnosed with functional scoliosis, the nurse would explain the spinal curvature defect is usually caused by: a. Juvenile rheumatoid arthritis

b. Poor posture c. Heredity d. Myelomeningocele ANS: B Functional scoliosis usually is caused by poor posture, and it is not a spinal disease. DIF: Cognitive Level: Application REF: 563 OBJ: 14 TOP: Scoliosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A nurse assessing a preadolescent child for scoliosis would:

a. Ask the child to bend forward at the waist, and would observe the childs back for asymmetry

b. Observe the gait while the child is walking forward heel to toe

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c. Have the child flex the knees and look for uneven knee height

ANS: A

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d. Look at the childs shoulders and hips while fully clothed

The nurse looks at the back, as the child bends forward, for general body alignment and

asymmetry.

DIF: Cognitive Level: Application REF: 563 OBJ: 14 TOP: Scoliosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. The nurse caring for a child in Bryants traction knows that the risk of serious complications will be reduced by ensuring that:

a. Neurovascular checks are done frequently b. Ace bandages are wrapped tightly c. The baby is restrained from rolling over d. The childs buttocks are resting on the bed ANS: A The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is obstructed.

DIF: Cognitive Level: Analysis REF: 562 OBJ: N/A TOP: Traction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

juvenile rheumatoid arthritis would be:

16. The interventions that would be helpful in relieving morning discomfort associated with

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a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening

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c. Taking a warm tub bath the evening before d. Sleeping with two pillows under the head

ANS: B

Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness.

DIF: Cognitive Level: Application REF: 562 OBJ: 8 TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

17. The nurse providing instructions to an adolescent who has been fitted with a Milwaukee brace would teach the patient to: a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping. ANS: C

DIF: Cognitive Level: Application REF: 563 OBJ: 14

A Milwaukee brace is worn approximately 23 hours a day over a T-shirt that protects the skin.

TOP: Scoliosis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The observation that may cause the nurse to consider the possibility of child abuse when a

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mother says that her young child fell down the basement stairs is: a. The child has red, green, and yellow bruises on his body.

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b. The childs bruises are dispersed on his head, arms, and legs. c. The child had a broken arm last year and is described as accident prone.

ANS: A

d. The childs mother is very anxious for her son to get medical attention.

As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of what happened. DIF: Cognitive Level: Analysis REF: 568 OBJ: 6 TOP: Child Abuse KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. The nursing diagnosis that takes highest priority for this child is: a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction

ANS: A

Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from

muscle spasm and tissue trauma is the highest priority. DIF: Cognitive Level: Analysis REF: 558 OBJ: 10

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TOP: The Child With a Fracture in Traction

KEY: Nursing Process Step: Nursing Diagnosis

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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse notes as an abnormal finding on a musculoskeletal assessment of a 4-year-old that

the child:

a. Has inward-turned knees while standing b. Walks on his toes c. Appears to have flat feet d. Swings his arms when walking ANS: B Toe walking after 3 years of age may indicate a muscle problem.

DIF: Cognitive Level: Analysis REF: 550 OBJ: 2 TOP: Assessment of the Musculoskeletal System KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The nurse understands a difference in the childs skeletal system as compared to an adults is: a. The childs bone is less porous than adult bone. b. Bone growth is not affected by fractures.

c. Bone overgrowth in healing fractures is uncommon.

d. Callus formation in healing fractures occurs more rapidly.

ANS: B

Callus forms more rapidly in the child than the adult.

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DIF: Cognitive Level: Knowledge REF: 551 OBJ: 3 TOP: Differences Between the Child and Adult

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KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. The nurse demonstrates how all traction devices: Select all that apply. a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain

d. Align two bone fragments e. Immobilize the limb ANS: A, B, D, E Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some tractions may relieve pain, many tractions may actually cause pain. DIF: Cognitive Level: Analysis REF: 561 OBJ: 10

TOP: Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. The nurse performing a neurovascular check on a limb in traction will assess: Select all that apply.

c. Color quality

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d. Capillary refill

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b. Degree of sensation

a. Pulse quality

e. Degree of movement

ANS: A, B, C, D, E

All options listed are integral components of the neurovascular assessment that is done to ensure adequate perfusion to a limb in traction. DIF: Cognitive Level: Application REF: 556 OBJ: 11 TOP: Neurovascular Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

