Growth and Development | NCLEX Quiz 198

1. A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant?

Estrogen

HCG

Alpha-fetoprotein

Progesterone

Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%. but the test does not positively confirm pregnancy.

Explanation

Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%. but the test does not positively confirm pregnancy.

2. The nurse is assessing a six-month-old child. Which developmental skills are normal and should be expected?

Speaks in short sentences.

Sits alone.

Can feed self with a spoon.

Pulling up to a standing position.

A six-month-old child is learning to sit alone.Option A: The child develops language skills between the ages of one and three.Option C: The child begins to use a spoon at 12-15 months of age.Option D: The baby pulls himself to a standing position about ten months of age.

Explanation

A six-month-old child is learning to sit alone.Option A: The child develops language skills between the ages of one and three.Option C: The child begins to use a spoon at 12-15 months of age.Option D: The baby pulls himself to a standing position about ten months of age.

3. The nurse prepares for a Denver Screening test with a 3-year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. The BEST response is to tell her that the test

Measures potential intelligence

Assesses a child’s development

Evaluates psychological responses

Diagnoses specific problems

The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social. fine motor adaptive. language and gross motor development. A child experiences the fun of play during the test.

Explanation

The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social. fine motor adaptive. language and gross motor development. A child experiences the fun of play during the test.

4. The nurse is caring for the mother of a newborn. The nurse recognizes that the mother needs more teaching regarding cord care because she

Keeps the cord exposed to the air.

Washes her hands before sponge bathing her baby.

Washes the cord and surrounding area well with water at each diaper change.

Checks it daily for bleeding and drainage.

Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection.Option A: Exposure to air helps dry the cord.Option B: Good hand washing is the prime mechanism for preventing infection.Option D: It is important to check for complications of bleeding and drainage that might occur.

Explanation

Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection.Option A: Exposure to air helps dry the cord.Option B: Good hand washing is the prime mechanism for preventing infection.Option D: It is important to check for complications of bleeding and drainage that might occur.

5. While giving nursing care to a hospitalized adolescent. the nurse should be aware that the MAJOR threat felt by the hospitalized adolescent is

Pain management

Restricted physical activity

Altered body image

Separation from family

The hospitalized adolescent may see each of these as a threat. but the major threat that they feel when hospitalized is the fear of altered body image. because of the emphasis on physical appearance.

Explanation

The hospitalized adolescent may see each of these as a threat. but the major threat that they feel when hospitalized is the fear of altered body image. because of the emphasis on physical appearance.

6. While teaching a 10-year-old child about their impending heart surgery. the nurse should

Provide a verbal explanation just prior to the surgery

Provide the child with a booklet to read about the surgery

Introduce the child to another child who had heart surgery three days ago

Explain the surgery using a model of the heart

According to Piaget. the school-age child is in the concrete operations stage of cognitive development. Using something concrete. like a model will help the child understand the explanation of the heart surgery.

Explanation

According to Piaget. the school-age child is in the concrete operations stage of cognitive development. Using something concrete. like a model will help the child understand the explanation of the heart surgery.

7. When caring for an elderly client it is important to keep in mind the changes in color vision that may occur. What colors are apt to be most difficult for the elderly to distinguish?

Red and blue.

Blue and gold.

Red and green.

Blue and green.

The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age.Option A: The elderly are better able to distinguish between red and blue because of the difference in wavelengths.Option B: The elderly are better able to distinguish between blue and gold because of the difference in wavelengths.Option C: The elderly are better able to distinguish between red and green because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age.

Explanation

The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age.Option A: The elderly are better able to distinguish between red and blue because of the difference in wavelengths.Option B: The elderly are better able to distinguish between blue and gold because of the difference in wavelengths.Option C: The elderly are better able to distinguish between red and green because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age.

8. A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for eight hours and is four (4) cm dilated. Since she is a candidate for infection. the nurse should include which of the following in the care plan?

Universal precautions.

Oxytocin administration.

Frequent temperature monitoring.

More frequent vaginal examinations.

Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus. membranes. and uterine cavity.Option A: Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected.Option B: Oxytocin may be needed to induce labor if it is not progressing. but it is not done initially.Option D: More frequent vaginal examinations are not recommended. as frequent vaginal exams can increase chances of infection.

Explanation

Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus. membranes. and uterine cavity.Option A: Universal precautions are necessary for all clients but a specific assessment of the client’s temperature will give an indication the client is becoming infected.Option B: Oxytocin may be needed to induce labor if it is not progressing. but it is not done initially.Option D: More frequent vaginal examinations are not recommended. as frequent vaginal exams can increase chances of infection.

9. The nurse is planning care for an 18 month-old child. Which of the following should be included the in the child's care?

Hold and cuddle the child often

Encourage the child to feed himself finger food

Allow the child to walk independently on the nursing unit

Engage the child in games with other children

According to Erikson. the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living.

Explanation

According to Erikson. the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living.

10. A 27-year-old woman has Type I diabetes mellitus. She and her husband want to have a child. so they consulted her diabetologist. who gave her information on pregnancy and diabetes. Of primary importance for the diabetic woman who is considering pregnancy should be

A review of the dietary modifications that will be necessary.

Early prenatal medical care.

Adoption instead of conception.

Understanding that this is a major health risk to the mother.

Pregnancy makes metabolic control of diabetes more difficult. It is essential that the client starts prenatal care early so that potential complications can be controlled or minimized by the efforts of the client and health care team.Option A: A review of dietary modifications is important once the woman is pregnant. However. it is not of primary importance when considering pregnancy.Option C: The alternative of adoption is not necessary just because the client is a diabetic. Many diabetic women have pregnancies with successful outcomes if they receive good care.Option D: While there is some risk to the pregnant diabetic woman. it is not considered a major health risk. The greater risk is to the fetus.

Explanation

Pregnancy makes metabolic control of diabetes more difficult. It is essential that the client starts prenatal care early so that potential complications can be controlled or minimized by the efforts of the client and health care team.Option A: A review of dietary modifications is important once the woman is pregnant. However. it is not of primary importance when considering pregnancy.Option C: The alternative of adoption is not necessary just because the client is a diabetic. Many diabetic women have pregnancies with successful outcomes if they receive good care.Option D: While there is some risk to the pregnant diabetic woman. it is not considered a major health risk. The greater risk is to the fetus.

Growth And Development | NCLEX Quiz 198