Maternal and Child Health Practice Test Part 3 (Practice Mode)- www.RNpedia.com

1. When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done?

1 month

2 months

3 months

4 months

Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.

Explanation

Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.

2. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?

Sucking ability

Respiratory status

Locomotion

GI function

Because of the defect, the child will be unable to from the mouth adequately around nipple, thereby requiring special devices to allow for feeding and sucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip.

Explanation

Because of the defect, the child will be unable to from the mouth adequately around nipple, thereby requiring special devices to allow for feeding and sucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip.

3. Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night?

“Allow him to fall asleep in your room, then move him to his own bed.”

“Tell him that you will lock him in his room if he gets out of bed one more time.”

“Encourage active play at bedtime to tire him out so he will fall asleep faster.”

“Read him a story and allow him to play quietly in his bed until he falls asleep.”

Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

Explanation

Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

4. While performing physical assessment of a 12 month-old, the nurse notes that the infant's anterior fontanelle is still slightly open. Which of the following is the nurse's most appropriate action?

Notify the physician immediately because there is a problem.

Perform an intensive neurologic examination.

Perform an intensive developmental examination.

Do nothing because this is a normal finding for the age.

The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate.

Explanation

The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate.

5. Which of the following best describes parallel play between two toddlers?

Sharing crayons to color separate pictures

Playing a board game with a nurse

Sitting near each other while playing with separate dolls

Sharing their dolls with two different nurses

Toddlers engaging in parallel play will play near each other, but not with each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play. Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of cooperative play.

Explanation

Toddlers engaging in parallel play will play near each other, but not with each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play. Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of cooperative play.

6. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

Instituting infection control precautions

Encouraging adequate intake of iron-rich foods

Assisting with coping with chronic illness

Administering medications via IM injections

Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. Iron-rich foods help with anemia, but dietary iron is not an initial intervention. The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. Injections should be discouraged, owing to increased risk from bleeding due to thrombocytopenia.

Explanation

Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. Iron-rich foods help with anemia, but dietary iron is not an initial intervention. The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. Injections should be discouraged, owing to increased risk from bleeding due to thrombocytopenia.

7. Which of the following would be most appropriate for a nurse to use when describing menarche to a 13-year-old?

A female’s first menstruation or menstrual “periods”

The first year of menstruation or “period”

The entire menstrual cycle or from one “period” to another

The onset of uterine maturation or peak growth

Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occurs before menarche.

Explanation

Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occurs before menarche.

8. Which of the following statements by the parents of a child with school phobia would indicate the need for further teaching?

“We’ll keep him at home until phobia subsides.”

“We’ll work with his teachers and counselors at school.”

“We’ll try to encourage him to talk about his problem.”

“We’ll discuss possible solutions with him and his counselor.”

The parents need more teaching if they state that they will keep the child home until the phobia subsides. Doing so reinforces the child’s feelings of worthlessness and dependency. The child should attend school even during resolution of the problem. Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions.

Explanation

The parents need more teaching if they state that they will keep the child home until the phobia subsides. Doing so reinforces the child’s feelings of worthlessness and dependency. The child should attend school even during resolution of the problem. Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions.

9. By the end of which of the following would the nurse most commonly expect a child’s birth weight to triple?

4 months

7 months

9 months

12 months

A child’s birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.

Explanation

A child’s birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.

10. Which of the following information, when voiced by the mother, would indicate to the nurse that she understands home care instructions following the administration of a diphtheria, tetanus, and pertussis injection?

Measures to reduce fever

Need for dietary restrictions

Reasons for subsequent rash

Measures to control subsequent diarrhea

The pertusis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother’s verbalization of information about measures to reduce fever indicates understanding. No dietary restrictions are necessary after this injection is given. A subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine, not the diphtheria, pertussis, and tetanus vaccine. Diarrhea is not associated with this vaccine.

Explanation

The pertusis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother’s verbalization of information about measures to reduce fever indicates understanding. No dietary restrictions are necessary after this injection is given. A subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine, not the diphtheria, pertussis, and tetanus vaccine. Diarrhea is not associated with this vaccine.

11. Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit?

Report the child’s condition to Protective Services immediately.

Schedule a follow-up visit to check for more bruises.

Notify the child’s physician immediately.

Don nothing because this is a normal finding in a toddler.

Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm. Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect the child’s safety. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility. Multiple bruises and burns are not normal toddler injuries.

Explanation

Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm. Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect the child’s safety. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility. Multiple bruises and burns are not normal toddler injuries.

12. Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?

Medicate him with acetaminophen.

