More Practice Exam Questions – Flashcards
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A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? A Biophysical profile B Amniocentesis C Maternal serum alpha-fetoprotein (MSAFP) D Transvaginal ultrasound
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D A biophysical profile is a method of biophysical assessment of fetal well-being in the third trimester. An amniocentesis is performed after the fourteenth week of pregnancy. A MSAFP test is performed from week 15 to week 22 of the gestation (weeks 16 to 18 are ideal). An ultrasound is the method of biophysical assessment of the infant that is performed at this gestational age. Transvaginal ultrasound is especially useful for obese women whose thick abdominal layers cannot be penetrated adequately with the abdominal approach.
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A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A sometimes uses vibroacoustic stimulation. B is an invasive test; however, contractions are stimulated. C is considered negative if no late decelerations are observed with the contractions. D is more effective than nonstress test (NST) if the membranes have already been ruptured.
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C Vibroacoustic stimulation is sometimes used with NST. CST is invasive if stimulation is by IV oxytocin but not if by nipple stimulation. No late decelerations indicate a positive CST. CST is contraindicated if the membranes have ruptured.
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The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? A Doppler blood flow analysis B Contraction stress test (CST) C Amniocentesis D Daily fetal movement counts
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A Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high-risk pregnancies because of intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.
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Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that: A chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis. B screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects. C percutaneous umbilical blood sampling (PUBS) is one of the quad-screen tests for Down syndrome. D MSAFP is a screening tool only; it identifies candidates for more definitive procedures.
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D CVS does provide a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. MSAFP screening is recommended for all pregnant women. MSAFP, not PUBS, is part of the quad-screen tests for Down syndrome. This is correct. MSAFP is a screening tool, not a diagnostic tool. Further diagnostic testing is indicated after an abnormal MSAFP.
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The nurse is reviewing lab values to determine Rh incompatibility between mother and fetus. The nurse should assess which specific lab result? A Indirect Coombs test B Hemoglobin level C hCG level D Maternal serum alpha-fetoprotein (MSAFP)
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A The indirect Coombs test is a screening tool for Rh incompatibility. If the maternal titer for Rh antibodies is greater than 1:8, amniocentesis for determination of bilirubin in amniotic fluid is indicated to establish the severity of fetal hemolytic anemia. Hemoglobin reveals the oxygen carrying capacity of the blood. hCG is the hormone of pregnancy. Maternal serum alpha-fetoprotein (MSAFP) levels are used as a screening tool for NTDs in pregnancy
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The nurse is caring for a woman with mitral stenosis who is in the active stage. Which action should the nurse take to promote cardiac function? A Maintain the woman in a side-lying position with the head and shoulders elevated to facilitate hemodynamics B Prepare the woman for delivery by cesarean section since this is the recommended delivery method to sustain hemodynamics C Encourage the woman to avoid the use of narcotics or epidural regional analgesia since this alters cardiac function D Promote the use of the Valsalva maneuver during pushing in the second stage to improve diastolic ventricular filling
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A The side-lying position with the head and shoulders elevated helps to facilitate hemodynamics during labor. A vaginal delivery is the preferred method of delivery for a woman with cardiac disease as it sustains hemodynamics better than a cesarean section. The use of supportive care, medication, and narcotics or epidural regional analgesia is not contraindicated with a woman with heart disease. The use of the Valsalva maneuver during pushing in the second stage should be avoided because it reduces diastolic ventricular filling and obstructs left ventricular outflow.
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Maternal and neonatal risks associated with gestational diabetes mellitus are: A maternal premature rupture of membranes and neonatal sepsis. B maternal hyperemesis and neonatal low birth weight. C maternal preeclampsia and fetal macrosomia. D maternal placenta previa and fetal prematurity
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C Premature rupture of membranes and neonatal sepsis are not risks associated with gestational diabetes. Hyperemesis is not seen with gestational diabetes, nor is there an association with low birth weight of the infant. Women with gestational diabetes have twice the risk of developing hypertensive disorders such as preeclampsia, and the baby usually has macrosomia. Placental previa and subsequent prematurity of the neonate are not risks associated with gestational diabetes.
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In planning for the care of a 30-year-old woman with pregestational diabetes, the nurse recognizes that the most important factor affecting pregnancy outcome is the: A mother's age. B number of years since diabetes was diagnosed. C amount of insulin required prenatally. D degree of glycemic control during pregnancy.
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D Although advanced maternal age may pose some health risks, for the woman with pregestational diabetes the most important factor remains the degree of glycemic control during pregnancy. The number of years since diagnosis is not as relevant to outcomes as the degree of glycemic control. The key to reducing risk in the pregestational diabetic woman is not the amount of insulin required but rather the level of glycemic control. Women with excellent glucose control and no blood vessel disease should have good pregnancy outcomes.
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Diabetes in pregnancy puts the fetus at risk in several ways. Nurses should be aware that: A with good control of maternal glucose levels, sudden and unexplained stillbirth is no longer a major concern. B the most important cause of perinatal loss in diabetic pregnancy is congenital malformations. C infants of mothers with diabetes have the same risks for respiratory distress syndrome because of the careful monitoring. D at birth, the neonate of a diabetic mother is no longer at any greater risk.
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B Even with good control, sudden and unexplained stillbirth remains a major concern. Congenital malformations account for 30% to 50% of perinatal deaths. Infants of diabetic mothers are at increased risk for respiratory distress syndrome. The transition to extrauterine life often is marked by hypoglycemia and other metabolic abnormalities.
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A pregnant woman at 28 weeks of gestation has been diagnosed with gestational diabetes. The nurse caring for this client understands that: A oral hypoglycemic agents can be used if the woman is reluctant to give herself insulin. B dietary modifications and insulin are both required for adequate treatment. C glucose levels are monitored by testing urine 4r times a day and at bedtime. D dietary management involves distributing nutrient requirements over three meals and two or three snacks.
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D Oral hypoglycemic agents can be harmful to the fetus and less effective than insulin in achieving tight glucose control. In some women gestational diabetes can be controlled with dietary modifications alone. Blood, not urine, glucose levels are monitored several times a day. Urine is tested for ketone content; results should be negative. Small frequent meals over a 24-hour period help decrease the risk for hypoglycemia and ketoacidosis.
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During a physical assessment of an at-risk client, the nurse notes generalized edema, crackles at the base of the lungs, and some pulse irregularity. These are most likely signs of: A euglycemia. B rheumatic fever. C pneumonia. D cardiac decompensation.
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D Euglycemia is a condition of normal glucose levels. These symptoms indicate cardiac decompensation. Rheumatic fever can cause heart problems, but it does not present with these symptoms, which indicate cardiac decompensation. Pneumonia is an inflammation of the lungs and would not likely generate these symptoms, which indicate cardiac decompensation. Symptoms of cardiac decompensation may appear abruptly or gradually.
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Thalassemia is a relatively common anemia in which: A an insufficient amount of hemoglobin is produced to fill the red blood cells (RBCs). B RBCs have a normal life span but are sickled in shape. C folate deficiency occurs. D there are inadequate levels of vitamin B12 .
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A Thalassemia is a hereditary disorder that involves the abnormal synthesis of the á or â chains of hemoglobin. An insufficient amount of hemoglobin is produced to fill the RBCs. This is the underlying description for sickle cell anemia. Folate deficiency is the most common cause of megaloblastic anemias during pregnancy. B12 deficiency must also be considered if the pregnant woman presents with anemia.
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From 4% to 8% of pregnant women have asthma, making it one of the most common preexisting conditions of pregnancy. Severity of symptoms usually peaks: A in the first trimester. B between 24 to 36 weeks of gestation. C during the last 4 weeks of pregnancy. D immediately postpartum.
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B Women often have few symptoms of asthma during the first trimester. The severity of symptoms peaks between 24 and 36 weeks of gestation. Asthma appears to be associated with intrauterine growth restriction and preterm birth. During the last 4 weeks of pregnancy symptoms often subside. The period between 24 and 36 weeks of pregnancy is associated with the greatest severity of symptoms. Issues have often resolved by the time the woman delivers.
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A pregnant woman with cardiac disease is informed about signs of cardiac decompensation. She should be told that the earliest sign of decompensation is most often: A orthopnea. B decreasing energy levels. C moist frequent cough and frothy sputum. D crackles (rales) at the bases of the lungs on auscultation.
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B Orthopnea is a finding that appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Decreasing energy level (fatigue) is an early finding of heart failure. Care must be taken to recognize it as a warning rather than a typical change of the third trimester. Cardiac decompensation is most likely to occur early in the third trimester, during childbirth, and during the first 48 hours following birth. A moist, frequent cough appears later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema. Crackles and rales appear later when a failing heart reduces renal perfusion and fluid accumulates in the pulmonary interstitial space, leading to pulmonary edema.
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The nurse is preparing to discharge a 30-year-old woman who has experienced a miscarriage at 10 weeks of gestation. Which statement by the woman would indicate a correct understanding of the discharge instructions? A "I will not experience mood swings since I was only at 10 weeks of gestation." B "I will avoid sexual intercourse for 6 weeks and pregnancy for 6 months." C "I should eat foods that are high in iron and protein to help my body heal." D "I should expect the bleeding to be heavy and bright red for at least 1 week."
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C After a miscarriage a woman may experience mood swings and depression from the reduction of hormones and the grieving process. Sexual intercourse should be avoided for 2 weeks or until the bleeding has stopped and should avoid pregnancy for 2 months. A woman who has experienced a miscarriage should be advised to eat foods that are high in iron and protein to help replenish her body after the loss. The woman should not experience bright red, heavy, profuse bleeding; this should be reported to the health care provider.
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A woman with severe preeclampsia is receiving a magnesium sulfate infusion. The nurse becomes concerned after assessment when the woman exhibits: A a sleepy, sedated affect. B a respiratory rate of 10 breaths/min. C deep tendon reflexes of 2+. D absent ankle clonus.
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B Because magnesium sulfate is a central nervous system (CNS) depressant, the client will most likely become sedated when the infusion is initiated. A respiratory rate of 10 breaths/min indicates that the client is experiencing respiratory depression (bradypnea) from magnesium toxicity. Deep tendon reflexes of 2+ are a normal finding. Absent ankle clonus is a normal finding.
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A woman with severe preeclampsia is being treated with an IV infusion of magnesium sulfate. This treatment is considered successful if: A blood pressure is reduced to prepregnant baseline. B seizures do not occur. C deep tendon reflexes become hypotonic. D diuresis reduces fluid retention.
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B A temporary decrease in blood pressure can occur; however, this is not the purpose of administering this medication. Magnesium sulfate is a central nervous system (CNS) depressant given primarily to prevent seizures. Hypotonia is a sign of an excessive serum level of magnesium. It is critical that calcium gluconate be on hand to counteract the depressant effects of magnesium toxicity. Diuresis is not an expected outcome of magnesium sulfate administration.
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A woman with severe preeclampsia has been receiving magnesium sulfate by IV infusion for 8 hours. The nurse assesses the woman and documents the following findings: temperature 37.1° C, pulse rate 96 beats/min, respiratory rate 24 breaths/min, blood pressure 155/112 mm Hg, 3+ deep tendon reflexes, and no ankle clonus. The nurse calls the physician, anticipating an order for: A hydralazine. B magnesium sulfate bolus . C diazepam. D calcium gluconate.
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A Hydralazine is an antihypertensive commonly used to treat hypertension in severe preeclampsia. An additional bolus of magnesium sulfate may be ordered for increasing signs of central nervous system irritability related to severe preeclampsia (e.g., clonus) or if eclampsia develops. Diazepam sometimes is used to stop or shorten eclamptic seizures. Calcium gluconate is used as the antidote for magnesium sulfate toxicity. The client is not currently displaying any signs or symptoms of magnesium toxicity.
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The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: A bleeding. B intense abdominal pain. C uterine activity. D cramping.
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B Bleeding may be present in varying degrees for both placental conditions. Pain is absent with placenta previa and may be agonizing with abruptio placentae. Uterine activity may be present with both placental conditions. Cramping is a form of uterine activity that may be present in both placental conditions.
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A woman at 39 weeks of gestation with a history of preeclampsia is admitted to the labor and birth unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes; dark red vaginal bleeding; and a tense, painful abdomen. The nurse suspects the onset of: A eclamptic seizure. B rupture of the uterus. C placenta previa. D placental abruption.
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D Eclamptic seizures are evidenced by the presence of generalized tonic-clonic convulsions. Uterine rupture presents as hypotonic uterine activity, signs of hypovolemia, and in many cases the absence of pain. Placenta previa presents with bright red, painless vaginal bleeding. Uterine tenderness in the presence of increasing tone may be the earliest finding of premature separation of the placenta (abruptio placentae or placental abruption). Women with hypertension are at increased risk for an abruption.
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In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? A Administration of blood B Preparation of the woman for invasive hemodynamic monitoring C Restriction of intravascular fluids D Administration of steroids
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A Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters. Central monitoring would not be ordered initially in a woman with DIC because this can contribute to more areas of bleeding. Management of DIC includes volume replacement, not volume restriction. Steroids are not indicated for the management of DIC.
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Signs of a threatened abortion (miscarriage) are noted in a woman at 8 weeks of gestation. What is an appropriate management approach for this type of abortion? A Prepare the woman for a dilation and curettage (D&C). B Place the woman on bed rest for at least 1 week and reevaluate. C Prepare the woman for an ultrasound and blood work. D Comfort the woman by telling her that if she loses this baby, she may attempt to get pregnant again in 1 month.
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C D&C is not considered until signs of the progress to an inevitable abortion are noted or the contents are expelled and incomplete. Bed rest is recommended for 48 hours initially. Repetitive transvaginal ultrasounds and measurement of human chorionic gonadotropin (hCG) and progesterone levels may be performed to determine if the fetus is alive and within the uterus. If the pregnancy is lost, the woman should be guided through the grieving process. Telling the client that she can get pregnant again soon is not a therapeutic response because it discounts the importance of this pregnancy.
