INTRODUCTION TO MATERNITY AND PAEDIATRIC NURSING 8TH EDITION BY LEIFER TEST BANK| COMPLETE

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NURSINGTB.COM INTRODUCTIONTOMATERNITYANDPEDIATRICNURSING8THEDITIONLEIFER INTRODUCTION TO MATERNITY AND PAEDIATRIC NURSING 8TH EDITION BY LEIFER TEST BANK| COMPLETE Chapter 01: The Past, Present, ... and Future MULTIPLE CHOICE 1. A patient choosesto have the certified nursemidwife (CNM) provide care during her pregnancy. What doesthe CNMs scope of practice include? a. Practice independent from medical supervision b. Comprehensive prenatal care c. Attendance at all deliveries d. Cesarean sections ANS: B The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensuresthat a backup physician is available in case of unforeseen problems. DIF: Cognitive Level: Comprehension REF: Page 6 TOP: Advance PracticeNursing Roles KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. Whichmedical pioneer discovered the relationship between the incidence of puerperal fever and unwashedhands? a. Karl Cred b. Ignaz Semmelweis c. Louis Pasteur d. Joseph Lister ANS: B Ignaz Semmelweis deduced that puerperal fever wasseptic, contagious, and transmitted by the unwashed hands of physicians andmedical students. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 2 TOP: The Past KEY: Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. A pregnant woman who hasrecently immigrated to the United States commentsto the nurse, I am afraid ofchildbirth. It is so dangerous. I am afraid I will die. What is the best nursing response reflecting cultural sensitivity? a. Maternal mortality in theUnited Statesis extremely low. b. Anesthesia is available to relieve pain during labor and childbirth. c. Tell me why you are afraid of childbirth. d. Your condition will bemonitored during labor and delivery. ANS: C Asking the patient about her concerns helps promote understanding and individualizes patient care. DIF: Cognitive Level: Application REF: Page 7 TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation 4. An urban area has been reported to have a high perinatal mortality rate. Whatinformation doesthis provide? a. Maternal and infant deaths per 100,000 live births per year b. Deaths of fetuses weighing more than 500 g per 10,000 births per yearNURSINGTB.COM INTRODUCTIONTOMATERNITYANDPEDIATRICNURSING8THEDITIONLEIFER c. Deaths of infants up to 1 year of age per 1000 live births per year d. Fetal and neonatal deaths per 1000 live births per year ANS: D The perinatal mortality rate includesfetal and neonatal deaths per 1000 live births per year.DIF: Cognitive Level: Comprehension REF: Page 12INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 4 NURSINGTB.COM OBJ: 9 TOP: The Present-Child Care KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 5. Whatisthe focus of current maternity practice? a. Hospital birthsfor the majority of women b. The traditional family unit c. Separation oflaborroomsfrom delivery rooms d. A quality family experience for each patient ANS: D Currentmaternity practice focuses on a high-quality family experience for all families,traditional or otherwise. DIF: Cognitive Level: Comprehension REF: Page 6 TOP: The Present-Maternity Care KEY:Nursing Process Step:N/AMSC: NCLEX: Health Promotion and Maintenance 6. Who advocated the establishment ofthe Childrens Bureau? a. Lillian Wald b. Florence Nightingale c. Florence Kelly d. Clara Barton ANS: A Lillian Wald is credited with suggesting the establishment of a federal Childrens Bureau. DIF: Cognitive Level: Knowledge REF: Page 4 TOP: The Past KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 7. What wasthe result ofresearch done in the 1930s by the Childrens Bureau? a. Children with heart problems are now cared for by pediatric cardiologists. b. The Child Abuse and Prevention Act was passed. c. Hotlunch programs were established inmany schools. d. Childrens asylums were founded. ANS: C School hotlunch programs were developed as a result ofresearch by the Childrens Bureau on the effects of economic depression on children. DIF: Cognitive Level: Knowledge REF: Page 4 TOP: The Past KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance: Coordinated Care 8. What government program wasimplemented to increase the educational exposure of preschool children? a. WIC b. Title XIX of Medicaid c. The Childrens Charter d. Head Start ANS: D Head Start programs were established to increase educational exposure of preschool children. DIF: Cognitive Level: Knowledge REF: Page 3 TOP:GovernmentInfluencesin Maternity and PediatricCare KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. What guidelines definemultidisciplinary patient care in terms of expected outcome and timeframe fromdifferent areas of care provision?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 5 NURSINGTB.COM a. Clinical pathways b. Nursing outcome criteria c. Standards of care d. Nursing care plan ANS: A Clinical pathways, also known as critical pathways or caremaps, are collaborative guidelinesthat define patient care across disciplines. Expected progress within a specified timeline is identified. DIF: Cognitive Level: Knowledge REF: Page 12 TOP:Health Care Delivery Systems KEY:Nursing Process Step:N/A MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 10. A nursing student hasreviewed a hospitalized pediatric patient chart, interviewed hermother, and collectedadmission data. What is the nextstep the student will take to develop a nursing care plan for this child? a. Identify measurable outcomes with a timeline. b. Choose specific nursing interventionsforthe child. c. Determine appropriate nursing diagnoses. d. State nursing actionsrelated to the childsmedical diagnosis. ANS: C The nurse uses assessment data to select appropriate nursing diagnosesfrom the NANDA-I list.Outcomes and interventions are then developed to address the relevant nursing diagnoses. DIF: Cognitive Level: Application REF: Page 11 TOP:Nursing Process KEY:Nursing Process Step:Nursing Diagnosis MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 11. A nursing student on an obstetric rotation questionsthe floor nurse about the definition of the LVN/LPNscope of practice. What resource can the nurseNsUuRgSgeINstGtoTBth.CeOstMudent? a. American Nurses Association b. States board of nursing c. Joint Commission d. Association of WomensHealth,Obstetric andNeonatal Nurses ANS: B The scope of practice of the LVN/LPN is published by the states board of nursing. DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 18 TOP: Critical Thinking KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 12. What wasrecommended by Karl Cred in 1884? a. All women should be delivered in a hospitalsetting. b. Chemical meansshould be used to combatinfection. c. Podalic version should be done on all fetuses. d. Silver nitrate should be placed in the eyes of newborns. ANS: D In 1884 Karl Cred recommended the use of 2% silver nitrate in the eyes of newbornsto reduce the incidence of blindness. DIF: Cognitive Level: Knowledge REF: Page 2 TOP:Use of SilverNitrate KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 13. Whatisthe purpose of the White House Conference on Children and Youth?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 6 NURSINGTB.COM a. Set criteria for normal growth patterns.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 7 NURSINGTB.COM b. Examine the number oflive birthsinminority populations. c. Raisemoney to support well-child clinicsin rural areas. d. Promote comprehensive child welfare. ANS: D White House Conferences on Children and Youth are held every 10 yearsto promote comprehensive child welfare. DIF: Cognitive Level: Knowledge REF: Page 4 TOP:White House Conferences KEY: Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. Howmany hours of hospitalstay doeslegislation currently allow for a postpartum patient who hasdelivered vaginally without complications? a. 24 b. 48 c. 36 d. 72 ANS: B Postpartumpatients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have had a cesarean delivery usually stay 4 days. DIF: Cognitive Level: Knowledge REF: Page 6 TOP: Hospital Terms for Postpartum Patients KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. How doesthe clinical pathway or critical pathway improve quality of care? a. Lists diagnosis-specific implementations NURSINGTB.COM b. Outlines expected progress with stated timelines c. Prioritizes effective nursing diagnoses d. Describes common complications ANS: B Critical pathways outline expected progress with stated timelines. Any deviation fromthose timelinesis calleda variance. DIF: Cognitive Level: Comprehension REF: Page 12 TOP: Critical Pathway KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 16. A patient asksthe nurse to explain whatis meant by gene therapy. What isthe nurses bestresponse? a. Gene therapy can replacemissing genes. b. Gene therapy evaluatesthe parents genes. c. Gene therapy can change the sex of the fetus. d. Gene therapy supportsthe regeneration of defective genes. ANS: A Gene therapy can replacemissing or defective genes. DIF: Cognitive Level: Knowledge REF: Page 8 TOP:Gene Therapy KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 17. The nurse is clarifying information to a patientregarding diagnosis-related groups(DRGs). Whatisthe nurses best response when the patient asks how DRGs reduce medical care costs? a. By determining payment based on diagnosis b. By requiring twomedical opinionsto confirm a diagnosisINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 8 NURSINGTB.COM c. By organizing HMOs d. By defining a person who willrequire hospitalization ANS: A DRGs determine the amount of payment and length of hospitalstay based on the diagnosis. DIF: Cognitive Level: Comprehension REF: Page 8 TOP: DRGs KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 18. Whatisthe best example of a Nursing Interventions Classification (NIC) intervention? a. Patient will ambulate in the hall independently for 10 minutesthree times a day. b. Nurse willreporttemperature elevationsto the charge nurse. c. Nurse will offer extra liquids at all meals. d. Patient will express pain relief aftermassage. ANS: C NIC is a guide to nursing