Maternal And Child Health Nursing (Nurs320)
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The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black. She asks the nurse if something is wrong. The nurse should respond to this mother's concern by:
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Telling the mother not to worry because all breastfed babies have this type of stool
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Explaining to the mother that this stool is called meconium and is expected for the first few bowel movements of all newborns
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Asking the mother what she ate for her last meal
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Suggesting to the mother that she ask her pediatrician to explain normal newborn stooling patterns to her
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This quiz for NURS320, Maternal and Child Health Nursing, assesses key competencies in managing pain in infants and children. Topics include pain indicators, assessment tools, and effective medication strategies, equipping nursing students with essential skills for pediatric care.
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- 2.
An appropriate nursing intervention when caring for a child with pneumonia is which of the following?
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Avoid placing child on affected side.
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Monitor respiratory status frequently.
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Place in Trendelenburg position.
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Administer antitussive agents around the clock.
Correct Answer
A. Monitor respiratory status frequently.Explanation
2. The child's respiratory rate, status, oxygenation, general disposition, and level of activity are frequently monitored.
1. Lying on the affected side may promote comfort by splinting the chest and reducing pleural rubbing. The child should be positioned with the unaffected side up to promote maximum expansion.
3. Children should be placed in a semierect position or position of comfort.
4. Antitussives are usually not indicated.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: ImplementationRate this question:
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- 3.
An expectant father confides in the nurse that his pregnant wife, 10 weeks of gestation, is driving him crazy. "One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?" The nurse's best response is:
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"This is normal behavior and should begin to subside by the second trimester."
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"She may be having difficulty adjusting to pregnancy; I will refer her to a counselor I know."
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"This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant."
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"You seem impatient with her. Perhaps this is precipitating her behavior."
Correct Answer
A. "This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant."Explanation
This is the most appropriate response because it gives an explanation and a time frame for when the mood swings may stop.Rate this question:
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- 4.
The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their child one more time. The nurse should do which of the following?
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Grant their request.
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Assess why they think this is necessary.
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Discourage this because it will only prolong their grief.
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Kindly explain that they need to say good-bye to their child now and leave.
Correct Answer
A. Grant their request.Explanation
1. The parents should be allowed to remain with their child after the death. The nurse can remove all the tubes and equipment and offer the parents the option of preparing the body.
2. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
3. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
4. The parents should be allowed to remain with their child after the death. This is an important part of the grieving process and should be allowed if the parents desire. It is important for the nurse to ascertain whether the family has any special needs.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 5.
A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to have a drink with dinner now. The nurse tells her:
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"Because you're in your second trimester, there's no problem with having one drink with dinner."
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"One drink every night is too much. One drink three times a week should be fine."
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"Because you're in your second trimester, you can drink as much as you like."
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"Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy."
Correct Answer
A. "Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy."Explanation
A safe level of alcohol consumption during pregnancy has not yet been established. Although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised.Rate this question:
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- 6.
Nurses, certified nurse-midwives, and other advanced practice nurses have the knowledge and expertise to assist women in making informed choices regarding contraception. A multidisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. Which action should the nurse take first when meeting with a new client to discuss contraception?
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Obtain data about the frequency of coitus.
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Determine the woman's level of knowledge about contraception and commitment to any particular method.
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Assess the woman's willingness to touch her genitals and cervical mucus
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Evaluate the woman's contraceptive life plan.
Correct Answer
A. Determine the woman's level of knowledge about contraception and commitment to any particular method.Explanation
This is the primary step of this nursing assessment and necessary before completing the process and moving on to a nursing diagnosis. Once the client's level of knowledge is determined, the nurse can interact with the woman to compare options, reliability, cost, comfort level, protection from sexually transmitted infections (STIs), and a partners willingness to participate.Rate this question:
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- 7.
Nursing interventions to promote coping among the siblings of a child with special needs include which of the following?
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Explain to the siblings that embarrassment is unhealthy.
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Encourage the parents not to expect siblings to help them care for the child with special needs.
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Provide information to the siblings about the child’s condition only as requested.
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Suggest to the parents ways of showing gratitude to the siblings when they help care for the child with special needs.