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A woman diagnosed with marginal placenta previa gave birth vaginally 15 minutes ago. At the present time she is at the greatest risk for: A hemorrhage. B infection. C urinary retention. D thrombophlebitis.
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A Hemorrhage is the most immediate risk because the lower uterine segment has limited ability to contract to reduce blood loss. Infection is a risk because of the location of the placental attachment site; however, it is not a priority concern at this time. Placenta previa poses no greater risk for urinary retention than with a normally implanted placenta. There is no greater risk for thrombophlebitis than with a normally implanted placenta.
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A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: A weight gain of 1 to 3lbs. B quickening. C fatigue and lethargy. D bloody show.
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D Women usually experience a weight loss of 1 to 3 lbs. Quickening is the perception of fetal movement by the mother, which occurs at 16 to 20 weeks of gestation. Women usually experience a burst of energy or the nesting instinct. Passage of the mucous plug (operculum) also termed pink/bloody show occurs as the cervix ripens.
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The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: A progressive uterine contractions with cervical change. B lightening. C rupture of membranes. D passage of the mucous plug (operculum).
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A Regular, progressive uterine contractions that increase in intensity and frequency are the definitive sign of true labor along with cervical change. Lightening is a premonitory sign indicating that the onset of labor is getting closer. Rupture of membranes usually occurs during labor itself. Passage of the mucous plug is a premonitory sign indicating that the onset of labor is getting closer
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On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? A The fetal presenting part is 1 cm above the ischial spines. B Effacement is 4 cm from completion. C Dilation is 50% completed. D The fetus has achieved passage through the ischial spines.
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A Station of -1 indicates that the fetal presenting part is above the ischial spines and has not yet passed through the pelvic inlet. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Progress of effacement is referred to by percentages, with 100% indicating full effacement and dilation by centimeters, with 10 cm indicating full dilation. Passage through the ischial spines with internal rotation would be indicated by a plus station such as +1.
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In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: A the woman's blood pressure increases during contractions and falls 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 reduces leg cramps. D the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.
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D Blood pressure increases during contractions but remains somewhat elevated between them. Use of the Valsalva maneuver is discouraged during second stage labor because of a number of potentially unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother's perception of pain.
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The nurse knows that the second stage of labor, the descent phase, has begun when: A the amniotic membranes rupture. B the cervix cannot be felt during a vaginal examination. C the woman experiences a strong urge to bear down. D the presenting part is below the ischial spines.
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C Rupture of membranes has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm of dilation.
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Nurses can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A Latent: mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B Active: moderate, regular contractions; 4 to 7 cm dilation; duration of 3 to 6 hours C Lull: no contractions; dilation stable; duration of 20 to 60 minutes D Transition: very strong but irregular contractions; 8 to 10 cm dilation; duration of 1 to 2 hours
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B The latent phase is characterized by mild to moderate, irregular contractions; dilation up to 3 cm; brownish to pale pink mucus; and a duration of 6 to 8 hours. The active phase is characterized by moderate, regular contractions; 4 to 7 cm dilation; and a duration of 3 to 6 hours. No official "lull" phase exists in the first stage. The transition phase is characterized by strong to very strong, regular contractions; 8 to 10 cm dilation; and a duration of 20 to 40 minutes.
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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
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C A. A semirecumbent position does not assist in increasing the size of the pelvic outlet. B. Although sitting may assist with fetal descent, this position does not increase the size of the pelvic outlet. C. 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. D. A side-lying position is unlikely to assist in increasing the size of the pelvic outlet.
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Concerning the third stage of labor, nurses should be aware that: A the placenta eventually detaches itself from a flaccid uterus B the duration of the third stage may be as short as 3 to 5 minutes C it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface D the major risk for women during the third stage is a rapid heart rate
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B A. The placenta cannot detach itself from a flaccid (relaxed) uterus. B. The third stage of labor lasts from birth of the fetus until the placenta is delivered. The duration may be as short as 3 to 5 minutes, although up to 1 hour is considered within normal limits. C. Which surface of the placenta comes out first is not clinically important. D. The major risk for women during the third stage of labor is postpartum hemorrhage. The risk of hemorrhage increases as the length of the third stage increases.
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A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A encourage the woman to breathe more slowly. B help the woman breathe into a paper bag. C turn the woman on her side. D administer a sedative.
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B Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension.
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A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A Encourage her to empty her bladder. B Decrease her intravenous (IV) rate to a keep vein-open rate. C Turn the woman to the left lateral position or place a pillow under her hip. D No action is necessary since a decrease in the woman's blood pressure is expected.
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C Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.
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A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: A fentanyl (Sublimaze). B promethazine (Phenergan). C butorphanol tartrate (Stadol). D nalbuphine (Nubain).
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A Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.
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A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A counterpressure against the sacrum. B pant-blow (breaths and puffs) breathing techniques. C effleurage. D biofeedback.
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A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.
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Nurses should be aware of the difference experience can make in labor pain, such as: A sensory pain for nulliparous women often is greater than for multiparous women during early labor. B affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C women with a history of substance abuse experience more pain during labor. D multiparous women have more fatigue from labor and therefore experience more pain.
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A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.
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With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: A either hot or cold applications may provide relief, but they should never be used together in the same treatment. B acupuncture can be performed by a skilled nurse with just a little training. C hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. D therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.
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C Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. The woman and her partner should experiment with massage before labor to see what might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.
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With regard to systemic analgesics administered during labor, nurses should be aware that: A systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B effects on the fetus and newborn can include decreased alertness and delayed sucking. C IM administration is preferred over IV administration. D IV patient-controlled analgesia (PCA) results in increased use of an analgesic.
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B Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.
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After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A visceral. B referred C somatic. D afterpain.
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B Visceral pain is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.
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When assessing a fetal heart rate (FHR) tracing, the nurse notes a decrease in the baseline rate from 155 to 110. The rate of 110 persists for more than 10 minutes. The nurse could attribute this decrease in baseline to: A maternal hyperthyroidism. B initiation of epidural anesthesia that resulted in maternal hypotension. C maternal infection accompanied by fever. D alteration in maternal position from semirecumbent to lateral.
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B Hyperthyroidism would result in baseline tachycardia. Fetal bradycardia is the pattern described and results from the hypoxia that would occur when uteroplacental perfusion is reduced by maternal hypotension. The woman receiving epidural anesthesia needs to be well hydrated before and during induction of the anesthesia to maintain an adequate cardiac output and blood pressure. A maternal fever could cause fetal tachycardia. Assumption of a lateral position enhances placental perfusion and should result in a reassuring FHR pattern.
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On review of a fetal monitor tracing, the nurse notes that for several contractions, the fetal heart rate decelerates as a contraction begins and returns to baseline just before it ends. The nurse should: A describe the finding in the nurse's notes. B reposition the woman onto her side. C call the physician for instructions. D administer oxygen at 8 to 10 L/min with a tight face mask.
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A An early deceleration pattern from head compression is described. No action other than documentation of the finding is required since this is an expected reaction to compression of the fetal head as it passes through the cervix. These actions would be implemented when non-reassuring or ominous changes are noted. These actions would be implemented when non-reassuring or ominous changes are noted. These actions would be implemented when non-reassuring or ominous changes are noted.
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Which finding meets the criteria of a reassuring fetal heart rate (FHR) pattern? A FHR does not change as a result of fetal activity. B Average baseline rate ranges between 100 and 140 beats/min. C Mild late deceleration patterns occur with some contractions. D Variability averages between 6 to 10 beats/min.
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D FHR should accelerate with fetal movement. Baseline range for the FHR is 120 to 160 beats/min. Late deceleration patterns are never reassuring, although early and mild variable decelerations are expected, reassuring findings. Variability indicates a well-oxygenated fetus with a functioning autonomic nervous system.
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Late deceleration patterns are noted when assessing the monitor tracing of a woman whose labor is being induced with an infusion of Pitocin. The woman is in a side-lying position, and her vital signs are stable and fall within a normal range. Contractions are intense, last 90 seconds, and occur every 1½ to 2 minutes. The nurse's IMMEDIATE action would be to: A change the woman's position. B stop the Pitocin. C elevate the woman's legs. D administer oxygen via a tight mask at 8 to 10 L/min.
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B The woman is already in an appropriate position for uteroplacental perfusion. Late deceleration patterns noted are most likely related to alteration in uteroplacental perfusion associated with the strong contractions described. The immediate action would be to stop the Pitocin infusion since Pitocin is an oxytocic that stimulates the uterus to contract. Elevation of her legs would be appropriate if hypotension were present. Oxygen is appropriate but not the immediate action.
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You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase IV fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take? A Notify nursery nurse of imminent delivery. B Insert a Foley catheter. C Start oxytocin (Pitocin). D Notify the primary health care provider immediately (HCP).
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D This is not the most important nursing measure at this time. The patient needs to be evaluated by the HCP immediately to determine whether delivery is warranted at this time. If the FHR were to continue in an abnormal or non-reassuring pattern, a cesarean section may be warranted. This would require the insertion of a Foley catheter; however, the physician must make that determination. Oxytocin may put additional stress on the fetus. To relieve an FHR deceleration, the nurse can reposition the mother, increase IV fluid, and provide oxygen. Also if oxytocin is infusing, it should be discontinued. If the FHR does not resolve, the primary health care provider should be notified immediately.
question
When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware that: A the examiner's hand should be placed over the fundus before, during, and after contractions. B the frequency and duration of contractions are measured in seconds for consistency. C contraction intensity is given a judgment number of 1 to 7 by the nurse and client together. D the resting tone between contractions is described as either placid or turbulent.
answer
A The assessment is done by palpation; duration, frequency, intensity, and resting tone must be assessed. The duration of contractions is measured in seconds; the frequency is measured in minutes. The intensity of contractions usually is described as mild, moderate, or strong. The resting tone usually is characterized as soft or relaxed.
question
The nurse caring for a laboring woman is aware that maternal cardiac output can be increased by: A change in position. B oxytocin administration. C regional anesthesia. D intravenous analgesic.
answer
A Maternal supine hypotension syndrome is caused by the weight and pressure of the gravid uterus on the ascending vena cava when the woman is in a supine position. This reduces venous return to the woman's heart, as well as cardiac output, and subsequently reduces her blood pressure. The nurse can encourage the woman to change positions and avoid the supine position. Oxytocin administration may reduce maternal cardiac output. Regional anesthesia may reduce maternal cardiac output. Intravenous analgesic may reduce maternal cardiac output.
question
Fetal well-being during labor is assessed by: A the response of the fetal heart rate (FHR) to uterine contractions (UCs). B maternal pain control. C accelerations in the FHR. D an FHR greater than 110 beats/min.
answer
A Fetal well-being during labor can be measured by the response of the FHR to UCs. In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min with no periodic changes, a moderate baseline variability, and accelerations with fetal movement. Maternal pain control is not the measure used to determine fetal well-being in labor. Although FHR accelerations are a reassuring pattern, they are only one component of the criteria by which fetal well-being is assessed. Although an FHR greater than 110 beats/min may be reassuring, it is only one component of the criteria by which fetal well-being is assessed. More information is needed to determine fetal well-being.
question
Which characteristic is associated with false labor contractions? A Painless B Decrease in intensity with ambulation C Regular pattern of frequency established D Progressive in terms of intensity and duration
answer
B True labor contractions are painful. Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation. A regular pattern of frequency is a sign of true labor. A progression of intensity and duration indicates true labor.
question
A pregnant couple has formulated a birth plan and is reviewing it with the nurse at an expectant parent's class. Which aspect of their birth plan would be considered unrealistic and require further discussion with the nurse? A "My husband and I have agreed that my sister will be my coach since he becomes anxious with regard to medical procedures and blood. He will be nearby and check on me every so often to make sure everything is OK." B "We plan to use the techniques taught in the Lamaze classes to reduce the pain experienced during labor." C "We want the labor and birth to take place in a birthing room. My husband will come in the minute the baby is born." D "We do not want the fetal monitor used during labor since it will interfere with movement and doing effleurage."
answer
D These are acceptable requests during labor and delivery. These are acceptable requests during labor and delivery. These are acceptable requests during labor and delivery. Since monitoring is essential to assess fetal well-being, it is not a factor that can be determined by the couple. The nurse should fully explain its importance. The option for intermittent electronic monitoring could be explored if this is a low-risk pregnancy and as long as labor is progressing normally.
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The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia is: A severe postpartum headache. B limited perception of bladder fullness. C increase in respiratory rate. D hypotension.
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D Headache is not a side effect since the spinal fluid is not disturbed by this anesthetic because it would be with a low spinal (saddle block) anesthetic. Limited perception of bladder fullness is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication. Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure.
question
When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include: A encouraging the woman to try various upright positions, including squatting and standing. B telling the woman to start pushing as soon as her cervix is fully dilated. C continuing an epidural anesthetic so that pain is reduced and the woman can relax. D coaching the woman to use sustained, 10- to 15-second, closed-glottis bearing-down efforts with each contraction.
answer
A Upright positions and squatting may enhance the progress of fetal descent. Many factors dictate when a woman will begin pushing. Complete cervical dilation is necessary, but it is only one factor. If the fetal head is still in a higher pelvic station, the physician or midwife may allow the woman to "labor down" (allowing more time for fetal descent, thereby reducing the amount of pushing needed) if she is able. The epidural may mask the sensations and muscle control needed for the woman to push effectively. Closed-glottic breathing may trigger the Valsalva maneuver, which increases intrathoracic and cardiovascular pressure, reducing cardiac output and inhibiting perfusion of the uterus and placenta. In addition, holding the breath for longer than 5 to 7 seconds diminishes the perfusion of oxygen across the placenta, resulting in fetal hypoxia.
