Conception Through Adolescence

1. Which of the following data is the most important for the nurse to assess when caring for a woman in her second trimester of pregnancy?

1.
Detection of fetal movement
2.
Observation that the uterus is below the pubis
3.
Confirmation of the desire to breast- or bottle-feed
4.
Determination of the presence of morning sickness

ANS: 1

During the second trimester, between 16 and 20 weeks’ gestation, the mother begins to feel fetal movement. During the second trimester, the uterus should be above the level of the symphysis pubis. Confirmation of the desire to breast- or bottle-feed is more likely to take place during the third trimester. Morning sickness is most likely to occur during the first trimester.

DIF: C REF: 151 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6-month well-baby visit?

1.
Moro
2.
Startle
3.
Babinski
4.
Extrusion

ANS: 3

The Babinski reflex is a normal reflex found in a 6-month-old infant. The Moro reflex is seen in the newborn. The startle reflex is seen in the newborn. Before 6 months of age, the extrusion reflex causes food to be pushed out of the mouth. It is normally present from birth to 4 months.

DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

3. In evaluating an infant’s physical status and growth, the nurse expects to find:

1.
Birth weight triples by 6 months
2.
Anterior fontanel closes 4 to 8 weeks after birth
3.
Chest circumference is larger than head circumference at 12 months
4.
Birth height increases 1 inch each month for the first 6 months

ANS: 4

Height increases an average of 1 inch during each of the first 6 months and inch the next 6 months. Birth weight doubles in approximately 5 months and triples by 12 months. The anterior fontanel closes at about 12 to 18 months. The head and chest circumference are equal at 1 year of age.

DIF: A REF: 155 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

4. Upon evaluation of a 6-month-old infant’s developmental status, the nurse expects that the child at this age will be able to:

1.
Completely roll over
2.
Pull self to a standing position
3.
Creep on all four extremities
4.
Assume a sitting position independently

ANS: 1

A 6-month-old infant is able to roll over. A 9-month-old infant is able to pull self to a standing position, creep on all four extremities, and attain a sitting position independently.

DIF: A OBJ: Knowledge TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

5. For a 2-year-old child, cognitive development is characterized by:

1.
Recognizing right and wrong
2.
Initiating play with other children
3.
Having a vocabulary of at least 1000 words
4.
Using short sentences to express independence

ANS: 4

A 2-year-old child uses short sentences to express independence and control, does not understand the concepts of right and wrong, may engage in solitary play and begin to participate in parallel play, may initiate play with other children, and has a vocabulary up to 300 words.

DIF: A REF: 159 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

6. In planning nursing care for an 18-month-old child, the nurse should know that the predominant developmental characteristic of children this age is:

1.
Parallel play
2.
Peer pressure
3.
Mutilation anxiety
4.
Imaginary playmates

ANS: 1

During toddlerhood, the child begins to participate in parallel play, which is playing beside rather than with another child. Peer pressure is seen with the school-age child. A fear of the preschool child is bodily harm. The preschool child may have imaginary playmates.

DIF: A REF: 159 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was admitted to the surgical center to have his tonsils removed to:

1.
Perform his own preoperative hygienic care
2.
Have alone time to relax before the procedure
3.
Handle the equipment when taking his blood pressure
4.
Have access to age-appropriate magazines and puzzles for diversion

ANS: 3

Preschool children may cooperate if they are allowed to manipulate the equipment. A preschooler is unable to take responsibility for his or her own preoperative hygienic care.

Leaving the preschooler alone may increase the child’s anxiety. Magazines and puzzles would be more appropriate activities for the older child. The preschool child likes to engage in pretend play, using their imagination and imitating adult behavior.

DIF: A REF: 160 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

8. A parent of a 3-year-old boy states that she is concerned because he was potty trained long before hospitalization but now refuses to use the toilet. What is the correct response by the nurse?

1.
“Your son is probably feeling neglected, and you should make an effort to spend more time with him.”
2.
“This is common behavior that is expressed when the hospitalized child is stressed or anxious.”
3.
“You may need to include discipline because children easily lose the ability to be toilet trained during hospitalization.”
4.
“Your son was probably not ready to be potty trained, and you may want to continue the training for the next 6 months.”