actions. DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 15 TOP:NICs KEY: Nursing Process Step:N/A MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 19. How does electronic charting ensure comprehensive charting more effectively than handwritten charting? a. Provides a uniform style of chart b. Requires certain responses before allowing the user to progress c. All documentation isreflective of the nursing care plan d. Requires a daily audit by the charge nurse ANS: B NURSINGTB.COM Comprehensive electronic documentation is ensured by requiring specific inputin designated categories before the user can progress through the system. DIF: Cognitive Level: Comprehension REF: Page 15 TOP: Computer Charting KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 20. The nurse remindsfamilymembersthatthe philosophy of family-centered care isto provide control to thefamily over health care decisions. What is the appropriate term for this type of control? a. Empowerment b. Insight c. Regulation d. Organization ANS: A The term empowermentrefersto the control a family has overits own health care decisions. DIF: Cognitive Level: Knowledge REF: Page 2 TOP: Empowerment KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. A patient in the prenatal clinic is concerned about losing her job because of her pregnancy. The nurse instructs her thatthe Family Medical Leave Act (FMLA) allows an employee to be absentfrom work without pay. How many weeks does the FMLA allow a woman to recover from childbirth or care for a sick family member without loss of benefits or pay status? a. 4 b. 6 c. 10 d. 12INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 9 NURSINGTB.COM ANS: D The FMLA allowsfor employeesto leave work for up to 12 weeksto recover from childbirth or to care for an ill family member without losing benefits or pay status. DIF: Cognitive Level: Knowledge REF: Page 3 TOP: FMLA KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 22. Whatterm appropriately describesthe nurse who is able to adapt health care practicesto meetthe needs ofvarious cultures? a. Culturally aware b. Culturally sensitive c. Culturally competent d. Culturally adaptive ANS: C The nurse who is able to adapt health care to meet the needs of various culturesissaid to be culturally competent. DIF: Cognitive Level: Knowledge REF: Page 7 TOP: Cultural Competency KEY:Nursing Process Step: N/A MSC: NCLEX: N/A 23. Whatis onemajor advantage to the application of criticalthinking? a. Problem-free care b. Limitation of approachesto care c. Decreased need for assessment d. Problem prevention ANS: D NURSINGTB.COM Criticalthinking resultsin problem prevention in designing nursing care. DIF: Cognitive Level: Comprehension REF: Page 14 TOP: Critical Thinking KEY:Nursing Process Step: N/AMSC: NCLEX: N/A 24. Student practical nurses are discussing the North American Nursing Diagnosis Association International (NANDA-I)taxonomy in post conference on the acute care clinicalsetting. The students are aware thatthe roleof the LPN with nursing diagnosis formulation is what? a. To initiate and identify nursing diagnosisspecific to patient b. To update changesin nursing diagnosis as needed c. To have an understanding of nursing diagnosisterminology d. To accurately document nursing diagnosis on patient plan of care ANS: C The registered nurse isresponsible to initiate, identify, update, and document nursing diagnoses. The licensed practical nurse is responsible to have an understanding of nursing diagnosis terminology. DIF: Cognitive Level: Comprehension REF: Page 14 TOP: NANDA-I taxonomy KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques MULTIPLE RESPONSE 25. Whatservices are birthing centers able to provide? (Select allthat apply.) a. Prenatal care b. Labor and delivery services c. Classesfor newmothersINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 10 NURSINGTB.COM d. Adoption referrals e. Family planning ANS: A, B, C, E Birthing centers are capable of providing full-service obstetric care, classesfor new mothers, and family planning. Birthing centers do not offer adoption services. DIF: Cognitive Level: Comprehension REF: Page 6 TOP: Birthing Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 26. What developmentsin the early 20th century encouraged women to seek hospitalization for childbirth?(Select all that apply.) a. Use ofspecialized obstetric instruments b. Use of anesthesia c. Physicians closerrelationships with hospitals d. Focus on family-centered care e. Insurance coverage ANS: A, B, C In the early 1900s,the development ofspecialized obstetric instruments, better modes of anesthesia, and the physicians reliance on hospital services were instrumental in encouraging women to seek hospitalization forchildbirth. DIF: Cognitive Level: Comprehension REF: Page 3 TOP: Hospitalization for Childbirth KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 27. What nonfamily-centered policies were prevalentin the 1960s? (Select allthat apply.) a. Waiting roomforfathers b. Sedation ofmother during labor c. Delay ofreunion of mother and infant d. Lenient visiting hours NURSINGTB.COM e. Restrictions of visitations byminor children ANS: A, B, C, E Hospital policiesin the 1960s provided a separate waiting room forfathers while themother wentthrough labor in a sedated state. The reunion of mother and infant was delayed for several hours because of the sedation. Visiting hours were rigid and disallowed the visitation of minor children. DIF: Cognitive Level: Comprehension REF: Page 3 TOP: Nonfamily-centered Practices KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 28. The nurse is aware thatthere is a legalresponsibility to report certain diseases and conditionsto county orstate health authorities. Which would be included? (Select all that apply.) a. Tuberculosis b. Child abuse c. Industrial accidents d. Sexually transmitted diseases e. Food-borne infections ANS: A, B, D, E The nurse has a legalresponsibility to report communicable diseases(such astuberculosis and sexually transmitted diseases), food-borne infections, child abuse, and threats of suicide. DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 6 TOP: Reportable DiseasesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 11 NURSINGTB.COM KEY:Nursing Process Step: PlanningINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 12 NURSINGTB.COM MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 29. An inservice program at a long-term care facility isreviewing theNursingOutcomes Classification (NOC) with nursing staff. After the presentation the nurses review resident care plans. Which of the following are found to be appropriately written outcomes? (Select all that apply.) a. Suction patient orally every 4 hours and as needed. b. Auscultate lung sounds every 2 hours. c. Provide Tylenol as ordered by health care provider. d. Patientstates Pain has decreased aftermedication administration. e. Patient blood pressure recorded as 120/72 after dressing change. ANS: D, E NOC was developed to identify outcomes of nursing care that are directly influenced by nursing actions. Outcomes are defined asthe behaviors and feelings of the patientin response to the nursing care given. Suctioning patient, auscultating lung sounds, and providing Tylenol are nursing actions. DIF: Cognitive Level: Application REF: Page 12 TOP: Nursing Outcomes Classification (NOC) KEY: Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 30. Practical nursing students are using criticalthinking skillsto study for an upcoming test. What willthese students include when studying? (Select all that apply.) a. Memorization offactsfirst b. Prioritizing information c. Relating factsto other facts d. Making assumptions e. Reviewing before the test ANS: B, C, E NURSINGTB.COM Using critical thinking when studying involves understanding facts before memorizing, prioritizing information to bememorized,relating factsto otherfacts, using all five senses,reviewing before tests, and reading critically. Critical thinking does not involve assumption as does general thinking. DIF: Cognitive Level: Comprehension REF: Page 15 TOP: Critical Thinking KEY:Nursing Process Step: EvaluationMSC: NCLEX: Safe, Effective Care Environment 31. Whatfactors have played a role in meeting the goals of Healthy People 2020 asitrelatesthe goals foroutcomes of pregnancy? (Select all that apply.) a. Early prenatal care b. Increased number ofsurgical births c. NICU care d. Use of prenatal glucocorticoids e. Fetalsurgery ANS: A, C, D, E Early prenatal care,fetalsurgery, use of prenatal glucocorticoids,technology, andNICU care have played a role in increasing the positive outcome of pregnancy, and the goals of Healthy People 2020 may well be met.Increase in surgical births and multiple gestations do not work toward meeting the goals of Healthy People2020. DIF: Cognitive Level: Comprehension REF: Page 16 TOP:Healthy People 2020 KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection 32. A community health nurse is providing specialized care to patientsin the home setting. What kind ofspecialized care may this nurse be providing? (Select all that apply.)