Nursing Care of Infants and Children Practice Exam

Nursing Care of Infants and Children Practice Exam

 

What Are Key Developmental Milestones in Infants and Children?

Answer:
Developmental milestones are benchmarks that indicate typical growth and development in children.

• Infants (0–12 months): Rolling over (4–6 months), sitting unsupported (6–8 months), and walking with support (9–12 months).
• Toddlers (1–3 years): Walking independently (12–15 months), building two-block towers (18 months), and simple sentences (2–3 years).
• Preschoolers (3–5 years): Gross motor skills like hopping and fine motor tasks like drawing shapes.
• School-aged children (6–12 years): Logical thinking, better coordination, and social skills development.

What Are Common Health Issues in Infants and Children?

Answer:

• Respiratory Conditions: Bronchiolitis, asthma, and croup.
• Infectious Diseases: Measles, mumps, chickenpox, and otitis media.
• Gastrointestinal Problems: Diarrhea, constipation, and gastroesophageal reflux disease (GERD).
• Chronic Conditions: Juvenile diabetes and cystic fibrosis.
• Developmental Disorders: Autism, ADHD, and delayed speech.

 

How Should Nurses Assess Pediatric Patients?

Answer:

• Infants: Assess reflexes (e.g., Moro, rooting), weight gain, and feeding habits.
• Toddlers and Preschoolers: Use play techniques for physical exams and observe behaviors.
• School-Age Children: Allow the child to ask questions and explain procedures clearly.
• Adolescents: Include them in discussions about their health and respect their privacy.

 

What Are Effective Pain Management Strategies for Children?

Answer:

• Use age-appropriate pain assessment tools (e.g., FLACC scale for infants, Wong-Baker Faces Scale for older children).
• Non-pharmacological methods: Distraction, storytelling, or toys.
• Pharmacological interventions: Acetaminophen or ibuprofen (age-appropriate doses).

How Do Nurses Manage Feeding Issues in Infants?

Answer:

• Breastfeeding Support: Teach correct latching and feeding positions.
• Formula Feeding: Educate parents about preparation and feeding schedules.
• Special Conditions: For GERD, recommend upright positioning after feeds and smaller, frequent meals.

What Are the Components of Family-Centered Care?

Answer:

• Involving family in care planning.
• Educating parents about the child’s condition and treatment.
• Providing emotional support to families during stressful situations.

What Are Common Pediatric Immunizations?

Answer:
Vaccines recommended include:

• Infants: Hepatitis B, DTaP, Hib, polio, pneumococcal, and rotavirus.
• Toddlers and Preschoolers: MMR, varicella, and annual influenza.
• School-Age Children: HPV, Tdap, and meningococcal vaccines.

What Is the Role of Nurses in Managing Acute Respiratory Distress in Children?

Answer:

• Monitor respiratory rate, oxygen saturation, and effort.
• Administer oxygen therapy as prescribed.
• Educate parents on recognizing signs of distress.
• Provide nebulized bronchodilators for conditions like asthma or croup.

 

How Do Nurses Support Children with Developmental Delays?

Answer:

• Collaborate with developmental specialists and therapists.
• Encourage age-appropriate play and social interaction.
• Teach parents exercises or activities to stimulate development.

What Are Key Safety Considerations in Pediatric Nursing?

Answer:

• Prevent falls by using safety rails on cribs.
• Avoid choking hazards by using age-appropriate toys and feeding utensils.
• Administer medications accurately, considering weight-based dosing.

What Are Signs of Dehydration in Infants and Children?

Answer:

• Sunken fontanelle in infants.
• Dry mucous membranes and decreased urine output.
• Lethargy or irritability.
• Poor skin turgor and absence of tears when crying.

How Do Nurses Provide End-of-Life Care for Pediatric Patients?

Answer:

• Address physical comfort by managing pain and symptoms.
• Provide emotional support to the child and family.
• Ensure a peaceful environment and involve families in care decisions.

 

What Are the Basic Principles of Pediatric Medication Administration?

Answer:

• Use weight-based dosing (mg/kg).
• Confirm medication calculations with a second nurse.
• Use oral syringes for liquid medications to ensure accuracy.

 

What Are Strategies for Managing Separation Anxiety in Hospitalized Children?

Answer:

• Encourage parents to stay with the child.
• Use familiar objects (e.g., favorite toys or blankets).
• Establish routines to provide a sense of security.

 

How Can Nurses Promote Healthy Growth and Development?

Answer:

• Encourage balanced nutrition with proper portion sizes.
• Teach parents about developmental play activities.
• Monitor growth parameters and address concerns early.

 

Perspectives of Pediatric Nursing

 

MULTIPLE CHOICE

 

1. The clinic nurse is reviewing statistics on infant mortality for the United States versus other countries. Compared with other countries that have a population of at least 25 million, the nurse makes which determination?

 

a.	The United States is ranked last among 27 countries.
b.	The United States is ranked similar to 20 other developed countries.
c.	The United States is ranked in the middle of 20 other developed countries.
d.	The United States is ranked highest among 27 other industrialized countries.

ANS: A

Although the death rate has decreased, the United States still ranks last in infant mortality among nations with a population of at least 25 million. The United States has the highest infant death rate of developed nations.

 

2. Which is the leading cause of death in infants younger than 1 year in the United States?

a.	Congenital anomalies
b.	Sudden infant death syndrome
c.	Disorders related to short gestation and low birth weight
d.	Maternal complications specific to the perinatal period

ANS: A

Congenital anomalies account for 20.1% of deaths in infants younger than 1 year compared with sudden infant death syndrome, which accounts for 8.2%; disorders related to short gestation and unspecified low birth weight, which account for 16.5%; and maternal complications such as infections specific to the perinatal period, which account for 6.1% of deaths in infants younger than 1 year of age.

 

3. What is the major cause of death for children older than 1 year in the United States?

a.	Heart disease
b.	Childhood cancer
c.	Unintentional injuries
d.	Congenital anomalies

ANS: C

Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. The leading cause of death for those younger than 1 year is congenital anomalies, and childhood cancers and heart disease cause a significantly lower percentage of deaths in children older than 1 year of age.

 

4. In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years?

a.	Suicide and cancer
b.	Suicide and homicide
c.	Drowning and cancer
d.	Homicide and heart disease

ANS: B

Suicide and homicide account for 16.7% of deaths in this age group. Suicide and cancer account for 10.9% of deaths, heart disease and cancer account for approximately 5.5%, and homicide and heart disease account for 10.9% of the deaths in this age group.

 

5. The nurse is planning a teaching session to adolescents about deaths by unintentional injuries. Which should the nurse include in the session with regard to deaths caused by injuries?

a.	More deaths occur in males.
b.	More deaths occur in females.
c.	The pattern of deaths does not vary according to age and sex.
d.	The pattern of deaths does not vary widely among different ethnic groups.

ANS: A

The majority of deaths from unintentional injuries occur in males. The pattern of death does vary greatly among different ethnic groups, and the causes of unintentional deaths vary with age and gender.

 

6. What do mortality statistics describe?

a.	Disease occurring regularly within a geographic location
b.	The number of individuals who have died over a specific period
c.	The prevalence of specific illness in the population at a particular time
d.	Disease occurring in more than the number of expected cases in a community

ANS: B

Mortality statistics refer to the number of individuals who have died over a specific period.

Morbidity statistics show the prevalence of specific illness in the population at a particular time. Data regarding disease within a geographic region, or in greater than expected numbers in a community, may be extrapolated from analyzing the morbidity statistics.

 

7. The nurse should assess which age group for suicide ideation since suicide in which age group is the third leading cause of death?

a.	Preschoolers
b.	Young school age
c.	Middle school age
d.	Late school age and adolescents

ANS: D

Suicide is the third leading cause of death in children ages 10 to 19 years; therefore, the age group should be late school age and adolescents. Suicide is not one of the leading causes of death for preschool and young or middle school-aged children.

 

8. Parents of a hospitalized toddler ask the nurse, “What is meant by family-centered care?” The nurse should respond with which statement?

a.	Family-centered care reduces the effect of cultural diversity on the family.
b.	Family-centered care encourages family dependence on the health care system.
c.	Family-centered care recognizes that the family is the constant in a child’s life.
d.	Family-centered care avoids expecting families to be part of the decision-making process.

ANS: C

The three key components of family-centered care are respect, collaboration, and support. Family-centered care recognizes the family as the constant in the child’s life. The family should be enabled and empowered to work with the health care system and is expected to be part of the decision-making process. The nurse should also support the family’s cultural diversity, not reduce its effect.

 

9. The nurse is describing clinical reasoning to a group of nursing students. Which is most descriptive of clinical reasoning?

a.	Purposeful and goal directed
b.	A simple developmental process
c.	Based on deliberate and irrational thought
d.	Assists individuals in guessing what is most appropriate

ANS: A

Clinical reasoning is a complex developmental process based on rational and deliberate thought. When thinking is clear, precise, accurate, relevant, consistent, and fair, a logical connection develops between the elements of thought and the problem at hand.

 

10. Evidence-based practice (EBP), a decision-making model, is best described as which?

a.	Using information in textbooks to guide care
b.	Combining knowledge with clinical experience and intuition
c.	Using a professional code of ethics as a means for decision making
d.	Gathering all evidence that applies to the child’s health and family situation

ANS: B

EBP helps focus on measurable outcomes; the use of demonstrated, effective interventions; and questioning what is the best approach. EBP involves decision making based on data, not all evidence on a particular situation, and involves the latest available data. Nurses can use textbooks to determine areas of concern and potential involvement.

 

11. Which best describes signs and symptoms as part of a nursing diagnosis?

a.	Description of potential risk factors
b.	Identification of actual health problems
c.	Human response to state of illness or health
d.	Cues and clusters derived from patient assessment

ANS: D

Signs and symptoms are the cues and clusters of defining characteristics that are derived from a patient assessment and indicate actual health problems. The first part of the nursing diagnosis is the problem statement, also known as the human response to the state of illness or health. The identification of actual health problems may be part of the medical diagnosis. The nursing diagnosis is based on the human response to these problems. The human response is therefore a component of the nursing diagnostic statement. Potential risk factors are used to identify nursing care needs to avoid the development of an actual health problem when a potential one exists.

 

Social, Cultural, Religious, and Family Influences on Child Health Promotion

 

MULTIPLE CHOICE

 

1. Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which factor may be culturally determined?

a.	Ethnicity
b.	Racial variation
c.	Status
d.	Geographic boundaries

ANS: C

Status is culturally determined and varies according to each culture. Some cultures ascribe higher status to age or socioeconomic position. Social roles also are influenced by the culture. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. It is one component of culture. Race and culture are two distinct attributes. Whereas racial grouping describes transmissible traits, culture is determined by the pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. Cultural development may be limited by geographic boundaries, but the boundaries are not culturally determined.