COMPLETION 1. The nurse explains that Bryants traction is reserved for children who weigh less than ____________________ pounds. ANS: 40 DIF: Cognitive Level: Knowledge REF: 553 OBJ: 10 TOP: Bryants Traction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control NOT: Rationale: Bryants traction is a skin traction used in the treatment of orthopedic disorders

counterbalance and injury to soft tissues.

of young children who weigh less than 40 pounds. Greater weight would cause excessive

2. The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from

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ANS: pathological

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____________________ fracture.

vigorous weight-bearing during treatment with radiation to reduce the risk of a

Chapter 41: The Child with an Integumentary Disorder/Communicable Disease

MULTIPLE CHOICE

1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-monthold because the infants skin, compared to the adults, has: a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption ANS: D

The childs skin has a dramatically greater ability to absorb than does that of the adult. DIF: Cognitive Level: Application REF: 675, Figure 29-1 OBJ: 2 TOP: Skin Comparison KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse takes into consideration that children who have been diagnosed with infantile

eczema have an increased risk of: a. Pneumonia b. Acne

c. Sun sensitivity

d. Asthma

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ANS: D

Some children with eczema also develop asthma and hay fevertype allergies.

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DIF: Cognitive Level: Application REF: 680 OBJ: 4 TOP: Infantile Eczema KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The appropriate technique for the application of a topical treatment for a child with eczema is: a. Apply skin lotions in a circular motion. b. Apply prescribed ointments with a gloved hand. c. Apply as much and as frequently as relieves the symptoms. d. Choose lanolin-based ointments. ANS: B

The prescribed amount of ointment is usually applied to the skin by a gloved hand in long, smooth strokes. Lanolin-based preparations should be avoided because of a possible allergy to wool. DIF: Cognitive Level: Application REF: 681 OBJ: 4 TOP: Infantile Eczema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. When the 2-day-old infant is noted to have small pustules on her skin, the nurse should:

a. Report it immediately because it may be a staphylococcus infection. b. Keep the affected area dry and clean.

c. Teach the parents how to care for seborrheic dermatitis.

d. Chart the finding as it may be the beginning of a strawberry nevus.

ANS: A

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A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn must be reported immediately.

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DIF: Cognitive Level: Analysis REF: 681 OBJ: N/A

TOP: Staphylococcal Infection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity 5. The home health nurse discovers a family infected with pediculosis and helps the mother understand ways to start eradication of the lice, such as: a. Covering the hair with Vaseline b. Applying a soda-vinegar solution to the hair c. Combing through the hair with a vinegar-water solution d. Shampooing the hair with dish detergent

ANS: C Combing a vinegar/water solution through the hair with a fine-tooth comb and then shampooing is an initial step toward eradication. DIF: Cognitive Level: Application REF: 685 OBJ: 5 TOP: Tinea Capitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. A group of football players is taking oral griseofulvin for tinea pedis. The school nurse

cautions that while they are taking this medication they should avoid: a. Changing socks often

d. Taking corticosteroids

c. Alcohol consumption

b. Eating shellfish

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ANS: C

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Consumption of alcohol while taking griseofulvin will cause severe tachycardia. DIF: Cognitive Level: Application REF: 679 OBJ: N/A

TOP: Tinea Capitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. Before the 17-year-old boy starts a protocol of Accutane for his acne, the nurse should instruct him to: a. Get a prescription for oral contraceptives. b. Increase the dose if his acne worsens. c. Limit intake of chocolate, cola, and peanuts. d. Increase exposure to sunlight.

ANS: A Oral contraceptives are prescribed to young males to reduce androgens, which make the skin greasy. DIF: Cognitive Level: Application REF: 679 OBJ: N/A TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

8. The nurse assesses a major burn as: a. Partial-thickness burn involving 25% of the body surface b. Partial-thickness burn involving 12% of the body surface

c. Full-thickness burn involving 20% of the body surface

d. Full-thickness burn involving 5% of the body surface

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ANS: C

A full-thickness burn involving 10% or more of the body surface is considered a major burn.

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DIF: Cognitive Level: Analysis REF: 687 OBJ: 6 TOP: Burns KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. A child had a burn evidenced by pink skin and blistering. The child complains of pain and is crying. The nurse documents the burn as: a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree

ANS: B A second-degree superficial burn appears blistered, moist, and pink or red. The pain associated with this burn indicates tissue viability. DIF: Cognitive Level: Analysis REF: 688, Table 29-2 OBJ: 6 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The best first action to take when a child sustains a second-degree deep thermal burn to the

hand is to: a. Immerse the burned area in cold water.

c. Break any blisters that are present.

b. Apply ice to the burned area.

d. Apply petroleum jelly to the burned skin.