Correct Answer
A. Suggest to the parents ways of showing gratitude to the siblings when they help care for the child with special needs.Explanation
4. The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked to take on additional responsibilities to help the parents to care for the child. The parents should show gratitude, such as an increase in allowance, special privileges, and verbal praise.
1. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner.
2. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities.
3. The siblings need to be informed about the child's condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is wrong with the child.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 8.
The school nurse is caring for a child with hemophilia who fell on his arm during recess. Which of the following supportive measures should the nurse do until factor replacement therapy can be instituted?
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Apply warm, moist compresses.
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Apply tourniquet for at least 5 minutes.
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Elevate arm above the level of the heart.
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Begin passive range of motion unless pain is severe.
Correct Answer
A. Elevate arm above the level of the heart.Explanation
3. The initial response should include elevation.
1. Cold should be applied to the arm. This will aid in vasoconstriction.
2. Pressure is effective in small areas, but would not work for an extremity.
4. Passive range of motion is not recommended. The child can perform active range of motion after the bleeding episode has resolved.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: ImplementationRate this question:
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- 9.
Which of the following self-report pain rating scales can be used in children as young as 3 years of age?
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Poker Chip Tool
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Visual Analog Scale
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FACES Pain Rating Scale
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Word-Graphic Rating Scale
Correct Answer
A. FACES Pain Rating ScaleExplanation
1. The Poker Chip Tool has been validated for children age 4 years who have been determined to have the cognitive ability to identify the larger of 2 numbers.
2. The Visual Analog Scale can be used for children over 4 years of age, but is most appropriate for ages 7 and older.
3. The FACES Pain Rating Scale is for children as young as 3 years of age.
4. The Word-Graphic Rating Scale uses descriptive words and is recommended for children age 4-17 years.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 10.
The nurse is providing support to a family who is experiencing anticipatory grief related to their child's imminent death. Which of the following is an appropriate nursing intervention?
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Be available to family.
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Attempt to “lighten the mood.”
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Suggest activities to cheer up the family.
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Discourage crying until actual time of death.
Correct Answer
A. Be available to family.Explanation
1. One of the most important nursing interventions around the time of death is the availability of the nurse for the family.
2. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
3. Attempting to "lighten the mood" or suggesting activities to cheer up the family would be highly inappropriate. The parents are in engaged in the grieving process.
4. The parents should be encouraged to express their feelings appropriately.
Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 11.
A pregnant woman at 10 weeks of gestation jogs three or four times per week. She is concerned about the effect of exercise on the fetus. The nurse should inform her:
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"You don't need to modify your exercising any time during your pregnancy."
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"Stop exercising, because it will harm the fetus."
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"You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month."
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"Jogging is too hard on your joints; switch to walking now."
Correct Answer
A. "You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month."Explanation
Typically, running should be replaced with walking around the seventh month of pregnancy.Rate this question:
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- 12.
The nurse should recognize that when a child develops diabetic ketoacidosis, this is which of the following?
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Expected outcome
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Best treated at home
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Life-threatening situation
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Best treated at practitioner’s office or clinic
Correct Answer
A. Life-threatening situationExplanation
3. Diabetic ketoacidosis is the state of complete insulin deficiency. It is a medical emergency that must be diagnosed and treated. The child is usually admitted to an intensive care unit for assessment, insulin administration, and fluid and electrolyte replacement.
1. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
2. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
4. Diabetic ketoacidosis is a medical emergency needing prompt assessment and intervention, usually in an intensive care environment.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning; Nursing Process: EvaluationRate this question:
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- 13.
A woman taking an oral contraceptive pill (OCP) as her birth control method of choice should notify her health care provider immediately if she notes:
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Breast tenderness and swelling
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Weight gain
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Swelling and pain in one of her legs
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Mood swings
Correct Answer
A. Swelling and pain in one of her legsExplanation
Leg pain and swelling (edema) may indicate thrombophlebitis and should be reported immediately.Rate this question:
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- 14.
Which of the following is an important nursing consideration in the care of a child with celiac disease?
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Refer to a nutritionist for detailed dietary instructions and education.
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Help child and family understand that diet restrictions are usually only temporary.
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Teach proper hand washing and Standard Precautions to prevent disease transmission.
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Suggest ways to cope more effectively with stress to minimize symptoms.
