1. A nurse in a clinic is assessing the weight of an infant. Which infants weight indicates to the nurse that the infants weight is normal for the infants age?1. The babys weight has tripled in the first 6 months of life2. The babys weight has doubled in the first year of life3. The babys weight has doubled in the first 6 months of life and tripled in the first year4. The babys weight has doubled in the first 6 months and doubled again in the next 6 monthsANSWER: 3A babys weight should double in the first 4 to 6 months of life and triple by the end of the first year. The weight needs to more than double the first year. Test-taking Tip: As you read each option, take the normal weight of a newborn and apply the weight in the option before making a selection.2. A student explains to an instructor that the infant period is categorized as the oral phase according to Freuds theory. Which statements by the student suggest an understanding of this phase? SELECT ALL THAT APPLY.1. An infant sucks for nourishment as well as pleasure2. An infant does not find pleasure in sucking but does find enjoyment from the nourishment3. An infant may have more pleasure in breastfeeding than bottle feeding because it expends more energy4. An infant does not find pleasure in use of a pacifier5. An infant explores the world through the mouth6. An infant begins to explore the genital area to learn sexual identityANSWER: 1, 3, 5An infant has the desire to suck, which may actually build the ego and self-esteem of an infant. There is more pleasure in breastfeeding because it expends more energy and also provides other comforting mechanisms, such as warmth. An infant explores the world through the mouth, especially the tongue. Freud believed the oral phase is important for both nutrition and pleasure in the first year of life. An infant finds pleasure in sucking on a pacifier, according to Freud. A preschooler learns sexual identity through awareness of the genital area. Test-taking Tip: Look for key words in each option.3. An 8-month-old baby girl, who is developing appropriately, is admitted to a pediatric unit for respiratory syncytial virus (RSV). The baby is crying and being held by her mother. A nurse wants to provide appropriate care based on Eriksons developmental stages. In which stage is this baby, according to Eriksons theory?1. Punishment versus obedience orientation2. Oral stage3. Initiative versus guilt4. Trust versus mistrustANSWER: 4Based on Eriksons stages of development, trust versus mistrust is appropriate for a child under a year old. The child learns to love and be loved. Experiences that add to security include soft sounds, touch, and visual stimulation for an active child. Punishment-versus-obedience orientation is not a developmental stage. Initiative versus guilt is a developmental task in the preschool stage. The oral phase is based on Freud not Erikson. Test-taking Tip: Use the process of elimination. Recall thatEriksons developmental tasks include achievement of a taskversus nonachievement of a task.4. A nurse is caring for a 3-month-old infant. Based on the developmental age of the child, which motor skill should the nurse expect to see during an assessment?1. Bangs objects held in hand2. Begins to grab objects using a pincer grasp3. Grabs objects using a palmar grasp4. Looks and plays with own fingersANSWER: 4Three-month-old babies can play with their own fingers. At 3 months, infants can reach for attractive objects in front of them, but because their grasp is unpracticed, they usually miss them. A 2-month-old infant will hold an object for a few minutes. A 10-month-old infant uses a pincer grasp. A 6-month-old infant uses a palmar grasp. Test-taking Tip: Awareness of the developmental stages and age of a 3-month-old will assist with answering this question correctly.A nurse case manager is meeting with the parents of an 8-year-old client. The 8-year-old is scheduled for surgery to repair a cleft palate. The parents ask the case manager when they should discuss and explain the surgery to their child. Based on the childs developmental age, which is the best response by the nurse?1. Explain the surgery immediately before it is carried out.2. Explain the surgery 1 to 2 hours before it is carried out.3. Explain the surgery up to 1 week before it is carried out.4. Explain the surgery several days before it is carried out.ANSWER: 4An 8-year-old can receive teaching several days before surgery. School-age children have concrete operational thought and can remember events. A preschooler will remember explanations for only a couple of hours. A toddler has limited attention span and limited ability to remember things. An adolescent can handle information for the longest period of time. Test-taking Tip: Focus on the length of time in each of the options and how long an 8-year-old should be able to remember events.6. A 4-year-old child is hospitalized with a high fever. While the child is in bed, the child comforts himself by sucking the thumb. The mother of the child becomes concerned because her child has not sucked his thumb for 6 months. Which nursing response to the mothers concerns is most appropriate?1. I dont know why he is sucking his thumb; maybe your child just needs more attention.2. This is a form of developmental regression and can be a normal response for a child who is hospitalized. Continue to love and support your child.3. Is there anything else going on in your family right now that may be causing your child to feel anxious?4. Where is the childs father? Maybe the child wants his father?ANSWER: 2It is common for preschoolers to revert to a behavior they have outgrown in an effort to cope with difficult situations. Sucking a thumb is a comfort measure for the child. Thumb-sucking does not indicate that the child is not getting enough attention. Thumb-sucking does not mean there are other contributing factors. The hospitalization is enough stress in a childs life. Having a father present may or may not be helpful to the child. Test-taking Tip: Consider the developmental stages of the 4-year-old.7. 1. A 1-day-old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9F. Which of the following could explainthis assessment finding?1. This is a normal temperature for a preterm neonate.2. Axillary temperatures are not valid for preterm babies.3. The supply of brown adipose tissue is incomplete.4. Conduction heat loss is pronounced in the baby.1. 1. The normal temperature of a prematurebaby is the same as a full-term baby.2. Axillary temperatures, when performedcorrectly, provide accurate information.3. Preterm babies are born with an insufficientsupply of brown adipose tissuethat is needed for thermogenesis,or heat generation.4. There is nothing in the question thatwould explain conduction heat loss.TEST-TAKING TIP: It is important for thetest taker not to read into questions.Even though conduction can be a meansof heat loss in the neonate and, moreparticularly, in the premature, there arethree other means by which neonateslose heatradiation, convection, andevaporation. Conduction could only besingled out as a cause of the hypothermiaif it were clear from the question thatthat were the cause of the problem8. 5. A baby is grunting in the neonatal nursery. Which of the following actions by thenurse is appropriate?1. Place a pacifier in the babys mouth.2. Check the babys diaper.3. Have the mother feed the baby.4. Assess the respiratory rate.5. 1. Grunting is a sign of respiratory distress.Offering a pacifier is an inappropriate intervention.2. Diapering is an inappropriate intervention.3. The baby is not hungry. Rather the babyis in respiratory distress.4. Grunting is often accompanied bytachypnea, another sign of respiratorydistress.TEST-TAKING TIP: If the test taker were toattempt to grunt, he or she would feelthe respiratory effort that the baby is creating.Essentially, the baby is producinghis or her own positive end-expiratorypressure (PEEP) in order to maximize hisor her respiratory function.6. A 6-month-old child developed kernicterus immediately after birth. Which of thefollowing tests should be done to determine whether or not this child has developedany sequelae to the illness?1. Blood urea nitrogen and serum creatinine.2. Alkaline phosphotase and bilirubin.3. Hearing and vision assessments.4. Peak expiratory flow and blood gas assessments.6. 1. Blood urea nitrogen and serum creatininetests are done to assess the renal system.Kernicterus does not affect the renal system.It results from an infiltration ofbilirubin into the central nervous system.2. Although alkaline phosphotase and bilirubinwould be evaluated when a child isjaundiced, they are not appropriate as assessment tests for the child who has developedkernicterus.3. Because the central nervous system(CNS) may have been damaged by thehigh bilirubin levels, testing of thesenses as well as motor and cognitiveassessments are appropriate.4. The respiratory system is unaffected byhigh bilirubin levels.TEST-TAKING TIP: The test taker must beaware that kernicterus is the syndromethat develops when a neonate is exposedto high levels of bilirubin over time. Thebilirubin crosses the blood-brain barrier,often leading to toxic changes in the CNS.9. A client asks about the difference between cows milk and the milk from her breasts. The nurse should respond that cows milk differs from human milk in that it contains: 1. Less protein, less calcium, and more carbohydrates 2. Less protein, more calcium, and more carbohydrates 3. More protein, less calcium, and fewer carbohydrates 4. More protein, more calcium, and fewer carbohydrates Answer 4 Rationale 1. Cows milk contains more protein and more calcium. Rationale 2. Cows milk contains more protein and fewer carbohydrates. Rationale 3. Cows milk contains more calcium. Rationale 4. Cows milk is more difficult to digest because it is meant to meet the calls, not the infants, nutritional needs. It is not recommended until after the infant is 1 year old. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning. Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