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Evidence-based care practices designed to support normal labor and birth recommend which practice during the immediate newborn period? A The healthy newborn should be taken to the nursery for a complete assessment. B After drying, the infant should be given to the mother wrapped in a receiving blanket. C Encourage skin-to-skin contact of mother and baby. D The father or support person should be encouraged to hold the infant while awaiting delivery of the placenta.
answer
C Although this is the practice in many facilities, it is neither evidence-based nor supportive of family-centered care. This is a common practice and more family friendly than separating mother and baby; however, ideally the baby should be placed skin to skin. The unwrapped infant should be placed on the woman's bare chest or abdomen, then covered with a warm blanket. Skin-to-skin contact keeps the newborn warm, prevents neonatal infection, enhances physiologic adjustment to extrauterine life, and fosters early breastfeeding. The father or support person is likely anxious to hold and admire the newborn. This can happen after the infant has been placed skin to skin and breastfeeding has been initiated.
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Which description of the phases of the second stage of labor is accurate? A Latent phase: feels sleepy, fetal station is 2+ to 4+, duration is 30 to 45 minutes B Active phase: overwhelmingly strong contractions, Ferguson reflux activated, duration is 5 to 15 minutes C Descent phase: significant increase in contractions, Ferguson reflux activated, average duration varies D Transitional phase: woman "laboring down," fetal station is 0, duration is 15 minutes
answer
C The latent phase is the lull, or "laboring down," period at the beginning of the second stage. It lasts 10 to 30 minutes on average. The second stage of labor has no active phase. The descent phase begins with a significant increase in contractions, the Ferguson reflex is activated, and the duration varies, depending on a number of factors. The transition phase is the final phase in the second stage of labor; contractions are strong and painful.
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Which test is performed to determine if membranes are ruptured? A Urine analysis B Fern test C Leopold maneuvers D Artificial Rupture of Membranes (AROM)
answer
B A urine analysis should be performed on admission to labor and delivery. This test is used to identify the presence of glucose and protein. In many instances a sterile speculum examination and a Nitrazine (pH) and fern test are performed to confirm that fluid seepage is indeed amniotic fluid. The nurse performs Leopold maneuvers to identify fetal lie, presenting part, and attitude. AROM is the procedure of artificially rupturing membranes, usually with a device known as an amnihook.
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A woman who is 39 weeks pregnant expresses fear about her impending labor and how she will manage. The nurse's best response is: A "Don't worry about it. You'll do fine." B "It's normal to be anxious about labor. Let's discuss what makes you afraid." C "Labor is scary to think about, but the actual experience isn't." D "You may have an epidural. You won't feel anything."
answer
B This statement negates the woman's fears and is not therapeutic. This statement allows the woman to share her concerns with the nurse and is a therapeutic communication tool. This statement negates the woman's fears and offers a false sense of security. This statement is not true. A number of criteria must be met for use of an epidural. Furthermore, many women still experience the feeling of pressure with an epidural.
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A laboring woman's amniotic membranes have just ruptured. The immediate action of the nurse would be to: A assess the fetal heart rate (FHR) pattern. B perform a vaginal examination. C inspect the characteristics of the fluid. D assess maternal temperature.
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A The first nursing action after the membranes are ruptured is to check the FHR. Compression of the cord could occur after rupture leading to fetal hypoxia as reflected in an alteration in FHR pattern, characteristically variable decelerations. The same initial action should follow artificial rupture of the membranes (amniotomy). These are all important and should be done after the FHR and pattern are assessed. These are all important and should be done after the FHR and pattern are assessed. These are all important and should be done after the FHR and pattern are assessed.
question
A woman is evaluated to be using an effective bearing-down effort if she: A begins pushing as soon as she is told that her cervix is fully dilated and effaced. B takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. C uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. D continues to push for short periods between uterine contractions throughout the second stage of labor.
answer
B Bearing-down efforts should begin during the active-descent phase of the second stage of labor when the urge to bear down (Fresno reflex) is perceived. Cleansing breaths at the onset of a contraction allow it to build to a peak before pushing begins. They also enhance gas exchange in the alveoli and help the woman relax after the uterine contraction subsides. Women should avoid closed-glottis pushing (Valsalva maneuver) since uteroplacental perfusion is usually reduced. Open-glottis pushing is recommended. The woman should push with contractions to combine the force of both powers of labor: uterine and abdominal. Pushing gently between contractions is only advised when the fetal head is being delivered.
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In planning for an expected cesarean birth for a woman who has given birth by cesarean previously and who has a fetus in the transverse presentation, the nurse includes which information? A "Because this is a repeat procedure, you are at the lowest risk for complications." B "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." C "Because this is your second cesarean birth, you will recover faster." D "You will not need preoperative teaching because this is your second cesarean birth."
answer
B This statement is not accurate. Maternal and fetal risks are associated with every cesarean section. This statement is the most appropriate. This statement is not accurate. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure.
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For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? A Fetal heart rate of 116 beats/min B Cervix dilated 2 cm and 50% effaced C Score of 8 on the biophysical profile D One fetal movement noted in 1 hour of assessment by the mother
answer
D A fetal heart rate of 116 beats/min is a normal finding at 42 weeks of gestation. Cervical dilation of 2 cm with 50% effacement is a normal finding in a 42-week gestation woman. A score of 8 on the BPP is a normal finding in a 42-week gestation pregnancy. Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If fewer than four movements have been felt by the mother, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation.
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A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? A Place the woman in the knee-chest position. B Cover the cord in a sterile towel saturated with warm normal saline. C Prepare the woman for a cesarean birth. D Start oxygen by face mask.
answer
A A. The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. B. If the cord is protruding from the vagina, it may be covered with a sterile towel soaked in saline. Although this is an appropriate intervention, relieving pressure on the cord is the nursing priority. C. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete. D. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. This intervention should be initiated after pressure is relieved on the cord. Not only should the woman be placed in knee-chest position, the nurse may also use her gloved hand or two fingers to lift the presenting part off the cord.
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A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: A uterine contractions occurring every 8 to 10 minutes B a fetal heart rate (FHR) of 180 with absence of variability C the client needing to void D rupture of the client's amniotic membranes
answer
B The oxytocin should be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. This FHR is non-reassuring. The oxytocin should be immediately discontinued and the physician should be notified. This is not an indication to discontinue the oxytocin induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is non-reassuring or the client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be notified that the client's membranes have ruptured.
question
With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: A the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. B there are no important maternal (as opposed to fetal) contraindications. C its most important function is to afford the opportunity to administer antenatal glucocorticoids. D if the client develops pulmonary edema while on tocolytics, IV fluids should be given.
answer
C Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Tocolytic-induced edema can be caused by IV fluids.
question
With regard to dysfunctional labor, nurses should be aware that: A women who are underweight are more at risk. B women experiencing precipitous labor are about the only "dysfunctionals" not to be exhausted. C hypertonic uterine dysfunction is more common than hypotonic dysfunction. D abnormal labor patterns are most common in older women.
answer
B Short women more than 30 lbs overweight are more at risk for dysfunctional labor. Precipitous labor lasts less than 3 hours. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years of age.
question
A nurse providing care to a woman in labor should be aware that cesarean birth: A is declining in frequency in the United States. B is more likely to be done for the poor in public hospitals who do not get the nurse counseling that wealthier clients do. C is performed primarily for the benefit of the fetus. D can be either elected or refused by women as their absolute legal right.
answer
C Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear.
question
Which statement is most likely to be associated with a breech presentation? A Least common malpresentation B Descent is rapid C Diagnosis by ultrasound only D High rate of neuromuscular disorders
answer
D Breech is the most common malpresentation affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as is the fetal head. Diagnosis is made by abdominal palpation and vaginal examination. It is confirmed by ultrasound. Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus.
question
Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: A return to prepregnant weight is usually achieved by the end of the postpartum period. B fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb weight loss. C the expected weight loss immediately after birth averages about 11 to 13 lbs. D lactation will inhibit weight loss since caloric intake must increase to support milk production.
answer
C Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 lbs. The expected weight loss immediately following delivery is 11 to 13 lbs, followed by a gradual decrease and a return to prepregnancy weight in 2 to 3 months. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process.
question
The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: A wear a snug, supportive bra. B allow warm water to soothe the breasts during a shower. C express milk from breasts occasionally to relieve discomfort. D place absorbent pads with plastic liners into her bra to absorb leakage.
answer
A A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.
question
A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A urinary tract infection. B excessive uterine bleeding. C a ruptured bladder. D bladder wall atony.
answer
B A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. Excessive bleeding can occur immediately after birth if the bladder becomes distended, because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.
question
What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? A "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." C "I will not have a menstrual cycle for 6 months after childbirth." D "My first menstrual cycle will be heavier than normal and then will be light for several months after."
answer
B She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. This is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.
question
With regard to afterbirth pains, nurses should be aware that these pains are: A caused by mild, continual contractions for the duration of the postpartum period. B more common in first-time mothers. C more noticeable in births in which the uterus was overdistended. D alleviated somewhat when the mother breastfeeds.
answer
C The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus. Breastfeeding intensifies afterbirth pain because it stimulates contractions.
question
Postbirth uterine/vaginal discharge, called lochia: A is similar to a light menstrual period for the first 6 to 12 hours. B is usually greater after cesarean births. C will usually decrease with ambulation and breastfeeding. D should smell like normal menstrual flow unless an infection is present.
answer
D Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection.
question
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include: A little if any change B leakage of milk at let-down C swollen, warm, and tender on palpation D a few blisters and a bruise on each areola E small amount of clear, yellow fluid expressed
answer
A Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used. E. Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts during the first 24 hours.
question
When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A massage the fundus. B administer Methergine, 0.2 mg PO, that has been ordered prn. C assist the woman to empty her bladder. D recognize this as an expected finding during the first 24 hours following birth.
answer
C A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.
question
The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A place her on a bedpan to empty her bladder. B massage her fundus. C call the physician. D administer Methergine, 0.2 mg IM, which has been ordered prn.
answer
B There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.
question
On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: A begin an IV infusion of Ringer's lactate solution. B assess the woman's vital signs. C call the woman's primary health care provider. D massage the woman's fundus.
answer
D The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from an impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.
question
Excessive blood loss after childbirth can have several causes; however, the most common is: A vaginal or vulvar hematomas. B unrepaired lacerations of the vagina or cervix. C failure of the uterine muscle to contract firmly. D retained placental fragments.
answer
C Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
question
Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth? A 1 hour B 30 minutes C 2 hours D 4 hours
answer
A Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the Baby-Friendly Hospital Initiative (BFHI) mandates 1 hour. Ideally an infant should go no longer than 2 hours after delivery before being put to breast. This is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.
question
Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: A bladder distention B uterine atony C constipation D hematoma formation
answer
D Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
question
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A tell the woman she can rest after she feeds her baby. B recognize this as a behavior of the taking-hold stage. C record the behavior as ineffective maternal-newborn attachment. D take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.
answer
D The woman should not be told what to do and needs to care for her own well-being. The taking-hold stage occurs about 1 week after birth. Because the woman needs to rest does not indicate ineffective maternal-newborn attachment. The behavior described is typical of this stage and not a reflection of ineffective attachment unless it persists. Mothers need to reestablish their own well-being to effectively care for their baby.
question
Parents can facilitate the adjustment of their other children to a new baby by: A having the children choose or make a gift to give to the new baby on its arrival home. B emphasizing activities that keep the new baby and other children together. C having the mother carry the new baby into the home so she can show him or her to the other children. D reducing stress on other children by limiting their involvement in the care of the new baby.
answer
A Having the sibling make or choose a gift for the new baby helps to make the child feel a part of the process. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.
question
A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: A foster an active role in the baby's care. B provide time for the mother to reflect on the events of and her behavior during childbirth. C recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. D promote maternal independence by encouraging her to meet her own hygiene and comfort needs.
answer
B Once the mother's needs are met, she would be more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition.
question
The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? A Talks and coos to her son B Seldom makes eye contact with her son C Cuddles her son close to her D Tells visitors how well her son is feeding
answer
B Talking and cooing to her son is a normal infant-parent interaction. The woman should be encouraged to hold her infant in the en face position and make eye contact with him. Cuddling is a normal infant-parent interaction. Sharing her son's success at feeding is a normal infant-parent interaction.
question
In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior? A The parents have difficulty naming the infant. B The parents hover around the infant, directing attention to and pointing at the infant. C The parents make no effort to interpret the actions or needs of the infant. D The parents do not move from fingertip touch to palmar contact and holding.
answer
B Reluctance to name the baby is an inhibiting behavior. Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. Failure to interpret the actions and needs of the infant is an inhibiting behavior. Lack of fingertip, palmar touch, and holding represents an inhibiting behavior.
question
Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? A PPD symptoms are consistently severe. B This syndrome affects only new mothers. C PPD can easily go undetected. D Only mental health professionals should teach new parents about this condition.
answer
C PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers. PPD may also occur in new fathers. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.
question
Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect: A bladder distention. B uterine atony. C constipation. D hematoma formation.
answer
D Bladder distention would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
question
Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to: A acidify the urine by drinking three glasses of orange juice each day. B maintain a fluid intake of 1 to 2 L/day. C empty her bladder every 4 hours throughout the day. D perform perineal care on a regular basis.
answer
D Urine is acidified with cranberry juice. The woman should drink at least 3 L of fluid each day. The woman should empty her bladder every 2 hours to prevent stasis of urine. Keeping the perineum clean will help prevent a urinary tract infection.
question
The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: A call the woman's primary health care provider B administer the standing order for an oxytocic C palpate the uterus and massage it if it is boggy D assess maternal blood pressure and pulse for signs of hypovolemic shock
answer
C The most important nursing intervention is to stop the bleeding. Once the nurse has applied firm massage of the uterine fundus, the primary health care provider should be notified or the nurse can delegate this task to another staff member. This intervention is appropriate after assessment and immediate steps have been taken to control the bleeding. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Vital signs will need to be ascertained after fundal massage has been applied.