ANS: 2

During times of stress or illness, preschoolers may revert to bed-wetting or thumb-sucking and want the parent to feed, dress, and hold them. Reassuring the parent that this is normal coping behavior may help alleviate their concern. Reverting to a prior level of functioning, such as a child who was potty trained now refusing to use the toilet, does not indicate the child is feeling neglected. The behavior demonstrates that the child is experiencing stress and this is a coping behavior. Disciplining the child would not be a correct response. The child should be provided with experiences he or she can master. Such successes help the child to return to their prior level of independent functioning.

Reverting to a prior level of functioning, such as a child who was potty trained now refusing to use the toilet, does not indicate the child was unready to be potty trained. The behavior more likely demonstrates that the child is experiencing stress, and this is a coping behavior.

DIF: A REF: 161 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

9. A 4 1/2-year-old child is crying from pain related to her fractured leg. Which of the following is the most appropriate nursing response to her alteration in comfort?

1.
“Please try to not move your leg and that will make it feel better.”
2.
“I’ll give you a shot of medicine that will help take the pain away.”
3.
“It’s okay if you need to cry. Would you like to hold your favorite doll?”
4.
“Would you like to tell me now where you want me to give you your shot?”

ANS: 3

Telling the child it’s okay to cry and hold a toy informs the child what they can do, and involves an age-appropriate familiar toy to provide comfort. Telling the child not to move when they are in pain is unlikely to be effective. A preschool child may have difficulty in understanding the request. Telling the child they are going to get a shot may increase their anxiety, as they fear bodily harm. If a child is allowed to determine the site for administration of an injection, specific sites should be offered as choices. However, the nurse needs to avoid allowing procrastination by the child.

DIF: A REF: 160 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

10. When teaching basic infant safety to the parents of a 3-month-old, the nurse should emphasize:

1.
Placing gates at stairways
2.
Keeping bathroom doors closed
3.
Giving large, hard teething biscuits
4.
Removing feeding bibs at bedtime

ANS: 4

Bibs should be removed at bedtime to avoid suffocation. Placing gates or fences at stairways is an appropriate safety measure to prevent falls of the 8- to 12-month-old infant. Keeping bathroom doors closed is an appropriate safety measure to prevent drowning of the 8- to 12-month-old infant. Caution should be exercised when giving teething biscuits to a 4- to 7-month-old infant because large chunks may be broken off and aspirated. Teething biscuits are typically not given to a 3-month-old.

DIF: A REF: 156 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse informs the parents that the child will be able to:

1.
Say Da-da
2.
Smile responsively
3.
Differentiate strangers
4.
Play social peekaboo games

ANS: 2

Two- and 3-month-old infants begin to smile responsively rather than reflexively. By 1 year of age, infants have two- or three-word vocabularies such as Da-da. By 8 months, most infants can differentiate a stranger from a familiar person. By 9 months, infants play simple social games such as patty-cake and peekaboo.

DIF: A REF: 155 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing. The nurse responds correctly by telling the client that:

1.
“The sex of the baby can be determined.”
2.
“There is a fine hair that covers the body.”
3.
“Fingers and toes are differentiated clearly.”
4.
“The organ systems are beginning to develop.”

ANS: 4

During the first trimester of pregnancy, the organ systems are beginning to develop. During the second trimester of pregnancy, the sex of the fetus can be determined, and fine hair, called lanugo, covers most of the body of the fetus. Also during the second trimester of pregnancy, fingers and toes are differentiated.

DIF: A REF: 150 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

13. The nurse assists the family of a 9-year-old with nutritional information. A recommended after-school snack for a child this age is:

1.
Milk shakes
2.
Potato chips
3.
Plain popcorn
4.
Bite-size candy

ANS: 3

Plain popcorn, fresh fruit, raw vegetables, cheese, skim-milk pudding, and hot chocolate are appropriate after-school snacks. Thick milk shakes would be high in fat and calories. There are better food choices for after-school snacks. Potato chips should be discouraged as a snack because they are high in fat and low in nutritional value. Candy bars should be discouraged as a snack because they are high in fat and calories, are low in nutrition, and are cariogenic.