Correct Answer
A. Refer to a nutritionist for detailed dietary instructions and education.Explanation
1. The main consideration is helping the child adhere to dietary management. Considerable time is spent in explaining to the child and parents the disease process, the specific role of gluten in aggravating the condition, and those foods that must be restricted. Referral to a nutritionist would help in this process.
2. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong.
3. Celiac disease is not transmissible.
4. Celiac disease is not stress related.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Teaching/LearningRate this question:
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- 15.
An adolescent girl dies in the emergency department after a car accident. Her family arrives at the hospital shortly after death. They request to see her body. Because she is disfigured from the accident, the most appropriate nursing action is which of the following?
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Contact a clergyperson to discuss this problem with them.
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Explain that their daughter is disfigured and it would be best not to see her.
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Encourage them to wait for viewing until the funeral home has prepared her body.
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Inform them of what to expect and then let them see their daughter.
Correct Answer
A. Inform them of what to expect and then let them see their daughter.Explanation
4. Prepare the family before viewing by telling them what to expect. Include bodily changes from the accident, tubes, and cold skin.
1. The parents can be asked if they would like a clergyperson present. Requesting to see their daughter is not a problem.
2. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.
3. Encouraging the parents to delay or to not see their daughter are not appropriate interventions. The parents should be accompanied by a staff member with bereavement training.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 16.
An important nursing consideration when caring for a child with sickle cell anemia is which of the following?
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Refer parents and child for genetic counseling.
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Teach parents and child how to recognize signs and symptoms of crises.
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Help the child and family adjust to a short-term disease.
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Observe for complications of multiple blood transfusions.
Correct Answer
A. Teach parents and child how to recognize signs and symptoms of crises.Explanation
2. Parents need specific instructions on the need to watch for changes in the child's condition, including adequate hydration, and environmental concerns.
1. Genetic counseling is important, but teaching care of the child is a priority.
3. Sickle cell anemia is a long-term, chronic illness.
4. Multiple blood transfusions are an option for some children with sickle cell disease. The priority for all children with this condition is properly preparing the parents to care for them.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 17.
One of the goals for children with asthma is to prevent respiratory tract infection. This is because respiratory tract infection does which of the following?
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Increases sensitivity to allergens
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Causes exercise-induced asthma
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Lessens effectiveness of medications
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Can trigger an episode or aggravate asthmatic state
Correct Answer
A. Can trigger an episode or aggravate asthmatic stateExplanation
4. Viral respiratory tract infections can exacerbate asthma, especially in young children, whose airways are mechanically smaller and more reactive than those of older children.
1. Respiratory tract infections do not affect sensitivity to allergens.
2. Exercise precipitates exercise-induced asthma.
3. The respiratory tract infection does not lessen the effectiveness of the medications.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: ImplementationRate this question:
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- 18.
Which of the following urine tests of renal function is used to estimate glomerular filtration?
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PH
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Creatinine
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Osmolality
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Protein level
Correct Answer
A. CreatinineExplanation
2. The most useful clinical estimation of glomerular filtration is the clearance of creatinine. The production and secretion of creatinine remain relatively constant from day to day, and its appearance in the urine is determined by the serum level.
1. The pH is a measure of alkalinity, not glomerular filtration.
3. Osmolality is a measure of concentration.
4. Presence of protein is indicative of abnormal glomerular permeability.
Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 19.
The father of a 9-year-old child with several physical disabilities tells the nurse that his son concentrates on what he can, rather than cannot, do and is as independent as possible. The nurse's best interpretation of this is which of the following?
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The father is experiencing denial.
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The father is expressing his own views.
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Child is using an adaptive coping style.
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Child is using a maladaptive coping style.
Correct Answer
A. Child is using an adaptive coping style.Explanation
3. The father is describing a well-adapted child who has learned to accept physical limitations. These children function well at home, at school, and with peers. Their understanding of their disorder allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation.
1. The father is describing his child's behavior. He is not denying the child's limitations.
2. The father is describing his child's behavior, not his own views.
4. The father is describing a well-adapted child who has learned to accept physical limitations. This is descriptive of an adaptive coping style.
Level of cognitive ability: Application
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 20.