 

2. The nurse is aware that if patients’ different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what?

a.	Acculturation
b.	Ethnocentrism
c.	Cultural shock
d.	Cultural sensitivity

ANS: B

Ethnocentrism is the belief that one’s way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of one’s ethnic group are superior to those of others. Acculturation is the gradual changes that are produced in a culture by the influence of another culture that cause one or both cultures to become more similar. The minority culture is forced to learn the majority culture to survive. Cultural shock is the helpless feeling and state of disorientation felt by an outsider attempting to adapt to a different culture group. Cultural sensitivity, a component of culturally competent care, is an awareness of cultural similarities and differences.

 

3. Which term best describes the sharing of common characteristics that differentiates one group from other groups in a society?

a.	Race
b.	Culture
c.	Ethnicity
d.	Superiority

ANS: C

Ethnicity is a classification aimed at grouping individuals who consider themselves, or are considered by others, to share common characteristics that differentiate them from the other collectivities in a society, and from which they develop their distinctive cultural behavior. Race is a term that groups together people by their outward physical appearance. Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that serve as a frame of reference for individual perception and judgments. Superiority is the state or quality of being superior; it does not apply to ethnicity.

 

4. After the family, which has the greatest influence on providing continuity between generations?

a.	Race
b.	School
c.	Social class
d.	Government

ANS: B

Schools convey a tremendous amount of culture from the older members to the younger members of society. They prepare children to carry out the traditional social roles that will be expected of them as adults. Race is defined as a division of humankind possessing traits that are transmissible by descent and are sufficient to characterize race as a distinct human type; although race may have an influence on childrearing practices, its role is not as significant as that of schools. Social class refers to the family’s economic and educational levels. The social class of a family may change between generations. The government establishes parameters for children, including amount of schooling, but this is usually at a local level. The school culture has the most significant influence on continuity besides family.

 

5. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal?

a.	Adapt, as necessary, ethnic practices to health needs.
b.	Attempt, in a nonjudgmental way, to change ethnic beliefs.
c.	Encourage continuation of ethnic practices in the hospital setting.
d.	Strive to keep ethnic background from influencing health needs.

ANS: A

Whenever possible, nurses should facilitate the integration of ethnic practices into health care provision. The ethnic background is part of the individual; it should be difficult to eliminate the influence of ethnic background. The ethnic practices need to be evaluated within the context of the health care setting to determine whether they are conflicting.

 

6. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child’s mother says she has rubbed the edge of a coin on her child’s oiled skin. The nurse should recognize this as what?

a.	Child abuse
b.	Cultural practice to rid the body of disease
c.	Cultural practice to treat enuresis or temper tantrums
d.	Child discipline measure common in the Vietnamese culture

ANS: B

This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the child’s oiled skin. The mother is attempting to rid the child’s body of disease. Coining is a cultural healing practice. Coining is not specific for enuresis or temper tantrums. This is not child abuse or discipline.

 

7. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?

a.	The parent is trying to feed the child only what the child likes most.
b.	Hispanics believe the “evil eye” enters when a person gets cold.
c.	The parent is trying to restore normal balance through appropriate “hot” remedies.
d.	Hispanics believe an innate energy called chi is strengthened by eating soup.

ANS: C

In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe certain properties completely unrelated to temperature. Respiratory conditions such as pneumonia are “cold” conditions and are treated with “hot” foods. The child may like broth but is unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe in chi as an innate energy.

 

8. How is family systems theory best described?

a.	The family is viewed as the sum of individual members.
b.	A change in one family member cannot create a change in other members.
c.	Individual family members are readily identified as the source of a problem.
d.	When the family system is disrupted, change can occur at any point in the system.

ANS: D

Family systems theory describes an interactional model. Any change in one member will create change in others. Although the family is the sum of the individual members, family systems theory focuses on the number of dyad interactions that can occur. The interactions, not the individual members, are considered to be the problem.

 

9. Which family theory is described as a series of tasks for the family throughout its life span?

a.	Exchange theory
b.	Developmental theory
c.	Structural-functional theory
d.	Symbolic interactional theory

ANS: B

In developmental systems theory, the family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. Exchange theory assumes that humans, families, and groups seek rewarding statuses so that rewards are maximized while costs are minimized. Structural-functional theory states that the family performs at least one societal function while also meeting family needs. Symbolic interactional theory describes the family as a unit of interacting persons with each occupying a position within the family.

 

10. Which family theory explains how families react to stressful events and suggests factors that promote adaptation to these events?

a.	Interactional theory
b.	Family stress theory
c.	Erikson’s psychosocial theory
d.	Developmental systems theory

ANS: B

Family stress theory explains the reaction of families to stressful events. In addition, the theory helps suggest factors that promote adaptation to the stress. Stressors, both positive and negative, are cumulative and affect the family. Adaptation requires a change in family structure or interaction. Interactional theory is not a family theory. Interactions are the basis of general systems theory. Erikson’s theory applies to individual growth and development, not families. Developmental systems theory is an outgrowth of Duvall’s theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others.

 

11. Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together?

a.	Blended
b.	Nuclear
c.	Extended
d.	Binuclear

ANS: C

An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. A blended family contains at least one stepparent, stepsibling, or half-sibling. A nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children.

 

12. Which type of family should the nurse recognize when a mother, her children, and a stepfather live together?

a.	Traditional nuclear
b.	Blended
c.	Extended
d.	Binuclear

ANS: B

A blended family contains at least one stepparent, stepsibling, or half-sibling. A traditional nuclear family consists of a married couple and their biologic children. No other relatives or nonrelatives are present in the household. An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children.

 

13. Which is an accurate description of homosexual (or gay-lesbian) families?

a.	A nurturing environment is lacking.
b.	The children become homosexual like their parents.
c.	The stability needed to raise healthy children is lacking.
d.	The quality of parenting is equivalent to that of nongay parents.

ANS: D

Although gay or lesbian families may be different from heterosexual families, the environment can be as healthy as any other. Lacking a nurturing environment and stability is reflective on the parents and family, not the type of family. There is little evidence to support that children become homosexual like their parents.

 

14. The nurse is teaching a group of new nursing graduates about identifiable qualities of strong families that help them function effectively. Which quality should be included in the teaching?

a.	Lack of congruence among family members
b.	Clear set of family values, rules, and beliefs
c.	Adoption of one coping strategy that always promotes positive functioning in dealing with life events
d.	Sense of commitment toward growth of individual family members as opposed to that of the family unit

ANS: B

A clear set of family rules, values, and beliefs that establish expectations about acceptable and desired behavior is one of the qualities of strong families that help them function effectively. Strong families have a sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs. Varied coping strategies are used by strong families. The sense of commitment is toward the growth and well-being of individual family members, as well as the family unit.

 

15. When assessing a family, the nurse determines that the parents exert little or no control over their children. This style of parenting is called which?

a.	Permissive
b.	Dictatorial
c.	Democratic
d.	Authoritarian

ANS: A

Permissive parents avoid imposing their own standards of conduct and allow their children to regulate their own activity as much as possible. The parents exert little or no control over their children’s actions. Dictatorial or authoritarian parents attempt to control their children’s behavior and attitudes through unquestioned mandates. They establish rules and regulations or standards of conduct that they expect to be followed rigidly and unquestioningly. Democratic parents combine permissive and dictatorial styles. They direct their children’s behavior and attitudes by emphasizing the reasons for rules and negatively reinforcing deviations. They respect their children’s individual natures.

 

16. When discussing discipline with the mother of a 4-year-old child, which should the nurse include?

a.	Parental control should be consistent.
b.	Withdrawal of love and approval is effective at this age.
c.	Children as young as 4 years rarely need to be disciplined.
d.	One should expect rules to be followed rigidly and unquestioningly.

ANS: A

For effective discipline, parents must be consistent and must follow through with agreed-on actions. Withdrawal of love and approval is never appropriate or effective. The 4-year-old child will test limits and may misbehave. Children of this age do not respond to verbal reasoning. Realistic goals should be set for this age group. Discipline is necessary to reinforce these goals. Discipline strategies should be appropriate to the child’s age and temperament and the severity of the misbehavior. Following rules rigidly and unquestioningly is beyond the developmental capabilities of a 4-year-old child.

 

17. Which is a consequence of the physical punishment of children, such as spanking?

a.	The psychologic impact is usually minimal.
b.	The child’s development of reasoning increases.
c.	Children rarely become accustomed to spanking.
d.	Misbehavior is likely to occur when parents are not present.

ANS: D

Through the use of physical punishment, children learn what they should not do. When parents are not around, it is more likely that children will misbehave because they have not learned to behave well for their own sake but rather out of fear of punishment. Spanking can cause severe physical and psychologic injury and interfere with effective parent–child interaction. The use of corporal punishment may interfere with the child’s development of moral reasoning. Children do become accustomed to spanking, requiring more severe corporal punishment each time.

 

18. The parents of a young child ask the nurse for suggestions about discipline. When discussing the use of time-outs, which should the nurse include?

a.	Send the child to his or her room if the child has one.
b.	A general rule for length of time is 1 hour per year of age.
c.	Select an area that is safe and nonstimulating, such as a hallway.
d.	If the child cries, refuses, or is more disruptive, try another approach.

ANS: C

The area must be nonstimulating and safe. The child becomes bored in this environment and then changes behavior to rejoin activities. The child’s room may have toys and activities that negate the effect of being separated from the family. The general rule is 1 minute per year of age. An hour per year is excessive. When the child cries, refuses, or is more disruptive, the time-out does not start; the time-out begins when the child quiets.

 

19. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

a.	It is best to wait until the child asks about it.
b.	The best time to tell the child is between the ages of 7 and 10 years.
c.	It is not necessary to tell a child who was adopted so young.
d.	Telling the child is an important aspect of their parental responsibilities.

ANS: D

It is important for the parents not to withhold information about the adoption from the child. It is an essential component of the child’s identity. There is no recommended best time to tell children. It is believed that children should be told young enough so they do not remember a time when they did not know. It should be done before the children enter school to prevent third parties from telling the children before the parents have had the opportunity.

 

Hereditary Influences on Health Promotion of the Child and Family

 

MULTIPLE CHOICE

 

1. Which genetic term refers to a person who possesses one copy of an affected gene and one copy of an unaffected gene and is clinically unaffected?

a.	Allele
b.	Carrier
c.	Pedigree
d.	Multifactorial

ANS: B

An individual who is a carrier is asymptomatic but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expressions of genes at a different locus. A pedigree is a diagram that describes family relationships, gender, disease, status, or other relevant information about a family. Multifactorial describes a complex interaction of both genetic and environmental factors that produce an effect on the individual.

 

2. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage?

a.	Trisomy
b.	Monosomy
c.	Translocation
d.	Nondisjunction

ANS: C

Translocation is the transfer of all or part of a chromosome to a different chromosome after chromosome breakage. It can be balanced, producing no phenotypic effects, or unbalanced, producing severe or lethal effects. Trisomy is an abnormal number of chromosomes caused by the presence of an extra chromosome, which is added to a given chromosome pair and results in a total of 47 chromosomes per cell. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction is the failure of homologous chromosomes or chromatids to separate during mitosis or meiosis.