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 13 NURSINGTB.COM a. GlucosemonitoringINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 14 NURSINGTB.COM b. Heparin therapy c. Family education d. Total parenteral nutrition e. Provision ofreferralservices ANS: A, B, D Glucosemonitoring, heparin therapy, and total parenteral nutrition are categorized asspecialized care that maybe provided by the community health nurse. Family education and provision of referral are categorized as therapeutic care. DIF: Cognitive Level: Application REF: Page 16 TOP: Community Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 33. The nurse who is very conscientious about hand hygiene isfollowing the conceptsset out by and . ANS: Lister, PasteurOR Pasteur, Lister Both Lister and Pasteurset outthat handwashing could reduce incidence of infection by cross-contamination. DIF: Cognitive Level: Knowledge REF: Page 2 TOP:Handwashing KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Safety and Infection Control 34. The firstWhite House Conference on Children and Youth was called by President . ANS: Theodore Roosevelt NURSINGTB.COM Theodore Roosevelt called the first White House Conference in 1909. DIF: Cognitive Level: Knowledge REF: Page 4 TOP:White House Conferences KEY: Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 35. The nurse reviewing the specific recovery goalsset out on a clinical pathway observed thattwo goals werenotmet by their designated timeline. The nurse records a negative for these two goals. ANS: variance Using a clinical pathwaymodel with goals and associated timelines,the nursemustrecord a negative variance when a timeline is not met and consider a new approach or an extended timeline. DIF: Cognitive Level: Comprehension REF: Page 12 TOP: Variances KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Management of Care 36. . is purposeful, goal-directed thinking based on scientificevidence rather than assumption or memorization. ANS: Critical thinking Criticalthinking is purposeful and goal-directed thinking as opposed to generalthinking, which involvesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 15 NURSINGTB.COM random ormemorized thoughts. DIF: Cognitive Level: Knowledge REF: Page 14 TOP: Critical Thinking KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Management of Care NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 16 NURSINGTB.COM Chapter 02: Human Reproductive Anatomy and Physiology MULTIPLE CHOICE 1. A 14-year-old boy is atthe pediatric clinic for a checkup. What physical changes of puberty willthe nurse indicate are related to the production of testosterone? a. Stimulation of production of white cells and platelets b. Promotion of growth ofsmall bones c. Increase inmusclemass and strength d. Decrease in production ofsebaceous gland secretions ANS: C Testosterone increasesmusclemass, promotesstrength and growth of long bones, and enhances production ofred blood cells. DIF: Cognitive Level: Knowledge REF: Page 22 TOP: Male Reproductive System KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is educating high schoolstudents about puberty. What willthe nurse indicate regulates theproduction of sperm and secretion hormones? a. Testes b. Vas deferens c. Ejaculatory ducts d. Prostate gland ANS: A The testes have two functions:manufacture ofspermatozoa and secretion of androgens. DIF: Cognitive Level: Knowledge REF: PageN2U3RSINGTB.COM TOP: Male Reproductive System KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse isspeaking with a couple trying to conceive a child. What will the nurse remind the couple is afactor that can decrease sperm production? a. Infrequentsexual intercourse b. Theman not being circumcised c. The penis and testes being small d. The testes being too warm ANS: D The scrotum issuspended away from the perineum to lowerthe temperature of the testesforsperm production. DIF: Cognitive Level: Comprehension REF: Page 24 TOP: Male Reproductive System KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 4. When describing the female reproductive tract to a pregnant woman, the nurse would explain that whichuterine layer is involved in implantation? a. Perimetrium b. Endometrium c. Myometrium d. Internal os ANS: B The endometrium isthe inner mucosal layer of the uterusthatis governed by cyclical hormonal changes. Itis functional during menstruation and during the implantation of a fertilized ovum.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 17 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 23INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 18 NURSINGTB.COM TOP: Female Reproductive System KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth and Development 5. A group of nursing students plansto teach a class ofsixth-grade girls aboutmenstruation. What correctinformation will the nursing students teach to the class? a. Menarche usually occurs around 12 years of age. b. Ovulation occursregularly from the very first cycle. c. A regular cycle is established by the third period. d. Typically,menstrual flow is heavy and lasts up to 10 days. ANS: A The beginning ofmenstruation, calledmenarche, occurs at about 12 years of age. Early cycles are irregular and anovulatory. DIF: Cognitive Level: Comprehension REF: Page 29 TOP: Female Reproductive Cycle and Menstruation KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 6. A 10-year-old girl asksthe nurse, Whatisthe firstsign of puberty? What isthe correct nursing response? a. An increase in height b. Breast development c. Appearance of axillary hair d. The firstmenstrual period ANS: B The first outward change of puberty in girlsisthe development of breasts at about 10 to 11 years of age. DIF: Cognitive Level: Knowledge REF: Page 23 TOP: PubertyFemale KEY: Nursing Process SNteUpR:SImINpGleTmBe.CnOtaMtion MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 7. A 12-year-old female pediatric patient experienced menarche 3 months ago. Her mother voices concern tothe pediatric office nurse regarding the irregularity of her daughters menstrual cycle. What isthe nurses best response? a. Worrying is notthe answer. b. I willtalk to the pediatrician about a gynecologicalreferral. c. I can only discussthis with your daughter. d. Early cycles are often irregular. ANS: D Early cycles are often irregular and may be anovulatory. Regular cycles are usually established within 6 monthsto 2 years of the menarche. In an average cycle, the flow (menses) occurs every 28 days, plus or minus5 to 10 days. DIF: Cognitive Level: Application REF: Page 29 TOP: Menstrual Cycle KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 8. Which hormone initiatesthematuration of the ovarian follicle? a. Estrogen b. Follicle-stimulating hormone c. Progesterone d. Luteinizing hormone ANS: B Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle. DIF: Cognitive Level: Knowledge REF: Page 29INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 19 NURSINGTB.COM TOP: Female Reproductive Cycle KEY:Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 9. Whatstatementindicates a woman has correctinformation about oogenesis? a. Womenmake fewer ova asthey age. b. Women have all of their ova at the time they are born. c. Ova production begins at birth and continues until puberty. d. New ova aremade every month from puberty to climacteric. ANS: B Oogenesis(formation ofimmature ova) does not occur afterfetal development. Females are born with about 2 million immature ova, which rapidly reduce by adulthood. DIF: Cognitive Level: Comprehension REF: Page 27 TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. A pregnant woman asksthe nurse, Will I be able to have a vaginal delivery? The nurse knowsthat which is the most favorable pelvic type for vaginal birth? a. Gynecoid b. Android c. Anthropoid d. Platypelloid ANS: A The gynecoid pelvisisthe typical female pelvis and ismostfavorable for vaginal birth. DIF: Cognitive Level: Knowledge REF: Page 27 TOP: Female Reproductive System KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and MainteNnaUnRcSe:INPGreTvBen.CtiOoMn and Early Detection of Disease 11. A motheris anxious about her ability to breastfeed after her child is born because of hersmall breast size.What would be an important point to teach this mother? a. Milk is produced in ducts and lobulesregardless of breastsize. b. Supplementing breastfeeding with formula allowsthe infantto receive adequate nutrition. c. Breastsize can be increased with exercise. d. Drinking extramilk during pregnancy allows breaststo produce adequate amounts of milk. ANS: A Breastsize does notinfluence the ability to secretemilk. DIF: Cognitive Level: Comprehension REF: Page 29 TOP: Female Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. For whatisthe decrease in estrogen and progesterone during the menstrual cycle responsible? a. Degeneration ofthe corpusluteum b. Ovulation c. Follicle maturation d. Shedding ofthe endometrium ANS: D The fall in estrogen and progesterone causesthe endometrium to break down,resulting inmenstruation. DIF: Cognitive Level: Comprehension REF: Page 29 TOP: Female Reproductive Cycle KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 13. The nurse is assisting with pelvic inletmeasurements on a pregnant woman. What measurement willINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 20 NURSINGTB.COM provide the nurse with information aboutwhether the woman can deliver vaginally? a. Diagonal conjugate b. Obstetric conjugate c. Transverse diameter d. Anteroposterior diameter ANS: B Thismeasurement determinesifthe fetus can passthrough the birth canal. DIF: Cognitive Level: Comprehension REF: Page 28 TOP: Female Reproductive System KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. The nurse has explainedmenstruation to a 13-year-old girl. Whatstatementindicatesthe girl needsadditional education? a. Periodslast about 5 days. b. My cycle should getregular in 6 months. c. Ishould expect heavy bleeding with clots. d. Periods come about every 4 weeks. ANS: C Clots are not normally seen in menstrual discharge. A normal menstrual flow is 30 to 40 mL blood and 30 to 50 mL serous fluid. DIF: Cognitive Level: Comprehension REF: Page 29 TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. A mother asksthe nurse, When will I know my child has entered puberty? What will the nurse state basedon an understanding of changes associated witNhUpRuSbIeNrtGy?TB.COM a. Your daughter will have herfirst period. b. Youllrecognize puberty by themood swings. c. The child becomesinterested in the opposite sex. d. Secondary sex characteristics,such as pubic hair, appear. ANS: D Puberty begins when the secondary sex characteristics appear. Puberty ends when mature sperm are formed inthe male and when regular menstrual cycles occur in the female. DIF: Cognitive Level: Comprehension REF: Page 22 TOP: Puberty KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. A nurse is planning to teach couples aboutthe physiology of the sex act. What correct information will thenurse provide? a. Fertilization of an ovumrequires penetration by severalsperm. b. An ovum must be fertilized within 24 hours of ovulation. c. Ittakes 4 to 5 daysforsperm to reach the fallopian tubes. d. Sperm live for only 24 