Maternal And Child Health Nursing NCLEX Quiz 21

2.

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.”

Correct Answer

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

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.Option B: The child should attend school even during resolution of the problem.Option C: Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions.Option D: 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.

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3.

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.

Correct Answer

A. Denial of the pregnancy is common early on.

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.Option A: The incidence of adolescent pregnancy has declined since 1991. yet morbidity remains high.Option B: Most teenage pregnancies are unplanned and occur out of wedlock.Option D: 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.

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4.

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 which of 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.

Correct Answer

A. Ineffective functioning of the Eustachian tubes

Explanation

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

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5.

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

Correct Answer

A. Lifting of head and chest when prone

Explanation

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

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6.

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

Correct Answer

A. 12 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.

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7.

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

Correct Answer

A. Sitting near each other while playing with separate dolls

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.Options A. B. and D: Sharing crayons. playing a board game with a nurse. or sharing dolls with two different nurses are all examples of cooperative play.

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8.

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

Correct Answer

A. Instituting infection control precautions

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.Option B: Iron-rich foods help with anemia. but dietary iron is not an initial intervention.Option C: 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.Option D: Injections should be discouraged. owing to increased risk of bleeding due to thrombocytopenia.

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9.

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 diphtheria. tetanus. and pertussis injection?

Measures to reduce fever
Need for dietary restrictions
Reasons for subsequent rash
Measures to control subsequent diarrhea

Correct Answer

A. Measures to reduce fever

Explanation

The pertussis 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.Option B: No dietary restrictions are necessary after this injection is given.Option C: Subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine. not diphtheria. pertussis. and tetanus vaccine.Option D: A Diarrhea is not associated with this vaccine.

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10.

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.

Correct Answer

A. Report the child’s condition to Protective Services immediately.

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.Option B: Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data.Option C: 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.Option D: Multiple bruises and burns are not normal toddler injuries.

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Maternal And Child Health Nursing NCLEX Quiz 21

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

Quiz Preview

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

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?

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 which of the following?

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

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

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

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

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 diphtheria. tetanus. and pertussis injection?

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?