10. The nurse should explain to a client that breastfeecling is always contraindicated with: 1. Mastitis 2. Hepatitis C 3. Inverted nipples 4. Herpes genitalis Answer 2 Rationale 1. Breastfeeding by a mother with mastitis is not always contraindicated: the baby already has the organism in the mouth. Rationale 2. Breastfeeding by a mother with hepatitis C is contraindicated to limit the transmission of infection. Rationale 3. Breastfeeding is not contraindicated with inverted nipples, because a breast shield can provide mild suction to help evert a nipple. Rationale 4. Breastfeeding is not always contraindicated with this disorder. Client Need: Safety and Infection Control Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning. Planning/Implementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

11. At 10 hours of age an infant has a large amount of mucus and becomes cyanotic. What should the nurse do first? 1. Suction 2. Administer oxygen 3. Record the incident 4. Insert a nasogastric tube Answer 1 Rationale 1. To maintain a patent airway and promote respiration and gaseous exchange. mucus must be removed. Rationale 2. If the airway is obstructed. 2 will be of no use. Rationale 3. Documentation is important, but secondary to clearing a passageway for air. Rationale 4. This is for aspirating the stomach contents, not for airway clearance. Client Need: Physiological Adaptation Cognitive Level: Application Integrated ProcessiNursing Process: Planningllmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

12. After the birth of a healthy neonate. the ductus arteriosus becomes the: 1. Venous ligament 2. Vesical ligament 3. Ligamentum teres 4. Ligamentum arteriosum Answer 4 Rationale 1. This refers to the ductus venosus after it closes. Rationale 2. There is no such ligament. Rationale 3. This is a descriptive term meaning a long and round ligament. Rationale 4. There is anatomic obliteration of the lumen by fibrous proliferation. leading to the term ligamentum artenosum. Chent Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Anaysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

13. When assessing a 9-lb neonate 2 hours after birth, the nurse identifies jitteriness. irregular respirations, and temperature instability. The nurse knows that these are indications that the neonate probably has: 1. Hyponatremia 2. Hypoglycemia 3.Acardiac defect 4.An immature CNS Answer 2 Rationale 1. These are not signs of this problem. Rationale 2. Hypoglycemia causes central nervous system and sympathetic nervous symptom responses. Rationale 3. These are not signs of this problem. Rationale 4. These are not signs of this problem. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

14. When caring for preterm infants with respiratory distress, the nurse should keep: 1. Them prone to prevent aspiration 2. Them in a high-humidity environment 3. Their caloric intake low to decrease metabolic rate 4. Their oxygen concentration low to prevent eye damage Answer 2 Rationale 1. They should be positioned side-lying rather than prone: the prone position is associated with apnea and SIDS. Rationale 2. The moisture provided by the humidity liquefies the tenacious secretions. making gas exchange possible. Rationale 3. Actually the caloric intake is increased: the amount. number. and type of feedings are related to the metabolic rate. Rationale 4. This is not a routine action: the concentration of oxygen that is administered depends on the 2 concentration of the blood gases. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

15. The client response that indicates understanding of teaching regarding breast care for the mother who is breastfeeding is. I will: 1. Use a mild soap for washing 2. Remove my brassiere at night. 3.Air dry my nipples after feeding. 4. Line my breast pads with plastic Answer 3 Rationale 1.Application of soap to breast tissue may result in drying and cracking Rationale 2. Wearing a brassiere continuously, except for bathing. is recommended for 2 to 3 weeks postpartum to provide support to breast tissue structures. Rationale 3. Air-drying nipples after feedings limits irritation and disruption of skin integrity. Rationale 4. Plastic liners trap moisture against tissue and may cause skin breakdown. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: TeachingiLeaming, Evaluation/Outcomes Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

16. When perlorming a newborn assessment, the nurse should measure the vital signs in which sequence? 1. Pulse. respirations, temperature 2. Temperature. pulse. respirations 3. Respirations. temperature. pulse 4. Respirations, pulse, temperature Answer 4 Rationale 1. Measuring the respirations should precede heart rate measurement because the vital signs will change when the baby is touched. Rationale 2. Temperature should be measured last. Rationale 3. Respirations should be measured first, but temperature should be measured after the heart rate. Rationale 4. This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: AssessmentiAnalysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

17. The nurse knows that neonates have difficulty maintaining their body temperature. However, they have several mechanisms to help them maintain it. Select all that apply. 1. Flexed fetal position 2. Hepatic insulin stores 3. Brown fat metabolism 4. Peripheral vasoconstnction 5. Parasympathetic nervous system Answer 1,3,4 sympathetic nervous system: when the body becomes cool, the sympathetic nervous system stimulates the breakdown of brown fat. which releases heat as a byproduct. 4 Peripheral vasoconstnction helps conserve heat by keeping the central core warm and not allowing heat to dissipate. 5 The sympathetic. not parasympathetic. nervous system is involved in thermoregulation. Rationale: 1 Full-term neonates have a flexed fetal position. which provides heat conservation. 2 Insulin is not stored in the liver and is not involved with maintaining neonatal body temperature. 3 Brown fat starts being deposited at 28 weeks gestation and is innervated by the

18. An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has Apgar scores of 7/9. on admission to the nursery, it is not necessary for the nurse to: 1. Record vital signs 2. Administer oxygen 3. Evaluate the neonates health status 4. Support the neonates body temperature Answer 2 Rationale 1. This is an important part of record keeping for all newborns. Rationale 2. The babys Apgar score (7/9) does not indicate a need for 2 Rationale 3.All newborns are evaluated immediately. Rationale 4. Poor thermoregulation necessitates keeping the baby warm to stabilize body temperature. Client Need: Reduction of Risk Potential Cognitive Level: Application Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

19. On a home visit the visiting nurse assesses that the 4-day-old infant who was born at home has a purulent discharge from the eyes. The nurse suspects that the infant hasp 1. Signs of Chiamydia tractiomatis infection 2. Acquired immunodefic iency syndrome (AIDS) 3. Retinopathy of prematurity (retrolental fibroplasia) 4.A reaction to the ophthalmic antibiotic instilled after birth Answer I Rationale I. This conjunctivitis occurs about 3 to 4 days after birth: if it is not treated with an antibiotic, chronic follicular conjunctivitis with conjunctival scarring will occur. Rationale 2. AIDS in the newborn does not manifest itself with conjunctivitis. Rationale 3. High 2 concentrations given to severely compromised preterm infants cause vasoconstriction of retinal capillaries, which can lead to blindness: there are no data to indicate that this infant was preterm or severely compromised Rationale 4. This chemical conjunctivitis occurs within the first 48 hours and is not purulent. Client Need: Physiological Adaptation Cognitive Level: Analysis Integrated Process/Nursing Process: Assess mentlAnalysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

20. An infants intestines are sterile at birth, therefore lacking the bacteria necessary for the synthesis of: 1. Bilirubin 2. Bile salts 3. Prothrombin 4. Intrinsic factor Answer 3 Rationale 1. This is an orange bile pigment produced by the breakdown of hemoglobin. Rationale 2. Bile salts are manufactured in the liver, not synthesized by bacteria. Rationale 3. Bacteria. especially Eschericflia coil, produce substances necessary to synthesize prothrombin. Rationale 4. This is secreted by the gastric glands. not synthesized by bacteria. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Assess mentlAnalysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

21. At 12 weeks gestation. a client who is Rh-negative completely expels the products of conception. After determining that she has not been previously sensitized, the nurse should: 1.Administer Rh0GAM within 72 hours 2. Make certain the client receives Rh0GAM at her first clinic visit 3. Withhold the RhoGAM. because it is not used after the birth of a stillborn 4. Withhold administration of the RhoGAM. because the gestation lasted only 12 weeks Answer 1 Rationale 1. RhoGAM must be given within 72 hours postpartum if the client has not been sensitized previously, irrespective of the length of the gestation. Rationale 2. It would be useless at this time because antibodies have been produced already. Rationale 3. Rh0GAM is always indicated at the termination of a pregnancy, even with fetal demise. Rationale 4. Rh0GAM is always indicated at the termination of a pregnancy. even with a short-term pregnancy. Client Need: Pharmacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