question
Which postpartum conditions are considered medical emergencies that require immediate treatment? A Inversion of the uterus and hypovolemic shock B Hypotonic uterus and coagulopathies C Subinvolution of the uterus and idiopathic thrombocytopenic purpura D Uterine atony and disseminated intravascular coagulation (DIC)
answer
A Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin. Coagulopathies should be identified before delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment. ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications; however, uterine inversion is a medical emergency requiring immediate intervention.
question
Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? A Endometritis B Wound infections C Mastitis D Urinary tract infections (UTIs)
answer
C Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.
question
The priority nursing intervention for a woman who suffered a perineal laceration is to: A apply a cold compress. B establish hemostasis. C administer analgesia. D administer a stool softener.
answer
B Bleeding should be stopped first. After bleeding has been controlled, the care of the woman with lacerations of the perineum includes analgesia administration, hot or cold applications, and stool softeners. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.
question
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? A Apical heart rate of 90 beats/min, slightly irregular, when awake and active B Acrocyanosis C Harlequin color sign D Weight loss representing 5% of the newborn's birth weight
answer
A The heart rate of a newborn should range from 120 to 140 beats/min, especially when active. The rate should be regular with sharp, strong sounds. Acrocyanosis is a normal finding in a newborn at 24 hours of age. A harlequin sign is a normal finding related to the immature neurologic system of a newborn. A 5% weight loss is acceptable in the newborn.
question
When caring for a newborn, the nurse must be alert for signs of cold stress, including: A decreased activity level. B increased respiratory rate. C hyperglycemia. D shivering.
answer
B Infants experiencing cold stress would have an increased activity level. An increased respiratory rate is a sign of cold stress in the newborn. Hypoglycemia would occur with cold stress. Newborns are unable to shiver as a means of increasing heat production; they increase their activity level instead.
question
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern since the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by: A telling the mother not to worry since all breastfed babies have this type of stool. B explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements. C asking the mother what she ate at her last meal. D suggesting that the mother ask her pediatrician to explain newborn stool patterns to her.
answer
B This type of stool is the first stool that all newborns, not just breastfed babies, have. At this early age this type of stool (meconium) is typical of both bottle-fed and breastfed newborns. The mother's nutritional intake is not responsible for the appearance of meconium stool. The nurse is fully capable of and responsible for teaching a new mother about the characteristics of her newborn, including expected stool patterns.
question
When weighing a newborn, the nurse should: A leave its diaper on for comfort. B place a sterile scale paper on the scale for infection control. C keep hand on the newborn's abdomen for safety. D weigh the newborn at the same time each day for accuracy.
answer
D The baby should be weighed without a diaper or clothes. Clean scale paper is acceptable; it does not need to be sterile. The nurse's hand should be above, not on, the abdomen for safety. Weighing a newborn at the same time each day allows for accurate weights.
question
Vitamin K is given to the newborn to: A reduce bilirubin levels. B increase the production of red blood cells. C enhance ability of blood to clot. D stimulate the formation of surfactant.
answer
C Vitamin K does not reduce bilirubin levels. Vitamin K does not increase the production of red blood cells. Newborns have a deficiency of vitamin K until intestinal bacteria that produce vitamin K are formed. Vitamin K is required for the production of certain clotting factors. Vitamin K does not stimulate the formation of surfactant.
question
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: A tonic neck reflex. B Moro reflex. C cremasteric reflex. D Babinski reflex.
answer
B Tonic neck reflex refers to the "fencing posture" a newborn assumes when supine and turns the head to the side. These actions show the Moro reflex. The cremasteric reflex refers to retraction of testes when chilled. The Babinski reflex refers to the flaring of the toes when the sole is stroked.
question
A newborn male, estimated to be 39 weeks of gestation, would exhibit: A extended posture when at rest. B testes descended into scrotum. C abundant lanugo over his entire body. D ability to move his elbow past his sternum.
answer
B The newborn's good muscle tone will result in a more flexed posture when at rest. A full-term male infant will have both testes in his scrotum and rugae on his scrotum. The newborn will exhibit only a moderate amount of lanugo, usually on his shoulders and back. The newborn would have the inability to move his elbow past midline.
question
A nurse caring for a newborn should be aware that the sensory system least mature at the time of birth is: A vision. B hearing. C smell. D taste.
answer
A The visual system continues to develop for the first 6 months. As soon as the amniotic fluid drains from the ear (minutes), the infant's hearing is similar to that of an adult. Newborns have a highly developed sense of smell. The newborn can distinguish and react to various tastes.
question
The newborn's nurse should alert the health care provider when which newborn reflex assessment findings are seen? A Newborn turns head toward stimulus when eliciting rooting reflex. B Newborn's fingers fan out when palmar reflex checked. C Newborn forces tongue outward when tongue touched. D Newborn exhibits symmetric abduction and extension of arms, and fingers form "C" when Moro reflex elicited. E Newborn's toes hyperextend with dorsiflexion of big toe when sole of foot stroked upward along lateral aspect.
answer
B The baby's fingers should curl around the examiner's fingers when eliciting the palmar reflex. When eliciting rooting reflex, the characteristic response is for the baby to turn head toward stimulus and open mouth. Extrusion is elicited by touching tongue, and newborn's tongue is forced outward. The newborn should elicit symmetric abduction and extension of the arms and fingers form a "C" with the Moro reflex. The Babinski reflex is elicited by stroking upward along the lateral aspect on the sole of the feet. The expected response is hyperextension of the toes with dorsiflexion of the big toe.
question
In most healthy newborns, blood glucose levels stabilize at _________ mg/dL during the first hours after birth:
answer
50-60
question
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: A instill within 15 minutes of birth for maximum effectiveness. B cleanse eyes from inner to outer canthus before administration. C apply directly over the cornea. D flush eyes 10 minutes after instillation to reduce irritation.
answer
B Instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents, an activity that fosters bonding and attachment, especially for fathers. The newborn's eyes should be cleansed from the inner to the outer canthus before the administration of erythromycin ointment. Erythromycin should be applied into the conjunctival sac to avoid accidental injury to the eye. The eyes should not be flushed after instillation of the erythromycin.
question
Newborns are at high risk for injury if appropriate safety precautions are not implemented. Parents should be taught to: A place the newborn on the abdomen (prone) after feeding and for sleep. B avoid use of pacifiers. C use a rear-facing car seat. D use a crib with side rail slats that are no more than 3 inches apart.
answer
C The prone position is no longer recommended since it may interfere with chest expansion and lead to sudden infant death syndrome. Approved pacifiers are safe to use and fulfill a newborn's need to suck. If the newborn is breastfed, the use of pacifiers should be delayed until breastfeeding is well established to avoid the development of nipple confusion. Your baby should be in a rear-facing infant car safety seat from birth until age 2 years or until exceeding the car seat's limits for height and weight. Slats in a crib should be no more than 2 inches apart.
question
Following circumcision of a newborn, the nurse provides instructions to his or her parents regarding postcircumcision care. The nurse should tell the parents to: A apply topical anesthetics with each diaper change. B expect a yellowish exudate to cover the glans after the first 24 hours. C change the diaper every 2 hours and cleanse the site with soap and water or baby wipes. D apply constant pressure to the site if bleeding occurs and call the physician.
answer
B Topical anesthetics are applied before the circumcision. Infant-comforting techniques are generally sufficient following the procedure. Parents should be taught that a yellow exudate will develop over the glans and should not be removed. The diaper is changed frequently, but the site is cleansed with warm water only since soap and baby wipes can cause pain/burning and irritation at the site. Intermittent pressure is applied if bleeding occurs.
question
When placing a newborn under a radiant heat warmer to stabilize the temperature after birth, the nurse should: A place the thermistor probe on the left side of the chest. B cover the probe with a nonreflective material. C recheck the temperature by periodically taking a rectal temperature. D prewarm the radiant heat warmer and place the undressed newborn under it
answer
D The thermistor probe should be placed on the upper abdomen away from the ribs. It should be covered with reflective material. Rectal temperatures should be avoided since rectal thermometers can perforate the intestine, and the temperature may remain normal until cold stress is advanced. The radiant warmer should be prewarmed so the infant does not experience more cold stress.
question
With regard to umbilical cord care, nurses should be aware that: A the stump can easily become infected. B a nurse noting bleeding from the vessels of the cord should immediately call for assistance. C the cord clamp is removed at cord separation. D the average cord separation time is 5 to 7 days.
answer
A The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, then the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.
question
A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: A are benign if they disappear within 48 hours of birth B result from increased blood volume C should always be further investigated D usually occur with forceps delivery
answer
A Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.
question
A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? A Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. C Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. D Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.
answer
C With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. This action is appropriate when caring for an infant who has had a circumcision. Yellow exudate covers the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudate should not be removed.
question
At 1 minute following birth, the newborn exhibited the following: heart rate of 155; loud, vigorous crying with active movement of all extremities; sneezing when nose is stimulated with a catheter; hands and feet bluish and cool to the touch. The Apgar score of this newborn should be recorded as________.
answer
9
question
The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should: A encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs. B suggest that the mother switch to bottle-feeding since the breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. C notify the physician since the newborn is being poorly nourished. D refer the mother to a lactation consultant to improve her breastfeeding technique.
answer
A Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. Breastfeeding is effective at this time. Breastfeeding is effective, and bottle-feeding does not need to be initiated at this time. The infant is not undernourished, and the physician does not need to be notified. The weight loss is within normal limits; breastfeeding is effective.
question
Which action of a breastfeeding mother indicates the need for further instruction? A Holds breast with four fingers along bottom and thumb at top. B Leans forward to bring breast toward the baby. C Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth. D Puts her finger into newborn's mouth before removing breast.
answer
B Holding the breast with four fingers along the bottom and the thumb at top is a correct technique. To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. Stimulating the rooting reflex is correct. Placing the finger in the mouth to remove the baby from the breast is correct.
question
The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they: A wash the top of the can and can opener with soap and water before opening the can. B adjust the amount of water added according to the weight gain pattern of the newborn. C add some honey to sweeten the formula and make it more appealing to a fussy newborn. D warm formula in a microwave oven for a couple of minutes before feeding.
answer
A Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for a parent to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water since a microwave can easily overheat it.
question
In helping the breastfeeding mother position the baby, nurses should keep in mind that: A the cradle position is usually preferred by mothers who had a cesarean birth. B women with perineal pain and swelling prefer the modified cradle position. C whatever the position used, the infant is "belly to belly" with the mother. D while supporting the head, the mother should push gently on the occiput.
answer
C The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The infant inevitably faces the mother, belly to belly. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.
question
Which statement regarding infant weaning is correct? A Weaning should proceed from breast to bottle to cup. B The feeding of most interest should be eliminated first. C Abrupt weaning is easier than gradual weaning. D Weaning can be mother or infant initiated.
answer
D Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants less than 6 months. If the infant is weaned before 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning. Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. Mother-led weaning means that the mother decides which feedings to drop.
question
With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is: A an on-demand feeding schedule. B breastfeeding. C lower-calorie infant formula. D smaller, more frequent feedings.
answer
B All breastfed infants should be fed on demand. Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also assists the woman to return to her prepregnant weight sooner. Lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period.
question
What is the PRIORITY teaching tip the nurse should provide about bottle-feeding? A Infants may stool with each feeding in the first weeks. B Feed newborn at least every 3 to 4 hours. C Hold infant semiupright while feeding. D Some infants take longer to feed than others.
answer
C The infant may have a stool with each feeding in the first 2 weeks, although this amount may decrease to one or two stools each day Newborns should be fed at least every 3 to 4 hours and should never go longer than 4 hours without feeding until a satisfactory pattern of weight gain is established. Infants should be held and never left alone while feeding. Never prop the bottle. The infant might inhale formula or choke on any that was spit up. Airway is priority. Taking a few sucks and then pausing briefly before continuing to suck again is normal for infants. Some infants take longer to feed than others. Be patient. Keep the baby awake; encouraging sucking may be necessary. Moving the nipple gently in the infant's mouth may stimulate sucking.
question
With regard to hemolytic diseases of the newborn, nurses should be aware that: A Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. B ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. C exchange transfusions frequently are required in the treatment of hemolytic disorders. D the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
answer
D Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility. An indirect Coombs' test may be performed on the mother a few times during pregnancy.
question
Congenital heart defects (CHDs) are anatomic abnormalities in the heart that are present at birth, although they may not be diagnosed immediately. The most common type of CHD is: A tetralogy of Fallot. B ventricular septal defect (VSD). C pulmonary stenosis. D transposition of the great vessels.
answer
B Tetralogy of Fallot has an incidence of 4.7 per 10,000 births and is the most common cardiac defect with decreased blood flow. VSD with increased pulmonary blood flow is the most common type of heart defect with a prevalence of 27 per 10,000 births and accounts for about 30% to 35% of all congenital heart defects. Pulmonary stenosis is less common and is a defect that causes obstruction to blood flow out of the heart. Transposition of the great vessels is a complex cardiac anomaly that involves a flow of mixed saturated and desaturated blood in the heart or great vessels.
question
Concerning congenital abnormalities involving the central nervous system, nurses should be aware that: A although the death rate from most congenital anomalies has decreased over the past several decades, neural tube defects (NTDs) have gone up in the last few years. B spina bifida cystica usually is asymptomatic and may not be diagnosed unless associated problems are present. C a major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. D microcephaly can be corrected with timely surgery.
answer
C Most congenital anomalies have had a stable neonatal death rate since the 1930s; NTDs are declining because of mandatory food fortification with folic acid. Spina bifida occulta often is asymptomatic; spina bifida cystica has a visible sac. The nurse protects the infant by laying the baby on his or her side. Microcephaly is a tiny head; there is no treatment.