 

3. Which is a birth defect or disorder that occurs as a new case in a family and is not inherited?

a.	Sporadic
b.	Polygenic
c.	Monosomy
d.	Association

ANS: A

Sporadic describes a birth defect previously unidentified in a family. It is not inherited. Polygenic inheritance involves the inheritance of many genes at separate loci whose combined effects produce a given phenotype. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. A nonrandom cluster of malformations without a specific cause is an association.

 

4. The nurse is assessing a neonate who was born 1 hour ago to healthy white parents in their early forties. Which finding should be most suggestive of Down syndrome?

a.	Hypertonia
b.	Low-set ears
c.	Micrognathia
d.	Long, thin fingers and toes

ANS: B

Children with Down syndrome have low-set ears. Infants with Down syndrome have hypotonia, not hypertonia. Micrognathia is common in trisomy 16, not Down syndrome. Children with Down syndrome have short hands with broad fingers.

 

5. Which abnormality is a common sex chromosome defect?

a.	Down syndrome
b.	Turner syndrome
c.	Marfan syndrome
d.	Hemophilia

ANS: B

Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy 21 (three copies rather than two copies of chromosome 21). Marfan syndrome is a connective tissue disorder inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.

 

6. Turner syndrome is suspected in an adolescent girl with short stature. What causes this?

a.	Absence of one of the X chromosomes
b.	Presence of an incomplete Y chromosome
c.	Precocious puberty in an otherwise healthy child
d.	Excess production of both androgens and estrogens

ANS: A

Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. These young women have 45 rather than 46 chromosomes.

 

7. Which is a sex chromosome abnormality that is caused by the presence of one or more additional X chromosomes in a male?

a.	Turner
b.	Triple X
c.	Klinefelter
d.	Trisomy 13

ANS: C

Klinefelter syndrome is characterized by one or more additional X chromosomes. These individuals are tall with male secondary sexual characteristics that may be deficient, and they may be learning disabled. An absence of an X chromosome results in Turner syndrome. Triple X and trisomy 13 are not abnormalities that involve one or more additional X chromosomes in a male (Klinefelter syndrome).

 

8. Parents ask the nurse about the characteristics of autosomal dominant inheritance. Which statement is characteristic of autosomal dominant inheritance?

a.	Females are affected with greater frequency than males.
b.	Unaffected children of affected individuals will have affected children.
c.	Each child of a heterozygous affected parent has a 50% chance of being affected.
d.	Any child of two unaffected heterozygous parents has a 25% chance of being affected.

ANS: C

In autosomal dominant inheritance, only one copy of the mutant gene is necessary to cause the disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for the disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not “skip” a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for the disorder. In autosomal recessive inheritance, any child of two unaffected heterozygous parents has a 25% chance of being affected.

 

9. Parents ask the nurse about the characteristics of autosomal recessive inheritance. Which is characteristic of autosomal recessive inheritance?

a.	Affected individuals have unaffected parents.
b.	Affected individuals have one affected parent.
c.	Affected parents have a 50% chance of having an affected child.
d.	Affected parents will have unaffected children.

ANS: A

Parents who are carriers of a recessive gene are asymptomatic. For a child to be affected, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic but can have affected children. In autosomal recessive inheritance, there is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance, affected parents can have unaffected children.

 

10. Which is characteristic of X-linked recessive inheritance?

a.	There are no carriers.
b.	Affected individuals are principally males.
c.	Affected individuals are principally females.
d.	Affected individuals will always have affected parents.

ANS: B

In X-linked recessive disorders, the affected individuals are usually male. With recessive traits, usually two copies of the gene are needed to produce the effect. Because the male only has one X chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disorders. The X chromosome that does not have the recessive gene will produce the “normal” protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected.

 

11. A father with an X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. Which response should the nurse make?

a.	“Male children will be carriers.”
b.	“All male children will be affected.”
c.	“None of the sons will have the disorder.”
d.	“It cannot be determined without more data.”

ANS: C

When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes only his Y chromosome (not the X chromosome) to his sons. Therefore, none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question.

 

12. The inheritance of which is X-linked recessive?

a.	Hemophilia A
b.	Marfan syndrome
c.	Neurofibromatosis
d.	Fragile X syndrome

ANS: A

Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an X-linked trait.

 

13. Chromosome analysis of the fetus is usually accomplished through the testing of which?

a.	Fetal serum
b.	Maternal urine
c.	Amniotic fluid
d.	Maternal serum

ANS: C

Amniocentesis is the most common method to retrieve fetal cells for chromosome analysis. Viable fetal cells are sloughed off into the amniotic fluid, and when a sample is taken, they can be cultured and analyzed. It is difficult to obtain a sample of the fetal blood. It is a high-risk situation for the fetus. Fetal cells are not present in the maternal urine or blood.

 

14. A couple asks the nurse about the optimal time for genetic counseling. They do not plan to have children for several years. When should the nurse recommend they begin genetic counseling?

a.	As soon as the woman suspects that she may be pregnant
b.	Whenever they are ready to start their family
c.	Now, if one of them has a family history of congenital heart disease
d.	Now, if they are members of a population at risk for certain diseases

ANS: D

Persons who seek genetic evaluation and counseling must first be aware if there is a genetic or potential problem in their families. Genetic testing should be done now if the couple is part of a population at risk. It is not feasible at this time to test for all genetic diseases. The optimal time for genetic counseling is before pregnancy occurs. During the pregnancy, genetic counseling may be indicated if a genetic disorder is suspected. Congenital heart disease is not a single-gene disorder.

 

15. A woman, age 43 years, is 6 weeks pregnant. It is important that she be informed of which?

a.	The need for a therapeutic abortion
b.	Increased risk for Down syndrome
c.	Increased risk for Turner syndrome
d.	The need for an immediate amniocentesis

ANS: B

Women who are older than age 35 years at the birth of a single child or 31 years at the birth of twins are advised to have prenatal diagnosis. The risk of having a child with Down syndrome increases with maternal age. There is no indication of a need for a therapeutic abortion at this stage. Turner syndrome is not associated with advanced maternal age. Amniocentesis cannot be done at a gestational age of 6 weeks.

 

16. A couple has given birth to their first child, a boy with a recessive disorder. The genetic counselor tells them that the risk of recurrence is one in four. Which statement is a correct interpretation of this information?

a.	The risk factor remains the same for each pregnancy.
b.	The risk factor will change when they have a second child.
c.	Because the parents have one affected child, the next three children should be unaffected.
d.	Because the parents have one affected child, the next child is four times more likely to be affected.

ANS: A

Each pregnancy has the same risks for an affected child. Because an odds ratio reflects the risk, this does not change over time. The statement by the genetic counselor refers to a probability. This does not change over time. The statement “Because the parents have one affected child, the next child is four times more likely to be affected” does not reflect autosomal recessive inheritance.

 

17. A couple expecting their first child has a positive family history for several congenital defects and disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which should the nurse consider when counseling the couple?

a.	The couple should be encouraged to have recommended diagnostic testing.
b.	The couple needs counseling regarding advantages and disadvantages of pregnancy termination.
c.	Diagnostic testing is required by law in this situation.
d.	Diagnostic testing is of limited value if termination of pregnancy is not an option.

ANS: A

The benefits of prenatal diagnostic testing extend beyond decisions concerning abortion. If the child has congenital disorders, decisions can be made about fetal surgery if indicated. In addition, if the child is expected to require neonatal intensive care at birth, the mother is encouraged to deliver at a level III neonatal center. The couple is counseled about the advantages and disadvantages of prenatal diagnosis, not pregnancy termination, although the family cannot be forced to have prenatal testing. The information gives the parents time to grieve and plan for their child if congenital disorders are present. If the child is free of defects, then the parents are relieved of a major worry.

 

18. Parents ask the nurse if there was something that should have been done during the pregnancy to prevent their child’s cleft lip. Which statement should the nurse give as a response?

a.	“This is a type of deformation and can sometimes be prevented.”
b.	“Studies show that taking folic acid during pregnancy can prevent this defect.”
c.	“This is a genetic disorder and has a 25% chance of happening with each pregnancy.”
d.	“The malformation occurs at approximately 5 weeks of gestation; there is no known way to prevent this.”

ANS: D

Cleft lip, an example of a malformation, occurs at approximately 5 weeks of gestation when the developing embryo naturally has two clefts in the area. There is no known way to prevent this defect. Deformations are often caused by extrinsic mechanical forces on normally developing tissue. Club foot is an example of a deformation often caused by uterine constraint. Cleft lip is not a genetic disorder; the reasons for this occurring are still unknown. Taking folic acid during pregnancy can help to prevent neural tube disorders but not cleft lip defects.

 

19. The nurse is teaching parents of a child with cri du chat syndrome about this disorder. The nurse understands parents understand the teaching if they make which statement?

a.	“This disorder is very common.”
b.	“This is an autosomal recessive disorder.”
c.	“The crying pattern is abnormal and catlike.”
d.	“The child will always have a moon-shaped face.”

ANS: C

Typical of this disease is a crying pattern that is abnormal and catlike. Cri du chat, or cat’s cry, syndrome is a rare (one in 50,000 live births) chromosome deletion syndrome, not autosomal recessive, resulting from loss of the small arm of chromosome 5. In early infancy this syndrome manifests with a typical but nondistinctive facial appearance, often a “moon-shaped” face with wide-spaced eyes (hypertelorism). As the child grows, this feature is progressively diluted, and by age 2 years, the child is indistinguishable from age-matched control participants.

 

20. The nurse is reviewing a client’s prenatal history. Which prescribed medication does the nurse understand is not considered a teratogen and prescribed during pregnancy?

a.	Phenytoin (Dilantin)
b.	Warfarin (Coumadin)
c.	Isotretinoin (Accutane)
d.	Heparin sodium (Heparin)

ANS: D

Teratogens, agents that cause birth defects when present in the prenatal environment, account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens include drugs (phenytoin [Dilantin], warfarin [Coumadin], isotretinoin [Accutane]). Heparin is the anticoagulant used during pregnancy and is not a teratogen. It does not cross the placenta.

 

Communication, Physical, and Developmental Assessment

 

MULTIPLE CHOICE

 

1. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?

a.	Introduce him- or herself.
b.	Make the family comfortable.
c.	Give assurance of privacy.
d.	Explain the purpose of the interview.

ANS: A

The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurse’s role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.

 

2. Which is considered a block to effective communication?

a.	Using silence
b.	Using clichés
c.	Directing the focus
d.	Defining the problem

ANS: B

Using stereotyped comments or clichés can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention.

 

3. Which is the single most important factor to consider when communicating with children?

a.	Presence of the child’s parent
b.	Child’s physical condition
c.	Child’s developmental level
d.	Child’s nonverbal behaviors

ANS: C

The nurse must be aware of the child’s developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the child’s developmental level and physical condition. Although the child’s physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents.

 

4. Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?

a.	Focus communication on the child.
b.	Use easy analogies when possible.
c.	Explain experiences of others to the child.
d.	Assure the child that communication is private.

ANS: A

Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding.

 

5. The nurse’s approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?

a.	The child may think the equipment is alive.
b.	Explaining the equipment will only increase the child’s fear.
c.	One brief explanation will be enough to reduce the child’s fear.
d.	The child is too young to understand what the equipment does.