22. The nurse is aware that a healthy newborns respirations are: 1. Irregular. thoracic, 30 to 60/mm. deep 2. Regular. abdominal, 40 to 50/mm, deep 3. Regular. thoracic. 40 to 60/mm. shallow 4. Irregular. abdominal. 30 to 60/mm. shallow Answer 4 Rationale 1. Newborns respirations are abdominal. Rationale 2. Newborns respirations usually are irregular. Rationale 3. Newborns respirations are irregular and abdominal in origin. Rationale 4. The healthy newborns breathing is abdominal and irregular in rhythm and depth (alternates between shallow and deep) the rate ranges from 30 to 60 breaths/mm. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

23. A new mother is breastfeeding her 2-day-old infant and tells the home health nurse that she cannot believe her newborn wants to breastfeed again, since she just fed him 2112 hours ago. The nurse should plan to teach the client that a newborn usually should be nursed: 1. Every hour 2. On demand 3. Every 4 hours 4.At 5-hour intervals Answer 2 Rationale 1. A newborn may want to nurse hourly if irritable, but this is not a usual feeding pattern. Rabonale 2. Breast milk is digested faster than formula: therefore breastfed newborns become hungry sooner. Rationale 3. A breastfed newborn must be fed more often than this. Rabonale 4. All newborns must be fed more often than this. Client Need: Basic Care and Comfort Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning.. Planning/Implementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

24. A low Apgar score at 5 minutes after bwth correlates with the occurrence of: 1. Cerebral palsy 2. Genetic defects 3. Mental retardation 4. Neonatal morbidity Answer 4 Rationale 1. The diagnosis of cerebral palsy is not related to the Apgar score. Rationale 2. Genetic defects may or may not be apparent at this time. They are not related to the Apgar score. Rationale 3. This has not been proven, although research continues in this area Rationale 4. This is related to neonatal morbidity and mortality: by 5 minutes the healthy neonate is relatively stable and requires routine care. Chent Need: Reduction of Risk Potential Cognitive Level: Application Integrated Process/Nursing Process: E valuation/U utcomes Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

25. A preterm neonate admitted to the neonatal intensive care nursery has muscle twitching. seizures, cyanosis. abnormal respirations. and a short, shrill cry. The nurse suspects that this infant may have: 1. Tetany 2. Spina bitida 3. Hyperkalemia 4. Intracranial hemorrhage Answer 4 Rationale 1. This is caused by hypocalcemia: it is manifested by exaggerated muscular twitching. Rationale 2. This is an obvious defect of the spinal column: it is easily recognized. Rationale 3. Elevated potassium level causes cardiac irregulanties. Rationale 4. Intracranial bleeding may occur in the subdural, subarachnoid. or intraventricular spaces of the brain, causing pressure on vital centers: clinical signs are related to the area and degree of cerebral involvement. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

26. The nurse in the newborn nursery observes a yellowish skin color of an infant whose mother had a cesarean birth. The immediate nursing action should be to: 1. Notify the practitioner 2. Ascertain the age of the neonate 3. Take a heel blood sample and send it to the laboratory 4. Cover the eyes and place the infant under the ultraviolet light Answer 2 Rationale 1. Unless the jaundice was pathologic (occurring in the first 24 hours of life), this is not necessary. Rationale 2. The infants age is critical because the development of jaundice before 24 to 48 hours after birth may indicate a blood dyscrasia requiring immediate investigation. Jaundice occurring between 48 and 72 hours after birth (physiologic jaundice) is a consequence of the expected breakdown of fetal red cells and immaturity of the liver. Rationale 3. First. the age of the infant must be ascertained to determine if this is physiologic or pathologic jaundice. then, the nurse should perform a heelstick to determine the amount of bilirubin in the blood Rationale 4. Bilirubin studies would be done first to determine whether the amount of bilirubin present warranted phototherapy Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: AssessmentlAnalysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

27. The nurse should know that an asymmetric Moro reflex is frequently associated with: 1. Down syndrome 2. Cranial nerve damage 3. Cerebral or cerebellar injuries 4. Brachial plexus. clavicular. or humeral injuries Answer 4 Rationale 1. Children with Down syndrome exhibit a normal Moro reflex. Rationale 2. This frequently is not associated: however, if the cochlea were undeveloped or the eighth cranial (vestibulocochlear) nerve were injured, it would affect equilibrium and response to the test. Rationale 3. These injuries usually cause a symmetric loss of the Moro reflex. Rationale 4. Injury to the brachial plexus. clavicle, or humerus prevents abduction and adduction movements of an upper extremity. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

28. After bwth. when inspecting her newborn girl, the mother notices a discharge from the nipples of both of her infants breasts. The nurse should explain that this is evidence of: 1. Monilia contracted during birth 2.An infection contracted in utero 3. Congenital hormonal imbalance 4.An effect from maternal hormones Answer 4 Rationale 1. This usually is manifested in the oral mucosa as thrush (white. adherent patches). Rationale 2. Evidence of infection would not appear so rapidly after birth. Rationale 3. This is uncommon and usually undetectable in the newborn period. Rationale 4. Some maternal oxytocin crosses the placenta and induces the secretion of fluids that have accumulated in the fetal breasts (sometimes called witchs milKs). Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Teachinglleaming, Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc. 29. The nurse understands that one of the factors influencing the availability of milk in the lactating woman is the: 1. Distribution of erectile tissue in nipples 2.Age of the woman at the time of the birth 3. Viewpoint of the womans family toward breastfeeding 4. Amount of milk products consumed during the pregnancy Answer 3 Rationale 1.This has no influence on lactation. Rationale 2. This has no influence on lactation. Rationale 3. If the woman perceives a negative viewpoint about breastfeeding from significant others, she may be tense and the let-down may not occur; a positive attitude from significant others toward breastfeeding promotes relaxation and the let-down reflex. Rationale 4. Milk or milk product intake during pregnancy has little influence on lactation. Client Need: Psychosocial Integrity Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

30. Which assessment, observed immediately after birth, will probably necessitate prolonged follow-up care of a newborn? 1.Apgar score of 5 2. Weight of 3500 g 3. Umbilical cord that contains 2 blood vessels 4. Aspiration of 20 mL of milky-colored gastric fluid Answer 3 Rationale 1. If the Apgar score 5 minutes later showed marked improvement, there would be no need for placing the infant in the ICU. Rationale 2. This is the average weight for a full-term newborn. Rationale 3. The congenital absence of a blood vessel in the umbilical cord is often associated with life-threatening congenital anomalies Rationale 4. The fetus may have swallowed some amniotic fluid: this is not unusual or dangerous. Client Need: Physiological Adaptation Cognitive Level: Analysis Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

31. A peripheral central venous catheter has just been inserted in the arm of a 7-year- old child on the pediatric unit. A peripheral IV line is still in place. An antibiotic is to be administered immediately. Which intravenous access line should the nurse use for the antibiotic infusion and why? 1. Central venous catheter, because this will help determine its patency 2. Peripheral line, because the central venous catheter is reserved for fluids 3. Peripheral line, because the central venous catheter placement has not been confirmed by radiography 4. Central venous catheter, because the antibiotic must be given systemically as quickly as possible Answer 3 Rationale 1. The central line should not be used until placement is confirmed. Rationale 2. Drugs and fluids can be administered through central venous lines most devices have multiple ports. Rationale 3. The peripheral line must be used until the placement of the central venous line is confirmed by radiography or fluoroscopy this prevents fluid from entering the lung or interstitial space if the catheter is misplaced. Rationale 4. The central line should not be used until placement is confirmed. Client Need: Pharmacological and Parenteral Therapies Cognitive Level: Analysis Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

32. A nurse. planning an initial home care visit to a mother who gave birth to a high- risk infant, understands that the visit will be more productive if scheduled when the: 1. Husband is out of the home 2. Mother is feeding the infant 3. Time is convenient for the family 4. Nurse has time to spend with the family Answer 3 Rationale 1. The father should be included in the visit if at all possible. Rationale 2. This may be an inconvenient time for the mother and interfere with productivity. Rationale 3. The family members are more inclined to share problems with the nurse if they are not feeling pressured: in addition, it aids in the development of a productive relationship. Rationale 4. This may be at a time that is inconvenient for the family and thus interfere with productive interaction. Client Need: Management of Care Cognitive Level: Application Integrated Process/Nursing Process: Caring. Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

33. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse notes that the respiratory rate is less than 24 breaths/mm. No other changes are observed, and because the infant is apparently well, there is no report or documentation of the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. Legal responsibility in this instance should take into consideration that: 1. Most infants respirations are slow when they are uncomfortable 2. The respirations of young infants are irregular so a drop in rate is unimportant 3. Vital signs that are outside the expected parameters are significant and should be documented 4. The respiratory tract of young infants is underdeveloped and their respiratory rate is not significant Answer: 3 Rationale 1. Respirations Will accelerate when there is discomfort. Rationale 2.Any significant change should be reported immediately. Rationale 3.A respiratory rate below 30 breathslmin in the young infant is not within the expected range of 30 to 60 breaths/mm: a drop below 30/mm is a significant change and should be documented. Rationale 4. The respiratory tract is fully developed at birth, and the respiratory rate is a cardinal sign of the infants well-being. Client Need: Management of Care Cognitive Level: Application Integrated Process/Nursing Process: Communication/Documentation, Evaluation/Outcomes Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

34. The nurse teaches a 5-year-old girl with cystic fibrosis how to use an inhaler. What is the most appropriate way to evaluate her understanding? 1. Showing the nurse how to use the inhaler 2. Asking questions about using the inhaler 3. Explaining how the inhaler will be used at home 4. Telling the nurse about the things that have been learned Answer 1 Rabonale 1. The nurse can best evaluate teaching by asking the learner for a demonstration. Behavior, rather than words, more readily shows what a child has learned. Rabonale 2. The child may be too young to know if there are any questions. Rabonale 3. A demonstration rather than an explanation can be evaluated more readily. Rationale 4. This would be difficult for 5 year olds their vocabularies are still growing. Client Need: Pharmacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning.. Evaluation/Outcomes Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

35. The nurse plans specific care for infants based on the knowledge that infants are at greater risk for a fluid volume deficit and hyperosmolar imbalance than adults because 1. Their metabolic processes are slower 2. They have a slower glomerular filtration rate 3. Their body fluid loss is proportionately greater per kilogram of weight 4. They have not yet developed a generalized response to insensible fluid loss Answer 3 Rationale 1. Their metabolic rate is more rapid. Rationale 2. Infants have a rapid glomerular filtration rate: a decreased rate is common in the older adult. Rationale 3. Infants are not protected from water loss because they ingest and excrete a relatively greater daily water volume than adults, therefore the proportion of total body water is higher. Rationale 4. Infants and children have a rapid generalized response to insensible fluid loss. Chent Need: Basic Care and Comfort Cognitive Level: Analysis Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

36. A 7-year-old girl develops a urinary tract infection. The practitioner orders a sulfonamide preparation. What is a major nursing responsibility when administering this drug? 1. Weigh the child daily. 2. Give milk with the medication. 3. Monitor the childs temperature frequently. 4. Administer the drug at the prescribed times. Answer 4 Rationale 1. Weighing is important with drugs that affect fluid balance. Rationale 2. Giving medication with milk or meals is important with drugs that cause GI distress. Rabonale 3. Monitoring temperature would be important with antipyretic drugs. Rabonale 4. To maintain the desired blood level, the drug must be given in the exact amount at the times directed. It the blood level of the drug falls, the organisms have an opportunity to build resistance to the drug. Client Need: Phaimacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

37. When picked up by the mother or the nurse. an 8-month-old infant screams and seems to be in pain. The nurse notes the behavior and talks to the mother about. 1.Accidents and the importance of their prevention 2. Limiting play time with other children in the family 3.Any other behaviors that the mother may have noticed 4. Food and specific vitamins that should be given to infants Answer 3 Raonale 1. The nurse should gather more data to determine the basis for the problem. Rationale 2. More data are needed before recommendations can be made. Rationale 3. When taking a health history, all areas of concern should be explored fully before deciding how to address the problem. Rationale 4. The data are inadequate to focus on nutrition. Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Integrated Process/Nursing Process: Communication/Documentation, Planning/Implementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

38. The mother of a 2-year-old child tells the nurse she is having difficulty disciplining her child. What is the nurses most appropriate response to this comment? 1. This is a difficult age that your child is going through right now. 2. Tell me more about your difficulty. Im not sure what you mean by that. 3. its important to be consistent with toddlers when they need disciplining. 4. I can understand what you mean. Thats why this age is called the terrible twos. Answer 2 Rationale 1.Atthough this may be true, it cuts off communication: further communication should be encouraged Rationale 2. The nurse should obtain clarification as to the mothers specific concerns regarding the childs behavior Rationale 3. This response assumes the mother has been inconsistent: the nurse needs more information. Rationale 4. This is inappropriate because the nurse is explaining a developmental factor without exploring what the mother means. Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Integrated ProcesslNursing Process: CommunicationlDocumentation. Planningllmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

39. Which nursing intervention provides the most support to the parents of a newborn with an obvious physical defect? 1. Encourage them to express their concerns. 2. Discourage them from talking about their baby. 3. Tell them not to worry because the defect can be repaired. 4. Show them postoperative photographs of infants who had similar defects. Answer 1 Rabonale 1. This helps and encourages parents to put their fears and feelings into words. Once these sentiments are expressed. they can then be examined and addressed. Rationale 2. This would not assist the parents in coping with the problem: neither would it demonstrate the supportive, empathetic role of the nurse. Rationale 3. This response lacks insight. Parents will worry about their infant anyway. Rationale 4. This may or may not be helpful. Client Need: Psychosocial Integrity Cognitive Level: Application Integrated Process/Nursing Process: Caring, Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

40. When planning to prOvide teaching about self-administration of insulin to a school- age child newly diagnosed with diabetes mellitus. the nurse should first: 1.Assess the childs developmental level 2. Determine familys understanding of the procedure 3. Discuss community resources for the child in the future 4. Collaborate with the school nurse for ensuring continuity of care in school Answer 1 Rationale 1. Teaching methods in each age-group are different depending on the childrens cognitive ability: individual differences depend on a variety of factors including intelligence and emotional status; the childs readiness to learn must be assessed before developing a teaching plan that will bring success. Rationale 2. This would be important later, but not initially. Rationale 3. This would be important later, but not initially. Rationale 4. This would be important later, but not initially. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: TeachingiLeaming, Assessment(A.nalysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

41. Based on developmental norms for a 5-year-old child, the nurse should withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the practitioner when the childs apical pulse rate first drops below: 1.60 beats/mm 2. 70 beats/mm 3.90 beats/mm 4. 100 beats/mm Answer 2 Rationale 1. This rate is well below that which necessitates withholding Lanoxin for children: it is the correct rate for withholding Lanoxin in adults. Rationale 2. The purpose of digoxmn (Lanoxin) is to slow and strengthen the apical rate. The apical rate for a healthy child of 5 years is 70 to 110 beats/mm. If the apical rate is slow (10 to 20 beats below normal), administration of the drug may lower the apical rate to an unsafe level. Rationale 3. This is within the normal range of the heart rate of 5 year olds and does not necessitate withholding Lanoxin. Rationale 4. This is within the normal range of the heart rate of 5 year olds and does not necessitate withholding Lanoxin. Client Need: Pharmacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: Planninglmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

42. A 2-week-old boy is admitted with a tentative diagnosis of a ventncular septal defect. The parents report that their baby has had difficulty feeding since he has been home. The nurse explains that: 1. Feeding problems are common in neonates 2. Inadequate sucking is not significant in the absence of cyanosis 3. Ineffective sucking and swallowing may be early indications of a heart defect 4. Many neonates retain mucus and this may interfere with feeding for several weeks Answer 3 RaonaIe 1. When a feeding problem persists in a neonate, it is generally an indication of some pathology. Rationale 2. Inadequate sucking is never insignificant: it may be indicative of many problems, such as CNS involvement or immaturity as well as heart disease. Rabonale 3. Compromised heart functioning caused decreased cardiac output: this often results in cyanosis and fatigue from ineffective sucking and swallowing Rationale 4. Generally most newborns are free from mucus within 24 to 48 hours after birth. Chent Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning.. Planning/I mplementat ion Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