Notify the physician immediately

Release the traction

Monitor him every 5 minutes

Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation. Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia. The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate. In this situation, specific action not continued monitoring is indicated.

Explanation

Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation. Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia. The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate. In this situation, specific action not continued monitoring is indicated.

13. Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

Susceptibility to respiratory infection

Bleeding tendencies

Frequent vomiting and diarrhea

Seizure disorder

Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

Explanation

Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

14. Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is learning forward and drooling?

Auscultate his lungs and place him in a mist tent.

Have him lie down and rest after encouraging fluids.

Examine his throat and perform a throat culture

Notify the physician immediately and prepare for intubation.

The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal.

Explanation

The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal.

15. Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?

Small tongue

Transverse palmar crease

Large nose

Restricted joint movement

Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high-arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.

Explanation

Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high-arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.

16. The infant of a substance-abusing mother is at risk for developing a sense of which of the following?

Mistrust

Shame

Guilt

Inferiority

According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. Schoolagers develop a sense of inferiority when they do not develop a sense of industry.

Explanation

According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. Schoolagers develop a sense of inferiority when they do not develop a sense of industry.

17. The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse’s best response?

“ Let her cry for a while before picking her up, so you don’t spoil her”

“Babies need to be held and cuddled; you won’t spoil her this way”

“Crying at this age means the baby is hungry; give her a bottle”

“If you leave her alone she will learn how to cry herself to sleep”

Infants need to have their security needs met by being held and cuddled. At 2 months of age, they are unable to make the connection between crying and attention. This association does not occur until late infancy or early toddlerhood. Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age. Infants cry for many reasons. Assuming that the child s hungry may cause overfeeding problems such as obesity.

Explanation

Infants need to have their security needs met by being held and cuddled. At 2 months of age, they are unable to make the connection between crying and attention. This association does not occur until late infancy or early toddlerhood. Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age. Infants cry for many reasons. Assuming that the child s hungry may cause overfeeding problems such as obesity.

18. The adolescent’s inability to develop a sense of who he is and what he can become results in a sense of which of the following?

Shame

Guilt

Inferiority

Role diffusion

According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-agechildren develop a sense of inferiority when they do not develop a sense of industry.

Explanation

According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-agechildren develop a sense of inferiority when they do not develop a sense of industry.

19. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

Notify the physician immediately

Administer antidiarrheal medications

Monitor child ever 30 minutes

Nothing, this is characteristic of Hirschsprung disease

For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation.

Explanation

For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation.

20. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?

Rice

Milk

Wheat

Chicken

Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided. Rice, milk, and chicken do not contain gluten and need not be avoided.

Explanation

Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided. Rice, milk, and chicken do not contain gluten and need not be avoided.

21. When teaching parents about the child’s readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler?

Demonstrates dryness for 4 hours

Demonstrates ability to sit and walk

Has a new sibling for stimulation

Verbalizes desire to go to the bathroom

The child must be able to sate the need to go to the bathroom to initiate toilet training. Usually, a child needs to be dry for only 2 hours, not 4 hours. The child also must be able to sit, walk, and squat. A new sibling would most likely hinder toilet training.

Explanation

The child must be able to sate the need to go to the bathroom to initiate toilet training. Usually, a child needs to be dry for only 2 hours, not 4 hours. The child also must be able to sit, walk, and squat. A new sibling would most likely hinder toilet training.

22. Which of the following skills is the most significant one learned during the schoolage period?

Collecting

Ordering

Reading

Sorting

The most significant skill learned during the school-age period is reading. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. Collective, ordering, and sorting, although important, are not most significant skills learned.

Explanation

The most significant skill learned during the school-age period is reading. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. Collective, ordering, and sorting, although important, are not most significant skills learned.

23. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?

Regurgitation

Steatorrhea

Projectile vomiting

“Currant jelly” stools

Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease. “Currant jelly” stools are characteristic of intussusception.

Explanation

Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease. “Currant jelly” stools are characteristic of intussusception.

24. Which of the following toys should the nurse recommend for a 5-month-old?

A big red balloon

A teddy bear with button eyes

A push-pull wooden truck

A colorful busy box

A busy box facilitates the fine motor development that occurs between 4 and 6 months. Balloons are contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy.

Explanation

A busy box facilitates the fine motor development that occurs between 4 and 6 months. Balloons are contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy.

25. When providing therapeutic play, which of the following toys would best promote imaginative play in a 4-year-old?

Large blocks

Dress-up clothes

Wooden puzzle

Big wheels

Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play. Building blocks and wooden puzzles are appropriate for encouraging fine motordevelopment. Big wheels and tricycles encourage gross motor development.