The nurse caring for a pregnant woman knows that her health teaching regarding fetal circulation has been effective when the woman reports that she has been sleeping:
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In a side-lying position
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On her back with a pillow under her knees
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With the head of the bed elevated
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On her abdomen
Correct Answer
A. In a side-lying positionExplanation
Optimal circulation is achieved when the woman is lying at rest on her side. Decreased uterine circulation may lead to intrauterine growth restriction. Previously it was believed that the left lateral position promoted maternal cardiac output, thereby enhancing blood flow to the fetus. However, it is now known that either side-lying position enhances uteroplacental blood flow.Rate this question:
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- 21.
The nurse suspects a child is having an adverse reaction to a blood transfusion. The first action by the nurse should be which of the following?
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Notify physician.
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Take vital signs and blood pressure and compare them with baseline.
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Dilute infusing blood with equal amounts of normal saline.
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Stop transfusion and maintain a patent intravenous line with normal saline and new tubing.
Correct Answer
A. Stop transfusion and maintain a patent intravenous line with normal saline and new tubing.Explanation
4. Stopping the transfusion and maintaining a patent intravenous line with normal saline and new tubing is the priority nursing action. If an adverse reaction is occurring, it is essential to minimize the amount of blood that is infused.
1. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
2. Notifying a physician and taking vital signs and blood pressure should be performed after the blood transfusion is stopped and infusion of normal saline has begun.
3. Blood should not be diluted; it should be returned to the blood bank if an adverse reaction has occurred.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: ImplementationRate this question:
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- 22.
The clinical manifestations of nephrotic syndrome include which of the following?
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Hematuria, bacteriuria, weight gain
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Gross hematuria, albuminuria, fever
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Hypertension, weight loss, proteinuria
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Proteinuria, hypoalbuminemia, edema
Correct Answer
A. Proteinuria, hypoalbuminemia, edemaExplanation
4. Edema, proteinuria, hypoalbuminemia, and hypercholesterolemia are the clinical manifestations of nephrotic syndrome in children.
1. Bacteriuria is not a diagnostic criterion for nephrotic syndrome.
2. Fever is not associated with nephrotic syndrome.
3. Weight gain occurs secondary to the edema.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 23.
Which of the following is the definition that best describes children with special health care needs?
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Having a loss or abnormality of structure or function
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Having a condition or barrier imposed by society, the environment, or one’s self
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Having a condition that interferes with daily function for more than 3 months a year, causes hospitalization of more than 1 month a year, or is likely to do either of these
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Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in general
Correct Answer
A. Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in generalExplanation
4. Being at increased risk for a chronic physical, behavioral, developmental, or emotional condition and also requiring health and related services of a type or amount beyond those required by children in general is the definition of children with special health care needs used by the federal Maternal and Child Health Bureau.
1. Having a loss or abnormality of structure or function is the definition of impairment.
2. Having a condition or barrier imposed by society, the environment, or one's self is the definition of handicap.
3. Having a condition that interferes with daily function for more than 3 months a year, causes hospitalization of more than 1 month a year, or is likely to do either of these is the definition of chronic illness.
Level of cognitive ability: Knowledge
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: PlanningRate this question:
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- 24.
The nurse is caring for a child dying from cancer. Parents ask how they will know that the child is approaching death. The nurse's answer should include which of the following?
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Rapid pulse
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Change in respiratory pattern
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Sensation of cold although body feels hot
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Loss of hearing followed by loss of other senses
Correct Answer
A. Change in respiratory patternExplanation
2. The respiratory pattern will become slower and shallower with periodic deep sighs, followed by Cheyne-Stokes respirations and the "death rattle."
1. The pulse rate will slow.
3. The child may have sensations of heat, while the body feels cool.
4. Hearing is the last sense to fail.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Teaching/LearningRate this question:
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- 25.
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 exam. The cervix has not changed. Five minutes have passed, and the FHR remains in the 80s. What additional nursing measures should you take?
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Call for help.
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Insert a Foley catheter.
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Start oxytocin (Pitocin).
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Notify the primary health care provider immediately.
Correct Answer
A. Notify the primary health care provider immediately.Explanation
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.Rate this question:
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- 26.
Which of the following interventions will foster a sense of independence in a toddler with disabilities?
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Help parents learn special care needs of their child.