43. The nurse is administering IV fluids to a dehydrated infant. Which intervention is necessary? 1. Ensuring the sterility of equipment 2. Calculating the total necessary intake 3. Continuing the prescribed rate of flow 4. Maintaining the fluid at body temperature Answer 3 Rationale 1. This is important for everyone receiving IV fluids, not just infants. Rationale 2. This is the practitioners role. Rationale 3M infants intravascular compartment is limited and cannot accommodate a large volume of fluid administered in a short time. Equipment such as an infusion pump with a volume-control chamber should be used because it controls the prescribed amount of fluid to be infused. Rationale 4. IV fluids are administered at room temperature. Client Need: Pharmacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

44. A 4-month-old infant is in a spica cast. What should the nurse include in the discharge instructions? 1. Obtain a specially designed car seat. 2. Change infants position every 8 hours. 3. Diapers alone should be used to reduce soiling of the cast. 4. Use the abduction bar between the infants legs for position changes. Answer 1 Rationale 1. Standard seat belts and car seats are not readily adapted for use by children in spica casts: specially designed devices are available to meet safety requirements. Rationale 2. This is inadequate, the childs position should be changed at least every 2 hours. Rationale 3. Other strategies in addition to diapers will be necessary to keep the cast clean. Rationale 4. Using the abduction bar for lifting or turning could weaken the cast: the abduction bar is designed to keep the hips in alignment. Client Need: Safety and Infection Control Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning, Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

45. A child with cystic fibrosis has been hospitalized with bacterial pneumonia The nurse determines that the child has no known allergies. Selection of the antibiotic to treat the pneumonia depends primarily on the: 1. Tolerance of the child 2. Selectivity of the bacteria 3. Sensitivity of the bacteria 4. Preference of the practitioner Answer 3 Rahonale 1. The tolerance of the child to the particular antibiotic is unknown since up to this time the child has not developed any allergies. Rationale 2. Bacteria are not selective. Rationale 3. When the causative organism is isolated, it is tested for antimicrobial susceptibility (sensitivity) to various antimicrobial agents. When an organism is sensitive to a medication, the medication is capable of destroying the organism. Rationale 4. Although the practitioner may have a preference for a particular antibiotic, it first must be determined if the bacteria have exhibited sensitivity to it. Chent Need: Pharmacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

46. What should the nurse include in the teaching plan for parents of an infant diagnosed with PKU? 1. Mental retardation occurs if PKU is untreated. 2. Testing for PKU is done immediately after birth. 3. Treatment for PKU includes lifelong medications. 4. PKU is transmitted by an autosomal dominant gene. Answer 1 Rationale 1. In PKU the absence of the hepatic enzyme phenylalanine hydroxylase prevents metabolism (hydroxylation to tyrosine) of the amino acid phenylalanine. The increased fluid levels of phenylalanine in the body and the alternate metabolic by-products (phenylketones) are associated with severe mental retardation if not identified and treated early. Rationale 2. Testing for PKU cannot be done until after several days of milk ingestion. Rationale 3. Medications are not part of therapy. Rationale 4. PKU is transmitted by an autosomal recessive gene. Client Need: Physiological Adaptation Cognitive Level: Comprehension Integrated Process/Nursing Process: Teaching/Learning.. Planning/Implementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

47. AS-month-old infant has been diagnosed with congenital hypothyroidism. What is the probable effect on the childs future if treatment is not begun in early infancy? 1. Lifelong myxedema 2. More severe mental retardation 3. Development of spastic paralysis 4. Repeated episodes of thyrotoxicosis Answer 2 Rationale 1. Congenital hypothyroidism does not become myxedema. Rationale 2. Congenital hypothyroidism is the result of insufficient secretion by the thyroid gland because of an embryonic defect. Decreased thyroid hormone affects the fetus before birth during cerebral development. so it is likely that there will be some cognitive impairments at birth. Treatment before 3 months will prevent further damage Rationale 3. This could only occur if the infant had cerebral palsy Rationale 4. Thyrotoxicosis is another term for hyperthyroidism: it is not expected but it can occur with an overdose of exogenous thyroid hormone. Client Need: Physiological Adaptation Cognitive Level: Comprehension Integrated Process/Nursing Process: Assess mentlAnalysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

48. What nursing intervention best meets a major developmental need of a newborn in the immediate postoperative period? 1. Give a pacifier to the infant. 2. Put a mobile over the infants crib. 3. Provide the infant with a soft cuddly toy. 4. Warm the infants formula before feeding Answer 1 Rationale 1. Sucking meets oral needs, which are primary during infancy. Rationale 2.An infant a few days old is too young to focus well on a mobile, in addition, the newborn will be placed in a side-lying position postoperatively and thus would not be able to see the mobile. Rationale 3. A 2-day-old infant is not developmentally capable of enjoying a soft. cuddly toy. Rationale 4. This is not a developmental need. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Caring. Planningilmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

49. Before surgery to relieve an intestinal obstruction, a 3-month-old infant is kept NPO and has a nasogastnc tube in place. Which nursing intervention will help to calm the infant, as well as meet developmental needs? 1.Allow the infant to suck on a pacifier. 2. Offer the infant a favorite toy to hold. 3. Hang a brightly colored mobile in the infants crib. 4. Place the infant on the abdomen to permit crawling. Answer I Rationale I. Sucking is a primary need of infancy. It decreases anxiety and does not interfere with gastric decompression. Rationale 2. This would be more helpful if the child were a toddler. Rationale 3. Usually this does not help to calm the infant. Rationale 4. This will probably increase the pain from abdominal distention: 3-month- old infants are not developmentally ready to crawl: infants should not be placed on their abdomens because this practice is associated with SIDS. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Caring. Planningilmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

50. A newborn has been diagnosed with Down syndrome. The nurse recognizes that these infants usually have several problems in conjunction with Down syndrome. On what should the nurse focus when doing the initial assessment? 1. Reflex responses for hypotonicity 2. Eye examination for congenital cataracts 3. Sensory stimulation for muscle flaccidity 4. Cardiac irregularities for congenital heart disease Answer I Rabonale 1. Children with Down syndrome have a high incidence of congenital heart defects as indicated by altered heart sounds. Without treatment the heart defect may become life-threatening. Rationale 2. This is expected and is not life-threatening. Rationale 3. This is expected and is not life-threatening. Rationale 4. This is expected and is not life-threatening. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

51. When caring for a child with croup. what should be the nurses priority action? 1. Initiate measures to reduce fever. 2. Continually assess respiratory status. 3. Ensure delivery of humidified 2 4. Provide support to reduce apprehension. Answer 2 Rationale 1. This is important, but maintenance of respirations has priority. Rationale 2. Laryngeal spasms can occur abruptIy patency of the airNay is determined by constant assessment for signs of respiratory distress. Rationale 3. This is important, but maintenance of respirations has priority. Rationale 4. This is important, but maintenance of respirations has priority. Client Need: Reduction of Risk Potential Cognitive Level: Application Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

52. When an infants vomiting is uncontroed. it is most important for the nurse to assess for which complication? 1. Acidosis 2. Alkalosis 3. Hyperkalemia 4. Hypernatremia Answer 2 Rabonale 1. This is caused by retention of hydrogen ions and a loss of base bicarbonates, which is more likely to occur with diarrhea Rationale 2. Excessive vomiting causes an increased loss of hydrogen ions (hydrochloric acid), which leads to metabolic alkalosis. an excess of base bicarbonate Rationale 3. Hypokalemia. not hyperkalemia. will occur. Rationale 4. With the loss of chloride ions. hyponatremia is more likely to occur. Client Need: Physiological Adaptation Cognitive Level: Anaiysis Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

53. A mother brings her 1-week-old infant to the clinic because the infant continually regurgitates. Chalasia is suspected. What instructions should the nurse give the mother? 1. Keep the infant prone following feedings. 2. Prevent the infant from crying for prolonged periods. 3. Be sure the infant drinks a full bottle of formula at each feeding 4. Keep the infant in a semi-sitting position. particularly after feedings. Answer 4 Rationale 1. This will promote regurgitation: it is an unsafe position because of the danger of SIDS. Rationale 2. This will probably have little effect on chalasia. Rationale 3. This will promote vomiting because it is too much formula for a 1-week- old infant. Rationale 4. Chalasia is an incompetent cardiac sphincter, which allows a reflux of gastric contents into the esophagus and eventual regurgitation. Placing the infant in an upright position keeps the gastric contents in the stomach by gravity and limits the pressure against the cardiac sphincter. Chent Need: Safety and Infection Control Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning.. Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