hoursfollowing ejaculation. ANS: B After ovulation,the egg livesfor only 24 hours. Sperm must be available during thattime iffertilization isto occur. DIF: Cognitive Level: Comprehension REF: Page 31 TOP: Physiology ofthe Sex Act KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. A newly married couple tellsthe nurse they would like to wait a few years before starting a family. WhichINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 21 NURSINGTB.COM statementmade by theman indicates an understanding aboutsexual activity and pregnancy? a. My wife cant get pregnant ifI withdraw before climax. b. A man can secrete semen before ejaculation. c. If we dont have intercourse very often, my wife wont get pregnant. d. Itissafe to ejaculate outside the vagina. ANS: B Semenmay be secreted during sexual intercourse before ejaculation. DIF: Cognitive Level: Comprehension REF: Page 31 TOP: Male Reproductive System KEY:Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Reduction of Risk 18. The nurse is aware thatthe diagonal conjugate is 12 centimeters. Whatisthe measurementin centimetersof the obstetric conjugate? a. 10 to 10.5 b. 11 to 11.5 c. 12.5 to 13 d. 14 to 14.5 ANS: A The obstetric conjugate is approximately 1.5 to 2 centimetersshorter than the diagonal conjugate. DIF: Cognitive Level: Knowledge REF: Page 28 TOP:Obstetric Conjugate KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 19. The nurse uses a diagram to demonstrate the fimbriae when teaching nursing students about the femaleanatomy. What is true about fimbriae? a. They form the passageway for the sperm toNmUeRetStIhNeGoTvBu.mCO. M b. They are the site of fertilization. c. They are fingerlike projectionsthat capture the ovum. d. They propel the egg through the fallopian tube. ANS: C Fimbriae are the fingerlike projectionsfromthe infundibulum that capture the ovum at ovulation and conductiinto the fallopian tube. DIF: Cognitive Level: Comprehension REF: Page 27 TOP: Fimbriae KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 20. What willthe nurse explain to a 12-year-old patient when describing what characterizes nocturnalemissions? a. A drop in testosterone level b. Sexualstimulation c. Absence ofsperm in ejaculate d. Association with violent dreams ANS: C Nocturnal emissions, also known as wet dreams, occur withoutsexualstimulation and contain no sperm. Testosterone levels are constant until midlife. DIF: Cognitive Level: Comprehension REF: Page 23 TOP: Nocturnal Emissions KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The nurse is educating a pregnant patient who expectsto breastfeed. The nurse knowsthat when a patientbreastfeeds, which portions of the breast secrete milk?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 22 NURSINGTB.COM a. Lactiferoussinuses b. Lobes c. Montgomerys glands d. Alveoli ANS: D The alveolisecrete milk. DIF: Cognitive Level: Knowledge REF: Page 29 TOP: Milk Secretion KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. Where are the secretionsresponsible for nourishing sperm excreted from? a. Vas deferens b. Epididymis c. Cowpers gland d. Scrotum ANS: C The Cowpers gland secretions nourish the sperm. DIF: Cognitive Level: Knowledge REF: Page 24 TOP: Cowpers Gland KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 23. Whatsignifiesthe end of puberty for a male? a. Facial hairis evident. b. Erections can be sustained. c. Ejaculate is greater than 5 mL. d. Mature sperm are formed. ANS: D NURSINGTB.COM Puberty endsfor a male when mature sperm are formed by the testes. DIF: Cognitive Level: Knowledge REF: Page 22 TOP: End of Puberty KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 24. How long doessperm remain viable in the female reproductive tract? a. 12 hours b. 1 day c. 2 days d. 4 days ANS: D Sperm can remain viable in the reproductive tract of the female for aslong as 4 to 5 days. DIF: Cognitive Level: Knowledge REF: Page 31 TOP: Viability of Sperm KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 25. The nurse encouragesthemembers of a prenatal classto seriously consider breastfeeding. What doesbreast milk provide in addition to nourishment for the infant? a. Maternal antibodies b. Stimulusforred blood cell production c. Endorphinsthatsoothe the infant d. Hormones that stimulateINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 23 NURSINGTB.COM growthANS: AINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 24 NURSINGTB.COM Breastmilk provides maternal antibodiesto the infant that give the child acquired immunity from some diseases for several months. DIF: Cognitive Level: Comprehension REF: Page 29 TOP: Properties of Breast Milk KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 26. A female patientreports hermenstrual cycle consistently occurs every 32 days. What day of her cycle canthe woman anticipate ovulation? a. 14 b. 16 c. 18 d. 20 ANS: C Ovulation occurs when a mature ovum isreleased from the follicle about 14 days before the onset of the next menstrual period. DIF: Cognitive Level: Analysis REF: Page 29 TOP: Menstrual Cycle KEY:Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 27. The nurse conducting a sex education classforjunior high students describessome cultural rites celebrating the entry to adulthood. Whatinformation would the nurse include? (Select allthat apply.) a. Barmitzvah b. Displays of bravery c. Receiving part oftheirinheritance d. Ritual circumcision e. Displays ofself-defense NURSINGTB.COM ANS: A, B, D, E Some cultures celebrate the entry to adulthood with rites such as displays of strength, bravery, selfreliance,and self-defense. Ritual circumcisions and bar and batmitzvahs are also entry ritesto adulthood. Lack ofsuchrituals can sometimes confuse young people because there is no evidence of acceptance as an adult. DIF: Cognitive Level: Knowledge REF: Page 22 TOP: Rites of Passage KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 28. The nurse isreading a pregnant patients history and physical. Whatinformation doesthe nurse recognizemight indicate the need for a cesarean delivery? (Select all that apply.) a. History of childhood rickets b. Immobile coccyx c. Prepregnant weight of 100 pounds d. Avid horse rider e. Pelvic fracture 3 years ago ANS: A, B, E Pelvic conditionsthatmay predispose to a cesarean delivery are childhood rickets, pelvic fracture, and immobile coccyx. DIF: Cognitive Level: Comprehension REF: Page 29 TOP: Pelvic Conditions Predisposing Cesarean DeliveryKEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 25 NURSINGTB.COM 29. What are considered to be functions of the fallopian tubes? (Select allthat apply.)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 26 NURSINGTB.COM a. Passage forsperm to meet ova b. Passage for ovum to uterus c. Safe environment forzygote d. Restriction for only one ovum to enter uterus e. Site forfertilization ANS: A, B, C, E The fallopian tube provides passage for both sperm and ova, offering an optimum place forfertilization and a safe environment for the zygote. DIF: Cognitive Level: Knowledge REF: Page 27 TOP: Function of Fallopian Tubes KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 30. The nurse is providing an inservice to students beginning their obstetric clinicalrotation. Using a diagram,the nurse points out parts of the female pelvis. What will the nurse include? (Select all that apply.) a. Two innominates b. Obstetric conjugate c. Sacrum d. Perimetrium e. Coccyx ANS: A, C, E The bones of the pelvis are two innominates, the sacrum, and the coccyx. DIF: Cognitive Level: Knowledge REF: Page 27 TOP: Bones ofthe Pelvis KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. The nurse explains that testosterone is respNoUnRsiSbIlNe GfoTrBm.CaOleMs exceeding females in which aspects? (Select all that apply.) a. Strength b. Height c. Mental concentration d. Hematocritlevels e. Agility ANS: A, B, D DIF: Cognitive Level: Knowledge REF: Page 23OBJ: 2 TOP: Effects of Testosterone KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 32. A patientis being seen by her health care providerfor a suspected vaginal infection. What willthe nurseinclude when educating this patient on factors that affect the vaginal pH? (Select all that apply.) a. Antibiotic therapy b. Frequent douching c. Exercise d. Jet lag e. Use of vaginalsprays ANS: A, B, E The vagina isself-cleansing and during the reproductive years maintains a normal acidic pH of 4 to 5. The self cleansing activity may be altered by antibiotic therapy, frequent douching, and excessive use of vaginal sprays,deodorant sanitary pads, or deodorant tampons. DIF: Cognitive Level: Application REF: Page 25 TOP: Female ReproductiveOrgans KEY:Nursing Process Step: Assessment MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 27 NURSINGTB.COM COMPLETION 33. When the nurse readsin the history and physical of a pregnant patient thatshe has a platypelloid pelvis, thenurse is aware that this pelvis has a narrow diameter, making a vaginal birth unlikely. ANS: anteroposterior The platypelloid pelvisis very narrow fromfrontto back (anteroposterior). The shape of this pelvismakes vaginal delivery unlikely. DIF: Cognitive Level: Comprehension REF: Page 27 OBJ: 8 TOP: Platypelloid Pelvis KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 34. Inmalesthe follicle-stimulating hormone (FSH) and the luteinizing hormone (LH) from the anterior pituitary stimulate testosterone production in the cells of the testes. ANS: Leydig The Leydig cellsin the testes are stimulated by the FSH and LH to produce testosterone. DIF: Cognitive Level: Knowledge REF: Page 24 TOP: Leydig Cells KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 35. The is a period of years during which the womans ability to reproduce gradually declines. ANS: climacteric NURSINGTB.COM The climacteric is a period of years during which the womans ability to reproduce gradually declines. DIF: Cognitive Level: Knowledge REF: Page 29 TOP: Female Reproduction KEY:Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 36. Where the labia majora and the labia minorameetis known asthe fourchette or . ANS: obstetrical perineum Where the labiamajora and the labiaminorameetis known asthe fourchette or obstetrical perineum. Lacerations in this area often occur during childbirth. DIF: Cognitive Level: Knowledge REF: Page 24 TOP: Female Anatomy KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 37. The nurse outlinesthe phases of the sexualresponse. Arrange the phasesin order of occurrence. Put acomma and space between each answer choice (a, b, c, d, etc.) a. Nipples become erect. b. Involuntary muscle spasms occur. c. Engorgement resolves. d. Heartrate slows. e. Skin flushes.