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Help parents provide safe opportunities to explore the environment at home and in the hospital.
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Expose child to pleasurable experiences as much as possible.
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Avoid separation from family during hospitalization.
Correct Answer
A. Help parents provide safe opportunities to explore the environment at home and in the hospital.Explanation
2. Within the constraints of the disability, parents should provide safe opportunities for exploration that foster independence at home and in the hospital.
1. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.
3. Exposing the child to pleasurable experiences, especially sensory ones, is a supportive intervention. It does not support autonomy.
4. Helping parents learn special care needs of their child and avoiding separation from family during hospitalization are part of family-centered care. They do not necessarily foster autonomy.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: PlanningRate this question:
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- 27.
Which of the following best describes the 4-year-old child's concept of death?
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Death is temporary.
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Death is permanent.
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Death is inevitable at some age.
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Death is personified in various forms.
Correct Answer
A. Death is temporary.Explanation
1. Preschool-age children view death as a type of departure. It is temporary and reversible.
2. The older school-age child recognizes the permanence and inevitability of death.
3. The older school-age child recognizes the permanence and inevitability of death.
4. The young school-age child personifies death as the devil, God, or a bogeyman.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and CommunicationRate this question:
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- 28.
A 13-year-old girl is brought to the clinic with the complaint of insomnia and hyperactivity. Other symptoms include gradual weight loss despite a good appetite; warm, flushed, and moist skin; and unusually fine hair. These manifestations are most suggestive of which of the following?
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Hypothyroidism
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Hyperthyroidism
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Hypoparathyroidism
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Hyperparathyroidism
Correct Answer
A. HyperthyroidismExplanation
2. These symptoms are suggestive of hyperthyroidism. Other symptoms include academic difficulties resulting from a short attention span and inability to sit still, unexplained fatigue and sleeplessness, and difficulty with fine motor skills.
1. Hypothyroidism is seen with decelerated growth from chronic deprivation of thyroid hormone. Other manifestations are myxedematous skin changes (dry skin, puffiness around the eyes, sparse hair), constipation, sleepiness, and mental decline.
3. Early manifestations of hypoparathyroidism may be anxiety and mental depression, followed by paresthesia and evidence of heightened neuromuscular excitability.
4. Hyperparathyroidism results in hypercalcemia, which can be manifested by a change in behavior, gastrointestinal symptoms, and cardiac irregularities.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 29.
When planning care for a 4-month-old child admitted with respiratory distress caused by respiratory syncytial virus (RSV) and bronchiolitis, it is essential to include which of the following?
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Give antibiotics.
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Ensure adequate hydration.
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Administer cough syrup.
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Feed 4 oz of formula every 4 hours.
Correct Answer
A. Ensure adequate hydration.Explanation
2. When respiratory distress is present, hydration is an essential consideration. Usually infants cannot take fluids by the oral route because of the difficulty breathing. Intravenous fluid administration may be necessary.
1. RSV is a virus. Antibiotics are not beneficial.
3. Cough syrup is not routinely used in RSV.
4. Although fluid and calories are important, the infant with respiratory distress is usually unable to drink this amount of fluid.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Pharmacologic and Parenteral Therapy
Integrated process: Nursing Process: PlanningRate this question:
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- 30.
When teaching self-care prevention of genital tract infections, the nurse should instruct the woman to:
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Increase dietary sugar and avoid yogurt
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Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bath
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Choose underwear or hosiery with a nylon crotch
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Douche frequently
Correct Answer
A. Limit time spent in damp exercise clothes and limit exposure to bath salts or bubble bathExplanation
Clinical observations and research have suggested that tight-fitting clothing and underwear or pantyhose made of nonabsorbent materials create an environment in which a vaginal fungus can grow. Bathing in bath salts or bubble bath may further irritate sensitive genital tissue.Rate this question:
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- 31.
An essential component of counseling women regarding safe sex practices includes discussion regarding avoiding the exchange of body fluids. The physical barrier promoted for the prevention of sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) is the condom. Nurses can help motivate clients to use condoms by initiating a discussion related to a number of aspects of condom use. The most important of these is:
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Strategies to enhance condom use
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Choice of colors and special features
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Leaving the decision up to the male partner
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Places to safely carry condoms
Correct Answer
A. Strategies to enhance condom useExplanation
When the nurse opens discussion on safe sex practices, this gives the woman permission to clear up any concerns or misapprehensions she may have regarding condom use. The nurse can also suggest ways that the woman can enhance her condom negotiation and communications skills. These include role-playing, rehearsal, cultural barriers, and situations that put the client at risk.Rate this question:
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- 32.