54. A 10 year old is diagnosed with lymphocytic thyroiditis (Hashimotos disease). The nurse should explain to the parents and child that this condition is: 1. Chronic 2. Inherited 3. Difficult to treat 4. Probably temporary Answer 4 Rationale 1.ThiS is not a chronic disease. Rationale 2. There seems to be a strong genetic predisposition. but no mode of inheritance has been identified. Rationale 3. This is not an untreatable or fatal disorder: it can be controlled with a medical regimen. Rationale 4. The goiter associated with Hashimotos disease is usually transient and regresses spontaneously in 1 or 2 years. The child usually is euthyroid but may show signs of hypothyroidism or hyperthyroidism. Client Need: Physiological Adaptation Cognitive Level: Comprehension Integrated Process/Nursing Process: Teaching/Learning.. Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

55. The nurse is caring for a 3-month-old infant whose abdomen is distended and whose vomitus is bile stained. The nurse, suspecting an intestinal obstruction. should observe the infant for: 1. High-pitched cry and weak pulse 2. Constant pain and absence of stools 3. Irregular heart rate and hypotonicity 4. Paroxysmal pain and grunting respirations Answer 4 Rationale 1. These usually do not accompany intestinal obstruction. Rationale 2. The pain of intestinal obstruction is paroxysmal. Rationale 3. These are not characteristic of intestinal obstruction. Rationale 4. Paroxysmal pain is related to peristaltic action associated with intestinal obstruction. Abdominal distention pushes the diaphragm upward, causing respiratory distress characterized by grunting respirations. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

56. The most critical factor in the immediate care of an infant after repair of a cleft lip is: 1. Preventing vomiting 2. Maintaining a patent airway 3. Monitoring parenteral fluid infusions 4.Administenng medications that reduce oral secretions Answer 2 Rationale 1.Although this is important. maintaining a patent airway is essential. Rationale 2. These infants frequently have difficulty swallowing secretions as well as difficulty breathing after surgery. Nursing measures. such as placing the infant in a partial side-lying position or gently aspirating secretions from the mouth or nasopharynx. may be necessary to prevent aspiration and respiratory complications. Rationale 3. Fluids are usually administered carefully by mouth. Rationale 4. This is not necessary. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: TeachinglLeaming, Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

57. Play during infancy is important because it enhances: 1. Social development 2. Physical development 3. Cognitive development 4. Emotional development Answer 2 Rationale 1.Although social development is important. it requires human interaction. Rationale 2. Play during infancy (solitary play) promotes physical development: mobiles strengthen eye movement, rattles promote fine finger movement, and soft toys encourage tactile sense Rationale 3. The infant is too young to use play for cognition. Rationale 4. Although emotional development is important. it requires human interaction. Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension Integrated Process/Nursing Process: AssessmentlAnalysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

58. When explaining the occurrence of febrile seizures to a parents class, what information should the nurse include? 1. They may occur in minor illnesses. 2. The cause is usually readily identified. 3. They usually do not occur during the toddler years. 4. The frequency of occurrence is greater in females than males. Answer 1 Rationale 1. Febrile seizures usually are not associated with major neurologic problems. From 95% to 98% of these children do not develop epilepsy or other neurologic problems. Rationale 2. The cause of febrile seizures is still uncertain. Rationale 3. Most febnle seizures occur after 6 months of age and before age 3 years. with the average age of onset between 18 and 22 months. Rationale 4. Boys are affected about twice as often as girls. Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension Integrated Process/Nursing Process: Teaching/Learning. Planning/Implementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

59. An infant has had corrective surgery for hypertrophic pyloric stenosis. To reduce vomiting, the nurse should teach the mother that immediately afler feeding the infant, she should: 1. Rock the infant 2. Place the infant in an infant seat 3. Place the infant flat on the right side 4. Keep the infant awake with sensory stimulation Answer 2 Rationale 1. Movement increases the chance of vomiting. Rationale 2. An elevated position allows gravity to aid in preventing vomiting Rationale 3. This would not prevent reflux and could result in aspiration. Rationale 4. Activity increases the chance of vomiting. Chent Need: Basic Care and Comfort Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning, Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

60. An infant is diagnosed as having communicating hydrocephalus. When helping the parents understand the practitioners explanation of their babys problem. the nurse should respond: 1. Too much CSF is produced within the ventricles of the brain. 2. The flow of CSF through the brain cells does not empty effectively into the spinal cord. 3. The CSF is prevented from adequate absorption by a blockage in the ventricles of the brain. 4. There is a part of the brain surface that usually absorbs CSF after its production that is not functioning adequately. Answer 4 Rationale 1. This is often caused by a choroid plexus tumor and does not interfere with the flow of CSF through the ventricles. Rationale 2. This is an inaccurate answer: brain cells and the spinal cord are not involved Rationale 3. This reflects the pathophysiologic process of noncommunicating hydrocephalus. Rationale 4. This is what occurs in communicating hydrocephalus. Client Need: Physiological Adaptation Cognitive Level: Comprehension Integrated Process/Nursing Process: TeactiinglLearning, Planning)Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

61. When assessing infants and children with cardiac disorders, the nurse understands that one of the last signs of heart failure in infants and children is: 1. Tachypnea 2. Tachycardia 3. Peripheral edema 4. Penorbital edema Answer 3 Raonale 1. This is an early attempt by the body to compensate for decreased cardiac output. Rationale 2. This is an early attempt by the body to compensate for decreased cardiac output. Rationale 3. Heart failure is characterized by a decrease in the blood flow to the kidneys, causing sodium and water reabsorption. resulting in peripheral edema. The peripheral edema indicates severe cardiac decompensation. Rationale 4. This occurs most noticeably in children with post streptococcal glomerulonephritis. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

62. At a visit to the well-baby clinic, a mother is upset because her 9-month-old son has a severe diaper rash: the mother wants to know how to treat it and prevent it from recurring What explanation should the nurse give the mother about the etiology of diaper dermatitis? 1. Use of disposable diapers 2. Prolonged contact with an irritant 3. Too early introduction of solid foods 4. Decreased pH of the urine infants unne output Answer 2 Rationale 1. Both cloth and disposable diapers can cause diaper dermatitis if not changed frequently. Rationale 2. Diaper dermatitis is caused by prolonged repetitive contact with an irritant (e.g.. urine, feces, soaps. detergents. ointments, and friction). Rationale 3.Achange in diet may contribute, but there is no evidence that this is directly related. Rationale 4.An increased pH or alkaline urine can contribute to diaper dermatitis. Client Need: Basic Care and Comfort Cognitive Level: Comprehension Integrated Process/Nursing Process: Teaching/Learning, Planning/Implementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

63. Anticipating that a 4-year-old child, scheduled for open-heart surgery. will have chest tubes in place postoperatively the nurse informs the parents that the chest tubes will: 1. Increase tidal volumes 2. Promote drainage of air and fluid 3. Maintain positive intrapleural pressure 4. Regulate pressure on the pencardium and chest wall Answer 2 Rationale 1. The tidal volume increases as the lung reexpands, but it is not the reason for the insertion of chest tubes. Rationale 2. The intrapleural space must be drained of fluid and air to facilitate the reestablishment of negative pressure in the intrapleural space. Rationale 3. Closed chest drainage is related to intrapleural pressure. not pericardial and chest wall pressure. Rationale 4. Intrapleural pressure should be negative, not positive: positive intrapleural pressure would cause collapse of the lung. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning, Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

64. An infant is admitted to the pediatric intensive care unit after open-heart surgery for the repair of a ventricular septal defect. A nursing priority is to: 1. Monitor the infants urinary output 2. Ascertain the infants pulmonary status 3. Determine the status of the operative site 4. Check the patency of the intravenous catheter Answer 2 Raonale 1. This is important. but adequate ventilation is the priority. Rabonale 2. A patent airway and adequate pulmonary ventilation are always pnonties after surgery Rabonale 3. This is important. but adequate ventilation is the pnonty. Rationale 4. The IV lines would be checked once the airway, breathing, and circulation are determined to be functioning Client Need: Reduction of Risk Potential Cognitive Level: Application Integrated Process/Nursing Process: E valuation/U utcomes Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