ANS: A

Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the child’s fear. Preschoolers need repeated explanations as reassurance.

 

6. When the nurse interviews an adolescent, which is especially important?

a.	Focus the discussion on the peer group.
b.	Allow an opportunity to express feelings.
c.	Use the same type of language as the adolescent.
d.	Emphasize that confidentiality will always be maintained.

ANS: B

Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent.

 

7. The nurse is preparing to assess a 10-month-old infant. He is sitting on his father’s lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

a.	Initiate a game of peek-a-boo.
b.	Ask the infant’s father to place the infant on the examination table.
c.	Talk softly to the infant while taking him from his father.
d.	Undress the infant while he is still sitting on his father’s lap.

ANS: A

Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the father’s lap. The nurse should have the father undress the child as needed during the examination.

 

8. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?

a.	Ask her why she wants to know.
b.	Determine why she is so anxious.
c.	Explain in simple terms how it works.
d.	Tell her she will see how it works as it is used.

ANS: C

School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur.

 

9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful?

a.	Recommend that the child keep a diary.
b.	Provide supplies for the child to draw a picture.
c.	Suggest that the parent read fairy tales to the child.
d.	Ask the parent if the child is always uncommunicative.

ANS: B

Drawing is one of the most valuable forms of communication. Children’s drawings tell a great deal about them because they are projections of the children’s inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative.

 

10. Which data should be included in a health history?

a.	Review of systems
b.	Physical assessment
c.	Growth measurements
d.	Record of vital signs

ANS: A

A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination.

 

11. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?

a.	Request a detailed listing of symptoms.
b.	Ask the adolescent, “Why did you come here today?”
c.	Interview the parent away from the adolescent to determine the chief complaint.
d.	Use what the adolescent says to determine, in correct medical terminology, what the problem is.

ANS: B

The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help.

 

12. The nurse is interviewing the mother of an infant. The mother reports, “I had a difficult delivery, and my baby was born prematurely.” This information should be recorded under which heading?

a.	History
b.	Present illness
c.	Chief complaint
d.	Review of systems

ANS: A

The history refers to information that relates to previous aspects of the child’s health, not to the current problem. The difficult delivery and prematurity are important parts of the infant’s history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.

 

13. Where in the health history does a record of immunizations belong?

a.	History
b.	Present illness
c.	Review of systems
d.	Physical assessment

ANS: A

The history contains information relating to all previous aspects of the child’s health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status.

 

14. The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

a.	Ask her, “Are you sexually active?”
b.	Ask her, “Are you having sex with anyone?”
c.	Ask her, “Are you having sex with a boyfriend?”
d.	Ask both the girl and her parent if she is sexually active.

ANS: B

Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word “anyone” is preferred to using gender-specific terms such as “boyfriend” or “girlfriend.” Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone.

 

15. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?

a.	Lacking in protein
b.	Indicating they live in poverty
c.	Providing sufficient amino acids
d.	Needing enrichment with meat and milk

ANS: C

A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.

 

16. Which parameter correlates best with measurements of total muscle mass?

a.	Height
b.	Weight
c.	Skinfold thickness
d.	Upper arm circumference

ANS: D

Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body’s major protein reserve and is considered an index of the body’s protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the body’s fat content.

 

17. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?

a.	Appropriate because of child’s age
b.	Appropriate, but the mother may be uncomfortable
c.	Inappropriate because of child’s age
d.	Inappropriate because child is same sex as mother

ANS: A

It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the child’s need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination.

 

Pain Assessment and Management in Children

 

MULTIPLE CHOICE

 

1. Which is the most consistent and commonly used data for assessment of pain in infants?

a.	Self-report
b.	Behavioral
c.	Physiologic
d.	Parental report

ANS: B

Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate that they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

 

2. Children as young as age 3 years can use facial scales for discrimination. What are some suggested anchor words for the preschool age group?

a.	“No hurt.”
b.	“Red pain.”
c.	“Zero hurt.”
d.	“Least pain.”

ANS: A

“No hurt” is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age group. The child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age group. “Least pain” is less concrete than “no hurt.”

 

3. What is an important consideration when using the FACES pain rating scale with children?

a.	Children color the face with the color they choose to best describe their pain.
b.	The scale can be used with most children as young as 3 years.
c.	The scale is not appropriate for use with adolescents.
d.	The FACES scale is useful in pain assessment but is not as accurate as physiologic responses.

ANS: B

The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The child’s estimate of the pain should be used. The physiologic measures may not reflect more long-term pain.

 

4. What describes nonpharmacologic techniques for pain management?

a.	They may reduce pain perception.
b.	They usually take too long to implement.
c.	They make pharmacologic strategies unnecessary.
d.	They trick children into believing they do not have pain.

ANS: A

Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child’s pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.

 

5. Which nonpharmacologic intervention appears to be effective in decreasing neonatal procedural pain?

a.	Tactile stimulation
b.	Commercial warm packs
c.	Doing procedure during infant sleep
d.	Oral sucrose and nonnutritive sucking

ANS: D

Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

 

6. A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?

a.	The child will continue to sleep and be pain free.
b.	Parents cannot administer additional medication with the button.
c.	The pump can deliver baseline and bolus dosages.
d.	There is a high risk of overdose, so monitoring is done every 15 minutes.

ANS: C

The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a 6-year-old child, the parents and nurse must assess the child to ensure that adequate medication is being given because the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

 

7. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?

a.	Codeine sulfate (Codeine)
b.	Morphine (Roxanol)
c.	Methadone (Dolophine)
d.	Meperidine (Demerol)

ANS: B

The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is not used in a PCA but is given orally or intravenously for pain in the infant. Meperidine is not used for continuous and extended pain relief.

 

8. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning care, the nurse recognizes that the indicated action is which?

a.	Give only an opioid analgesic at this time.
b.	Increase dosage of analgesic until the child is adequately sedated.
c.	Plan a preventive schedule of pain medication around the clock.
d.	Give the child a clock and explain when she or he can have pain medications.

ANS: C

For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive because it focuses the child’s attention on how long he or she will need to wait for pain relief.

Childhood Communicable and Infectious Diseases

 

MULTIPLE CHOICE

1. Pertussis vaccination should begin at which age?

a.	Birth
b.	2 months
c.	6 months
d.	12 months

ANS: B

The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to pertussis, which can be a life-threatening illness in this age group.

DIF: Cognitive Level: Understanding REF: p. 209

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?

a.	This cannot be prevented.
b.	Infants do not feel pain as adults do.
c.	This is not a good reason for refusing immunizations.
d.	A topical anesthetic can be applied before injections are given.

ANS: D

To minimize the discomfort associated with intramuscular injections, a topical anesthetic agent can be used on the injection site. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. Infants have neural pathways that will indicate pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process.

DIF: Cognitive Level: Analyzing REF: p. 207

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

3. A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine). She is recovering from a cold but is otherwise healthy and afebrile. Her older sister has cancer and is receiving chemotherapy. Nursing considerations should include which?

a.	DTaP and IPV can be safely given.
b.	DTaP and IPV are contraindicated because she has a cold.
c.	IPV is contraindicated because her sister is immunocompromised.
d.	DTaP and IPV are contraindicated because her sister is immunocompromised.

ANS: A

These immunizations can be given safely. Serious illness is a contraindication. A mild illness with or without fever is not a contraindication. These are not live vaccines, so they do not pose a risk to her sister.

DIF: Cognitive Level: Analyzing REF: p. 202

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

4. Which serious reaction should the nurse be alert for when administering vaccines?

a.	Fever
b.	Skin irritation
c.	Allergic reaction
d.	Pain at injection site

ANS: C

Each vaccine administration carries the risk of an allergic reaction. The nurse must be prepared to intervene if the child demonstrates signs of a severe reaction. Mild febrile reactions do occur after administration. The nurse includes management of fever in the parent teaching. Local skin irritation may occur at the injection site after administration. Parents are informed that this is expected. The injection can be painful. The nurse can minimize the discomfort with topical analgesics and nonpharmacologic measures.

DIF: Cognitive Level: Understanding REF: p. 209 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

5. Which muscle is contraindicated for the administration of immunizations in infants and young children?

a.	Deltoid
b.	Dorsogluteal
c.	Ventrogluteal
d.	Anterolateral thigh

ANS: B

The dorsogluteal site is avoided in children because of the location of nerves and veins. The deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants.

DIF: Cognitive Level: Understanding REF: p. 196

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

6. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?

a.	Cyst
b.	Papule
c.	Pustule
d.	Vesicle

ANS: D

A vesicle is elevated, circumscribed, superficial, smaller than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A papule is elevated; palpable; firm; circumscribed; smaller than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid.

 

Health Promotion of the Newborn and Family

 

MULTIPLE CHOICE

 

1. What is a function of brown adipose tissue (BAT) in newborns?

a.	Generates heat for distribution to other parts of body
b.	Provides ready source of calories in the newborn period
c.	Protects newborns from injury during the birth process
d.	Insulates the body against lowered environmental temperature

ANS: A

Brown fat is a unique source of heat for newborns. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective only in heat production. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas should not protect the newborn from injury during the birth process. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat.

 

2. Which characteristic is representative of a full-term newborn’s gastrointestinal tract?

a.	Transit time is diminished.
b.	Peristaltic waves are relatively slow.
c.	Pancreatic amylase is overproduced.
d.	Stomach capacity is very limited.

ANS: D

Newborns require frequent small feedings because their stomach capacity is very limited. A newborn’s colon has a relatively small volume and resulting increased bowel movements. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats.

 

3. Which term is used to describe a newborn’s first stool?

a.	Milia
b.	Milk stool
c.	Meconium
d.	Transitional

ANS: C

Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is a newborn’s first stool. Milia involves distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies depending on whether the newborn is breast or formula fed. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium.

 

4. In term newborns, the first meconium stool should occur no later than within how many hours after birth?

a.	6
b.	8
c.	12
d.	24

ANS: D

The first meconium stool should occur within the first 24 hours. It may be delayed up to 7 days in very low–birth-weight newborns.

DIF: Cognitive Level: Understanding REF: p. 245

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. Which is true regarding an infant’s kidney function?

a.	Conservation of fluid and electrolytes occurs.
b.	Urine has color and odor similar to the urine of adults.
c.	The ability to concentrate urine is less than that of adults.
d.	Normally, urination does not occur until 24 hours after delivery.

ANS: C

At birth, all structural components are present in the renal system, but there is a functional deficiency in the kidney’s ability to concentrate urine and to cope with conditions of fluid and electrolyte stress such as dehydration or a concentrated solute load. Infants’ urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery. Newborns void when the bladder is stretched to 15 ml, resulting in about 20 voidings per day.

 

6. The Apgar score of an infant 5 minutes after birth is 8. Which is the nurse’s best interpretation of this?

a.	Resuscitation is likely to be needed.
b.	Adjustment to extrauterine life is adequate.
c.	Additional scoring in 5 more minutes is needed.
d.	Maternal sedation or analgesia contributed to the low score.