The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, "When something is worrying you, what do you do?" This should be interpreted as which of the following?
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Verbal cue to stop crying
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Part of assessing parent’s coping skills
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Inappropriate, because parent is so upset
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Diverting the present crisis to similar situations with which parent has dealt
Correct Answer
A. Part of assessing parent’s coping skillsExplanation
2. Assessments of coping skills are important data for the nurse to obtain. This question will provide information about the marital relationship (does the parent speak to the spouse?), alternate support systems, and ability to communicate. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed.
1. Emotional support is necessary. The nurse should acknowledge with body and facial language how difficult the diagnosis is for the parents. Tissues should be available.
3. Assessment of coping skills is an important part of assessment information.
4. The nurse is obtaining information to help support the parent through the diagnosis.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 33.
Pyloric stenosis can best be described as which of the following?
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Dilation of pylorus
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Hypertrophy of pyloric muscle
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Hypotonicity of pyloric muscle
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Reduction of tone in the pyloric muscle
Correct Answer
A. Hypertrophy of pyloric muscleExplanation
2. Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel.
1. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
3. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
4. Dilation of pylorus, hypotonicity of pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: AssessmentRate this question:
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- 34.
Which of the following is the primary clinical manifestation of acute renal failure?
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Oliguria
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Hematuria
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Proteinuria
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Bacteriuria
Correct Answer
A. OliguriaExplanation
1. Oliguria is the primary clinical symptom of acute renal failure. Generally, urinary output is less than 1 ml/kg/hr.
2. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
3. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
4. Hematuria, proteinuria, and bacteriuria may be present in renal disease, but they are not the primary manifestations of acute renal failure.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/Learning; Nursing Process: PlanningRate this question:
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- 35.
A school-age child with cancer is beginning to feel better now that the necessary medical procedures and treatments are not so traumatic. The child has also become very uncooperative with the parents. The nurse should explain that:
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The child is denying the seriousness of the illness.
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This is a common reaction and a way to express anger.
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More discipline is needed to deal with the uncooperativeness.
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Permissiveness is needed as child copes with a life-threatening illness.
Correct Answer
A. This is a common reaction and a way to express anger.Explanation
2. Children of this age-group are likely to exhibit fears through verbal uncooperativeness. It is the child's attempt to have some control over what is happening.
1. The child recognizes the seriousness of the illness and is attempting to exercise control.
3. Stricter discipline will not help with the child's behavior. It is necessary to allow the child to communicate feelings and provide outlets for aggression.
4. The child needs to have the support of the family and health care team. Structure is necessary with opportunities for communication and control when feasible.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Documentation and CommunicationRate this question:
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- 36.
A woman is 8 months pregnant. She tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. Which response by the nurse is most appropriate?
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"Many women imagine what their baby is like."
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"A baby in utero does respond to the mother's voice."
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"You'll need to ask the doctor if the baby can hear yet."
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"Thinking that your baby hears will help you bond with the baby."
Correct Answer
A. "A baby in utero does respond to the mother's voice."Explanation
Fetuses respond to sound by 24 weeks. The fetus can be soothed by the sound of the mother's voice.Rate this question:
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- 37.
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. Which of the following is an important consideration in managing the child's pain?
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Give only an opioid analgesic at this time.
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Increase the dosage of analgesic until the child is adequately sedated.
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Plan a preventive schedule of pain medication around the clock.
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Give the child a clock and explain when she or he can have pain medications.
Correct Answer
A. Plan a preventive schedule of pain medication around the clock.Explanation
3. For severe postoperative pain, a preventive around-the-clock schedule is necessary to prevent decreased plasma levels of medications.
1. The opioid analgesic will help for the present, but it is not an effective strategy.
2. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness.
4. This strategy is counterproductive. It focuses the child's attention on how long he or she will need to wait for pain relief.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: PlanningRate this question:
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- 38.