65. Surgery to correct hypertrophic pylonc stenosis is performed on a 2-week-old infant who had been formula-fed. Which postoperative feeding order is appropriate? 1. Thickened formula 24 hours after surgery 2. Withholding feedings for the first 24 hours 3. Regular formula feeding within 24 hours after surgery 4. Additional glucose feedings as desired after the first 24 hours Answer 3 Rabonale 1. Regular formula should be started within 24 hours after surgery in an attempt to gradually return the infant to a full feeding schedule. Rationale 2. This is not necessary. Rationale 3. Initial feedings of glucose and electrolytes in water or breast milk are given 4 to 6 hours after surgery. When clear fluids are retained, formula feedings are begun within 24 hours. Rationale 4. This is not necessary. Client Need: Basic Care and Comfort Cognitive Level: Application Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

66. The nurse is aware that an additional defect associated with exstrophy of the bladder is: 1. Imperforate anus 2. Absence of one kidney 3. Congenital heart disease 4. Pubic bone malformation Answer 4 Rationale 1. This defect is not associated with exstrophy of the bladder. Rationale 2. This defect is not associated with exstrophy of the bladder. Rationale 3. This defect is not associated with exstrophy of the bladder. Rationale 4. The pubic bone and the bladder form during the same time of embryonic development. Client Need: Physiological Adaptation Cognitive Level: Comprehension Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

67. A 2-year-old child has a congenital cardiac malformation that causes right-to-len shunting of blood through the heart. What clinical finding should the nurse expect? 1. Proteinuna 2. Peripheral edema 3. Elevated hematocnt 4. Absence of pedal pulses Answer 3 Rationale 1. This is not characteristic of heart malformations that cause a right-to- left shunting of blood. Rationale 2. Edema is not a common finding with heart malformations associated with a right-to-left shunting of blood. Rationale 3. Polycythemia. reflected in an elevated hematocnt. is a direct attempt of the body to compensate for the decrease in 2 to all body cells caused by the mixture of oxygenated and unoxygenated circulating blood. Rationale 4. This is characteristic of coarctation of the aorta, an obstructive malformation. Client Need: Reduction of Risk Potential Cognitive Level: Application Integrated ProcesslNursing Process: AssessmentJA.nalysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

68. What is a common finding that the nurse can identify in most children with symptomatic cardiac malformations? 1. Mental retardation 2. Inherited genetic factors 3. Delayed physical growth 4. Clubbing of the fingertips Answer 3 Rationale 1. Mental retardation is not a common finding in children with congenital heart disease. Rationale 2. Cardiac anomalies are more often a result of prenatal, rather than genetic, factors. Rationale 3. Children with cardiac malformations often use increased energy in activities of daily living decreased 2 utilization and increased energy output in the developing child result in a slow growth rate. Rationale 4. Clubbing is not characteristic of most children with cardiac anomalies, only of those with more severe hypoxia. Client Need: Physiological Adaptation Cognitive Level: Application Integrated ProcesslNursing Process: AssessmentJAsialysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc. 69. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. When palpating this infants abdomen, the nurse expects: 1.Adistended colon 2. Marked tenderness around the umbilicus 3.An olive-sized mass in the right upper quadrant 4. Rhythmic peristaltic waves in the lower abdomen Answer 3 Raonale 1. The obstruction is above the intestinal area: the colon is not involved. Rabonale 2. There is no significant tenderness in the abdomen. Rationale 3. The olivelike mass is caused by the thickened muscle (hypertrophy) of the pylonc sphincter. Rationale 4. There is little or no peristalsis in the intestines. Chent Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

70. What is the most serious complication of meningitis in young children? 1. Epilepsy 2. Blindness 3. Peripheral circulatory collapse 4. Communicating hydrocephalus Answer 3 Rationale 1. Although this may occur, it is controllable and not as serious as peripheral circulatory collapse. Rationale 2. Although this may occur. it is not as serious a complication as peripheral circulatory collapse. Rationale 3. Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock. petechiae. ecchymotic lesions, vomiting. prostration. and hypotension. Rationale 4. Although this may occur, it is rare and not as serious as peripheral circulatory collapse. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

71. What is the most serious complication of meningitis in young children? 1. Epilepsy 2. Blindness 3. Peripheral circulatory collapse 4. Communicating hydrocephalus Answer 3 Rationale 1. Although this may occur, it is controllable and not as serious as peripheral circulatory collapse. Rationale 2. Although this may occur. it is not as serious a complication as peripheral circulatory collapse. Rationale 3. Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock. petechiae. ecchymotic lesions, vomiting. prostration. and hypotension. Rationale 4. Although this may occur, it is rare and not as serious as peripheral circulatory collapse. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

72. Which cardiac defects are associated with tetralogy of Fallot? 1. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis 2. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle 3. Right ventricular hypertrophy. ventricular septal defect. pulmonic stenosis, and overriding aorta 4. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy. and an atnal septal defect Answer 3 Rationale 1. Although there is right ventricular hypertrophy. the other defects are not associated with tetralogy of Fallot. Rationale 2. These are the charactenstics of transposition of the great vessels. Rationale 3. Tetralogy of Fallot consists of four defects. Three of them are anatomic: ventricular septal defect. pulmonic stenosis. and overriding aorta. The fourth defect, right ventricular hypertrophy, is secondary to increased resistance to blood flow in that ventricle. Rationale 4. Although there is right ventricular hypertrophy, the other defects are not associated with tetralogy of Fallot. Chent Need: Physiological Adaptation Cognitive Level: Comprehension Integrated Process/Nursing Process: Assessment/Anaysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

73. What should be the school nurses first action when a child complains of a sore throat? 1. Examine the throat. 2. Have the child sent home. 3. Take the childs temperature. 4. Secure an order for an oral analgesic Answer 1 Rabonale 1. The priority is to assess the throat to determine the extent of inflammation. Significant swelling can create the potential for airway obstruction. Rationale 2. Assessment of the childs problem must be done before initiating any other actions Rationale 3. Assessment of the childs problem must be done before initiating any other actions. Rationale 4. Assessment of the childs problem must be done before initiating any other actions. Client Need: Reduction of Risk Potential Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

74. When teaching a mother how to prevent accidents while caring for her 6-month-old infant, the nurse should emphasize that at this age. the infant can usually: 1. Sit up 2. Roll over 3. Crawl short distances 4. Stand while holding on to furniture Answer 2 Raonale 1. Sitting up unsupported is accomplished by most infants at 7 to 8 months. Raonale 2. Muscular coordination and percepuon are developed enough at 6 months for the infant to roll over. If unaware of this ability, the mother could leave the infant unattended for a moment to reach for something and the infant could roll off an elevated surface. Rationale 3. Crawling takes place at about 9 months of age. Rationale 4. Standing by holding on to furniture is accomplished by most infants between 8 and 10 months of age. Client Need: Salety and Inlection Control Cognitive Level: Comprehension Integrated Process/Nursing Process: Teaching/Learning. Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

75. A 6-year-old child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing care plan for this child? 1. Rest 2. Exercise 3. Nutrition 4. Elimination Answer 1 Rationale 1. Rest reduces the need for 02 and minimizes metabolic needs during the acute. febrile stage of the disease. Rationale 2. The child requiring hospitalization for pneumonia is usually confined to bed and needs to reduce activity to conserve 2 Rationale 3. This is not a priority: the child is expected to be anorectic during the febnle phase. Rationale 4. Elimination is not usually a problem. except as a result of immobility. Client Need: Basic Care and Comfort Cognitive Level: Application Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

76. When teaching a class of mothers about how to position their infants during the first few weeks of life, the nurse tells them that the safest position is on their. 1. Stomachs lying flat 2. Backs or sides lying flat 3. Stomachs with their heads slightly elevated 4. Right or left sides with their heads slightly elevated Answer 2 Rationale 1. This position has been associated with the incidence of SIDS and should be avoided. Rationale 2. These positions offer the lowest risk for SIDS. Rationale 3. This position has been associated with the incidence of SIDS and should be avoided. Rationale 4. These positions are safe. but lying on their backs is also safe and using the three positions offers more variety. Client Need: Safety and Infection Control Cognitive Level: Application Integrated Process/Nursing Process: TeachingiLeaming, Planningllmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