ANS: B

The Apgar reflects an infant’s status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 7 indicate moderate difficulty. All infants are rescored at 5 minutes of life, and a score of 8 is not indicative of distress; the newborn does not have a low score. The Apgar score is not used to determine the infant’s need for resuscitation at birth.

 

7. Which statement best represents the first stage or the first period of reactivity in the infant?

a.	Begins when the newborn awakes from a deep sleep
b.	Is an excellent time to acquaint the parents with the newborn
c.	Ends when the amounts of respiratory mucus have decreased
d.	Provides time for the mother to recover from the childbirth process

ANS: B

During the first period of reactivity, the infant is alert, cries vigorously, may suck his or her fist greedily, and appears interested in the environment. The infant’s eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and infant to see each other. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased. The mother should sleep and recover during the second stage, when the infant is sleeping.

 

8. Which statement reflects accurate information about patterns of sleep and wakefulness in the newborn?

a.	States of sleep are independent of environmental stimuli.
b.	The quiet alert stage is the best stage for newborn stimulation.
c.	Cycles of sleep states are uniform in newborns of the same age.
d.	Muscle twitches and irregular breathing are common during deep sleep.

ANS: B

During the quiet alert stage, the newborn’s eyes are wide open and bright. The newborn responds to the environment by active body movement and staring at close-range objects. Newborns’ ability to control their own cycles depend on their neurobehavioral development. Each newborn has an individual cycle. Muscle twitches and irregular breathing are common during light sleep.

 

9. The nurse observes that a new mother avoids making eye contact with her infant. What should the nurse do?

a.	Ask the mother why she won’t look at the infant.
b.	Examine the infant’s eyes for the ability to focus.
c.	Assess the mother for other attachment behaviors.
d.	Recognize this as a common reaction in new mothers.

ANS: C

Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and mother. A mother’s failure to make eye contact with her infant may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Asking the mother why she will not look at the infant is a confrontational response that might put the mother in a defensive position. Infants do not have binocularity and cannot focus. Avoiding eye contact is an uncommon reaction in new mothers.

 

10. Which should the nurse use when assessing the physical maturity of a newborn?

a.	Length
b.	Apgar score
c.	Posture at rest
d.	Chest circumference

ANS: C

With the newborn quiet and in a supine position, the degree of flexion in the arms and legs can be used for determination of gestational age. Length and chest circumference reflect the newborn’s size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborn’s adjustment to extrauterine life.

 

11. What is the grayish white, cheeselike substance that covers the newborn’s skin?

a.	Milia
b.	Meconium
c.	Amniotic fluid
d.	Vernix caseosa

ANS: D

The vernix caseosa is the grayish white, cheeselike substance that covers a newborn’s skin.

 

Health Problems of Newborns

 

MULTIPLE CHOICE

 

1. Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?

a.	Hydrocephalus
b.	Cephalhematoma
c.	Caput succedaneum
d.	Subdural hematoma

ANS: C

Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum or blood (or both) accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It should not be visible on the scalp.

DIF: Cognitive Level: Remembering REF: p. 295

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?

a.	Positive scarf sign
b.	Asymmetric Moro reflex
c.	Swelling of fingers on affected side
d.	Paralysis of affected extremity and muscles

ANS: B

A newborn with a broken clavicle may have no signs. The Moro reflex, which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities, will most likely be asymmetric. The scarf sign that is used to determine gestational age should not be performed if a broken clavicle is suspected. Swelling of the fingers on the affected side and paralysis of the affected extremity and muscles are not signs of a fractured clavicle.

DIF: Cognitive Level: Analyzing REF: p. 297

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. The parents of a newborn ask the nurse what caused the baby’s facial nerve paralysis. The nurse’s response is based on remembering that this is caused by what?

a.	Birth injury
b.	Genetic defect
c.	Spinal cord injury
d.	Inborn error of metabolism

ANS: A

Pressure on the facial nerve (cranial nerve VII) during delivery may result in injury to the nerve. Genetic defects, spinal cord injuries, and inborn errors of metabolism did not cause the facial nerve paralysis. The paralysis usually disappears in a few days but may take as long as several months.

DIF: Cognitive Level: Understanding REF: p. 297

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

4. A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is what?

a.	Easily treated
b.	Benign and transient
c.	Usually not contagious
d.	Usually not disfiguring

ANS: B

Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The rash usually lasts about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not contagious. Successive crops of lesions heal without pigmentation.

DIF: Cognitive Level: Applying REF: p. 310

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

5. What should nursing care of an infant with oral candidiasis (thrush) include?

a.	Avoid use of a pacifier.
b.	Continue medication for the prescribed number of days.
c.	Remove the characteristic white patches with a soft cloth.
d.	Apply medication to the oral mucosa, being careful that none is ingested.

ANS: B

The medication must be continued for the prescribed number of days. To prevent relapse, therapy should continue for at least 2 days after the lesions disappear. Pacifiers can be used. The pacifier should be replaced with a new one or boiled for 20 minutes once daily. One of the characteristics of thrush is that the white patches cannot be removed. The medication is applied to the oral mucosa and then swallowed to treat Candida albicansinfection in the gastrointestinal tract.

DIF: Cognitive Level: Applying REF: p. 310 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

6. A mother brings her 6-week-old infant in with complaints of poor feeding, lethargy, fever, irritability, and a vesicular rash. What does the nurse suspect?

a.	Impetigo
b.	Candidiasis
c.	Neonatal herpes
d.	Congenital syphilis

ANS: C

Neonatal herpes is one of the most serious viral infections in newborns, with a mortality rate of up to 60% in infants with disseminated disease. Bullous impetigo is an infectious superficial skin condition most often caused byStaphylococcus aureus infection. It is characterized by bullous vesicular lesions on previously untraumatized skin. Candidiasis is characterized by white adherent patches on the tongue, palate, and inner aspects of the cheeks. Congenital syphilis has multisystem manifestations, including hepatosplenomegaly, lymphadenopathy, hemolytic anemia, and thrombocytopenia.

DIF: Cognitive Level: Analyzing REF: p. 310

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7. Which is a bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth?

a.	Port-wine stain
b.	Juvenile melanoma
c.	Cavernous hemangioma
d.	Strawberry hemangioma

ANS: D

Strawberry hemangiomas (or capillary hemangiomas) are benign cutaneous tumors that involve only capillaries. They are bright red, rubbery nodules with rough surfaces and well-defined margins. They may or may not be apparent at birth but enlarge during the first year of life and tend to resolve spontaneously by ages 2 to 3 years. A port-wine stain is a vascular stain that is a permanent lesion and is present at birth. Initially, it is a pink; red; or, rarely, purple stain of the skin that is flat at birth; it thickens, darkens, and proportionately enlarges as the infant grows. Melanoma is not differentiated into juvenile and adult forms. A cavernous hemangioma involves deeper vessels in the dermis and has a bluish red color and poorly defined margins.

DIF: Cognitive Level: Understanding REF: p. 312

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

8. What is an infant with severe jaundice at risk for developing?

a.	Encephalopathy
b.	Bullous impetigo
c.	Respiratory distress
d.	Blood incompatibility

ANS: A

Unconjugated bilirubin, which can cross the blood–brain barrier, is highly toxic to neurons. An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Bullous impetigo is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.

DIF: Cognitive Level: Understanding REF: p. 314

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

9. When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?

a.	2 to 12 hours
b.	12 to 24 hours
c.	2 to 4 days
d.	After the fifth day

ANS: C

Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mother’s milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake.

DIF: Cognitive Level: Understanding REF: p. 316

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

10. Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant?

a.	Institute early and frequent feedings.
b.	Bathe newborn when the axillary temperature is 36.3° C (97.5° F).
c.	Place the newborn’s crib near a window for exposure to sunlight.
d.	Suggest that the mother initiate breastfeeding when the danger of jaundice has passed.

ANS: A

Physiologic jaundice is caused by the immature hepatic function of the newborn’s liver coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot be excreted from the body. Feeding stimulates peristalsis and produces more rapid passage of meconium. Bathing does not affect physiologic jaundice. Placing the newborn’s crib near a window for exposure to sunlight is not a treatment of physiologic jaundice. Colostrum is a natural cathartic that facilitates meconium excavation.

DIF: Cognitive Level: Applying REF: p. 316

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

11. What is an important nursing intervention for a full-term infant receiving phototherapy?

a.	Observing for signs of dehydration
b.	Using sunscreen to protect the infant’s skin
c.	Keeping the infant diapered to collect frequent stools
d.	Informing the mother why breastfeeding must be discontinued

ANS: A

Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a “frying” effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breastfeeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.

DIF: Cognitive Level: Applying REF: p. 318

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

12. Rh hemolytic disease is suspected in a mother’s second baby, a son. Which factor is important in understanding how this could develop?

a.	The first child was a girl.
b.	The first child was Rh positive.
c.	Both parents have type O blood.
d.	She was not immunized against hemolysis.

ANS: B

 

The High-Risk Newborn and Family

 

MULTIPLE CHOICE

 

1. Which refers to an infant whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

a.	Postterm
b.	Postmature
c.	Low birth weight
d.	Small for gestational age

ANS: D

A small-for-gestational-age, or small-for-date, infant is one whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. A postterm, or postmature, infant is any child born after 42 weeks of gestation, regardless of birth weight. A low-birth-weight infant is a child whose birth weight is less than 2500 g, regardless of gestational age.

 

2. A woman in premature labor delivers an extremely low–birth-weight (ELBW) infant. Transport to a neonatal intensive care unit is indicated. The nurse explains that which level of service is needed?

a.	Level I
b.	Level IA
c.	Level II
d.	Level IIIB

ANS: D

A level IIIB neonatal unit has the capability of providing care for ELBW infants, including high-frequency ventilation and on-site access to medical subspecialties and pediatric surgery. A level I facility manages normal maternal and newborn care. Infants at less than 35 weeks of gestation are stabilized and transported to a facility that can provide appropriate care. A level IA facility does not exist. Level II facilities provide care for infants born at 32 weeks of gestation and weighing more than 1500 g. If the infant is ill, the health problems are expected to resolve rapidly and are not anticipated to require specialty care.

 

3. What is an essential component in caring for the very low– or extremely low–birth-weight infant?

a.	Holding the infant to help develop trust
b.	Using electronic monitoring devices exclusively
c.	Coordinating care to reduce environmental stress
d.	Incorporating infant stimulation elements during assessment

ANS: C

One of the principles of care for high-risk neonates is close observation and assessment with minimum handling. The nurse checks the apical rate against the monitor readings on a regular basis. The infant’s care is then clustered, and the infant is disturbed as little as possible. Holding an infant to help develop trust is not part of the assessment. In some areas, parents use “skin-to-skin” care with their infants. Although electronic monitoring devices are used, the nurse must validate the readings with the infant’s data. For an ill neonate, excessive stimulation creates stress.