The nurse is talking with the parents of a child who died 6 months ago. They sometimes still "hear" the child's voice and have trouble sleeping. They describe feeling empty and depressed. The nurse should recognize which of the following?
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These are normal grief responses.
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The pain of the loss is usually less by this time.
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These grief responses are more typical of the early stages of grief.
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This grieving is essential until the pain is gone and the child is gradually forgotten.
Correct Answer
A. These are normal grief responses.Explanation
1. Hearing the child, troubles sleeping, feeling empty and depressed are normal grief responses. The grief response is lengthy.
2. The resolution of grief may take years, with an intensification of grief during the early years.
3. The resolution of grief may take years, with an intensification of grief during the early years.
4. The child will never be forgotten by the parents.
Level of cognitive ability: Comprehension
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 39.
Which of the following is the primary clinical manifestation of diabetes insipidus?
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Oliguria
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Glycosuria
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Nausea, vomiting
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Polyuria, polydipsia
Correct Answer
A. Polyuria, polydipsiaExplanation
4. Diabetes insipidus results from the hyposecretion of antidiuretic hormone. Since insufficient amounts are produced, excessive amounts of urine are produced. When allowed access to fluids, the child maintains balance with an almost insatiable thirst.
1. Oliguria is diminished urinary output. Children with diabetes insipidus have increased urinary output.
2. Glycosuria is not a manifestation of diabetes insipidus. It may be a manifestation of diabetes mellitus.
3. Nausea and vomiting are not manifestations of diabetes insipidus. They can occur with oversecretion of antidiuretic hormone.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Nursing Process: AssessmentRate this question:
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- 40.
The nurse is caring for a child hospitalized with acute adrenocortical insufficiency. Because of the sudden, severe nature of the disease the family needs a great deal of emotional support. The most appropriate nursing action is which of the following?
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Prepare family for impending death.
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Prepare the family for each procedure.
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Prepare family for long-term consequences of paralysis.
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Reassure family that flaccid paralysis is not problematic.
Correct Answer
A. Prepare the family for each procedure.Explanation
2. By preparing the family for each procedure, the nurse is showing sensitivity to the family's emotional needs.
1. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
3. Acute adrenocortical insufficiency is a reversible condition when associated with adrenocortical insufficiency.
4. Flaccid paralysis is problematic if not reversible.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 41.
A school-age child recently diagnosed with type 1 diabetes mellitus asks the nurse if he can still play soccer, play baseball, and swim. The nurse's response should be based on knowledge that:
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Exercise is contraindicated.
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The level of activity depends on the type of insulin required.
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Exercise is not restricted unless indicated by other health conditions.
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Soccer and baseball are too strenuous, but swimming is acceptable.
Correct Answer
A. Exercise is not restricted unless indicated by other health conditions.Explanation
3. Exercise is encouraged for children with diabetes because it lowers blood glucose levels. Insulin and meal requirements require careful monitoring to ensure that the child has sufficient energy for exercise.
1. Exercise is highly encouraged. The decrease in blood glucose can be accommodated by having snacks available.
2. The level of activity is not dependent on the type of insulin used. Long- and short-acting insulin both may be used to compensate for the effects of training and sporting events.
4. Sports are encouraged to help regulate the insulin, and food should be adjusted according to the amount of exercise. The child needs to be cautioned to monitor responses to the exercises.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 42.
A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use:
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Counterpressure against the sacrum
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Pant-blow (breaths and puffs) breathing techniques
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Effleurage
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Biofeedback
Correct Answer
A. Counterpressure against the sacrumExplanation
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.Rate this question:
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- 43.
A 5-year-old has patient-controlled analgesia (PCA) for pain management following abdominal surgery. Your explanation to the parents should include:
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The child will be pain free.
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Only the child is allowed to push the button for a bolus.
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The pump allows for a continuous basal rate and delivers a constant amount of medication to control pain.
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There is a high risk of overdose so monitoring is done every 15 minutes.
Correct Answer
A. The pump allows for a continuous basal rate and delivers a constant amount of medication to control pain.Explanation
3. The PCA prescription can be set for a basal rate for a continued infusion of pain medication to prevent pain from returning during sleep and when patient cannot control the infusion.
1. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child of 5, the parents and nurse must assess the child to ensure that adequate medication is being given.
2. A child of 5 may not be able to understand the concept of pushing a button. Evidence suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary.
4. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.
Level of cognitive ability: Comprehension
Area of client needs: Physiologic Integrity/Physiologic Adaptation
Integrated process: Teaching/LearningRate this question:
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- 44.
Parents tell the nurse that their 7-year-old daughter wants to see her brother's body and attend the funeral. Which of the following should the nurse do?
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Encourage child to attend funeral but not see the body.
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Refer the child to someone who can assess her readiness for these experiences.
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Suggest that instead of these experiences the child visit the grave site after the services are over.
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Explain that her parents or another significant person should provide support during these experiences.
Correct Answer
A. Explain that her parents or another significant person should provide support during these experiences.Explanation
4. For children of this age and older, attendance at funerals is both useful and meaningful. It helps the child acknowledge the death, honor the deceased, and receive comfort and support from a parent or significant person.
1. If an open coffin is used for the funeral, the child should be prepared for how her brother will look.
2. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.
3. The child is asking to attend. Children who participate in the funeral planning and attend the services have higher self-esteem than those who are excluded.
Level of cognitive ability: Analysis
Area of client needs: Psychosocial Integrity/Coping and Adaptation
Integrated process: Nursing Process: ImplementationRate this question:
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- 45.
In providing nourishment for a child with cystic fibrosis (CF), which of the following factors should the nurse keep in mind?
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Fats and proteins must be greatly curtailed.
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Diet should be high in calories and protein.
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Most fruits and vegetables are not well tolerated.
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Diet should be high in easily digested carbohydrates and fats.
Correct Answer
A. Diet should be high in calories and protein.Explanation
2. Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption.
1. Fats and proteins are a necessary part of a well-balanced diet.
3. A well-balanced diet containing fruits and vegetables is important.
4. Enzyme supplementation helps digest foods; other modifications are not necessary.
Level of cognitive ability: Application
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: ImplementationRate this question:
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- 46.
Women with severe and persistent mental illness are likely to be more vulnerable to being involved in controlling and/or violent relationships. However, many women develop mental health problems as a result of long-term abuse. The psychologic consequences of continued abuse do not include:
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Substance abuse
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Posttraumatic stress disorder (PTSD)
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Eating disorders
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Bipolar disorder
Correct Answer
A. Bipolar disorderExplanation
Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to abuse.Rate this question:
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- 47.
Which of the following heart defects causes hypoxemia and cyanosis because desaturated venous blood is entering the systemic circulation?
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Coarctation of the aorta
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Atrial septal defect
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Patent ductus arteriosus
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Tetralogy of Fallot
Correct Answer
A. Tetralogy of FallotExplanation
4. Tetralogy of Fallot is a cardiac defect that has a mixed blood circulation.
1. Coarctation of the aorta is an obstructive defect. There is no mixing of oxygenated and unoxygenated blood.
2. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
3. Atrial septal defect and patent ductus arteriosus have increased flow of blood to the pulmonary system. The pressure gradient allows for oxygenated blood to return to the lungs.
Level of cognitive ability: Analysis
Area of client needs: Physiologic Integrity/Reduction of Risk Potential
Integrated process: Nursing Process: PlanningRate this question:
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- 48.
During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurse's first response should be to:
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Advise the woman of mandatory state reporting laws pertaining to abuse and confidentiality
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Reassure the woman that the abuse is not her fault
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Give the woman referrals to local agencies and shelters where she can obtain help
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Formulate an escape plan for the woman that she can use the next time her husband abuses her
Correct Answer
A. Advise the woman of mandatory state reporting laws pertaining to abuse and confidentialityExplanation
Many states have mandatory reporting laws for health care providers. It is important to inform the woman that you may need to report this. Nurses should be knowledgeable about the reporting requirements of the state in which they practice.Rate this question:
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- 49.
A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease?
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Meperidine (Demerol)
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Promethazine (Phenergan)
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Butorphanol tartrate (Stadol)
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Nalbuphine (Nubain)
Correct Answer
A. Meperidine (Demerol)Explanation
Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease.Rate this question:
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Mar 22, 2023Quiz Edited by
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Nov 27, 2012Quiz Created by
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