77. What should nursing care for an infant after the surgical repair of a cleft lip include? 1. Preventing the infant from crying 2. Placing the infant in a semi-sitting position 3. Keeping the infant NPO for 1 day after surgery 4. Feeding the infant with a spoon for 2 days after surgery Answer 1 Rationale 1. Crying should be prevented because it places tension on the suture line. Frequently an appliance called a Logan bow is taped to the cheeks to relax the operative site. which helps prevent trauma. Rationale 2. The infant may be positioned on the side and on the back with surveillance. Rationale 3. This is not necessary or desirable. Rationale 4. The feeding method of choice is by a rubber-tipped syringe or dropper. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Planning)lmplementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

78. The mother of an 18-month-old boy with a cleft palate asks the nurse why the pediatrician recommended that closure of the palate should be done before he is 2 years old. The nurse responds: 1. As he gets older the palate gets wider and more difficult to repair. 2. After age 2 surgery is very frightening and should be avoided if possible 3. The eruption of the 2-year molars often comphcates the surgical procedure. 4. Surgery should be performed before the child starts to use faulty speech patterns. Answer 4 Rationale 1.Although this may be true. this is not the reason why the repair is made at this age: these children may need multiple surgeries as the palate develops. Rationale 2. This is not the reason the surgery is done at this age. Rationale 3. Children with a cleft palate require orthodontic and prosthodontic treatment for many years because of the malformed palate and the malposition of the teeth: the eruption of the teeth may be considered relative to the timing of surgery throughout childhood, but the 2-year molars are of little importance when considering the overall problem. Rationale 4.Achild with a cleft palate has distinctive speech because the airflow required for speech cannot be controlled: although speech therapy is usually needed after surgery. surgery is scheduled before the child starts to speak because correct speech is easier to achieve. Client Need: Reduction of Risk Potential Cognitive Level: Comprehension Integrated Process/Nursing Process: TeachinglLeaming, PlanningAmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc. 79. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurses best initial action? 1. Call for assistance. 2. Attempt to open the jaw. 3. Lower the child to the floor. 4. Place a large pillow under the head. Answer 3 Rationale 1. Protecting the child is the priohty assistance at this time is futile. Rationale 2. This is unsafe: attempting to open the jaw could result in injury. Rationale 3. This limits the danger of falling and striking the head. Raonale 4. This may cause airway occlusion by forcing the chin onto the neck. Chent Need: Safety and Infection Control Cognitive Level: Application Integrated Process/Nursing Process: Planning/I mpiementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

80. A child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. Postoperatively, it is essential that the nurse prevent: 1. Crying 2. Coughing 3. Hard stools 4. Unnecessary movement Answer 3 Rationale 1. Crying is not a problem after cardiac surgery: it may. in fact, help prevent respiratory complications. Rationale 2. Coughing and deep breathing are essential for the prevention of postoperative respiratory complications. Rationale 3. Forceful evacuation results in the child taking a deep breath, holding it. and straining (Valsalva maneuver). This increases intrathoracic pressure. which puts excessive strain on the heart sutures. Rationale 4. Activity is gradually increased. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: PlanningAmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

81. A 5 month old develops severe diarrhea and is given IV fluids What is the rationale for frequent observation of the IV flow rate? 1. Restriction of output 2. Replacement of lost fluids 3. Avoidance of IV infiltration 4. Prevention of cardiac overload Answer 4 Rationale 1. Increased output is not the primary consideration. Rabonale 2. Although fluid replacement is important. prevention of cardiac problems from fluid overload is critical. Rationale 3. This is important, but an infiltrated IV is not as serious as a cardiac complication Rationale 4. If the circulation is overloaded with too much fluid or the rate is too rapid. the stress on the heart becomes too great and cardiac overload may occur. Client Need: Pharmacological and Parenteral Therapies Cognitive Level: Application Integrated Process/Nursing Process: E valuation/U utcomes Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

82. The nurse is caring for a child with the diagnosis of meningitis. What sign or symptom indicates an increase in intracranial pressure? 1. Bradycardia 2. Hyperalertness 3.Adecreased pulse pressure 4.A decreased systolic blood pressure Answer 1 Rationale 1. Braclycardia is a classic sign of increased intracranial pressure. Rationale 2. With increased intracranial pressure, there would be decreased alertness or loss of consciousness. Rationale 3. The pulse pressure increases with increased intracranial pressure. Rationale 4. Systolic BP increases with increased intracranial pressure. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

83. A young child has coarctation of the aorta. What should the nurse expect to identify when taking the childs vital signs? IA weak radial pulse 2.An irregular heartbeat 3.A bounding femoral pulse 4.An elevated blood pressure in the arm Answer 4 Rationale 1. This is not related to coarctation of the aorta. Rationale 2. The femoral pulses are weak or absent. Rationale 3. The radial pulses are bounding Rationale 4. Coarctation of the aorta is a narrowing of the aorta, usually in the thoracic segment. causing decreased blood flow below the constriction and increased blood volume above it. Client Need: Physiological Adaptation Cognitive Level: Application Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

84. A mother brings her 9-month-old son to the pediatric clinic and asks about the introduction of new foods. What should the nurse suggest? 1. Introduce a new food after he has had his regular feeding. 2. Offer a new food every day until he likes one and then offer it again. 3. Offer a new food after he has had some milk when he is still hungry. 4. Mix the pureed food with formula and have him dnnk it from the bottle. Answer 3 Rationale 1. Offering food after the regular feeding decreases the chance of success. because the infants hunger is already satisfied. Rationale 2. New foods should be initiated one at a time and continued for 4 to 5 days to assess for an allergic reaction. Rationale 3. Offering a new food after giving some formula associates this activity with eating and takes advantage of the infants unsatisfied hunger. Rationale 4. Solid food should be introduced by spoon to acquaint the infant with new tastes and textures, as well as the use of the spoon. Client Need: Health Promotion and Maintenance Cognitive Level: Application Integrated Process/Nursing Process: Teaching/Learning.. Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

85. When elevating the head of an infant in a spica cast. the nurse should: 1. Place 2 pillows under the shoulders 2. Limit this position to 1 hour at a time 3. Pad the edge of the cast with folded diapers 4. Raise the entire mattress at the head of the cnb Answer 4 Rationale 1. Pillows under the head or shoulders of a child in a spica cast will thrust the chest forward against the cast. causing discomfort and respiratory distress. Rationale 2. There is no reason to place a time limit on this position. Rationale 3. This will not help elevate the infants head. Rationale 4. When elevation of the head is desired. the entire mattress or crib should be raised at the head of the cnb. Client Need: Safety and Infection Control Cognitive Level: Application Integrated Process/Nursing Process: Planningllmplementation Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

86. When preparing for the admission of a child with acute laryngotracheobronchitis (croup). what should be the nurses priority intervention? 1. Pad the side rails of the crib. 2. Arrange for a quiet. cool room. 3. Obtain a cot so that a parent can stay. 4. Place a tracheotomy set at the bedside. Answer 4 Rationale 1. Although this would be helpful. it is not the priority. Rationale 2. This is unnecessary; it may be done if the child has a high fever or a history of febrile seizures. Rabonale 3. Although appropriate, this is not the priority. Raonale 4. The priority is a patent airway, and necessary equipment must be immediately available. Client Need: Reduction of Risk Potential Cognitive Level: Application Integrated Process/Nursing Process: Planning/Implementation Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

87. What common adaptation of children with tetralogy of Fallot should the nurse expect? 1. Slow respirations 2. Clubbing of fingers 3. Subcutaneous hemorrhages 4. Decreased RBC counts Answer 2 Rationale 1. The respirations are generally rapid to compensate for 2 deprivation. Rationale 2. Hypoxia leads to poor peripheral circulation: clubbing develops over time as a result of tissue hypertrophy and additional capillary development in the fingers. Rationale 3. This is not an adaptation that occurs in children with tetralogy of Fallot. Rationale 4. These children have polycythemia. Client Need: Physiological Adaptation Cognitive Level: Application Integrated ProcessiNursing Process: Assessment/Analysis Mosby items and derived items @ 2009. 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier Inc.

88. Which type of hernia involves an impaired blood supply? 1. Hiatal 2. Omphalocele 3. Incarcerated 4. Strangulated Answer 4 Rationale 1. A hiatal hernia is the intrusion of an abdominal structure, usually the stomach. through the esophageal hiatus. Rationale 2. An omphalocele is the protrusion of intraabclominal tissue through a defect in the abdominal wall at the umbilicus: the sac may be covered with per