question
A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to: A listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. B continue to observe and make no changes until the saturations are 75%. C continue with the admission process to ensure that a thorough assessment is completed. D notify the parents that their infant is not doing well.
answer
A These are appropriate nursing interventions to assist in optimal O2 saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained at more than 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. This is not appropriate. Further assessment and intervention are warranted before determination of fetal status.
question
Which infection could be contracted by the infant because the mother owned a cat? A Toxoplasmosis B Varicella-zoster C Parvovirus B19 D Rubella
answer
A Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. The varicella-zoster virus is responsible for chickenpox and shingles. Approximately 90% of childbearing women are immune. This virus cannot be contracted from a cat. During pregnancy infection with parvovirus can result in abortion, fetal anemia, hydrops, intrauterine growth restriction (IUGR), and stillbirth. This virus is spread by vertical transmission, not by felines. Since vaccination for rubella was begun in 1969, cases of congenital rubella infection have been reduced significantly. Vaccination failures, lack of compliance, and the migration of nonimmunized persons result in periodic outbreaks of rubella (German measles).
question
Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI? A Citalopram B Fluoxetine C Sertraline D Paroxetine
answer
D The absolute risk of any congenital abnormality associated with citalopram use is small. The absolute risk of any congenital abnormality associated with fluoxetine use is small. The absolute risk of any congenital abnormality associated with sertraline use is small. The American College of Obstetricians and Gynecologists (ACOG) has issued a recommendation that paroxetine be avoided both during pregnancy and in women considering pregnancy. There have also been reports linking paroxetine to other abnormalities, such as omphalocele, craniosynostosis, and anencephaly.
question
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A birth injury. B hypocalcemia. C hypoglycemia. D seizures.
answer
C This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis. This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia.
question
When teaching an adolescent mother about risk factors for neonatal death, the most important factor is: A low birth weight. B injuries to the mother during pregnancy. C newborn obesity. D chronic illness of the mother.
answer
A LBW, which is closely related to early gestational age, is considered the leading cause of neonatal death in the United States. Injuries are the leading cause of death in children over age 1 year, with the majority being motor vehicle accident (MVA) injuries. Injuries to the mother and chronic illness are not the major causes of neonatal death.
question
What is the most appropriate teaching point to include in a health promotion teaching plan for parents of children age 5 to 14? A Causes of mechanical suffocation B Keeping all medications out of childrens' reach C Storing firearms in locked cabinets. D Warning signs of violent crimes.
answer
C Improper use of firearms is the fourth leading cause of death from injury in children 5 to 14. Mechanical suffocation is the leading cause of death from injury in infants. Homicide is the second leading cause of death in 15 to 19 year olds. Poisoning causes a considerable number of injuries in children under 4 years of age.
question
The parent of a hospitalized child tells the nurse, "We do not eat meat. We are practicing Buddhists and strict vegetarians." The most appropriate intervention by the nurse is to: A order the child a meatless tray. B tell the parent to take any meat off the child's meal tray. C ask the parent if they would like to have a Buddhist priest visit. D explain to the parent that meat provides protein needed to heal their child.
answer
A It is essential for the nurse to respect the religious practices of the child and parent. The nurse is not culturally sensitive to the religious practices of the child and parent and should ensure that nutritionally complete vegetarian meals are prepared by the dietary department. Asking the parent if they would like a Buddhist priest is not addressing the vegetarian diet and not being respectful of the child and parent's religious beliefs. The nurse should not encourage the child and parent to go against their religious beliefs.
question
A camp nurse is assessing a group of children attending summer camp. Based on the nurse's knowledge of special parenting situations, which group of children is at risk for a sense of belonging? A Children adopted as infants B Children recently placed in foster care C Children whose parents recently divorced D Children who recently gained a stepparent
answer
B Children placed in foster care are at greater risk to have problems perceiving a sense of belonging. Children adopted at birth have fewer problems with acceptance when parents follow preadoption counseling about disclosure. Children of divorced parents often fear abandonment. Children who gain a stepparent are at risk for having trust problems with the new parent.
question
What is appropriate advice for parents who are preparing to tell their children about their decision to divorce? A Avoid crying in front of children. B Avoid discussing the reason for the divorce. C Give reassurance that the divorce is not the children's fault. D Give reassurance that the divorce will not affect most aspects of the children's lives.
answer
C Parents can cry in front of children; it may give the children permission to do the same. Parents should provide the reasons for the divorce in a manner the children will understand. If parents are able, they should hold and touch children and reassure them that they are not the cause of the divorce. This would most likely be false reassurance because many aspects will change.
question
The nurse is caring for a dying boy whose religion is Islam (Muslim/Moslem). An important nursing consideration related to his impending death and religion is that: A there are no special rites. B there are specific practices to be followed. C the family is expected to "wait" away from the dying person. D baptism should be performed if it has not been done previously.
answer
B The nurse should contact someone from the person's mosque to assist. Islam has specific rituals for bathing and wrapping the body in cloth before it is to be moved. Family may be present. No baptism is performed at this time.
question
The nurse is planning care for a patient with cultural background different from that of the nurse. An appropriate goal is to: A strive to keep cultural background from influencing health needs. B encourage continuation of cultural practices in the hospital setting. C attempt in a nonjudgmental way to change cultural beliefs. D adapt as necessary cultural practices to health need
answer
D The cultural background is part of the individual; it would be very difficult to eliminate its influence. The cultural practices need to be evaluated within the context of the health care setting to determine whether they are conflicting. The cultural background is part of the individual; it would be very difficult to eliminate its influence. Whenever possible, nursing care should facilitate the integration of cultural practices into health needs.
question
Before transporting a 16-year-old American Indian female for a magnetic resonance imaging (MRI) scan, the nurse notices the girl is wearing a decorated amulet necklace. The nurse's next BEST action is to: A remove the necklace and place it at the nurse's station. B explain the risks of wearing the necklace during the MRI. C ask the patient if there is a special reason for wearing the necklace. D place tape around the neck covering the necklace.
answer
C The nurse should first ask the patient the purpose of wearing the necklace. The amulet may be worn as a religious ritual or simply as an accessory. After assessing why the necklace is worn, the nurse could then explain the reason for having to remove the necklace for the procedure. The first step though is to assess. Placing tape around the neck is not an appropriate action and could be unsafe. The necklace should be left with family members if possible or in a locked cabinet, rather than at the nurse's station.
question
Parents of a 10-year-old child are concerned that their child has recently been showing signs of loneliness and abandonment. What should the nurse consider when discussing this issue with the parents? A Changing self-esteem is difficult after about age 5. B Self-esteem is the objective judgment of one's worthiness. C Transitory periods of loneliness and abandonment are expected developmentally. D High self-esteem develops when parents show adequate love for the child.
answer
C Self-esteem is influenced throughout adolescence. One aspect of self-esteem is a subjective judgment of one's worthiness. Self-esteem changes with development. Transient changes are expected and with positive encouragement and support are only temporary. Self-esteem is based on several components: competence, sense of control, moral worth, and worthiness of love and acceptance.
question
The nurse is talking to a group of parents about different types of play in which children engage. Which statement made by a parent would indicate a correct understanding of the teaching? A "Parallel-play children borrow and lend play materials and sometimes attempt to control who plays in the group." B "In associative play, children play independently but among other children." C "During onlooker play, children play alone with toys different from those used by other children in the same area." D "Cooperative play is organized, and children play in a group with other children."
answer
D Play in which children borrow and lend play materials and attempt to control who plays in the group is known as associative play. Parallel play occurs when children play independently but among other children. Onlooker play is described as play in which children watch but make no attempt to enter into play with other children. Cooperative play is play that is organized; children play in a group with other children and plan activities for purposes of accomplishing an end.
question
Which best describes Piaget's cognitive stage of formal operations? A Deductive and abstract reasoning B Inductive reasoning and beginning logic C Transductive reasoning and egocentrism D Cause-and-effect reasoning and object permanence
answer
A Piaget's cognitive stage of formal operations occurs between the ages of 11 and 15; deductive and abstract reasoning are developed. Inductive reasoning and beginning logic begin in the concrete operations stage between the ages of 7 and 11. Transductive reasoning and egocentrism occur in the preoperational stage at age 2 to 7. Cause-and-effect and object permanence occur during the sensorimotor stage from birth to 2 years.
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Parents are often confused by the terms growth and development and use the terms interchangeably. Based on the nurse's knowledge of growth and development, the most appropriate explanation of development is: A a child grows taller all through early childhood. B a child learns to throw a ball overhand. C a child's weight triples during the first year. D a child's brain increases in size until school age.
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B Development is the mental and cognitive attainment of skills. Growth is the increase in physical size—both height and weight.
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A nurse is knowledgeable about both growth and development. Which assessment finding indicates the child's development is on target? A The child has not gained weight for 3 months. B The child can throw a large ball but not a small ball. C The child's arms are the most rapidly growing part of the child's body. D The child can pull herself or himself to her or his feet before the child is able to sit steadily.
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B Development is continuous and proceeds from gross to refined, so children whose development is on target can usually throw large objects before small ones. Not gaining weight for 3 months is an abnormal assessment finding; it would indicate that the child's development may not be on target. In children, the legs are normally the most rapidly growing part of the body; if this is not the case, the child's development may not be on target. A child whose development is on target can sit steadily before pulling herself or himself up to her or his feet.
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Based on Piaget's theory of cognitive development, what is one basic concept a child is expected to attain during the first year of life? A If an object is hidden, that does not mean that it is gone. B He or she cannot be fooled by changing shapes. C Parents are not perfect. D Most procedures can be reversed.
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A Part of learning permanence is learning that although an object is no longer visible, it still exists. At 1 year of age, a child may not be able to understand that an object that changes shape is still the same object. Understanding conservation occurs between ages 7 to 11 years.
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A nurse is examining a toddler and is discussing with the mother psychosocial development according to Erikson's theories. Based on the nurse's knowledge of Erikson, the most age-appropriate activity to suggest to the mother at this stage is to: A feed lunch. B allow the toddler to start making choices about what to wear. C allow the toddler to pull a talking-duck toy. D turn on a TV show with bright colors and loud songs.
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B A toddler is developing autonomy and is able to start making some choices about what he or she can wear. A toddler is developing autonomy and focusing on doing things for himself or herself and therefore would not want the mother to feed him or her. The child is at the stage of autonomy versus shame and doubt, as defined by Erikson. At this age, the mother should provide opportunities for the child to be active and learn by experience and imitation. Providing toys the child can control will help achieve this stage. A toddler might easily become overstimulated by images from TV and loud sounds. Toddlers are more interested in manipulating and learning from objects in the environment.
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A preschool child watches a nurse pour medication from a tall, thin glass to a short, wide glass. Which statement is appropriate developmentally for this age group? A The amount of medicine is less. B The amount of medicine did not change, only its appearance. C Pouring medicine makes the medicine hot. D The glass changed shape to accommodate the medicine.
answer
A A preschool child does not have the ability to understand the concept of conservation. This concept is not developed until school age. Understanding conservation occurs between 7 to 10 years of age, when a child begins to realize that physical factors, such as volume, weight, and number, remain the same even though outward appearances are changed. Children are able to deal with a number of different aspects of a situation simultaneously. This is not an expected response by a child. A preschool child will not typically believe the glass changed shape to accommodate the medicine but rather that the amount of medicine is less in the short, wide glass.
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A nurse is discussing various developmental theories at a parenting class. Which individual is associated with the moral development theory? A Erikson B Fowler C Kohlberg D Freud
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C Kohlberg developed the theory of moral development sequence for children. It includes how children acquire moral reasoning and is based on cognitive developmental theory. Erikson developed the theory of psychosocial development. Fowler developed the theory of spiritual development. Freud developed the theory of psychosexual development.
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During their school-age years, children best understand concepts that can be seen or illustrated. The nurse knows this type of thinking is termed as: A concrete operations. B preoperational. C school-age rhetoric. D formal operations.
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A Black-and-white reasoning involves a situation in which only two alternatives are considered, when in fact there are additional options. Preoperational thinking is concrete and tangible. During the school-age years, children deal with thoughts and learn through observation. They do not have the ability to do abstract reasoning and learn best with illustration. Thought at this time is dominated by what the school-age child can see, hear, or otherwise experience. School-age rhetoric simply refers to the type of ideas that arise out of the years children attend school. Formal operations are characterized by the adaptability and flexibility that occurs during the adolescent years.
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Which statement helps explain the growth and development of children? A Development proceeds at a predictable rate. B The sequence of developmental milestones is predictable. C Rates of growth are consistent among children. D At times of rapid growth, there is also acceleration of development.
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B There is a fixed, precise order to development. There are periods of both accelerated and decelerated growth and development. Each child develops at his or her own rate. Physical growth and development proceed at differing rates.
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The nurse is interviewing the mother of Adam, 9 years old. As the nurse begins to assess Adam's school performance, the MOST appropriate question to ask is: A "Did Adam go to preschool?" B "Does Adam have problems at school?" C "How is Adam doing in school?" D "How well does Adam seem to be doing in school?"
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C This is a close-ended question, which will elicit a yes or no answer. This is a close-ended question that implies that Adam is not doing well. This is an open-ended question without any descriptive terms that may limit the mother's responses. This is a close-ended question that will have a short answer and assumes that Adam is doing well.
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Which statement explains why it can be difficult to assess a child's dietary intake? A No systematic assessment tool has been developed for this purpose. B Biochemical analysis for assessing nutrition is expensive. C Families usually do not understand much about nutrition. D Recall of children's food consumption is frequently unreliable.
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D Systematic tools have been developed and are available. Nutrients for different foods are known; it is the quantity and type of food consumed that are difficult to ascertain. The family does not need nutrition knowledge to describe what the child has eaten. It is difficult for parents to recall exactly what their child has eaten. Concurrent food diaries are somewhat more reliable.