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 28 NURSINGTB.COM ANS: A, E, B, C, D DIF: Cognitive Level: Comprehension REF: Page 31 TOP: Sexual Response KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 29 NURSINGTB.COM Chapter 03: Fetal Development MULTIPLE CHOICE 1. Whatisthe total number of chromosomes contained in amature sperm or ovum? a. 22 b. 23 c. 44 d. 46 ANS: B Gametes(sex chromosomes) contain 23 chromosomes. DIF: Cognitive Level: Knowledge REF: Page 33 TOP:Gametogenesis KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. A pregnant woman states, My husband hopesI will give him a boy because we have three girls. What willthe nurse explain to this woman? a. The sex chromosome of the fertilized ovumdeterminesthe gender of the child. b. When the sperm and ovum are united, there is a 75% chance the child will be a girl. c. When the pH of the female reproductive tract is acidic, the child will be a girl. d. If a sperm carrying a Y chromosome fertilizes an ovum,then a boy is produced. ANS: D When a Y-bearing sperm fertilizes an ovum, a male child is produced. DIF: Cognitive Level: Comprehension REF: Page 35 TOP: Sex Determination KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and MainteNnaUnRc Se: INGGroTwBt .ChOanMd Development 3. Whatisthe most common site forfertilization? a. Lowersegment of the uterus b. Outer third of the fallopian tube near the ovary c. Upper portion of the uterus d. Area of the fallopian tube farthest from the ovary ANS: B Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary. DIF: Cognitive Level: Knowledge REF: Page 35 TOP: Fertilization KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 4. The embryo istermed a fetus at which stage of prenatal development? a. 2 weeks b. 4 weeks c. 9 weeks d. 16 weeks ANS: C The fetus(third stage of prenatal development) begins atthe ninth week and continues untilthe 40th week of gestation or until birth. DIF: Cognitive Level: Knowledge REF: Page 38 TOP: Prenatal Developmental Milestones KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 30 NURSINGTB.COM 5. The nurse isreviewing fetal circulation with a pregnant patient and explainsthat blood circulatesthrough theplacenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries ANS: A The umbilical vein transportsrichly oxygenated blood from the placenta to the fetus. DIF: Cognitive Level: Knowledge REF: Page 41 TOP: Fetal Circulation KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 6. Where isthe usual location for implantation of the zygote? a. Uppersection of the posterior uterine wall b. Lower portion of the uterus near the cervical os c. Innerthird of the fallopian tube near the uterus d. Lateral aspect of the uterine wall ANS: A The zygote usually implantsin the uppersection ofthe posterior uterine wall. DIF: Cognitive Level: Knowledge REF: Page 37 TOP: Implantation KEY:Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 7. Whatisthe embryonicmembrane that containsfingerlike projections on itssurface, which attach to theuterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis NURSINGTB.COM ANS: C The chorion is a thickmembrane with fingerlike projections(villi) on its outermostsurface. DIF: Cognitive Level: Knowledge REF: Page 37 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. Which hormone isresponsible for converting the endometriuminto decidual cellsforimplantation? a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone ANS: D At high levels, progesteronemaintainsthe endometrial lining forimplantation of the zygote. DIF: Cognitive Level: Knowledge REF: Page 41 TOP: Placenta KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 9. A patient asksthe nurse when her infants heart will begin to pump blood. What willthe nurse reply? a. By the end of week 3 b. Beginning in week 8 c. Atthe end of week 16 d. Beginning in week 24INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 31 NURSINGTB.COM ANS: A The fetal heart beginsto pump by week 3 of gestation. DIF: Cognitive Level: Knowledge REF: Page 38 TOP: Prenatal Development KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 10. What organ doesthe ductus venosusshunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs d. Kidneys ANS: A Fetal blood bypassesthe liverthrough the ductus venosus by carrying blood directly to the inferior vena cava. DIF: Cognitive Level: Knowledge REF: Page 41 TOP: Prenatal Development KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 11. What complication can resultfromuntreated respiratory distressin the newborn? a. Esophageal atresia b. Gastric dilation c. Cold stress d. Reopening ofthe foramen ovale ANS: D Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 42 TOP: Fetal Circulation KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 12. During an ultrasound, two amnions and two placentas are observed. What will be themost likely result ofthis pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High birth-weight twins ANS: A Dizygotic twins always have two amnions and two chorions(placentas). DIF: Cognitive Level: Comprehension REF: Page 44 TOP: Multifetal Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. A woman who is 25 weeks pregnant asksthe nurse what herfetuslookslike. What doesthe nurse explainis one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin thatis pink and smooth d. Eyesthat are closed ANS: A By 25 weeks, the body of the fetusis covered with lanugo,the eyes are open, the skin is wrinkled, and the fetushas definite periods of movement and sleeping.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 32 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 39 OBJ: 5 TOP: Prenatal Development KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. At what pointin prenatal development do the lungs begin to produce surfactant? a. 17 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: C During week 25,the alveoli begin to produce surfactant, which enablesthe alveolito stay open for adequate lung oxygenation to occur. DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 15. A womanmissed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test.Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen ANS: C Human chorionic gonadotropin isthe basisfor most pregnancy tests. Itis detectable inmaternal blood as soonas implantation occurs, usually 7 to 9 days after fertilization. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 41 TOP: Accessory Structures of Pregnancy KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. When preparing to teach a class about prenatal development,the nurse would include information aboutfolic acid supplementation. What is folic acid known to prevent? a. Congenital heart defects b. Neuraltube defects c. Mentalretardation d. Premature birth ANS: B Itis now known that folic acid supplements can prevent neural tube defectssuch asspina bifida. DIF: Cognitive Level: Comprehension REF: Page 39 TOP: Prenatal Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. The nurse is educating a class of expectant parents aboutfetal development. Whatis considered fetal age ofviability? a. 14 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: B By 20 weeks of gestation,the lungs havematured enough forthe fetusto survive outside the uterus(age of viability).INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 33 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 39 TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse is presenting a conference on gene dominance. What doesthe nurse report asthe percentage ofchildren carrying the dominant gene if one parent has a dominant gene and the other parent does not? a. 10% b. 25% c. 50% d. 100% ANS: C If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait. DIF: Cognitive Level: Comprehension REF: Page 36 TOP:Dominant Traits KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 19. The nurse explainsthatthe birth weight of monozygotic twinsisfrequently below average. Whatis themost likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequatematernal health d. Inadequate placental nutrition ANS: D The single placenta may not be able to provide adequate nutrition to two fetuses. DIF: Cognitive Level: Comprehension REF: Page 44 TOP: Low Birth-weight Twins KEY: NursingNPUroRcSeIsNsGSTteBp.:CIOmMplementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The school nurse is counseling a group of adolescent girls. What doesthe nurse explain about spermejaculated near the cervix? a. They are destroyed by the acidic pH of the vagina. b. They survive up to 5 days and can cause pregnancy. c. They lose theirmotility in about 12 hours after intercourse. d. They are usually pushed out of the vagina by themuscular action of the vaginal wall. ANS: B Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation. DIF: Cognitive Level: Comprehension REF: Page 35 TOP: Fertilization KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 21. What doesthe nurse explain can affectthe survival of the X- and Y-bearing sperm after intercourse? a. Age b. Estrogen level c. Body temperature d. Level of feminine hygiene ANS: B Estrogen levels and the pH of the female reproductive tract can affect the survival of the X- and Y-bearing sperm as well as their motility. DIF: Cognitive Level: Knowledge REF: Page 35 TOP: Fertilization KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 34 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 35 NURSINGTB.COM 22. Of whatisthe normal umbilical cord comprised? a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus ANS: C The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus. DIF: Cognitive Level: Knowledge REF: Page 41 TOP: Fetal Circulation KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 23. What part of