DIF: A REF: 168 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

14. The elementary school nurse is responsible for evaluating each child’s overall physical development. During the school-age years, the nurse anticipates that:

1.
The child’s body weight will almost triple
2.
There will be few physical differences among children
3.
The child will grow an average of 1 to 2 inches per year
4.
Body fat will gradually increase, contributing to a heavier appearance

ANS: 3

During the school-age years, the child will grow an average of 1 to 2 inches per year and gain an average of 4 to 7 pounds a year. Many children double, not triple, their weight during these middle childhood years. Growth accelerates at different times for different children. There will be many physical differences apparent among children at the end of middle childhood. The school-age child appears slimmer as a result of changes in fat distribution and thickness.

DIF: A REF: 164 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

15. A 6-year-old is hospitalized for asthma. Which of the following activities would be appropriate to help this child resolve the crisis of hospitalization?

1.
Crayons and a coloring book
2.
A 1000-piece puzzle to complete
3.
A CD player with soothing CDs
4.
A Nerf football to throw around the room

ANS: 1

Providing a 6-year-old with crayons and a book to color in would be an age-appropriate activity to help the child with the crisis of hospitalization. Painting, drawing, playing computer games, and making models allow children to practice and improve newly refined skills. A 1000-piece puzzle would be too much for a 6-year-old to complete. A CD player with soothing CDs would not be an age-appropriate activity for a 6-year-old. Throwing a Nerf football around the room may not be appropriate for a hospitalized child with asthma.

DIF: A REF: 164 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

16. Which one of the following statements is correct regarding the preadolescence developmental stage?

1.
It appears 2 years earlier in boys than in girls.
2.
Intimate feelings are confided in the parents.
3.
Interest in the opposite sex is not a factor for this group.
4.
It signals the development of secondary sex characteristics.

ANS: 4

The preadolescence developmental stage (puberty) signals the development of secondary sex characteristics. Physical changes often begin 2 years earlier in girls than in boys. Preadolescents usually develop “best friends” with whom they share intimate feelings. New interest in the opposite sex develops in the preadolescence developmental stage.

DIF: A REF: 167 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

17. The nurse is teaching parents about probable warning signs that a teenager is considering suicide and tells parents to be alert to:

1.
An increase in appetite
2.
A sudden interest in school activities
3.
An unexplained increase in sleepiness
4.
Talking about death and personal harm

ANS: 4

A warning sign that a teenager is considering suicide includes verbalization of suicidal thoughts. Appetite disturbances, usually a decrease in appetite, may be a warning sign that a teenager is considering suicide. A decrease in school performance and loss of initiative are possible warning signs that a teenager is considering suicide. Sleep disturbances, such as the inability to sleep, are a warning sign for suicide.

DIF: A REF: 172 OBJ: Knowledge

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential/System Specific Assessments

18. In order to obtain the most information, which of the following is the most appropriate question asked of a 14-year-old female who is visiting the county health center for “birth control help?”

1.
“Have you told your parents that you are sexually active?”
2.
“Are any of your friends participating in sexual behaviors?”
3.
“What can you tell me about any of your past sexual activities?”
4.
“Have you been physically protecting yourself with safe sex measures?”

ANS: 3

The nurse can be proactive by using the interview process and open-ended questions such as this one, to identify risk factors in the adolescent. Once identified, the risk factors should lead to strategies for prevention. Inquiring what the client has told parents does not obtain the most information. Asking about friends’ activities does not address the individual and does not obtain the most information about the health behaviors of the client. Asking whether the client is having safe sex may be answered with a “yes” or “no” response and therefore does not obtain the most information.

DIF: A REF: 173-174 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Health Promotion and Maintenance/Growth and Development; Physiological Integrity/Reduction of Risk Potential+G1222

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