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ANS: A

First-aid treatment of a second-degree deep thermal burn is immersion of the burned area in

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water to halt the burning process.

DIF: Cognitive Level: Application REF: 715 OBJ: 6

TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. An allergy to which of the following would contraindicate the use of Silvadene as a topical agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations

d. Sulfa ANS: D The use of Silvadene cream on burns is contraindicated if the patient has a sulfa allergy. DIF: Cognitive Level: Analysis REF: 692, Box 29-2 OBJ: 11 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12. Which of the following would help the child with a serious burn meet nutritional needs during the subacute phase of recovery?

a. Decrease calories because the child will be on bed rest and will not need as many.

b. Increase calories and protein to compensate for the healing process. c. Increase fat to replace the layer of fat next to the burned skin.

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d. Decrease carbohydrates and starches because the pancreas is strained by the healing process.

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ANS: B

Frequent meals and snacks high in calories, protein, and iron are needed to meet the increased

metabolic needs of the child with burns.

DIF: Cognitive Level: Comprehension REF: 692 OBJ: 7 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The statement made by a parent indicating an understanding of the topical application of medications for a skin condition is: a. I apply the medication after I give my child a bath.

b. I rub the ointment in a circular motion over the rash. c. I increased the amount of cream because the rash was not improving. d. I use powder and cornstarch to keep the skin dry. ANS: A Absorption of topical medications is best when preparations are applied after a warm bath. DIF: Cognitive Level: Analysis REF: 681 OBJ: 9 TOP: Topical Medications KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. On the first day postburn the bodys fluid reserves have left the circulating volume and closely for:

c. Eschar formation

ANS: B

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d. Fluid overload

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b. Reduced urine output

a. Increasing intracranial pressure

entered the interstitial space, causing massive edema. The nurse monitors the burn victim very

With the fluid shift associated with severe burns, the nurse must be observant for the reduction of

urine, an indication of altered renal function. DIF: Cognitive Level: Analysis REF: 689 OBJ: 7 TOP: Burns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk

15. At a 2-month well-child visit, parents ask the nurse about the red area on the babys neck. They tell the nurse that the mark appeared a few weeks after birth. The nurse recognizes this skin lesion as a(n): a. Port wine nevus b. Strawberry nevus c. Exanthum d. Intertrigo ANS: B

The strawberry nevus is a common hemangioma consisting of dilated capillaries in the dermal space, which may not become apparent for a few weeks after birth.

OBJ: N/A TOP: Congenital Lesions

DIF: Cognitive Level: Comprehension REF: 677, Figure 29-3

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KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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16. A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infants neck and axilla. The nurse explains

the cause of this rash is most likely:

a. Sun exposure

b. Allergic reaction c. Infection d. Heat and moisture ANS: D Miliaria, or prickly heat rash, is caused by excess body heat and moisture.

DIF: Cognitive Level: Analysis REF: 677, Figure 29-5 OBJ: N/A TOP: Skin Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. What is the correct nursing response to a mother who asks, How can I get rid of the babys cradle cap? a. Rub baby oil on the infants head at night and shampoo the hair the next morning.

b. Use a brush with firm bristles to loosen the scales on the babys head several times a day.

c. Wash the babys head every night with a dandruff-control shampoo.

d. Lubricate the babys head every morning with a small amount of olive oil.

ANS: A

hair in the morning.

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Scales may be softened by applying baby oil to the head the evening before, and shampooing the

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DIF: Cognitive Level: Application REF: 678 OBJ: N/A TOP: Seborrheic Dermatitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. The statement made by a parent, indicating the need for further teaching about strategies to control itching for the infant with eczema, is: a. Wool is the best fabric for the babys clothing. b. I should avoid laundry detergents with fragrances. c. I put cotton gloves on the babys hands. d. The babys fingernails are kept short.