the fetal body derivesfrom the mesoderm? a. Nails b. Oil glands c. Muscles d. Lining of the bladder ANS: C Themesoderm isresponsible forthe development of muscles. Nails and oil glands derive from the ectoderm. The lining of the bladder derives from the endoderm. DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 4 TOP: Embryonic development KEY: Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 24. A couple justlearned they are expecting their first child and are curiousif they are having a boy or a girl.At what point of development can the couple fNirUstReSxINpeGcTt Bto.CseOeMthe sex of their child on ultrasound? a. 4 weeks gestational age b. 6 weeks gestational age c. 10 weeks gestational age d. 16 weeks gestational age ANS: C The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound examination. DIF: Cognitive Level: Knowledge REF: Page 39 TOP: Fetal Development KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 25. A nurse isteaching a lesson on fetal development to a class of high schoolstudents and explains theprimary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm ANS: A, B, C The zygote transformsits embryonic disc into three layers: the ectoderm,the mesoderm, and the endoderm. DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 4 TOP: Primary Germ Layers KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 36 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 26. What are the functions of amniotic fluid? (Select allthat apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetalskin d. Acting as a reservoirfor nutrients e. Acting as a cushion for the fetus ANS: A, E The amniotic fluid providesmaintenance of even temperature; prevents amnion fromadhering to fetalskin; allows buoyancy,symmetrical growth, and fetal movement; and acts as a cushion forthe fetus. Although the fetus does swallow amniotic fluid, it has no nutritional value. DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 6 TOP: Amniotic Fluid KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 27. A patient atthe obstetric office hasjustlearned she is pregnant with dizygotic twins. Whatfacts will thenurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twinsshare a placenta. c. Dizygotic pregnanciestend to repeatin families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases withmaternal age. ANS: C, D Dizygotic twinstend to repeatin families and have separate chorions. They can be the same sex or different sexes and have their own placenta. Incidence iNnUcrReSasINesGwTiBth.CmOaMternal age. DIF: Cognitive Level: Comprehension REF: Page 44 TOP:Dizygotic Twins KEY:Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 28. The nurse explainsthat priorto fertilization each cell isreduced from 46 chromosomesto 23 chromosomesThisisreferred to as the number. ANS: haploid When each cellreducesits chromosomesfrom 46 to 23, itis called the haploid number. DIF: Cognitive Level: Knowledge REF: Page 34 TOP:HaploidNumber KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 29. The component of developmentthat programsthe genetic code into the nucleus of the cell is . ANS: DNA TheDNA programsthe genetic code to the nucleus of the cellto be replicated. DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 4 TOP: DNA KEY: Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 37 NURSINGTB.COM 30. The vessels comprising the umbilical cord are cushioned and protected by a substance called . ANS: Whartonsjelly Whartonsjelly is a substance in the umbilical cord that cushions and protectsthe vessels. DIF: Cognitive Level: Knowledge REF: Page 41 TOP: Fetal Circulation KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. The normal volume of amniotic fluid is approximately mL at 37 weeks gestation. ANS: 1000 The volume of amniotic fluid steadily increasesfromabout 30 mL at 10 weeks of pregnancy to 350 mL at 20 weeks. The volume of fluid is about 1000 mL at 37 weeks. In the latter part of pregnancy the fetus may swallow up to 400 mL of amniotic fluid per day and normally excretes urine into the fluid. DIF: Cognitive Level: Knowledge REF: Page 37 TOP: Amniotic Fluid KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 32. Organize the developmentalstagesin the correct order. Put a comma and space between each answerchoice (a, b, c, d, etc.) a. Fetus b. Zygote c. Embryo d. Blastocyst e. Morula ANS: B, E, D, C, A NURSINGTB.COM The developmentfollowsthese stages:zygote,morula, blastocyst, embryo, and fetus. DIF: Cognitive Level: Comprehension REF: Page 36 TOP: Fetal Development KEY:Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 33. Putthe embryonic/fetal characteristicsin the correct order of occurrence fromweek 3 to week 36 ofgestation. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Subcutaneousfatis present. b. Bonemarrow forms blood cells. c. Spinal cord and brain appear. d. Skull and jaw ossify. e. Neuraltube closes. ANS: C, E, D, B, A Primitive spinal cord and brain appear at 3 weeks. Neural tube closes at 4 weeks. Skull and jaw ossify at 6 weeks. Spleen stopsforming blood cells and bone marrow takes over at 29 weeks. Subcutaneousfatis presentat 36 weeks. DIF: Cognitive Level: Comprehension REF: Page 37INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 38 NURSINGTB.COM OBJ: 5 TOP: Fetal Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 39 NURSINGTB.COM Chapter 04: Prenatal Care and Adaptations to Pregnancy MULTIPLE CHOICE 1. A woman who is 7 weeks pregnant tellsthe nurse that thisis not herfirst pregnancy. She has a 2-year-old son and had one previousspontaneous abortion. How would the nurse document the patients obstetric historyusing the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110 ANS: C Referto Box 4-1 in the textbook for the TPALM system of identifying gravida and para. DIF: Cognitive Level: Application REF: Page 51 OBJ: 1 TOP: Definition of Terms KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. A woman calls her health care providerto schedule prenatal visitsin an uncomplicated pregnancy. Howfrequently will the nurse assist the patient to schedule these appointments? a. Every 3 weeks untilthe 6th month, then every 2 weeks until delivery b. Every 4 weeks untilthe 7th month, after which appointments will becomemore frequent c. Monthly untilthe 8th month d. Every 2 to 3 weeksforthe entire pregnancy ANS: B Monthly visits are scheduled up to 28 weeks, and then visitsincrease to every 2 to 3 weeksthrough 36 weeks. From 36 weeks until delivery, visits are weekl Ny U. RSINGTB.COM DIF: Cognitive Level: Application REF: Page 49 TOP: Prenatal Visits KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 3. During the physical examination forthe first prenatal visit, itis noted that Chadwickssign is present. Whatis Chadwicks sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening ofthe areola and breast tenderness d. Palpation of the fetal outline ANS: A Chadwickssign isthe purplish or bluish discoloration of the cervix and vagina. DIF: Cognitive Level: Knowledge REF: Page 52 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Afterthe examination is completed,the patient asksthe nurse why Chadwickssign occurs duringpregnancy. What would the nurse explain as the cause of Chadwicks sign? a. Enlargement ofthe uterus b. Progesterone action on the breasts c. Increasing activity ofthe fetus d. Vascular congestion in the pelvic area ANS: DINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 40 NURSINGTB.COM Chadwickssign is caused by increased vascular congestion in the cervical and vaginal area.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 41 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 52 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse has explained physiological changesthat occur during pregnancy. Which statement indicates thatthe woman understands the information? a. Blood pressure goes up toward the end of pregnancy. b. My breathing will get deeper and a little faster. c. Ill notice a decreased pigmentation inmy skin. d. There will be a curvature in the upperspine area. ANS: B The pregnant woman breathesmore deeply, and herrespiratory rate may increase slightly. DIF: Cognitive Level: Comprehension REF: Page 55 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman reports that herlast normal menstrual period began on August 5, 2013. What isthis womansexpected delivery date using Ngeles rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014 ANS: C To determine the expected date of delivery, count backward 3 monthsfrom the first day of the lastmenstrual period, then add 7 days and change the year ifNnUecReSsIsNarGyT. B.COM DIF: Cognitive Level: Analysis REF: Page 51 OBJ: 5 TOP: Determining Estimated Date of DeliveryKEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 7. During the second prenatal visit,the nurse attemptsto locate the fetal heartbeat with an electronic Dopplerdevice. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks ANS: C The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device. DIF: Cognitive Level: Knowledge REF: Page 53 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. In a routine prenatal visit,the nurse examining a patient who is 37 weeks pregnant noticesthat the fetal heartrate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action? a. Ask if the patient hastaken a sedative. b. Notify the physician. c. Turn the patient to herrightside. d. Record the rate as a normal finding.