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The nurse is ready to begin a physical examination on an 8-month-old infant. The child is sitting contentedly on his mother's lap, chewing on a toy. What should the nurse do FIRST? A Elicit reflexes B Auscultate heart and lungs C Examine eyes, ears, and mouth D Examine head, systematically moving toward feet
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B This may disturb or upset the child, making auscultation and the remainder of the physical examination difficult. Auscultation should be performed while the child is quiet. This may disturb or upset the child, making auscultation and the remainder of the physical examination difficult. Although this is the way most physical examinations proceed, the nurse should perform the assessment for a child in an order that moves from least disturbing to most disturbing from the child's perspective.
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The most accurate method of determining the length of a child less than 12 months of age is: A standing height. B estimation of length to the nearest centimeter or ½ inch. C recumbent length measured in the prone position. D recumbent length measured in the supine position.
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D Infants are generally unable to stand to obtain a height measurement. Measurement should not be estimated since an accurate measurement is required to determine growth. The infant should be measured in the supine, not the prone, position. The crown-heel length measurement is the most accurate measurement in infants.
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The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large, and one is too small. The BEST nursing action is to: A use the small cuff. B use the large cuff. C use either cuff, using palpation method. D locate the proper size cuff before taking the blood pressure.
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D The smaller cuff gives a falsely increased blood pressure and is not the method of choice. The larger cuff, which may give a falsely lowered blood pressure, is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice. Auscultation is preferred to palpation. To obtain an accurate blood pressure reading, it is preferable to use the proper-size cuff. Thus locating one before taking the blood pressure is the best nursing action.
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The nurse is assessing skin turgor in a child. The nurse grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended, or tented, for a few seconds, then slowly falls back on the abdomen. Which evaluation can the nurse correctly assume? A The tissue shows normal elasticity. B The child is properly hydrated. C The assessment is done incorrectly. D The child has poor skin turgor.
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D In normal elasticity the skin would return immediately to its original position. If the child is properly hydrated, skin turgor would be elastic. This is the correct way to assess turgor. "Tenting" is the term for poor skin turgor.
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Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is MOST likely to minimize this sensation and promote relaxation? A Palpating another area simultaneously B Asking the child not to laugh or move if it tickles C Beginning with deeper palpation and gradually progressing to superficial palpation D Having the child "help" with palpation by placing his or her hand over the palpating hand
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D This would not promote relaxation and would make it more difficult to perform the abdominal assessment. This may only contribute to the child's laughter or may prove frustrating to both the child and the nurse. Deeper palpation enhances the "tickling" sensation, not lessen it. This allows the nurse to perform the assessment while including the child in the care.
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The nurse needs to give an injection in the deltoid to a 4-year-old child. The BEST approach to use is to: A smile while giving the injection to help child relax. B tell the child that you will be so quick that the injection will not even hurt. C explain that the child will experience a little stick in the arm. D explain with concrete terms, such as putting medicine under the skin.
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D This is too abstract. The young child will not correlate a smile with relaxation. Distraction techniques are more appropriate. The nurse does not know that the injection will not hurt the child. Lying or distorting the truth is never appropriate. This response will block trust, especially if the injection does hurt the child. The child may visualize an actual stick being placed in the arm. Children at this age are very literal. By using concrete terms the nurse helps the child understand what the nurse is going to do.
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A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on knowledge that: A children tend to be overmedicated for pain. B giving large doses of opioids causes euthanasia. C narcotic addiction is common in terminally ill children. D large doses of opioids are justified when there are no other treatment options.
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D A. Continuing studies report that children are consistently undermedicated for pain. B. The dosage of opioids is titrated to relieve pain, not cause death. C. Addiction refers to a psychologic dependence on the narcotic medication, which does not occur in terminal care. D. Large doses of opioids may be needed because the child has become physiologically tolerant to the drug, requiring higher doses to achieve the same degree of pain control. Pain is considered the fifth vital sign, and management of pain is critical to treatment of a child with bone cancer.
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The most consistent indicator of pain in infants is: A increased respirations. B increased heart rate. C clenching the teeth and lips. D facial expression of discomfort.
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D A. Respiratory pattern may be markedly variable in an infant in pain and thus is not a consistent indicator of pain. B. Heart rate may initially decrease in some infants with pain and then increase; thus it is not a consistent indicator of pain. C. Clenching the teeth and lips are signs of pain often assessed in the toddler, not the infant. D. Facial expression of discomfort is the most consistent behavioral manifestation of pain in infants.
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The nurse is starting an intravenous (IV) line on a school-age child with cancer. The child says, "I have had a million IVs. They hurt." The nurse's response should be based on the knowledge that: A children tolerate pain better than adults. B children become accustomed to painful procedures. C children often lie about experiencing pain. D children often demonstrate increased behavioral signs of discomfort with repeated painful procedures
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D A. There are no data to support the theory that children tolerate pain better than adults. B. The child has increasing difficulty with numerous and repeated painful procedures rather than becoming accustomed to them. C. Pain is whatever the experiencing person defines it to be. D. Children with chronic illnesses are more likely to identify invasive procedures as stressful compared with children with acute illnesses.
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An important consideration when using the FACES pain rating scale with children is: A that children color the face with the color they choose to best describe their pain. B the scale can be used with most children, including those as young as 3 years old. C the scale is not appropriate for use with adolescents. D the scale is useful in pain assessment but is not as accurate when assessing physiologic responses.
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B A. The child points at the face that best describes the pain being experienced. B. The FACES scale has been validated for children as young as 3 years old to rate pain. C. The scale is useful for all ages above 3 years, including adults. D. The scale does not have a means of assessing physiologic data.
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Nonpharmacologic strategies for pain management: A may reduce pain perception. B make pharmacologic strategies unnecessary. C usually take too long to implement. D trick children into believing that they do not have pain.
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A A. Nonpharmacologic techniques for pain management may help the child with associated fears and stress related to pain. The strategies may provide assistance with coping that may reduce the perception of pain, decrease anxiety, and increase effectiveness of medications. B. The child with moderate or severe pain will require pharmacologic intervention. C. The child should be taught nonpharmacologic pain management strategies before pain occurs, thus reducing the implementation time. D. The child will still have the pain, but the perception may be altered.
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The nurses caring for a child are concerned about the child's frequent requests for pain medication. During a team conference, a nurse suggests that they consider administering a placebo instead of the usual pain medication. This decision should be based on knowledge that: A this practice is unjustified and unethical. B this practice is effective in determining whether a child's pain is real. C the absence of a response to a placebo means the child's pain has an organic basis. D a positive response to a placebo will not occur if the child's pain has an organic basis.
answer
A A. Placebos should never be given by any route in the assessment or management of pain. B. Placebos should never be given as a means to determine whether pain is real. Individuals respond differently to placebos; thus the patient's response may not be an accurate measure of pain. C. Response to a placebo is not a measure of the origin of pain and should never be used as a means of assessing pain. D. Response to a placebo is not a measure of the origin of pain and should never be used as a means of assessing pain.
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A child who has been receiving morphine intravenously will now start receiving it orally. The nurse should anticipate that, to achieve equianalgesia (equal analgesic effect), the oral dose will be: A the same as the intravenous (IV) dose. B greater than the IV dose. C one half of the IV dose. D one fourth of the IV dose.
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B A. Oral morphine is not as effective at the same dose as IV morphine. B. When the route of morphine administration is changed from IV to PO (by mouth), it is essential that the dosage be increased to achieve an equianalgesic effect. C. The dosage of morphine is increased, not decreased, when the administration route changes from IV to PO. D. The dosage of morphine is increased, not decreased, when the administration route changes from IV to PO.
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Transdermal fentanyl (Duragesic) is being used for an adolescent with cancer who is in hospice care. The adolescent has been comfortable for several hours but now complains of severe pain. The most appropriate nursing action is to: A administer meperidine (Demerol) intramuscularly (IM). B administer morphine sulfate immediate release (MSIR) intravenously (IV). C use a nonpharmacologic strategy. D place another fentanyl patch on the adolescent.
answer
B A. Intramuscular injections should be avoided in cancer patients because of increased risk of bleeding and the fact that they do not act immediately. B. The nurse should administer an immediate-release opioid such as MSIR IV for the breakthrough pain. C. Nonpharmacologic strategies are not effective in severe pain. D. Transdermal fentanyl will take up to 24 hours to reach peak effect and thus is not effective for severe breakthrough pain.
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The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. An important consideration in managing the child's pain is to: A give only an opioid analgesic at this time. B increase the dosage of analgesic until the child is adequately sedated. C plan a preventive schedule of pain medication around the clock. D give the child a clock and explain when he or she can have pain medications.
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C A. This is appropriate for the immediate pain but will not facilitate the more long-term plan of pain management. B. The dosage of analgesic is increased until pain is controlled, not until sedation is adequate. C. An around-the-clock administration strategy should be used for a child recovering from trauma and surgery. This schedule will help prevent low plasma levels of the drug, leading to breakthrough pain. D. The child should be frequently assessed for pain, and medication doses titrated accordingly. It is inappropriate to give a child a clock with instructions as to when pain medication can be given, especially a child who has experienced a traumatic event.
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The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain: A cannot occur if a child is comatose. B may occur if a child regains consciousness. C requires astute nursing assessment and management. D is best assessed by family members who are familiar with the child.
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C Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must focus on physiologic and behavioral manifestations to accurately assess pain. Pain can occur in the comatose child. The child can be in pain while comatose. The family can provide insight into the child's different responses, but the nurse should be monitoring physiologic and behavioral manifestations.
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The nurse expects which characteristic of fine motor skills in a 5-month-old infant? A Strong grasp reflex B Neat pincer grasp C Able to build a tower of two cubes D Able to grasp object voluntarily
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D This is characteristic of a 1-month-old infant. This is characteristic of an 11-month-old infant. This is characteristic of a 15-month-old infant. This is appropriate for a 5-month-old infant.
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The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head lag. The nurse should recognize that: A this assessment is normal. B the child is probably cognitively impaired. C developmental/neurologic evaluation is needed. D the parent needs to work with the infant to stop head lag.
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C A 6-month-old infant should have social interaction beyond smiling and cooing. The child requires evaluation. The head lag should be almost gone by 4 months of age. This child requires evaluation. The child requires evaluation before interventions can be determined.
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The nurse educator instructs a nursing student that according to Erikson, infancy is concerned with acquiring a sense of: A trust. B industry. C initiative. D separation.
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A The task of infancy is the development of trust. Industry vs. inferiority is the developmental task of school-age children. Initiative vs. guilt is the developmental task of preschoolers. Separation occurs during the sensorimotor stage as described by Piaget.
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A parent of an 8-month-old infant tells the nurse that the baby cries and screams whenever he or she is left with the grandparents. The nurse's reply should be based on knowledge that: A the infant is most likely spoiled. B this is a normal reaction for this age. C this is an abnormal reaction for this age. D grandparents are not responsive to that infant.
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B These are developmentally appropriate. The infant is experiencing stranger anxiety, which is expected for this age child. These are developmentally appropriate. No data have been shown to support this.
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At what age would the nurse advise parents to expect their infant to be able to say "mama" and "dada" with meaning? A 4 months B 6 months C 10 months D 14 months
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C Consonants are added to infant vocalizations. Babbling resembles one-syllable sounds. At this age infants say sounds with meaning. This is late for the development of sounds with meaning.
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The parents of a 9-month-old infant tell the nurse that they are worried about their baby's thumb-sucking. What is the nurse's BEST reply? A A pacifier should be substituted for the thumb. B Thumb-sucking should be discouraged by age 12 months. C Thumb-sucking should be discouraged when the teeth begin to erupt. D There is no need to restrain nonnutritive sucking during infancy.
answer
D Evidence is inconclusive regarding whether a pacifier or thumb is better for satisfying sucking needs. Thumb-sucking and the use of pacifier should be stopped after 4 years of age. Thumb-sucking and the use of pacifier should be stopped after 4 years of age. Nonnutritive sucking reaches its peak at about 18 to 20 months of age.
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The mother of a 3-month-old breastfed infant asks about giving her baby water since it is summer and very warm. The nurse should recommend that: A fluids in addition to breast milk are not needed. B water should be given if the infant seems to nurse longer than usual. C water once or twice a day will make up for losses caused by environmental temperature. D clear juices would be better than water to promote adequate fluid intake.
answer
A The child will nurse according to needs. Additional fluids are not necessary for the breastfed baby. Supplemental water should not be given. It may cause water intoxication. Supplemental water should not be given. It may cause water intoxication. Clear juices do not provide sufficient caloric or nutrient intake and may interfere with breastfeeding.
question
The parent of a 12-month-old infant says to the nurse, "He pushes the teaspoon right out of my hand when I feed him. I can't let him feed himself; he makes too much of a mess." The nurse's BEST response is: A "It's important not to give in to this kind of temper tantrum at this age. Simply ignore the behavior and the mess." B "You need to try different types of utensils, bowls, and plates. Some are specifically designed for young children." C "It's important to let him make a mess. Just try not to worry about it so much." D "Feeding himself will help foster his growth and development. Perhaps we can discuss ways to make the messes more tolerable."
answer
D The child is developmentally ready for self-feeding. Ignoring the behavior and not allowing the child to self-feed is not fostering the child's development. The child is developmentally ready for self-feeding. The parent should not force the use of the spoon but should substitute finger foods. This response minimizes the parent's concerns about the mess created by self-feeding. At 12 months the child should be self-feeding. Since children this age eat primarily finger foods, it is useful to offer the parent suggestions for keeping the mess to a minimum.