ANS: A Clothing should be made of cotton. Wool is avoided because of its allergy potential. DIF: Cognitive Level: Analysis REF: 681 OBJ: 4 TOP: Infantile Eczema KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. When teaching about general skin care measures that could help prevent acne, the nurse

would include: a. Eliminate chocolate, peanuts, and cola from the diet. b. Wash the face with a cleansing product frequently.

d. Eat a balanced diet, and get sufficient rest.

c. Plan indoor activities to avoid sun exposure.

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ANS: D

General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help

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prevent exacerbations.

DIF: Cognitive Level: Application REF: 679 OBJ: 3

TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk 20. When the nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet, the nurse should: a. Report this sign immediately b. Place a warm towel over the extremities c. Gently sponge with cool water d. Medicate for pain

ANS: D A purple flush indicates the return of sensation and causes extreme pain. DIF: Cognitive Level: Application REF: 693 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. A child is brought to the emergency department with burns on the face and chest. The nurses

first priority is: a. Assessing respiratory status b. Administering pain medication

c. Removing clothing

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ANS: A

d. Inserting a Foley catheter

Airway assessment and establishing an airway are the initial priorities.

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DIF: Cognitive Level: Analysis REF: 687 OBJ: 9 TOP: Burns KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. The adolescent girl whose acne is being treated with an antibiotic in addition to topical applications is cautioned by the nurse to expect: a. Lessened effectiveness of oral contraceptives b. Urinary burning and frequency c. Breast engorgement d. Vaginitis

ANS: D Antibiotic therapy can cause a monilial vaginitis. DIF: Cognitive Level: Analysis REF: 679 OBJ: 3 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. When the nurse observes a tarry stool from a 16-year-old burn victim who has been in the

ICU for 2 weeks, the nurse documents and reports the probable complication of: a. Diverticulitis b. Stress diarrhea

c. Curlings ulcer

d. Perforated bowel

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ANS: C

Curlings ulcer is a complication of burn victims resulting from the stress of their trauma.

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DIF: Cognitive Level: Comprehension REF: 689 OBJ: 7 TOP: Burns KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. A child is brought to the emergency department with severe frostbite. The body parts that should be warmed first are: a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso

ANS: D In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the extremities. DIF: Cognitive Level: Application REF: 693 OBJ: 12 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 25. An adolescent is at the pediatricians office because he has been experiencing intense itching,

particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. This symptom is associated with:

a. Scabies

b. Pediculosis capitis c. Tinea corporis

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d. Eczema ANS: A

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Intense itching, especially at night, is characteristic of scabies.

DIF: Cognitive Level: Comprehension REF: 685 OBJ: N/A

TOP: Scabies KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. To avoid diaper rash, the nurse would offer instruction to the parents to: Select all that apply. a. Use emollients.

b. Expose perineum to light and air periodically. c. Use disposable diapers frequently. d. Avoid plastic pants. e. Change diaper frequently. ANS: A, B, C, D, E Keeping the skin dry and protected with emollients, changing the diaper frequently, and avoiding plastic pants will prevent diaper rash.

whooping cough, the nurse explains that those shots:

2. When the 8-year-old asks the nurse how she got the antibodies that kept her from getting

a. Were borrowed antibodies from another person who had whooping cough

c. Strengthened antibodies she was born with

b. Gave her a tiny case of whooping cough and then she made her own antibodies

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d. Are only temporary borrowed antibodies and she needs to have another shot every 5 years ANS: B

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Vaccines contain live weakened or dead organisms not strong enough to cause disease but they stimulate the body to develop an immune reaction and antibodies. This is active acquired

immunity.

DIF: Cognitive Level: Knowledge REF: Text Reference: 717 OBJ: Objective: 3 TOP: Topic: Types of Immunity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse would document a rash that has erythematous circular raised lesions as:

a. Macular b. Papular c. Vesicular d. Pustular ANS: B A papule is a circular, reddened elevated area on the skin. DIF: Cognitive Level: Knowledge REF: Text Reference: 718

OBJ: Objective: 6 TOP: Topic: Rashes

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse would delay the administration of DTaP when the mother says that her infant:

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a. Has diarrhea

b. Had a temperature of 105 F from the previous inoculation c. Is teething

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d. Is traveling with her to Europe in a week

ANS: B

A contraindication to giving the DTaP vaccine is a 105 F temperature following the previous vaccination.

DIF: Cognitive Level: Analysis REF: Text Reference: 721 OBJ: Objective: 4 TOP: Topic: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

5. The type of precaution that is necessary when caring for a toddler with varicella is: a. Contact b. Protective c. Airborne infection d. Large droplet infection ANS: C Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubeola. Small airborne particles caught on floating dust in the room can be

inhaled from anywhere in the room.