 

4. What explains why a neutral thermal environment is essential for a high-risk neonate?

a.	The neonate produces heat by increasing activity and shivering.
b.	Metabolism slows dramatically in the neonate experiencing cold stress.
c.	It permits the neonate to maintain a normal core temperature with minimum oxygen consumption.
d.	It permits the neonate to maintain a normal core temperature with increased caloric consumption.

ANS: C

A high-risk neonate is at greater risk for cold stress than a term infant because of the smaller muscle mass and fewer deposits of brown fat for producing heat, lack of insulating subcutaneous fat, and poor reflex control of skin capillaries. By definition, a neutral thermal environment is one that permits the infant to maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. Smaller muscle mass and poor reflex control of skin capillaries decrease the ability of a high-risk neonate to compensate for an environment that is not thermoneutral. Metabolism increases in an infant experiencing cold stress, creating a compensatory increase in oxygen and caloric consumption. Increased caloric consumption is to be avoided. Neonates need available calories for growth.

 

5. When caring for a neonate in a radiant warmer, what should the nurse be alert to?

a.	Exposure to prolonged cold stress
b.	Need for Plexiglas shields to protect the infant
c.	Transepidermal water loss leading to dehydration
d.	Increased risk of infection from the open environment

ANS: C

Radiant warmers result in greater evaporative fluid loss than normal, thus predisposing the infant to dehydration. Plastic wrap can help reduce this loss. Daily fluid requirements are increased to compensate. The radiant warmer protects the infant from cold stress. Plexiglas shields are not used in radiant warmers because they block the radiant heat waves. With clean and aseptic technique, there is not a greater risk of infection.

 

6. The nurse is caring for a high-risk neonate who has an umbilical catheter and is in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?

a.	Place socks on the infant’s feet.
b.	Elevate the infant’s feet 15 degrees.
c.	Wrap the infant’s feet loosely in a prewarmed blanket.
d.	Report the findings immediately to the practitioner.

ANS: D

Blanching of the feet in a neonate with an umbilical catheter is an indication of vasospasm. Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency situation and must be reported immediately.

 

7. Which statement is true concerning the nutritional needs of preterm infants?

a.	The secretion of lactase is low.
b.	Carbohydrates and fats are better tolerated than protein.
c.	The demand for nutrients is less than in full-term infants.
d.	Breast milk lacks the proper concentration of nutrients.

ANS: A

The enzyme lactase is not readily available in an infant’s body until after 34 weeks of gestation. Formulas containing lactose are not well tolerated. Carbohydrates and fats are less well tolerated than protein. Preterm infants require significantly higher intake of calories and other nutrients than full-term infants. The American Academy of Pediatrics recommends 105 to 130 kcal/kg/day. Breast milk from the infant’s mother is considered the ideal enteral nutrition for the infant. Several commercial formulas are designed for preterm infants.

 

8. While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action?

a.	Let the neonate rest before breastfeeding again.
b.	Resume gavage feedings until the neonate is asymptomatic.
c.	Recognize that this may indicate an underlying illness.
d.	Use a high-flow, pliable nipple because it requires less energy to use.

ANS: C

Apnea, pallor, and bradycardia may be signs of an underlying illness. The infant should be evaluated to ensure he or she is not developing problems. The infant can rest while waiting for the evaluation. If the child is becoming ill, the capacity to digest enteral feedings may be compromised. The type of nipple that is being used should not produce the signs being observed.

 

9. A preterm infant who is being fed commercial formula by gavage has had an increase in gastric residuals, abdominal distention, and apneic episodes. Which is the most appropriate nursing action?

a.	Notify the practitioner.
b.	Reduce the amount fed by gavage.
c.	Feed human milk by gavage.
d.	Feed only a glucose solution until the infant stabilizes.

ANS: A

These are signs that may indicate early necrotizing enterocolitis. The practitioner is notified for further evaluation. Enteral feedings are usually stopped until the cause of increased residuals is identified.

 

10. A mother planned to breastfeed her infant before giving birth at 33 weeks of gestation. The infant is stable and receiving oxygen. What is the most appropriate nursing action related to this?

a.	Assist the mother in expressing breast milk.
b.	Assess the infant’s readiness to breastfeed.
c.	Explain to the mother that the infant is too small to receive breast milk.
d.	Reassure the mother that infant formula is a good alternative to breastfeeding.

ANS: B

Research confirms that human milk is the best source of nutrition for term and preterm infants. Preterm infants should be breastfed as soon as they have adequate sucking and swallowing reflexes and no other complications such as respiratory complications or concurrent illnesses. If the infant has adequate sucking and swallowing, the infant should breastfeed for some of the feedings. The mother can express milk to be used in her absence.

 

11. A preterm neonate has begun breastfeeding, but the infant tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention?

a.	Encourage the mother to breastfeed.
b.	Resume orogastric feedings of formula.
c.	Try nipple feeding the preterm infant formula.
d.	Feed the remainder of breast milk by the orogastric route.

ANS: D

If a preterm infant tires easily or has weak sucking when breastfeeding is initiated, the nurse should feed the additional breast milk by the enteral route. The nurse supports the mother in the attempts to breastfeed and ensures that the infant is receiving adequate nutrition. Breast milk should be used as long as the mother can supply it.

 

Health Promotion of the Infant and Family

 

MULTIPLE CHOICE

 

1. At which age does an infant start to recognize familiar faces and objects, such as his or her own hand?

a.	1 month
b.	2 months
c.	3 months
d.	4 months

ANS: C

The child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is beginning to develop hand–eye coordination.

 

2. During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?

a.	Respond to name.
b.	React to loud noise with Moro reflex.
c.	Turn his or her head to side when sound is at ear level.
d.	Locate sound by turning his or her head in a curving arc.

ANS: C

At 2 months of age, an infant should turn his or her head to the side when a noise is made at ear level. At birth, infants respond to sound with a startle or Moro reflex. An infant responds to his or her name and locates sounds by turning his or her head in a curving arc at age 6 to 9 months.

 

3. Which characteristic best describes the fine motor skills of an infant at age 5 months?

a.	Neat pincer grasp
b.	Strong grasp reflex
c.	Builds a tower of two cubes
d.	Able to grasp object voluntarily

ANS: D

At age 5 months, the infant should be able to voluntarily grasp an object. The grasp reflex is present in the first 2 to 3 months of life. Gradually, the reflex becomes voluntary. The neat pincer grasp is not achieved until age 11 months. At age 12 months, an infant will attempt to build a tower of two cubes but will most likely be unsuccessful.

 

4. The nurse is checking reflexes on a 7-month-old infant. When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended. Which reflex is this?

a.	Landau
b.	Parachute
c.	Body righting
d.	Labyrinth righting

ANS: A

When the infant is suspended in a horizontal prone position, the head is raised and the legs and spine are extended; this describes the Landau reflex. It appears at 6 to 8 months and persists until 12 to 24 months. The parachute reflex occurs when the infant is suspended in a horizontal prone position and suddenly thrust downward; the infant extends the hands and fingers forward as if to protect against falling. This appears at age 7 to 9 months and lasts indefinitely. Body righting occurs when turning the hips and shoulders to one side causes all other body parts to follow. It appears at 6 months of age and persists until 24 to 36 months. The labyrinth-righting reflex appears at 2 months and is strongest at 10 months. This reflex involves holding infants in the prone or supine position. They are able to raise their heads.

 

5. In terms of gross motor development, what should the nurse expect an infant age 5 months to do?

a.	Sit erect without support.
b.	Roll from the back to the abdomen.
c.	Turn from the abdomen to the back.
d.	Move from a prone to a sitting position.

ANS: C

Rolling from the abdomen to the back is developmentally appropriate for a 5-month-old infant. The ability to roll from the back to the abdomen is developmentally appropriate for an infant at age 6 months. Sitting erect without support is a developmental milestone usually achieved by 8 months. A 10-month-old infant can usually move from a prone to a sitting position.

 

6. At which age can most infants sit steadily unsupported?

a.	4 months
b.	6 months
c.	8 months
d.	12 months

ANS: C

Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.

 

Health Problems of the Infant

 

MULTIPLE CHOICE

 

1. Rickets is caused by a deficiency in what?

a.	Vitamin A
b.	Vitamin C
c.	Folic acid and iron
d.	Vitamin D and calcium

ANS: D

Fat-soluble vitamin D and calcium are necessary in adequate amounts to prevent rickets. No correlation exists between rickets and folic acid, iron, or vitamins A and C.

 

2. Which factors will decrease iron absorption and should not be given at the same time as an iron supplement?

a.	Milk
b.	Fruit juice
c.	Multivitamin
d.	Meat, fish, poultry

ANS: A

Many foods interfere with iron absorption and should be avoided when iron is consumed. These foods include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables. Vitamin C–containing juices enhance the absorption of iron. Multivitamins may contain iron; no contraindication exists to taking the two together. Meat, fish, and poultry do not affect absorption.

 

3. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their children. Which is most likely lacking in their particular diet?

a.	Fat
b.	Protein
c.	Vitamins C and A
d.	Iron and calcium

ANS: D

Deficiencies can occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets because plant foods such as soy are high in phytates. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available.

 

4. A 1-year-old child is on a pure vegetarian (vegan) diet. This diet requires supplementation with what?

a.	Niacin
b.	Folic acid
c.	Vitamins D and B12
d.	Vitamins C and E

ANS: C

Pure vegetarian (vegan) diets eliminate any food of animal origin, including milk and eggs. These diets require supplementation with many vitamins, especially vitamin B6, vitamin B12, riboflavin, vitamin D, iron, and zinc. Niacin, folic acid, and vitamins C and E are readily obtainable from foods of vegetable origin.

 

5. What is marasmus?

a.	Deficiency of protein with an adequate supply of calories
b.	Syndrome that results solely from vitamin deficiencies
c.	Not confined to geographic areas where food supplies are inadequate
d.	Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)

ANS: C

Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic areas were food supplies are inadequate. Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears old, with flabby and wrinkled skin. Marasmus is a deficiency of both protein and calories.

 

6. At a well-child check-up, the nurse notes that an infant with a previous diagnosis of failure to thrive (FTT) is now steadily gaining weight. The nurse should recommend that fruit juice intake be limited to no more than how much?

a.	4 oz/day
b.	6 oz/day
c.	8 oz/day
d.	12 oz/day

ANS: A

Restrict juice intake in children with FTT until adequate weight gain has been achieved with appropriate milk sources; thereafter, give no more than 4 oz/day of juice.

 

7. An infant has been diagnosed with an allergy to milk. In teaching the parent how to meet the infant’s nutritional needs, the nurse states that

a.	Most children will grow out of the allergy.
b.	All dairy products must be eliminated from the child’s diet.
c.	It is important to have the entire family follow the special diet.
d.	Antihistamines can be used so the child can have milk products.

ANS: A

Approximately 80% of children with cow’s milk allergy develop tolerance by the fifth birthday. The child can have eggs. Any food that has milk as a component or filler is eliminated. These foods include processed meats, salad dressings, soups, and milk chocolate. Having the entire family follow the special diet would provide support for the child, but the nutritional needs of other family members must be addressed. Antihistamines are not used for food allergies.