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The parents of a 5-month-old girl complain to the nurse that they are exhausted because she still wakes up as often as every 1 to 2 hours during the night. When she awakens, they change her diaper, and her mother nurses her back to sleep. What should the nurse suggest to help them deal with this problem? A Putting her in parents' bed to cuddle B Beginning to put her to bed while still awake C Letting her cry herself back to sleep D Giving her a bottle of formula instead of breastfeeding her so often at night
answer
B The nurse needs to discuss the issue of co-sleeping with parents. Having the infant in bed with them may still interfere with their sleep. Parents need to develop bedtime rituals that involve putting the child in bed when awake. If the child is put in bed awake, she will be able to return to sleep more easily if she awakens at night. Providing formula at night contributes to bottle-mouth caries.
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A 4-month-old infant is brought to the clinic by his parents for a well-baby checkup. What should the nurse include at this time concerning injury prevention? A "Never shake baby powder directly on your infant because it can be aspirated into his lungs." B "Do not permit your child to chew paint from window ledges because he might absorb too much lead." C "When your baby learns to roll over, you must supervise him whenever he is on a surface from which he might fall." D "Keep doors of appliances closed at all times."
answer
C This is appropriate guidance for a first-month appointment. This information should be included at the 9-month visit when the infant is beginning to crawl and pull to a stand. Rolling over from abdomen to back occurs between 4 and 7 months. This is the appropriate anticipatory guidance for this age. This information should be included at the 9-month visit when the infant is beginning to crawl and pull to a stand.
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The nurse in the pediatric clinic identifies which infants at risk for developing vitamin D-deficient rickets? A Lacto-ovo vegetarians B Those who are breastfed exclusively C Those using yogurt as primary source of milk D Those exposed to daily sunlight
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C Individuals who follow this diet include milk and its products in their diet. Breast milk has sufficient vitamin D if the mother is not deficient in this vitamin. Yogurt may not be supplemented with vitamin D. Lack of sunlight contributes to vitamin D-deficient rickets.
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Which strategy might be recommended for an infant with failure-to-thrive to increase caloric intake? A Using developmental stimulation by a specialist during feedings B Avoiding solids until after the bottle is well accepted C Being persistent through 10 to 15 minutes of food refusal D Varying schedule of routine activities on a daily basis
answer
C Feeding times should have a nonstimulating environment so the focus is on the meal. Solids should be introduced slowly to decrease dependence on the bottle. Calm perseverance is important. Parents often fail to persist through the child's refusals. Daily schedule should be structured to provide consistency for the child.
question
The nurse is interviewing the parents of a 4-month-old male infant brought to the hospital emergency department. The infant is dead on arrival, and no attempt at resuscitation is made. The parents state that the baby was found in his crib with a blanket over his head, lying face down in bloody fluid from his nose and mouth. They say he was "just fine" when they put him in his crib already asleep. The nurse should suspect his death was caused by: A suffocation. B child abuse. C infantile apnea. D sudden infant death syndrome (SIDS).
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D Although the child was found under the blanket, the bloody fluid is consistent with SIDS, not suffocation. No other injuries are reported. No previous acute life-threatening events had been reported. The death is consistent with the characteristics of SIDS.
question
Apnea of infancy has been diagnosed in an infant who will soon be discharged with home monitoring. When teaching the parents about the infant's care, what is the most important information the nurse should include in the discharge teaching plan? A Cardiopulmonary resuscitation (CPR) B Administration of intravenous (IV) fluids C Reassurance that the infant cannot be electrocuted during monitoring D Advice that the infant not be left with other caretakers such as baby-sitters
answer
A CPR is essential for parent and caregivers to know. Most likely the child will not have venous access; thus home IV therapy is not necessary. The monitor is insulated and grounded. The parents should arrange for other caregivers to help out. All need to be taught how to use the monitoring equipment and how to perform CPR.
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A mother is bringing her 4-month-old infant into the clinic for a routine well-baby check. The mother is exclusively breastfeeding. There are no other liquids given to the infant. What vitamin does the nurse anticipate the provider will prescribe for this infant? A Vitamin B B Vitamin D C Vitamin C D Vitamin K
answer
B The American Academy of Pediatrics recommends that infants who are exclusively breastfed receive 200 IU of vitamin D daily by age 2 months to decrease vitamin D deficiency. Vitamin B is not needed. Vitamin C is not needed. Vitamin K is not needed.
question
A nurse is caring for a 2-month-old exclusively breastfed infant with an admitting diagnosis of colic. Based on the nurse's knowledge of breastfed infants, what type of stool is expected? A Dark brown and small hard pebbles B Loose with green mucus streaks C Formed and with white mucus D Semiformed, seedy, yellow
answer
D Colic does not change the appearance, texture, or color of stools. The color, consistency, and texture of the stools would be normal for the type of feeding. In a breastfeeding infant, that would be semiformed, seedy, and yellow. Dark brown, small hard pebbles are not a typical bowel movement of an exclusively breastfed infant. Loose stool with green mucus streaks is not a typical bowel movement of an exclusively breastfed infant. Formed stool with white mucus is not a typical bowel movement of an exclusively breastfed infant.
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The nurse is teaching the parents of a 24-month-old about motor skill development. The nurse should include which statement in the teaching? A The toddler walks alone but falls easily. B The toddler's activities begin to produce purposeful results. C The toddler is able to grasp small objects but cannot release them at will. D The toddler's motor skills are fully developed but occur in isolation from the environment.
answer
B The child is able to walk up and down stairs at this age. Gross and fine motor mastery occur with other activities. This is a task of infancy. Interaction with the environment is essential at this age.
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When completing the health assessment for a 2-year-old child, the nurse should expect the child to: A engage in parallel play. B fully dress self with supervision. C have a vocabulary of at least 500 words. D be one third of the adult height.
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A Two-year-olds typically play alongside each other (p. 1023). The child still needs help with clothing at 2 years of age. A vocabulary of 300 words is expected at this age. The child typically has grown to one half of adult height.
question
The parents of a toddler express frustration to the nurse because their child is a "fussy eater." The nurse's BEST response is: A "You should provide larger servings of different foods. B "Provide more bland food varieties as toddlers have few food preferences." C "Table manners will improve if you provide finger foods." D "Becoming a fussy eater is expected during the toddler years."
answer
D Toddlers have a decrease in appetite. They have strong taste preferences. Use of finger foods contributes to unpredictable table manners. Toddlers have physiologic anorexia that contributes to fussy eating.
question
Poisoning in toddlers can best be prevented by: A consistently using safety caps. B storing poisonous substances in a locked cabinet. C keeping ipecac syrup in the home. D storing poisonous substances out of reach.
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B Not all poisonous substances have safety caps. This is an appropriate action. Ipecac does not prevent poisoning and is not recommended. Toddlers can climb; therefore little is out of reach.
question
When explaining the proper restraint of toddlers in motor vehicles to a group of parents, the nurse should include: A wearing safety belts snugly over the toddler's abdomen. B placing the car seat in the front passenger seat if there is an airbag. C using lap and shoulder belts when the child is over 3 years of age. D placing the car seat in the back seat of the car facing forward.
answer
D Car seats are required for toddlers to prevent injury in case of a motor vehicle accident. The car seat should be placed in the back seat, forward facing. Safety belts can cause injuries if they are placed over a toddler's abdomen. Car seats should be in the rear of the car because airbags can injure the toddler. Three-year-olds should be restrained in car seats.
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According to Erikson, the primary psychosocial task of the preschool period is developing a sense of: A identity. B intimacy. C initiative. D industry.
answer
C Identity is the stage associated with adolescence. Intimacy is an adult stage. Preschoolers focus on developing initiative. The stage is known as initiative vs. guilt. Industry is an adult stage.
question
The nurse's BEST approach for effective communication with a preschool age child is through: A speech. B play. C drawing. D actions.
answer
B Language is not specific for children. Play is the child's way to learn to understand and adjust to situations. Drawing is not developed at this age. Actions are not effective for communication.
question
The parents of a 4-year-old girl are worried because she has an imaginary playmate. The nurse's BEST response is to tell the parents: A a psychosocial evaluation is indicated. B an evaluation of possible parent-child conflict is indicated. C having imaginary playmates is normal and useful at this age. D having imaginary playmates is abnormal after about age 2 years.
answer
C Since an imaginary playmate is part of normal development, an evaluation is not necessary. Since an imaginary playmate is part of normal development, an evaluation is not necessary. Imaginary playmates are a part of normal development at this age. The peak incidence of imaginary playmates occurs at 2.5 to 3 years of age. These "playmates" usually are not present once school starts.
question
The nurse would expect that most children would be using sentences of six to eight words by age: A 18 months. B 24 months. C 3 years. D 5 years.
answer
D This age child has a vocabulary of only 10 words. A child this age uses two- to three-word phrases. A child this age uses three- to four-word sentences. Children can make sentences of six to eight words at this age.
question
During a well-child visit, the father of a 4-year-old boy tells the nurse that he is not sure if his son is ready for kindergarten. His birthday is close to the cutoff date, and he has not attended preschool. The nurse's BEST recommendation is to: A start kindergarten. B perform developmental screening. C observe a kindergarten class. D postpone kindergarten and go to preschool.
answer
B This does not address the father's concern about readiness. A developmental screening will provide the necessary information to help the family determine readiness. Observing will provide information about kindergarten but not whether the child is ready. If the child is ready for kindergarten, preschool may lead to boredom.
question
A 4-year-old female child is afraid of dogs. What should the nurse recommend to her parents to help her with this fear? A Keep her away from dogs B Buy her a stuffed dog toy C Force her to touch a dog briefly D Let her watch other children play with a dog
answer
D The nurse preparing a nutritional teaching plan for the parents of a preschool child should include which information? A The quality of the food consumed is more important than the quantity. B Nutrition requirements for preschoolers are very different from requirements for toddlers. C Requirement for calories per unit of body weight increases slightly during the preschool period. D Average daily intake of preschoolers should be about 3000 calories.
question
A 4-year-old female child sometimes wakes her parents up at night screaming, thrashing, sweating, and apparently frightened. Yet she is not aware of her parents' presence when they check on her. She lies down and sleeps without any parental intervention. This is MOST likely described as: A a nightmare. B sleep terror. C seizure activity. D sleep apnea.
answer
B A nightmare is a frightening dream followed by full awakening. In sleep terrors the child is only partially aroused; therefore she does not remember her parents' presence. This does not resemble seizure activity. Sleep apnea is a cessation of breathing during sleep.
question
The nurse is giving anticipatory guidance to the parent of a 5-year-old. In this guidance, it is MOST important to: A prepare the parent for increased aggression. B encourage the parent to offer the child choices. C inform the parent to expect a more tranquil period at this age. D advise parents that this is the age when stuttering may develop.
answer
C This indicates age 4 anticipatory guidance. These actions are indicative of age 3 anticipatory guidance. The end of preschool/beginning of school age is a more tranquil period. These actions are indicative of age 3 anticipatory guidance.
question
A parent tells the nurse, "I am worried about my 13-year-old son. He hasn't started puberty, and my daughter did when she was 11 years of age." The nurse should explain to this parent that this is: A unusual and requires further evaluation of the son. B unusual because the onset of pubescence is usually the same in siblings. C normal because the onset of pubescence is usually earlier in girls than it is in boys. D abnormal because the onset of pubescence is usually earlier in boys than it is in girls.
answer
C The average age of onset for puberty in boys is 12 years old. Age of pubescence is gender related. Girls begin puberty an average of approximately 2 years before boys. The average age of onset for puberty in boys is 12 years old.
question
The nurse should teach volunteers in the after school program that which characteristic is MOST descriptive of the social development of school-age children? A Identification with peers is minimal. B Children frequently have "best friends." C Boys and girls play equally well with children of either gender. D Peer approval is not yet an influence toward conformity.
answer
B Identification with peer group is an important factor toward gaining independence from families. Same-sex peers form relationships that encourage sharing of secrets and jokes and coming to each other's aid. During the school-age years there are more gender-specific groups. Conforming to the rules is an essential part of group membership.
question
The nurse is preparing a health teaching session for school age children. The nurse should include which information about injury prevention in the plan? A Peer pressure is not strong enough to affect risk-taking behavior. B Most injuries occur in or near school or home. C Injuries from burns are the highest at this age because of fascination with fire. D Lack of muscular coordination and control results in an increased incidence of injuries.
answer
B Peer pressure is significant in this age group. This is where most injuries occur. Automobile accidents account for the majority of severe accidents, either as a pedestrian or passenger. School-age children have more refined muscle development, which results in an overall decrease in the number of accidents.
question
Parents of a 10-year-old child are concerned that their child has been recently showing signs of low self-esteem. Which should the nurse consider when discussing this issue with the parents? A Changing self-esteem is difficult after about 5 years old. B Self-esteem is the objective judgment of one's worthiness. C Transitory periods of lowered self-esteem are expected developmentally. D High self-esteem develops when parents show adequate love for the child.
answer
C Self-esteem changes with development. Transient declines are expected and, with positive encouragement and support, are only temporary. Self-esteem is influenced throughout adolescence. One aspect of self-esteem is a subjective judgment of one's worthiness. Self-esteem is based on several factors, including competence, sense of control, moral worth, and worthiness of love and acceptance.
question
When discussing pubertal growth changes with an adolescent male, the nurse will be sure to include what information? A In girls, puberty occurs about 1 year before it appears in boys. B In girls puberty occurs about 3 years before it appears in boys. C In boys puberty occurs about 1 year before it appears in girls. D The onset of puberty is about the same in both boys and girls.
answer
A Average age of onset is 9.5 years for girls and 10.5 years for boys. Although this may be true on an individual basis, the average difference is 1 year. Usually girls begin their pubertal growth spurt earlier than boys. Usually girls begin their pubertal growth spurt earlier than boys.
question
Girls experience an increase in weight and fat deposition during puberty. Nursing considerations related to these changes include: A giving reassurance that these changes are normal. B suggesting dietary measures to control weight gain. C recommending increased exercise to control weight gain. D encouraging low-fat diet to prevent fat deposition.