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 42 NURSINGTB.COM ANS: D The FHR at term rangesfrom a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. Thisshould be recorded as normal. The FHR drops in the late stages of pregnancy. DIF: Cognitive Level: Application REF: Page 53 TOP: Assessing Fetal Heart Tone KEY: Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A womans prepregnant weightis determined to be average for her height. What willthe nurse advise thewoman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds ANS: C The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds. DIF: Cognitive Level: Knowledge REF: Page 60 TOP:Nutrition in Pregnancy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. When the nurse tells a pregnant woman thatshe needs 1200 mg of calcium daily during pregnancy, thewoman responds, I dont like milk. What dietary adjustments could the nurse recommend? a. Increase intake of organmeats. b. Eatmore green leafy vegetables. c. Choosemore fresh fruits, particularly citrusfruits. d. Includemolasses and whole-grain breadsin the diet. ANS: B NURSINGTB.COM For women who do notlikemilk, othersources of calciuminclude enriched cereals, legumes, nuts, dried fruits, green leafy vegetables, and canned salmon and sardines that contain bones. DIF: Cognitive Level: Application REF: Page 63 TOP:Nutrition for Pregnancy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A pregnant woman is experiencing nausea in the earlymorning. Whatrecommendations would the nurseoffer to alleviate this symptom? a. Eatthree well-balancedmeals per day and limitsnacks. b. Drink a full glass of fluid atthe beginning of each meal. c. Have crackers handy atthe bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets. ANS: C The nurse can recommend eating dry toast or crackers before getting out of bed in the morning to alleviate nausea during pregnancy. DIF: Cognitive Level: Application REF: Page 68 OBJ: 10 TOP: CommonDiscomfortsin Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The patient who is 28 weeks pregnantshows a 10-pound weight gain from 2 weeks ago. Whatisthe nursesinitial action? a. Assessfood intake. b. Weigh the patient again. c. Take the blood pressure. d. Notify the physician.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 43 NURSINGTB.COM ANS: C Themarked weight gainmay be an indication of gestational hypertension. The blood pressure should be assessed before notifying the physician. DIF: Cognitive Level: Application REF: Page 56 TOP: Gestational Hypertension KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. Whatfood can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables ANS: C Foodsrich inDHA are redmeat,flounder, halibut, and soybean and canola oil. Frying fish negatively altersthe DHA. DIF: Cognitive Level: Application REF: Page 58 TOP:Nutrition in Pregnancy KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. The nurse encourages adequate intake offolic acid for women of childbearing age before and duringpregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neuraltube defects NURSINGTB.COM ANS: D Folic acid can reduce the incidence of neuraltube defectssuch asspina bifida and anencephaly. DIF: Cognitive Level: Knowledge REF: Page 48 OBJ: 8 TOP: Nutrition for Pregnancy KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 15. A woman tellsthe nurse thatshe is quite sure she is pregnant. The nurse recognizes which as a positivesign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCGdetected in the urine d. Fetal heartbeat ANS: D Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner. DIF: Cognitive Level: Knowledge REF: Page 53 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. At herinitial prenatal visit a woman asks, When can I hearthe babys heartbeat? At what gestational agecan the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 44 NURSINGTB.COM a. 4 weeksINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 45 NURSINGTB.COM b. 12 weeks c. 18 weeks d. 24 weeks ANS: C The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy. DIF: Cognitive Level: Knowledge REF: Page 53 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. A woman pregnant forthe first time asksthe nurse, When will I begin to feel the baby move? What is thenurses best response? a. You may notice the baby moving around the 4th or 5th month. b. Quickening varies with every woman. c. Youll feelsomething by the end of the firsttrimester. d. The baby will be big enough for you to feel in your 8th month. ANS: A Quickening,fetal movementfelt by themother, isfirst perceived at 16 to 20 weeks of gestation. DIF: Cognitive Level: Knowledge REF: Page 52 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. A pregnant woman inquires about exercising during pregnancy. Whatinformation should the nurse includewhen planning to educate this woman? a. Exercise elevates the mothers temperature aNnUdRimSIpNroGvTeBs.fCeOtaMl circulation. b. Exercise increases catecholamines, which can prevent preterm labor. c. A regularschedule ofmoderate exercise during pregnancy is beneficial. d. Pregnant women should limit waterintake during exercise. ANS: C In general,moderate exercise several times a week, from the 8th week through delivery, is advised during pregnancy. DIF: Cognitive Level: Comprehension REF: Page 65 TOP: Exercise During Pregnancy KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. An ultrasound confirmsthat a 16-year-old girl is pregnant. How doesthe need for prenatal care andcounseling for adolescents different from other age populations? a. A pregnant adolescentis experiencing twomajor life transitions atthe same time. b. Adolescents who get pregnant aremore likely to have other chronic health problems. c. Adolescents are at greaterrisk formultifetal pregnancies. d. Atthis age, a pregnant adolescent will accept the nurses advice. ANS: A The pregnant adolescentmust cope with two of lifesmoststress-laden transitionssimultaneously: adolescenceand parenthood. DIF: Cognitive Level: Comprehension REF: Page 72 TOP: Psychological Adaptations to Pregnancy KEY:Nursing Process Step: Planning MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 20. At what age is a woman who becomes pregnant forthe firsttime described as an elderly primip?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 46 NURSINGTB.COM a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old ANS: D A woman over the age of 35 who becomes pregnant forthe first time is described as an elderly primip. DIF: Cognitive Level: Knowledge REF: Page 72 TOP: Elderly Primip KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physical Adaptation 21. The nurse explainsthatthe softening of the cervix and vagina is a probable sign of pregnancy. What is theappropriate term for this sign? a. Chadwicks b. Hegars c. McDonalds d. Goodells ANS: D Goodellssign is one of the probable signs of pregnancy and describes a softened cervix and vagina. DIF: Cognitive Level: Knowledge REF: Page 52 TOP:Goodells Sign KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physical Adaptation 22. When obtaining a prenatal history on a pregnant patient the nurse notes a family history ofsickle celldisease. Given thisinformation, what lab test can the nurse anticipate the physician will order? a. Endovaginal ultrasound b. Pap test c. Complete blood count d. Hemoglobin electrophoresis NURSINGTB.COM ANS: D Hemoglobin electrophoresisidentifies presence ofsickle celltrait or disease (in women of African or Mediterranean descent). It is ordered in the first trimester, if indicated. DIF: Cognitive Level: Comprehension REF: Page 49 OBJ: 3 TOP: Prenatal laboratory tests KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prenatal Care 23. A pregnant woman is attending hersecond postpartum visit. Prenatal lab work indicatesshe is not immuneto the rubella virus. What is the most appropriate nursing intervention? a. Provide the rubella vaccine as ordered by the physician immediately. b. Inform the woman she should receive the vaccine in the hospital after delivery. c. Hold all immunizations until 1month postpartum. d. Encourage the patient to decide whether or not to get the rubella vaccine prenatally. ANS: B The rubella vaccine is contraindicated during pregnancy. A woman should be instructed to avoid pregnancy forat least 1 month following rubella immunization. It is not necessary to hold all immunizations until 1 month postpartum. DIF: Cognitive Level: Application REF: Page 75 TOP: Immunizations KEY: Nursing Process Step: ImplementationMSC: NCLEX: Health Promotion and Maintenance: Prenatal Care 24. A woman who is 37 weeks pregnantreportsfeeling dizzy when lying on her back. What doesthe nurseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 47 NURSINGTB.COM explain asthe most likely cause of thissymptom? a. Supine hypotension syndrome b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition ANS: A Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occurif the woman lies on her back. Symptoms of supine hypotension syndrome include faintness, lightheadedness, dizziness, and agitation. DIF: Cognitive Level: Comprehension REF: Page 56 TOP: Physiological Changes KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Health Promotion and Maintenance: Prenatal Care MULTIPLE RESPONSE 25. A woman who is 36 weeks pregnant tellsthe nurse she plansto take a 12-hourflight to Hawaii. Whatwould the nurse recommend that the patient do during the flight? (Select all that apply.) a. Weartight-fitting clothing to promote venousreturn. b. Eat a largemeal before boarding the flight. c. Request a seat with greater leg room. d. Drink atleast 4 ounces of water every hour. e. Get up and walk around the plane frequently. ANS: C, D, E Because ofthe increase in clotting potential,the pregnant patientis prone to a thromboembolism. Adequate hydration, frequent position changes, and movement decrease the risk. DIF: Cognitive Level: Application REF: PageN6U7RSINGTB.COM TOP: Flight Precautions KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 26. The nurse cautionsthe patientthat, because of hormonal changesin late pregnancy,the pelvic joints relax.What does this result in? (Select all that apply.) a. Waddling gait b. Jointinstability c. Urinary frequency d. Back pain e. Aching in cervicalspine ANS: A, B A waddling gait and jointinstability are the only signsthatrelate to joint changes. The other discomforts are related to the enlarging uterus with its attendant weight. DIF: Cognitive Level: Comprehension REF: Page 58 TOP:Joint Changes KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. The nurse assessesthe progressfromthe announcementstage of fatherhood to the acceptance stage whenthe patient reports which actions by the father? (Select all that apply.) a. Goesfishing every afternoon b. Hasrevised hisfinancial plan c. Spendsleisure time with hisfriends d. Traded hissports carfor a sedan e. Helped select a crib ANS: B, D, E Active planning for an infantis an indication of the acceptance stage. Concentration on a hobby and spendingINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 48 NURSINGTB.COM time away fromhome are indicators of nonacceptance. DIF: Cognitive Level: Comprehension REF: Page 71 TOP: Stages of Fatherhood KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 28. What nursing interventions are appropriate forthe prenatal patientin terms of prenatal care? (Select all thatapply.) a. Offer nutritional counseling. b. Reinforce responsibility of parenthood. c. Reduce risk factors. d. Improve health practices. e. Make financial arrangementsfor delivery. ANS: A, B, C, D Nutritional counseling,reinforcing and discussing the responsibility of parenthood,reducing risk factorsfor the pregnant woman and the fetus, and improving health practices are all goals of prenatal care. DIF: Cognitive Level: Comprehension REF: Page 47 TOP:Goals of Prenatal Care KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 29. The nurse recognizes which behavior characteristic(s) of women in theirfirsttrimester of pregnancy?