 

8. Lactose intolerance is diagnosed in an 11-month-old infant. Which should the nurse recommend as a milk substitute?

a.	Yogurt
b.	Ice cream
c.	Fortified cereal
d.	Cow’s milk–based formula

ANS: A

Yogurt contains the inactive lactase enzyme, which is activated by the temperature and pH of the duodenum. This lactase activity substitutes for the lack of endogenous lactase. Ice cream and cow’s milk–based formula contain lactose, which will probably not be tolerated by the child. Fortified cereal does not have the nutritional equivalents of milk.

 

9. Which term refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation?

a.	Congenital lactase deficiency
b.	Primary lactase deficiency
c.	Secondary lactase deficiency
d.	Developmental lactase deficiency

ANS: D

Developmental lactase deficiency refers to the relative lactase deficiency observed in preterm infants of less than 34 weeks of gestation. Congenital lactase deficiency occurs soon after birth after the newborn has consumed lactose-containing milk. Primary lactase deficiency, sometimes referred to as late-onset lactase deficiency, is the most common type of lactose intolerance and is manifested usually after 4 or 5 years of age. Secondary lactase deficiency may occur secondary to damage of the intestinal lumen, which decreases or destroys the enzyme lactase.

 

10. Which statement best describes colic?

a.	Periods of abdominal pain resulting in weight loss
b.	Usually the result of poor or inadequate mothering
c.	Periods of abdominal pain and crying occurring in infants older than age 6 months
d.	A paroxysmal abdominal pain or cramping manifested by episodes of loud crying

ANS: D

Colic is described as paroxysmal abdominal pain or cramping that is manifested by loud crying and drawing up the legs to the abdomen. Weight loss is not part of the clinical picture. There are many theories about the cause of colic. Emotional stress or tension between the parent and child is one component. This is not consistent throughout all cases. Colic is most common in infants younger than 3 months of age.

 

Health Promotion of the Toddler and Family

 

MULTIPLE CHOICE

 

1. What factor is most important in predisposing toddlers to frequent infections?

a.	Respirations are abdominal.
b.	Pulse and respiratory rates in toddlers are slower than those in infants.
c.	Defense mechanisms are less efficient than those during infancy.
d.	Toddlers have short, straight internal ear canals and large lymph tissue.

ANS: D

Toddlers continue to have the short, straight internal ear canals of infants. The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose toddlers to frequent infections. The abdominal respirations and lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection. The defense mechanisms are more efficient compared with those of infancy.

 

2. What do the psychosocial developmental tasks of toddlerhood include?

a.	Development of a conscience
b.	Recognition of sex differences
c.	Ability to get along with age mates
d.	Ability to delay gratification

ANS: D

If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that toddlers are concerned with is the ability to delay gratification. Development of a conscience and recognition of sex differences occur during the preschool years. The ability to get along with age mates develops during the preschool and school-age years.

 

3. The developmental task with which the child of 15 to 30 months is likely to be struggling is a sense of which?

a.	Trust
b.	Initiative
c.	Intimacy
d.	Autonomy

ANS: D

Autonomy versus shame and doubt is the developmental task of toddlers. Trust versus mistrust is the developmental stage of infancy. Initiative versus guilt is the developmental stage of early childhood. Intimacy and solidarity versus isolation is the developmental stage of early adulthood.

 

4. Parents of an 18-month-old boy tells the nurse that he says “no” to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. What is the nurse’s best interpretation of this behavior?

a.	This is normal behavior for his age.
b.	This is unusual behavior for his age.
c.	He is not effectively coping with stress.
d.	He is showing he needs more attention.

ANS: A

Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and use of the word “no.” Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old.

 

5. A 17-month-old child should be expected to be in which stage, according to Piaget?

a.	Preoperations
b.	Concrete operations
c.	Tertiary circular reactions
d.	Secondary circular reactions

ANS: C

A 17-month-old is in the fifth stage of the sensorimotor phase, tertiary circular reactions. The child uses active experimentation to achieve previously unattainable goals. Preoperations is the stage of cognitive development usually present in older toddlers and preschoolers. Concrete operations is the cognitive stage associated with school-age children. The secondary circular reaction stage lasts from about ages 4 to 8 months.

 

Health Promotion of the Preschooler and Family

 

MULTIPLE CHOICE

 

1. In terms of fine motor development, what should the 3-year-old child be expected to do?

a.	Tie shoelaces.
b.	Copy (draw) a circle.
c.	Use scissors or a pencil very well.
d.	Draw a person with seven to nine parts.

ANS: B

 

2. According to Piaget, magical thinking is the belief of which?

a.	Thoughts are all powerful.
b.	God is an imaginary friend.
c.	Events have cause and effect.
d.	If the skin is broken, the insides will come out.

ANS: A

 

3. In terms of cognitive development, a 5-year-old child should be expected to do which?

a.	Think abstractly.
b.	Use magical thinking.
c.	Understand conservation of matter.
d.	Understand another person’s perspective.

ANS: B

 

 The nurse is caring for a hospitalized 4-year-old boy. His parents tell the nurse they will be back to visit at 6 PM. When he asks the nurse when his parents are coming, what would the nurse’s best response be?

a.	“They will be here soon.”
b.	“They will come after dinner.”
c.	“Let me show you on the clock when 6 PM is.”
d.	“I will tell you every time I see you how much longer it will be.”

ANS: B

 

Health Problems of Early Childhood

 

MULTIPLE CHOICE

 

1. A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?

a.	Reassure the father that Visine is harmless.
b.	Direct him to seek immediate medical treatment.
c.	Recommend inducing vomiting with ipecac.
d.	Advise him to dilute Visine by giving his daughter several glasses of water to drink.

ANS: B

Visine is a sympathomimetic and if ingested may cause serious consequences. Medical treatment is necessary. Inducing vomiting is no longer recommended for ingestions. Dilution will not decrease risk.

 

2. The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product?

a.	Tinnitus
b.	Disorientation
c.	Stupor, lethargy, and coma
d.	Edema of the lips, tongue, and pharynx

ANS: D

Edema of the lips, tongue, and pharynx indicates a corrosive ingestion. Tinnitus is indicative of aspirin ingestion. Corrosives do not act on the central nervous system.

 

3. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is what?

a.	Hepatic dysfunction
b.	Dehydration secondary to vomiting
c.	Esophageal stricture and shock
d.	Bronchitis and chemical pneumonia

ANS: D

Lighter fluid is a hydrocarbon. The immediate danger is aspiration. Acetaminophen overdose, not hydrocarbons, causes hepatic dysfunction. Dehydration is not the primary danger. Esophageal stricture is a late or chronic consequence of hydrocarbon ingestion.

 

4. What is a clinical manifestation of acetaminophen poisoning?

a.	Hyperpyrexia
b.	Hepatic involvement
c.	Severe burning pain in stomach
d.	Drooling and inability to clear secretions

ANS: B

Hepatic involvement is the third stage of acetaminophen poisoning. Hyperpyrexia is a severe elevation in body temperature and is not related to acetaminophen poisoning. Acetaminophen does not cause burning pain in stomach and does not pose an airway threat.

 

5. An awake, alert 4-year-old child has just arrived at the emergency department after an ingestion of aspirin at home. The practitioner has ordered activated charcoal. The nurse administers charcoal in which manner?

a.	Giving half of the solution and then repeating the other half in 1 hour
b.	Mixing with a flavorful beverage in an opaque container with a straw
c.	Serving it in a clear plastic cup so the child can see how much has been drunk
d.	Administering it through a nasogastric tube because the child will not drink it because of the taste

ANS: B

Although activated charcoal can be mixed with a flavorful sugar-free beverage, it will be black and resemble mud. When it is served in an opaque container, the child will not have any preconceived ideas about its being distasteful. The ability to see the charcoal solution may affect the child’s desire to drink the solution. The child should be encouraged to drink the solution all at once. The nasogastric tube would be traumatic. It should be used only in children who cannot be cooperative or those without a gag reflex.

 

6. What is a significant secondary prevention nursing activity for lead poisoning?

a.	Chelation therapy
b.	Screening children for blood lead levels
c.	Removing lead-based paint from older homes
d.	Questioning parents about ethnic remedies containing lead

ANS: B

Screening children for lead poisoning is an important secondary prevention activity. Screening does not prevent the initial exposure of the child to lead. It can lead to identification and treatment of children who are exposed. Chelation therapy is treatment, not prevention. Removing lead-based paints from older homes before children are affected is primary prevention. Questioning parents about ethnic remedies containing lead is part of the assessment to determine the potential source of lead.

 

7. What is an important nursing consideration when a child is hospitalized for chelation therapy to treat lead poisoning?

a.	Maintain bed rest.
b.	Maintain isolation precautions.
c.	Keep an accurate record of intake and output.
d.	Institute measures to prevent skeletal fracture.

ANS: C

The iron chelates are excreted though the kidneys. Adequate hydration is essential. Periodic measurement of renal function is done. Bed rest is not necessary. Often the chelation therapy is done on an outpatient basis. Chelation therapy is not infectious or dangerous. Isolation is not indicated. Skeletal weakness does not result from high levels of lead.

 

8. What is the most common form of child maltreatment?

a.	Sexual abuse
b.	Child neglect
c.	Physical abuse
d.	Emotional abuse

ANS: B

Child neglect, which is characterized by the failure to provide for the child’s basic needs, is the most common form of child maltreatment. Sexual abuse, physical abuse, and emotional abuse are individually not as common as neglect.

 

9. A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). What is an important consideration in the care of this child?

a.	Monitoring the parents whenever they are with the child
b.	Reassuring the parents that the cause of the disorder will be found
c.	Teaching the parents how to obtain necessary specimens
d.	Supporting the parents as they cope with diagnosis of a chronic illness

ANS: A

MSBP refers to an illness that one person fabricates or induces in another. The child must be continuously observed for development of symptoms to determine the cause. MSBP is caused by an individual harming the child for the purpose of gaining attention. Nursing staff should obtain all specimens for analyzing. This minimizes the possibility of the abuser contaminating the sample. The child must be supported through the diagnosis of MSBP. The abuser must be identified and the child protected from that individual.

 

10. When only one child is abused in a family, the abuse is usually a result of what?

a.	The child is the firstborn.
b.	The child is the same gender as the abusing parent.
c.	The parent abuses the child to avoid showing favoritism.
d.	The parent is unable to deal with the child’s behavioral style.

ANS: D

 

Health Promotion of the School-Age Child and Family

 

MULTIPLE CHOICE

 

1. What statement accurately describes physical development during the school-age years?

a.	The child’s weight almost triples.
b.	Muscles become functionally mature.
c.	Boys and girls double strength and physical capabilities.
d.	Fat gradually increases, which contributes to children’s heavier appearance.

ANS: C

Boys and girls double both strength and physical capabilities. Their consistent refinement in coordination increases their poise and skill. In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 5 cm/yr and gain 3 kg/yr. Their weight will almost double. Although the strength increases, muscles are still functionally immature when compared with those of adolescents. This age group is more easily injured by overuse. Children take on a slimmer look with longer legs in middle childhood.