DIF: Cognitive Level: Application REF: Text Reference: 718

OBJ: Objective: 2 TOP: Topic: Medical Asepsis and Standard Precautions

KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. A parent is concerned because her son was exposed to varicella at preschool. The nurse would

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tell this parent that the incubation period for varicella is: a. 2 to 10 days

b. 4 to 14 days

c. 3 to 32 days

d. 14 to 21 days ANS: D The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days. DIF: Cognitive Level: Knowledge REF: Text Reference: 713, Table 31-1 OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases

KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 7. The nurse can be assured that parents understand how long a child who has varicella is contagious when they state: a. My child should stay home from school for 6 days after the pox appear. b. My child can return to school when the rash fades. c. My child must stay away from other children until all of the lesions have healed.

d. My child is contagious as long as he has a fever. ANS: A

The child with varicella is contagious for 6 days after the appearance of the rash.

DIF: Cognitive Level: Application REF: Text Reference: 713, Table 31-1

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OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Evaluation

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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. The statement made by a sexually active adolescent girl indicating an understanding of the

prevention of sexually transmitted diseases is:

a. I always douche after intercourse. b. I think you can get a vaccination for STDs now. c. I insist that my partner wear a condom. d. I am protected because I take the pill. ANS: C The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual intercourse.

DIF: Cognitive Level: Application REF: Text Reference: 725 OBJ: Objective: 8 TOP: Topic: Sexually Transmitted Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. The priority nursing diagnosis for a hospitalized infant who is HIV-positive would be: a. Risk for injury b. Altered nutrition

c. Impaired skin integrity

d. Risk for infection

ANS: D

The infant who is HIV-positive has impaired immunologic functioning and is at high risk for

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infection.

DIF: Cognitive Level: Analysis REF: Text Reference: 725

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OBJ: Objective: 7 TOP: Topic: Human Immunodeficiency Virus KEY: Nursing Process Step: Nursing Diagnosis

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A parent of a newborn asked the nurse, When will my baby get the hepatitis B vaccine? The nurse bases a response on the knowledge that the first dose of Comvax should be given to infants born to a hepatitis B-negative mother at: a. 2 months b. 4 months c. 6 months d. 1 year

ANS: B The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free hepatitis B vaccine, should be used for infants born to HBsAg-negative mothers beginning at the 2-month well-child visit. DIF: Cognitive Level: Knowledge REF: Text Reference: 722, Figure 31-6 OBJ: Objective: 4 TOP: Topic: Immunization Schedule KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

information that the child:

a. Came in contact with infected blood

11. The nurse would base a response to a parent about how his child got hepatitis A on the

b. Came in contact with droplets in the air

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c. Was bitten by a mosquito or a tick

ANS: D

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d. Ate shrimp while they were in Mexico

Hepatitis A results from ingestion of contaminated water or shellfish.

DIF: Cognitive Level: Comprehension REF: Text Reference: 714, Table 31-1 OBJ: Objective: 5 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse use when caring for the infant?

a. Large-droplet infection precautions b. Airborne-infection precautions c. Contact precautions d. Protective precautions ANS: C Contact precautions are used when the condition transmits organisms via skin-to-skin contact or indirect touch of a contaminated fomite.

DIF: Cognitive Level: Application REF: Text Reference: 718

KEY: Nursing Process Step: Implementation

OBJ: Objective: 2 TOP: Topic: Medical Asepsis and Standard Precautions

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

13. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the

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most appropriate response for the nurse to make when the child asks, Why do you have to wear a gown and mask when you are in my room?

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a. Nurses and doctors wear gowns and masks because you have a condition that could be spread to others.

b. The gown and mask are to protect you because you could get an infection very easily.

c. Im wearing this because there are a lot of bacteria in the hospital. d. I might look scary but you wont need this after you have had medication for 24 hours. ANS: B Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly susceptible to infection. DIF: Cognitive Level: Application REF: Text Reference: 718

OBJ: Objective: 2 TOP: Topic: Protective Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. The nurse is planning to administer immunizations at a well-child visit when a parent reports the 18-month-old child is allergic to eggs. The vaccine that would be contraindicated is: a. Influenza b. Inactivated polio vaccine

c. Diphtheria, tetanus, acellular pertussis d. Hepatitis B

ANS: A

The influenza vaccine should not be given to children who have an allergy to eggs.