answer
A A certain amount of fat is increased along with lean body mass to fill the characteristic contours of the child's gender. A healthy balance must be achieved between expected healthy weight gain and obesity. Such advice would not be given unless weight gain were excessive; eating disorders can develop in this group. Such advice would not be given unless weight gain were excessive; eating disorders can develop in this group. Some fat deposition is essential for normal hormone regulation. Menarche is delayed in girls with body fat contents that are too low.
question
An adolescent asks the nurse, "How will I know if I'm going through puberty?" The nurse discusses physical changes that usually occur, the first change being: A testicular enlargement. B voice changes. C growth of dark pubic hair. D increased size of penis.
answer
A Testicular enlargement is the first change that signals puberty in boys; it usually occurs between the ages of 9.5 and 14 years during Tanner stage 2. Voice change occurs between Tanner stages 3 and 4. Fine pubic hair may occur at the base of the penis; darker hair occurs during Tanner stage 3. Penis enlarges during Tanner stage 3.
question
A hospitalized teenager and family are praying at the bedside. The nurse is aware that the most accurate description of the spiritual development of the older adolescent is that: A beliefs become more abstract. B rituals and practices become increasingly important. C strict observance of religious customs is common. D emphasis is placed on external manifestations, such as whether a person goes to church.
answer
A Because of their abstract thinking abilities, adolescents are able to interpret analogies and symbol. These become less important as the adolescent questions values and ideals of families. These become less important as the adolescent questions values and ideals of families. Adolescents question external manifestations when they are not supported by adherence to supportive behaviors.
question
A 16-year-old adolescent male tells the school nurse that he is gay. The nurse's MOST appropriate response should be based on knowledge that: A he is too young to have had enough sexual activity to determine this. B it is important to provide a nonthreatening environment in which he can discuss this. C the nurse should be open to discussing his or her own beliefs about homosexuality. D homosexual adolescents do not have concerns that differ from heterosexual adolescents.
answer
B Adolescence is when sexual identity develops. The nurse needs to be open and nonjudgmental in interactions with adolescents. This will provide a safe environment in which to provide appropriate health care. The nurse's own beliefs should not bias the interaction with this student. Homosexual adolescents face very different challenges as they grow up because of society's response to homosexuality.
question
A 12-year-old child being seen in the clinic has not received the hepatitis B (HBV) vaccine. The nurse should recommend that: A only one dose of HBV will be needed sometime during adolescence. B one dose of HBV is needed at age 14. C the three-dose series of HBV should be started. D the three-dose series of HBV should be started at age 16 or sooner if the adolescent becomes sexually active.
answer
C Three doses are necessary to achieve immunity. Three doses are necessary to achieve immunity. Adolescents should be vaccinated against hepatitis B at this age if not done previously. The recommendation is that the hepatitis B vaccine series be started at birth. The American Academy of Pediatrics recommends vaccination by age 13.
question
When discussing sex and sexual activities with adolescents, the nurse should: A present normal body functions in a straightforward manner. B refer the adolescents to their parents for sexual information. C use scientific terminology to convey content. D defer giving information about pregnancy unless the adolescents are sexually active.
answer
A The nurse should provide accurate and complete information that is presented using correct terminology. Parents are important influences regarding the morals and values surrounding sexual activities; nurses should provide the adolescent with accurate, complete information about the normal physical aspects of sex. The adolescent may not understand the scientific names. Adolescents should have information before they become sexually active.
question
A 16-year-old girl tells the school nurse that she has not started to menstruate yet. Onset of secondary sexual characteristics occurred about 4 years ago. The nurse should: A explain that this is not unusual. B refer adolescent for an evaluation. C assume that the adolescent is pregnant. D suggest that adolescent stop exercising until menarche occurs.
answer
B Menstruation usually begins approximately 2 years after the beginning of secondary sexual characteristics. This meets the definition of primary amenorrhea and should be evaluated. Although this is a possibility, the nurse should not assume it until further assessment is performed. There is no indication that the adolescent is exercising excessively.
question
A sexually active adolescent asks the school nurse about prevention of sexually transmitted diseases (STDs). The nurse should recommend: A prophylactic antibiotics. B condom use. C any type of contraception method. D withdrawal method of contraception.
answer
B Prophylactic antibiotics are not recommended; they are only effective against bacteria, not viruses. Condoms provide a barrier to the organisms that cause STDs. Only condoms create a physical barrier that prevents contact with the organisms. Only condoms create a physical barrier that prevents contact with the organisms.
question
Nursing responsibilities in the management of adolescent obesity include: A planning a low-calorie, low-protein diet. B incorporating favorite foods into the child's diet. C encouraging diversional activities during mealtimes. D using nutritious foods as a method of reward.
answer
B A food plan high in nutrients, with calories and fats kept at a healthy level, is recommended. Incorporating small amounts of the adolescent's favorite foods will increase adherence to the nutritional plan. Diversional activities such as television watching may contribute to overeating. Foods should not be used as a reward.
question
When caring for a youngster with anorexia nervosa, the MOST important nursing intervention is to: A encourage weight gain. B correct malnutrition. C limit fluid intake. D prevent depression.
answer
B The individual with anorexia nervosa would probably not be receptive to encouragement because of the complex etiology of the disorder. This is the priority goal of treatment. Fluids are often restricted by the individual with anorexia. It is important to correct fluid and electrolyte imbalances if present. Depression may be a component of the process.
question
Nursing responsibilities when caring for the suicidal adolescent include: A emphasizing that a suicide attempt is an immature way of dealing with stress. B recognizing the warning signs that indicate a young person might attempt suicide. C ignoring threats of suicide because they are usually bids for attention. D recognizing a suicide attempt as an impulsive act resulting from a temporary crisis.
answer
B For the depressed young person, suicide may appear to be the only way out. It is imperative that the nurse recognize warning signs of a potential suicide. All threats must be taken seriously. Even if the crisis is temporary, the child's perception still may be that suicide is the only way out.
question
Which symptoms are commonly seen in a child with depression? (Select all that apply.) A Focus on violence B Excessive laughing C Somatic complaints D Increased motor activity E Poor school performance
answer
CE Children with depression will make nonspecific complaints such as not feeling well. Children with depression will show a lack of interest in doing homework or achieving in school and getting lower grades than usual. Focus on violence can be associated with depression in the adolescent. A child with depression exhibits predominantly sad facial expression with absence or diminished range of affective response. Children with depression will have diminished motor activity and complain of being too tired.
question
The nurse is caring for an 8-year-old child who has a chronic illness. The child has a tracheostomy, and a parent is rooming-in during this hospitalization. The parent insists on providing almost all of the child's care and tells the nurses how to care for the child. When planning the child's care, the primary nurse should recognize that the parent is: A controlling and demanding. B assuming the nurse's role. C the expert in care of the child. D not allowing nurses to function independently.
answer
C Because these parents care for this child with complex health needs at home, they are most familiar with the care requirements and routine. The nurse's role includes assessment and evaluation, not just the implementation phase. The nurse recognizes that the philosophy of family-centered care states that the parents are the experts in the care of their child. The nurse functions collaboratively with the family.
question
A 5-year-old girl's sibling dies from sudden infant death syndrome. The parents are concerned because she showed more outward grief when her cat died than she is showing now. The nurse should explain that: A this is suggestive of maladaptive coping and referral for counseling is needed. B the child is not old enough to have a concept of death. C the child is not old enough to have formed a significant attachment to her sibling. D the death may be so painful and threatening that the child must deny it for now.
answer
D This suggests limited defense mechanisms, not maladaptive coping. The child is beginning to understand the permanence of death. At 5 years old, this child will have formed a relationship with the infant sibling. A child at this age has limited defense mechanisms. Often the child will react with more overt grief to a less significant loss than to the loss of a very significant person.
question
A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on knowledge that: A children tend to be overmedicated for pain. B giving large doses of opioids causes euthanasia. C narcotic addiction is common in terminally ill children. D large doses of opioids are justified when there are no other treatment options.
answer
D Continuing studies report that children are consistently undermedicated for pain. The dose is titrated to relieve pain. Addiction refers to a psychologic dependence on the medication, which does not happen in terminal care. Large doses may be needed because the child has become physiologically tolerant to the drug, requiring higher doses to achieve the same degree of pain control.
question
The primary goal in caring for the child with cognitive impairment is to: A encourage play. B promote optimum development. C help families adjust to future care. D develop vocational skills.
answer
B Provide parents guidance for the selection of developmentally appropriate activities. A comprehensive approach is desirable to establish acceptable social behavior and feelings of self-worth in the child. This is an ongoing process that changes as the child meets developmental milestones. These skills will be addressed as the child's capabilities are developing.
question
A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold; that "He's like a rag doll. He doesn't cuddle up to me like my other babies did." The nurse's best interpretation of this lack of clinging or molding is that it is: A a sign of maternal deprivation. B a sign of detachment and rejection. C suggestive of autism associated with Down syndrome. D the result of the physical characteristics of Down syndrome.
answer
D Mothers may have difficulty forming attachment to their children because of these characteristics of Down syndrome. The nurse should recommend swaddling and wrapping the baby before picking him or her up. Mothers may have difficulty forming attachment to their children because of these characteristics of Down syndrome. The nurse should recommend swaddling and wrapping the baby before picking him or her up. Autism is not associated with Down syndrome. This lack of clinging is a result of the muscle hypotonicity and hyperextensibility of the joints associated with Down syndrome.
question
Early detection of a hearing impairment is critical because of its effect on areas of a child's life. The nurse should evaluate further for effects of the hearing impairment on: A reading development. B speech development. C relationships with peers. D performance at school.
answer
B The child will have greater difficulty learning to read, but the primary issue of concern is the effect on speech. The ability to hear sounds is essential for the development of speech. Babies imitate the sounds that they hear. Relationships with peers and performance at school will be affected by the child's lack of hearing. The effect will be augmented by difficulties with oral communication. Relationships with peers and performance at school will be affected by the child's lack of hearing. The effect will be augmented by difficulties with oral communication.
question
A child in the clinic exhibits reduced visual acuity in one eye despite appropriate optical correction. The nurse expects the child's health care provider to diagnosis the child with: A myopia. B hyperopia. C amblyopia. D astigmatism.
answer
C Myopia is nearsightedness, which is the ability to see objects up close but not clearly at a distance. Hyperopia is farsightedness, which is the ability to see distant objects clearly but not those up close. This is the definition of amblyopia. Astigmatism is an alteration in vision caused by unequal curvature in the refractive apparatus of the eye.
question
Which behavior would most likely be manifested in a young child experiencing the protest phase of separation anxiety? A Inactivity B Clings to parent C Depressed, sad D Regression to earlier behavior
answer
B These are characteristics of despair. In the protest phase, the child aggressively responds to separation from parents. These are characteristics of despair. These are characteristics of despair.
question
The most consistent indicator of pain in infants is: A increased respirations. B increased heart rate. C squirming and jerking. D facial expression of discomfort.
answer
D These responses vary, depending on infant and pain. These responses vary, depending on infant and pain. These responses vary, depending on infant and pain. This is the most consistent behavioral manifestation of pain in infants.
question
The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, O.K.?" The nurse should: A start the IV line because allowing the child to manipulate the nurse is bad. B start the IV line because unlimited procrastination results in heightened anxiety. C postpone starting the IV line until the child is ready so that the child experiences a sense of control. D postpone starting the IV line until the child is ready so the child's anxiety is reduced.
answer
B The nurse should start the IV line, recognizing that the child is attempting to gain control. Intravenous antibiotics are a priority action for the nurse. A short delay may be possible to allow the child some choice, but a prolonged delay only serves to increase the anxiety. If the timing of the IV line start was not essential for the start of IV antibiotics, this might be acceptable. The child may never be ready. The anxiety is likely to increase with prolonged delay.
question
A 4-year-old child will be having cardiac surgery next week. The child's parents call the hospital, asking about how to prepare her for this. The nurse's BEST response is to inform the parents that: A preparation at this age will only increase the child's stress. B preparation needs to be at least 2 to 3 weeks before hospitalization. C children who are prepared experience less fear and stress during hospitalization. D children who are prepared experience overwhelming fear by the time hospitalization occurs.
answer
C Preparation will reduce stress by having the child incorporate the threat more slowly. For this age group 1 week of preparation is recommended. Preparing the child for the hospitalization will reduce the number of unknown elements. Tours, handling some of the equipment, or being told stories about what to expect will increase the familiarity with items. A reduction in fear is usually observed.
question
A mother tells the nurse that she will visit her 2-year-old son tomorrow about noon. During the child's bath, he asks for mommy. The nurse's BEST reply is: A "Mommy will be here after lunch." B "Mommy always comes back to see you." C "Your mommy told me yesterday that she would be here today about noon." D "Mommy had to go home for a while, but she will be here today."
answer
A Since toddlers have a limited concept of time, the nurse should translate the mother's statement about being back around noon by linking the arrival time to a familiar activity that takes place at that time. Such statements do not give the child any information about when his mother will visit. Twelve noon is a meaningless concept for a toddler. Such statements do not give the child any information about when his mother will visit.
question
The nurse working in an outpatient surgery center for children should understand that: A children's anxiety is minimal in such a center. B waiting is not stressful for parents in such a center. C accurate and complete discharge teaching is the responsibility of the surgeon. D families need to be prepared for what to expect after discharge.
answer
D Although anxiety may be reduced because of the lack of an overnight stay, the child will still experience the stress associated with a medical procedure. The waiting period while the child is having the procedure is a very stressful time for families. Discharge teaching is a responsibility of both the surgeon and the nursing staff. Discharge instructions should be provided in both written and oral form. They need to include normal responses to the procedure and when to notify the practitioner if untoward reactions are occurring.