Explanation

Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play. Building blocks and wooden puzzles are appropriate for encouraging fine motordevelopment. Big wheels and tricycles encourage gross motor development.

26. When teaching parents about typical toddler eating patterns, which of the following should be included?

Food “jags”

Preference to eat alone

Consistent table manners

Increase in appetite

Toddlers become picky eaters, experiencing food jags and eating large amounts one day and very little the next. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. Toddlers typically enjoy socialization and limiting others at meal time. Toddlers prefer to feed themselves and thus are too young to have table manners. A toddler’s appetite and need for calories, protein, and fluid decrease due to the dramatic slowing of growth rate.

Explanation

Toddlers become picky eaters, experiencing food jags and eating large amounts one day and very little the next. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. Toddlers typically enjoy socialization and limiting others at meal time. Toddlers prefer to feed themselves and thus are too young to have table manners. A toddler’s appetite and need for calories, protein, and fluid decrease due to the dramatic slowing of growth rate.

27. When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen. Which of the following would explain the rationale for this finding?

Increased food intake owing to age

Underdeveloped abdominal muscles

Bowlegged posture

Linear growth curve

Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. During toddlerhood, food intake decreases, not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. Toddler growth patterns occur in a steplike, not linear pattern.

Explanation

Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. During toddlerhood, food intake decreases, not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. Toddler growth patterns occur in a steplike, not linear pattern.

28. Which of the following activities, when voiced by the parents following a teaching session about the characteristics of school-age cognitive development would indicate the need for additional teaching?

Collecting baseball cards and marbles

Ordering dolls according to size

Considering simple problem-solving options

Developing plans for the future

The school-aged child is in the stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete thought. The ability to consider the future requires formal thought operations, which are not developed until adolescence. Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operational thinking of the schoolager.

Explanation

The school-aged child is in the stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete thought. The ability to consider the future requires formal thought operations, which are not developed until adolescence. Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operational thinking of the schoolager.

29. A hospitalized schoolager states: “I’m not afraid of this place, I’m not afraid of anything.” This statement is most likely an example of whichof the following?

Regression

Repression

Reaction formation

Rationalization

Reaction formation is the schoolager’s typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. Regression is seen in toddlers and preshcoolers when they retreat or return to an earlier level ofdevelopment . Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors.

Explanation

Reaction formation is the schoolager’s typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. Regression is seen in toddlers and preshcoolers when they retreat or return to an earlier level ofdevelopment . Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors.

30. At which of the following ages would the nurse expect to administer the varicella zoster vaccine to child?

At birth

2 months

6 months

12 months

The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.

Explanation

The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.

31. Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play?

The child is exhibiting normal pre-school curiosity

The child is acting out personal experiences

The child does not know how to play with dolls

The child is probably developmentally delayed.

Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse should be suspected. Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. Whether or nor the child knows how to play with dolls is irrelevant.

Explanation

Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse should be suspected. Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. Whether or nor the child knows how to play with dolls is irrelevant.

32. Which of the following would the nurse need to keep in mind as a predisposing factor when formulating a teaching plan for child with a urinary tract infection?

A shorter urethra in females

Frequent emptying of the bladder

Increased fluid intake

Ingestion of acidic juices

In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection. Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development.

Explanation

In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection. Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development.

33. A 14-year-old boy has acne and according to his parents, dominates the bathroom by using the mirror all the time.
Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents?

“Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.”

“A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?”

“You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?”

Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time her spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive. The statement about peer acceptance and time spent in front of the mirror for the development of self image provides information about the adolescent’s needs to the parents and may help to gain trust with the adolescent. Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. Discussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient-teaching needs for the adolescent regarding cleansing.

Explanation

Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time her spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive. The statement about peer acceptance and time spent in front of the mirror for the development of self image provides information about the adolescent’s needs to the parents and may help to gain trust with the adolescent. Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. Discussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient-teaching needs for the adolescent regarding cleansing.

34. While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected?

A strong Moro reflex

A strong parachute reflex

Rolling from front to back

Lifting of head and chest when prone

A 3-month-old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months.

Explanation

A 3-month-old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months.

35. Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)?

Vomiting

Stools

Uterine

Weight

Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. No relationship exists between feedings and characteristics of stools and uterine. If feedings are ineffective, this should be noted before there is any change in the child’s weight.

Explanation

Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. No relationship exists between feedings and characteristics of stools and uterine. If feedings are ineffective, this should be noted before there is any change in the child’s weight.

36. When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?

Stool inspection

Pain pattern

Family history

Abdominal palpation

Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

Explanation

Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

37. Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, “You idiot, you have no idea how to care for my sick child”?