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DIF: Cognitive Level: Analysis REF: Text Reference: 720 OBJ: Objective: 3 TOP: Topic: Nurses Role in Immunizations-Allergy

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KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. The nurse would choose to administer the immunization injection of: a. DTaP subcutaneously b. Hib vaccine prepared in a separate syringe c. Varicella intramuscularly d. Varicella 1 week after the MMR vaccine ANS: B

Hib vaccine must be given in a separate syringe from other vaccines administered at the same time. DIF: Cognitive Level: Analysis REF: Text Reference: 722, Figure 31-6 OBJ: Objective: 3 TOP: Topic: Nurses Role in Immunizations KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. A child was sent to the school nurse because of a rash. The nurse noted the rash was present

on the trunk, extremities, and face. The childs cheeks were bright red. The nurse is aware this type of rash is consistent with:

a. Measles

b. Roseola c. Varicella

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d. Fifth disease ANS: D

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When a child has fifth disease, the child has a generalized rash and the cheeks have a slapped cheek appearance.

DIF: Cognitive Level: Application REF: Text Reference: 713, Table 31-1

OBJ: Objective: 6 TOP: Topic: Common Childhood Communicable Diseases KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 17. The nurse determined the parent understood the information when he stated: a. Ill have my son wear dark clothing on his hike.

b. We should all get the Lyme disease vaccine before our trip. c. Ill get a prescription for amoxicillin to take with us. d. We will wear long pants and long-sleeved shirts in the woods. ANS: D People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites.

Chapter 42: The Child with a Psychosocial Disorder

MULTIPLE CHOICE

1. When a parent asks the nurse to describe what is meant by a learning disability, the nurses

most helpful response would be:

a. A child may have difficulty with perception, language, comprehension, or memory.

b. It is characterized by inattention, impulsiveness, and hyperactivity.

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c. The childs intellectual ability limits his learning.

ANS: A

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d. The child has difficulty learning because of brain damage.

Learning disability is an educational term. Children with learning disabilities may have average

to above-average intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization. DIF: Cognitive Level: Application REF: 739 OBJ: 2 TOP: Learning Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

2. What would be the appropriate response to an adolescent who states, This has been the worst day of my life? a. You should focus your mind on positive thoughts. b. Everybody has a bad day now and then. c. Youre young. What could be so terrible? d. Tell me about the worst day in your life. ANS: D The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and

giving the adolescent full attention.

DIF: Cognitive Level: Application REF: 735, NCP 32-1

OBJ: 3 TOP: Suicide KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im not going to talk about that! Its none of your business, anyway! Leave me alone! The nurse

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recognizes that the outburst was stimulated by the fact that the adolescent is: a. Acting out and needs to be brought under control so the conference can continue

b. Trying to shift the focus of the conference away from himself, and the nurse needs to refocus

c. Demonstrating that this problem requires the assistance of a psychiatrist d. Responding to the discrediting of his parents, which causes anxiety in the child; thus reassurance is needed that blame will not be directed at anyone ANS: D Discrediting parents threatens the childs security and creates anxiety. DIF: Cognitive Level: Comprehension REF: 730 OBJ: 4

TOP: Suicide KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. The nurse answering phone calls at a local suicide prevention hotline would recognize the statement indicating the greatest risk of suicide is: a. I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself. b. My parents arent home and wont be back for 4 hours. That should be enough time for the pills to work. Ive got a hundred of them.

c. My dad will be home first, so hell find me. So I think Ill use his gun. I hope he didnt lock the cabinet.

d. My girlfriend is here with me. She told me to call because I was talking crazy about killing myself.

ANS: B

The risk of death increases when there is a definite plan of action, the means are readily

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available, and the person has few resources for help and support. DIF: Cognitive Level: Analysis REF: 764 OBJ: 3

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TOP: Suicide KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 5. The nurse assesses an early sign of depression in a 15- year-old boy who previously was active

in a band, and had saved his money to buy a special guitar when he: a. Gives up the band to spend time with his girlfriend b. Spends all of his time at the library studying in order to qualify for the honor society c. Gives his guitar away and spends his time listening to music in his room d. Withdraws all of his money out of the bank to buy an expensive leather jacket

ANS: C A major depression is characterized by a prolonged behavioral change from baseline that interferes with school, family life, and age-specific activities, frequently signaled by giving prized possessions away. DIF: Cognitive Level: Analysis REF: 733 OBJ: 3 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

6. A mother is concerned because her teenage son is always in trouble for fighting at school and always seems to be angry. She mentions that her husband drinks a bit. The understanding

guiding the nurses response is:

a. The boy is displaying antisocial behavior and should be evaluated for mental illness.

b. He is displaying one of the typical defense patterns of children of alcoholics and should receive immediate treatment.