 

2. The parents of 9-year-old twin children tell the nurse, “They have filled up their bedroom with collections of rocks, shells, stamps, and bird nests.” The nurse should recognize that this is which?

a.	Indicative of giftedness
b.	Indicative of typical twin behavior
c.	Characteristic of cognitive development at this age
d.	Characteristic of psychosocial development at this age

ANS: C

Classification skills involve the ability to group objects according to the attributes they have in common. School-age children can place things in a sensible and logical order, group and sort, and hold a concept in their mind while they make decisions based on that concept. Individuals who are not twins engage in classification at this age. Psychosocial behavior at this age is described according to Erikson’s stage of industry versus inferiority.

 

3. What statement characterizes moral development in the older school-age child?

a.	Rule violations are viewed in an isolated context.
b.	Judgments and rules become more absolute and authoritarian.
c.	The child remembers the rules but cannot understand the reasons behind them.
d.	The child is able to judge an act by the intentions that prompted it rather than just by the consequences.

ANS: D

Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rule violation is likely to be viewed in relation to the total context in which it appears. Rules and judgments become less absolute and authoritarian. The situation and the morality of the rule itself influence reactions.

 

4. An 8-year-old girl tells the nurse that she has cancer because God is punishing her for “being bad.” What should the nurse interpret this as?

a.	A common belief at this age
b.	Indicative of excessive family pressure
c.	Faith that forms the basis for most religions
d.	Suggestive of a failure to develop a conscience

ANS: A

Children at this age may view illness or injury as a punishment for a real or imagined misbehavior. School-age children expect to be punished and tend to choose a punishment that they think “fits the crime.” This is a common belief and not related to excessive family pressure. Many faiths do not include a God that causes cancer in response for “bad” behavior. This statement reflects the child’s belief in what is right and wrong.

 

5. What is the role of the peer group in the life of school-age children?

a.	Decreases their need to learn appropriate sex roles
b.	Gives them an opportunity to learn dominance and hostility
c.	Allows them to remain dependent on their parents for a longer time
d.	Provides them with security as they gain independence from their parents

ANS: D

 

Health Problems of the School-Age Child

 

MULTIPLE CHOICE

 

1. Deficiency of which vitamin or mineral results in an inadequate inflammatory response?

a.	A
b.	B1
c.	C
d.	Zinc

ANS: A

A deficiency of vitamin A results in an inadequate inflammatory response. Deficiencies of vitamins B1 and C result in decreased collagen formation. A deficiency of zinc leads to impaired epithelialization.

 

2. An occlusive dressing is applied to a large abrasion. This is advantageous because the dressing will accomplish what?

a.	Deliver vitamin C to the wound.
b.	Provide an antiseptic for the wound.
c.	Maintain a moist environment for healing.
d.	Promote mechanical friction for healing.

ANS: C

Occlusive dressings, such as Acuderm, are not adherent to the wound site. They provide a moist wound surface and insulate the wound. The dressing does not have vitamin C or antiseptic capabilities. Acuderm protects against friction.

 

3. A toddler has a deep laceration contaminated with dirt and sand. Before closing the wound, the nurse should irrigate with what solution?

a.	Alcohol
b.	Normal saline
c.	Povidone–iodine
d.	Hydrogen peroxide

ANS: B

Normal saline is the only acceptable fluid for irrigation listed. The nurse should cleanse the wound with a forced stream of normal saline or water. Alcohol is not used for wound irrigation. Povidone–iodine is contraindicated for cleansing fresh, open wounds. Hydrogen peroxide can cause formation of subcutaneous gas when applied under pressure.

 

4. The nurse should know what about Lyme disease?

a.	Very difficult to prevent
b.	Easily treated with oral antibiotics in stages 1, 2, and 3
c.	Caused by a spirochete that enters the skin through a tick bite
d.	Common in geographic areas where the soil contains the mycotic spores that cause the disease

ANS: C

Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve shirts and long pants tucked into socks should be worn. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores.

 

5. The school nurse is seeing a child who collected some poison ivy leaves during recess. He says only his hands touched it. What is the most appropriate nursing action?

a.	Soak his hands in warm water.
b.	Apply Burow’s solution compresses.
c.	Rinse his hands in cold running water.
d.	Scrub his hands thoroughly with antibacterial soap.

ANS: C

The first recommended action is to rinse his hands in cold running water within 15 minutes of exposure. This will neutralize the urushiol not yet bonded to the skin. Soaking his hands in warm water is effective for soothing the skin lesions after the dermatitis has begun. Antibacterial soap removes protective skin oils and dilutes the urushiol, allowing it to spread.

 

6. A 6-year-old boy with very fair skin will be joining his family during a beach vacation. What should the nurse recommend?

a.	Keep him off the beach during the daytime hours.
b.	Use sunscreen with an SPF of at least 15 and reapply it every 2 to 3 hours.
c.	Apply a topical sunscreen product with an SPF of 30 in the morning.
d.	Dress him in long pants and long-sleeved shirt and keep him under a beach umbrella.

ANS: B

A sunscreen with an SPF (sun protection factor) of at least 15 is recommended. The sunscreen should be reapplied every 2 to 3 hours and after the child is in the water or sweating excessively. During a beach vacation, avoiding the beach during daytime hours is impractical. The highest risk of sun exposure is from 10 AM to 3 PM. Sunlight exposure should be limited during this time. An SPF of 30 is good, but reapplying it is necessary every 2 to 3 hours and when the child gets wet. Long pants and a shirt are impractical. The beach umbrella can be used with the sunscreen to limit exposure to the sun.

 

7. The management of a child who has just been stung by a bee or wasp should include applying what?

a.	Cool compresses
b.	Antibiotic cream
c.	Warm compresses
d.	Corticosteroid cream

ANS: A

Bee or wasp stings are initially treated by carefully removing the stinger, cleansing with soap and water, applying cool compresses, and using common household agents such as lemon juice or a paste made with aspirin and baking soda. Antibiotic cream is unnecessary unless a secondary infection occurs. Warm compresses are avoided. Corticosteroid cream is not part of the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated.

 

8. A parent calls the clinic nurse because his 7-year-old child was bitten by a black widow spider. What action should the nurse advise the parent to take?

a.	Apply warm compresses.
b.	Carefully scrape off the stinger.
c.	Take the child to the emergency department.
d.	Apply a thin layer of corticosteroid cream.

ANS: C

The venom of the black widow spider has a neurotoxic effect. The parent should take the child to the emergency department for treatment with antivenin and muscle relaxants as needed. Warm compresses increase the circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream has no effect on the venom.

 

9. A school-age child has been bitten on the leg by a large snake that may be poisonous. During transport to an emergency facility, what should the care include?

a.	Apply ice to the snakebite.
b.	Immobilize the leg with a splint.
c.	Place a loose tourniquet distal to the bite.
d.	Apply warm compresses to the snakebite.

ANS: B

The leg should be immobilized. Ice decreases blood flow to the area, which allows the venom to work more destruction and decreases the effect of antivenin on the natural immune mechanisms. A loose tourniquet is placed proximal, not distal, to the area of the bite to delay the flow of lymph. This can delay movement of the venom into the peripheral circulation. The tourniquet should be applied so that a pulse can be felt distal to the bite. Warmth increases circulation to the area and helps the toxin into the peripheral circulation.

 

10. Parents phone the nurse and say that their child just knocked out a permanent tooth. What should the nurse’s instructions to the parents include?

a.	Place the tooth in dry container for transport.
b.	Hold the tooth by the crown and not by the root area.
c.	Transport the child and tooth to a dentist within 18 hours.
d.	Take the child to hospital emergency department if his or her mouth is bleeding.

ANS: B

 

Health Promotion of the Adolescent and Family

 

MULTIPLE CHOICE

 

1. How does the onset of the pubertal growth spurt compare in girls and boys?

a.	In girls, it occurs about 1 year before it appears in boys.
b.	In girls, it occurs about 3 years before it appears in boys.
c.	In boys. it occurs about 1 year before it appears in girls.
d.	It is about the same in both boys and girls.

ANS: A

The average age of onset is 9 1/2 years for girls and 10 1/2 years for boys. Although pubertal growth spurts may occur in girls 3 years before it appears in boys on an individual basis, the average difference is 1 year. Usually girls begin their pubertal growth spurt earlier than boys.

 

2. In girls, what is the initial indication of puberty?

a.	Menarche
b.	Growth spurt
c.	Breast development
d.	Growth of pubic hair

ANS: C

In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche. The usual sequence of secondary sexual characteristic development in girls is breast changes, a rapid increase in height and weight, growth of pubic hair, appearance of axillary hair, menstruation (menarche), and abrupt deceleration of linear growth.

 

3. Girls experience an increase in weight and fat deposition during puberty. What do nursing considerations related to this include?

a.	Give reassurance that these changes are normal.
b.	Suggest dietary measures to control weight gain.
c.	Encourage a low-fat diet to prevent fat deposition.
d.	Recommend increased exercise to control weight gain.

ANS: A

A certain amount of fat is increased along with lean body mass to fill the characteristic contours of the adolescent’s gender. A healthy balance must be achieved between expected healthy weight gain and obesity. Suggesting dietary measures or increased exercise to control weight gain would not be recommended unless weight gain was excessive because eating disorders can develop in this group. Some fat deposition is essential for normal hormonal regulation. Menarche is delayed in girls with body fat contents that are too low.

 

4. In boys, what is the initial indication of puberty?

a.	Voice changes
b.	Growth of pubic hair
c.	Testicular enlargement
d.	Increased size of penis

ANS: C

Testicular enlargement is the first change that signals puberty in boys; it usually occurs between the ages of 9 1/2 and 14 years during Tanner stage 2. Voice change occurs between Tanner stages 3 and 4. Fine pubic hair may occur at the base of the penis; darker hair occurs during Tanner stage 3. The penis enlarges during Tanner stage 3.

 

5. According to Piaget, adolescents tend to be in what stage of cognitive development?

a.	Concrete operations
b.	Conventional thought
c.	Postconventional thought
d.	Formal operational thought

ANS: D

Cognitive thinking culminates in the capacity for abstract thinking. This stage, the period of formal operations, is Piaget’s fourth and last stage. Concrete operations usually occur between ages 7 and 11 years. Conventional and postconventional thought refers to Kohlberg’s stages of moral development.

 

6. What aspects of cognition develop during adolescence?

a.	Ability to see things from the point of view of another
b.	Capability of using a future time perspective
c.	Capability of placing things in a sensible and logical order
d.	Progress from making judgments based on what they see to making judgments based on what they reason

ANS: B

Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years), children exhibit thought processes that enable them to see things from the point of view of another, place things in a sensible and logical order, and progress from making judgments based on what they see to making judgments based on what they reason.

 

7. Adolescents often do not use reasoned decision making when issues such as substance abuse and sexual behavior are involved. What is this because of?

a.	They tend to be immature.
b.	They do not need to use reasoned decision making.
c.	They lack cognitive skills to use reasoned decision making.
d.	They are dealing with issues that are stressful and emotionally laden.

ANS: D