Displacement

Projection

Repression

Psychosis

The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another. Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut. Repression is the submerging of painful ideas into the unconscious. Psychosis is a state of being out of touch with reality.

Explanation

The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another. Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut. Repression is the submerging of painful ideas into the unconscious. Psychosis is a state of being out of touch with reality.

38. Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child?

The child can use complex reasoning to think out situations.

Fear of body mutilation is a common preschool fear

The child engages in competitive types of play

Immediate gratification is necessary to develop initiative.

During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences. The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification.

Explanation

During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences. The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification.

39. Which of the following is an appropriate toy for an 18-month-old?

Multiple-piece puzzle

Miniature cars

Finger paints

Comic book

Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.

Explanation

Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.

40. A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following?

Hirschsprung disease

Celiac disease

Intussusception

Abdominal wall defect

Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

Explanation

Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

41. If parents keep a toddler dependent in areas where he is capable of using skills, the toddle will develop a sense of which of the following?

Mistrust

Shame

Guilt

Inferiority

According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Infants develop mistrust when their needs are not consistently gratified. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met.

Explanation

According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Infants develop mistrust when their needs are not consistently gratified. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met.

42. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?

Fluid volume deficit

Risk for aspiration

Altered nutrition: less than body requirements

Altered oral mucous membranes

GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.

Explanation

GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.

43. When developing a teaching plan for a group of high school students about teenage pregnancy, the nurse would keep in mind which of the following?

The incidence of teenage pregnancies is increasing.

Most teenage pregnancies are planned.

Denial of the pregnancy is common early on.

The risk for complications during pregnancy is rare.

The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. The incidence of adolescent pregnancy has declined since 1991, yet morbidity remains high. Most teenage pregnancies are unplanned and occur out of wedlock. The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and fetopelvic disproportion as well as numerous psychological crises.

Explanation

The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. The incidence of adolescent pregnancy has declined since 1991, yet morbidity remains high. Most teenage pregnancies are unplanned and occur out of wedlock. The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and fetopelvic disproportion as well as numerous psychological crises.

44. Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection?

Respiratory distress

Lethargy

Watery diarrhea

Weight gain

Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea. Respiratory distress is unlikely in a routine upper respiratory infection. Irritability, rather than lethargy, is more likely. Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased.

Explanation

Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea. Respiratory distress is unlikely in a routine upper respiratory infection. Irritability, rather than lethargy, is more likely. Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased.

45. After teaching a group of parents about accident prevention for schoolagers, which of the following statements by the group would indicate the need for more teaching?

“Schoolagers are more active and adventurous than are younger children.”

“Schoolagers are more susceptible to home hazards than are younger children.”

“Schoolagers are unable to understand potential dangers around them.”

“Schoolargers are less subject to parental control than are younger children.”

The schoolager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. Thus, schoolagers should be able to understand the potential dangers around them. With growth comes greater freedom andchildren become more adventurous and daring. The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abilities and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcohol, and medications. School-agechildren begin to internalize their own controls and need less outside direction. Plus the child is away from home more often. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities.

Explanation

The schoolager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. Thus, schoolagers should be able to understand the potential dangers around them. With growth comes greater freedom andchildren become more adventurous and daring. The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abilities and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcohol, and medications. School-agechildren begin to internalize their own controls and need less outside direction. Plus the child is away from home more often. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities.

46. When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?

Push-pull toys

Rattle

Large blocks

Mobile

Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection. Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment. Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation.

Explanation

Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection. Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment. Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation.

47. A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine?

In a month from now

In a year from now

At age 10

At age 13

Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13.

Explanation

Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13.

48. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to whichof the following?

Lowered resistance from malnutrition

Ineffective functioning of the Eustachian tubes

Plugging of the Eustachian tubes with food particles

Associated congenital defects of the middle ear.

Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques. Food particles do not pass through the cleft and into the Eustachian tubes. There is no association between cleft palate and congenial ear deformities.

Explanation

Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques. Food particles do not pass through the cleft and into the Eustachian tubes. There is no association between cleft palate and congenial ear deformities.

49. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?

Supine

Prone

In an infant seat

On the side

Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. If the child is placed in the supine position, he or she may aspirate. Using an infant seat does not facilitate drainage. Side-lying does not facilitate drainage as well as the prone position.

Explanation

Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. If the child is placed in the supine position, he or she may aspirate. Using an infant seat does not facilitate drainage. Side-lying does not facilitate drainage as well as the prone position.

50. Which of the following is characteristic of a preschooler with mid mental retardation?

Slow to feed self

Lack of speech

Marked motor delays

Gait disability

Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking. Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation.

Explanation

Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking. Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation.

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