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c. The mother is displaying her own anger with her husbands drinking, and she needs immediate intervention.

ANS: D

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d. This boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention.

Early recognition of and intervention for children of alcoholics are paramount. This adolescent is using the coping pattern of acting-out behaviors to deal with the family situation. DIF: Cognitive Level: Comprehension REF: 738 OBJ: 9 TOP: Substance Abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

7. The school nurse suggests to the classroom teacher that the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder would be: a. Seat the child in the back of the room to prevent distractions for other children. b. Pair the child with a student buddy to offer reminders to pay attention. c. Divide work assignments into shorter periods with breaks in between. d. Separate the child from others to increase his focus on schoolwork. ANS: C The child with attention deficit hyperactivity disorder needs breaks between periods of work and

study.

DIF: Cognitive Level: Application REF: 739, Box 32-2

OBJ: 11 TOP: Attention Deficit Hyperactivity Disorder

KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care

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8. The nurse explains that the person who is bulimic: a. Is severely underweight

b. Alternates binge eating with purging

c. Is an introverted perfectionist

d. Has extremely close family relationships ANS: B Bulimia is characterized by alternating binge eating and purge behavior. DIF: Cognitive Level: Knowledge REF: 740 OBJ: 12 TOP: Bulimia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 9. A 14-year-old girl with obsessive-compulsive disorder tells the nurse other teens tease her because she washes her hands many times during the school day. The nurse is aware that this disorder puts the adolescent at greater risk for: a. Anorexia nervosa b. Suicidal behavior c. Attention deficit hyperactivity disorder d. Learning disability

ANS: B

OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for

adolescents with OCD.

DIF: Cognitive Level: Comprehension REF: 732 OBJ: N/A

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TOP: Obsessive-Compulsive Disorder KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

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10. The statement made by a parent of an adolescent with anorexia nervosa indicating an understanding of this condition is:

a. There really isnt anything to worry about. Dont they say you can never be too thin?

b. My daughter just doesnt have much of an appetite. c. She is just trying to punish me for divorcing her father. d. She seems to see herself as fat, even though her weight is below normal. ANS: D Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes.

DIF: Cognitive Level: Application REF: 740, Figure 32-2 OBJ: 12 TOP: Anorexia Nervosa KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 11. An appropriate nursing intervention for a hospitalized child who is autistic would be to: a. Place the child in a location where she can watch all of the activity on the unit. b. Use the childs chronological age as a guide for communication.

c. Keep the childs room free of toys or objects that she might want to take home with her.

d. Organize care to provide as few disruptions to the routine as possible.

ANS: D

During hospitalization, the nurse should provide a highly structured environment with few

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distractions for a child who is autistic.

DIF: Cognitive Level: Application REF: 732 OBJ: N/A

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TOP: Autism KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

12. A nurse planning to speak with a parent support group about childhood autism would include the information:

a. Significant signs of the disorder manifest by 1 year of age. b. The earliest signs of autism are impulsivity and overactivity. c. Autism is usually diagnosed when the child goes to elementary school. d. Medications can cure childhood autism. ANS: A

Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are significant signs of dysfunction by 1 year of age. DIF: Cognitive Level: Application REF: 732 OBJ: N/A TOP: Autism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 13. An adolescent is brought to the emergency department after an automobile accident. When the nurse approaches the adolescent, he becomes combative. The nurse notes his speech is

slurred and his gait is ataxic. The nurse suspects the adolescent has used: a. Alcohol

b. Cocaine c. Amphetamines

d. PCP

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ANS: A

Behavioral signs of alcohol ingestion include slurred speech, short attention span, drowsiness,

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combativeness, and violence.

DIF: Cognitive Level: Analysis REF: 736, Table 32-1

OBJ: 7 TOP: Substance Abuse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 14. When the nurse is collecting a nursing history, an adolescent states that she has tried speed. The nurse recognizes this as the street name for: a. Barbiturates b. Cocaine

c. Methamphetamine d. Marijuana ANS: C Speed is the street name for methamphetamine. DIF: Cognitive Level: Knowledge REF: 737, Table 32-2 OBJ: 7 TOP: Substance Abuse

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

special training in psychoanalytic theory is the:

a. Psychiatrist

ANS: A

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d. Counselor

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b. Psychoanalyst c. Psychologist

15. The nurse explains that the member of the child guidance team who is a medical doctor with

The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a

psychologist. The psychologist is not a medical doctor, and neither is the counselor. DIF: Cognitive Level: Application REF: 731 OBJ: 5 TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 16. Because young children cannot express themselves well, the nurse uses the therapeutic intervention that allows children to act out their feelings, which is:

a. Art therapy b. Play therapy c. Music therapy d. Bibliotherapy ANS: B Play therapy allows a young child to act out with dolls or figures concerns that the child may be unable to adequately express verbally.

DIF: Cognitive Level: Comprehension REF: 731 OBJ: 1 TOP: Play Therapy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

has the negative aspect of:

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a. Sedating the child b. Impairing cognition

17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic child, but

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c. Causing hypotension

d. Creating fluid retention

ANS: B

Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the potential of self-injuring behavior. DIF: Cognitive Level: Application REF: 732 OBJ: 2 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

18. A 9-year-old has been admitted to the hospital after huffing lighter fluid. The nurse should assess for: a. Depressed respirations b. Severe vomiting c. Frightening hallucinations d. Elevation of temperature ANS: A

general sensorium.

DIF: Cognitive Level: Application REF: 735 OBJ: 7

Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and

TOP: Substance Abuse KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physical Integrity: Reducing Risk

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19. As the pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate, the nurse assesses possible dyslexia when the child:

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a. Becomes hyperactive and ceases to read b. Reads the word GOD as DOG

c. Makes up a story rather than reading the text

d. Stutters as he reads ANS: B

Dyslexics often transpose a word as they read; for example, the word is GOD, but it appears to the dyslexic child as the word DOG. DIF: Cognitive Level: Application REF: 739 OBJ: N/A TOP: Dyslexia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection MULTIPLE RESPONSE 1. The nurse describes the members of a mental health team for child guidance as including a: Select all that apply. a. Psychiatrist b. Pediatrician c. Psychologist

d. Dietitian e. Social worker

ANS: A, B, C, E

The traditional members of the child guidance team are the psychiatrist, pediatrician,

psychologist, and social worker. The dietitian is not usually on the treatment team.

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DIF: Cognitive Level: Comprehension REF: 731 OBJ: 5

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TOP: Members of the Child Guidance Team

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

2. The school nurse cautions a group of parents about the prevalence of children who get high by inhaling hydrocarbons and fluorocarbons, such as: Select all that apply. a. Glue b. Chlorine c. Cleaning fluid

d. Copy machine toner e. Aerosol sprays ANS: A, C, E Although there are many products that could be inhaled, the most frequently used products are glue, cleaning fluid, aerosol sprays, Freon, shoe polish, and gasoline products. DIF: Cognitive Level: Application REF: 736, Table 32-1 OBJ: 7 TOP: Inhaling Hydrocarbons

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

that the cause of this disorder is:

3. The nurse takes into consideration in planning the care of an adolescent with anorexia nervosa

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Select all that apply.

a. Discomfort relative to emerging sexuality

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b. Fear of intimacy

c. Pervasive low self-esteem d. Egocentricity

e. Inability to meet developmental needs ANS: A, B, C, D, E All options listed are considered to be the cause of anorexia nervosa. DIF: Cognitive Level: Application REF: 740 OBJ: 12 TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

COMPLETION 1. The nurse documents that every time the child is directed to discuss the relationship with her brother, she complains of shortness of breath and begins to have asthma-like symptoms. The nurse assesses this behavior as a ____________________ reaction. ANS: psychosomatic DIF: Cognitive Level: Analysis REF: 731 OBJ: 1 TOP: Psychosomatic Reaction KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

NOT: Rationale: A psychosomatic reaction is one in which a dysfunction of the body has an

emotional or mental cause.

2. The nurse assists with the intervention of ____________________ therapy, which provides a

physical and social environment that is stable and therapeutic.

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ANS: milieu