(Select all that apply.) a. Showing off hersonogram photos b. Ambivalence about pregnancy c. Emotional and labilemood d. Focusing on herinfant e. Fatigue ANS: A, B, C, E NURSINGTB.COM Showing off photos,feeling ambivalence aboutthe pregnancy,fragile emotions, and fatigue and sleepiness areall characteristic of behaviors seen in the first trimester. Women are not focused on their infant; they are focused on themselves and the physical changes they are experiencing. DIF: Cognitive Level: Comprehension REF: Page 70 TOP: Behaviors of First Trimester KEY:Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 30. The number of years betweenmenarche and the date of conception is known as age. ANS: gynecological Gynecological age is a term thatrefersto the number of years between the starting of the menses and the dateof conception. DIF: Cognitive Level: Comprehension REF: Page 64 TOP:Gynecological Age KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. The nurse remindsthe prenatal patientthatshe should add kcal to her daily intake to nourish thefetus. ANS: 300INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 49 NURSINGTB.COM The recommended dietary intake increase is 300 kcal a day. DIF: Cognitive Level: Comprehension REF: Page 62 TOP:Nutrition During Pregnancy KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 32. The patient confessesto eating crushed ice 10 or 12 times daily. The nurse assessesthis behavior as . ANS: pica Pica isthe craving and ingestion of nonfood substancessuch as clay, crushed ice, and ashes. DIF: Cognitive Level: Comprehension REF: Page 64 TOP: Pica KEY:Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 33. The nurse is aware that ANS: Leopolds maneuver can assessthe position and presentation of the fetus. Leopoldsmaneuver assessesthe position and the presentation of the fetus by palpation. DIF: Cognitive Level: Comprehension REF: Page 50 TOP: Leopolds Maneuver KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 34. Fathers go through phasessimilarto the expectant mother. Place the following phasesin orderfrom first tolast. Put a comma and space between each ansNwUeRr SchINoiGcTeB(a.C, bO,Mc, d, etc.) a. Focus phase b. Announcement phase c. Adjustment phase ANS: B, C, A Forfathers,the announcement phase begins when pregnancy is confirmed. The second phase of the fathers response isthe adjustment phase. The third phase of the fathersresponse isthe focus phase, in which active plansfor participation in the labor process, birth, and change in lifestyle result in the partner feeling like a father. DIF: Cognitive Level: Comprehension REF: Page 72 TOP: Impact on the Father KEY:Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Developmental Stages and TransitionsINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 50 NURSINGTB.COM Chapter 05: Nursing Care of Women with Complications DuringPregnancy MULTIPLE CHOICE 1. A pregnant patient tellsthe nurse thatshe has been nauseated and vomiting. How willthe nurse explain thathyperemesis gravidarum is distinguished from morning sickness? a. Hyperemesis gravidarum usually lastsforthe duration ofthe pregnancy. b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances. c. Sensitivity to smellsis usually the cause of vomiting in hyperemesis gravidarum. d. The woman with hyperemesis gravidarum will have persistent vomiting without weightloss. ANS: B Dehydration and electrolyte imbalancesresultfrom persistent nausea and vomiting associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta. DIF: Cognitive Level: Comprehension REF: Page 85 OBJ: 4 TOP: Hyperemesis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing sometissue. Cervical dilation is noted on examination. What isthe most likely cause of these symptoms? a. Inevitable abortion b. Incomplete abortion c. Complete abortion d. Missed abortion ANS: B NURSINGTB.COM Signs and symptoms of an incomplete abortion are similarto those of an inevitable abortion, butsome tissue is passed. DIF: Cognitive Level: Comprehension REF: Page 90 OBJ: 4 TOP: Incomplete Abortion KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse finds a woman crying aftershe has undergone a dilation and evacuation (D&E) for a missedabortion. What is the most appropriate statement by the nurse? a. There is usually something wrong with the fetus when this happens early in pregnancy. b. Now there. You can try to conceive on your next cycle. c. Im here if you need to talk. d. You are young and strong. I know you can have a healthy pregnancy. ANS: C An effective technique when communicating with a woman experiencing pregnancy lossisto say, Im here if you need to talk. The nurse listens and acknowledges the womans grief. DIF: Cognitive Level: Application REF: Page 91 TOP:Dilation and Evacuation (D&E) KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. A woman who is 8 weeks pregnant becomes concerned when she haslight vaginal bleeding accompanied byabdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statementindicatesthat the woman understands the explanation of an ectopic pregnancy? a. The chorionic villi develop vesicles within the uterus. b. The placenta developsin the lower part of the uterus. c. The fetus diesin the uterus during the first half of the pregnancy.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 51 NURSINGTB.COM d. The embryo isimplanted in the fallopian tube. ANS: D Ectopic pregnancy occurs when the fertilized ovum isimplanted outside of the uterine cavity. DIF: Cognitive Level: Comprehension REF: Page 92 TOP: Ectopic Pregnancy KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 5. An ultrasound on a woman who is 32 weeks pregnantrevealsthe placenta implanted overthe entire cervicalos. What does the nurse understand best describes this condition? a. Low-lying placenta b. Marginal placenta previa c. Partial placenta previa d. Total placenta previa ANS: D A total placenta previa describes a condition in which the placenta completely coversthe cervical opening. DIF: Cognitive Level: Comprehension REF: Page 94 TOP: Placenta Previa KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 6. Whatsymptom presented by a pregnant women isindicative of abruptio placentae? a. Painless vaginal bleeding b. Uterine irritability with contractions c. Vaginal bleeding and back pain d. Premature rupture ofmembranes ANS: C NURSINGTB.COM Bleeding accompanied by abdominal orlower back painis a typical manifestation of abruptio placentae. DIF: Cognitive Level: Knowledge REF: Page 95 TOP: Abruptio Placenta KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 7. Whatsituation would concern the nurse aboutthe presence of Rh incompatibility? a. Rh-negative mother, Rh-positive fetus b. Rh-positive mother, Rh-negative fetus c. Rh-negative mother, Rh-negative fetus d. Rh-positive mother, Rh-positive fetus ANS: A Rh incompatibility can occur only if the mother is Rh negative and the fetusis Rh positive. DIF: Cognitive Level: Analysis REF: Page 101 TOP: Rh Incompatibility KEY:Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. A primigravida in herfirsttrimesteris Rh negative. What willthis woman receive to prevent anti-Rh antibodies from forming? a. Rh immune globulin during labor b. Intrauterine transfusions withO-negative blood c. Rh immune globulin at 28 weeks and within 72 hours afterthe birth of an Rh-positive infant d. Rh immune globulin now and again in the last trimester ANS: C An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after the birth of an Rh-positive infant or abortion.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 52 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 101 TOP: Rh Incompatibility KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 9. A woman seeking prenatal care relates a history ofmacrosomic infants,two stillbirths, and polyhydramnioswith each pregnancy. What does the nurse recognize these factors highly suggest? a. Toxoplasmosis b. Abruptio placentae c. Hydatidiform mole d. Diabetesmellitus ANS: D Large (macrosomic) infants over 9 pounds are linked to gestational diabetes. DIF: Cognitive Level: Comprehension REF: Page 102 TOP:Diabetes Mellitus KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolismin what way? a. Placental hormonesincrease the resistance of cellsto insulin. b. Insulin cells cannotmeet the bodys demands asthe womans weightincreases. c. There is a decreased production ofinsulin during pregnancy. d. The speed ofinsulin breakdown is decreased during pregnancy. ANS: A Hormones and enzymes produced by the placenta increase the resistance of cellsto insulin. DIF: Cognitive Level: Knowledge REF: Page 102 TOP: Diabetes Mellitus KEY: Nursing ProcesNsUSRteSpI:NIGmTpBle.mCOenMtation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Why doesthe woman taking oral hypoglycemic agentsto control diabetes mellitus need to take insulinduring pregnancy? a. Insulin can crossthe placental barrier to the fetus. b. Insulin does not crossthe placental barrier to the fetus. c. Oral agents do not crossthe placenta. d. Oral agents are notsufficienttomeet maternal insulin needs. ANS: B Oral hypoglycemic agents are not used during pregnancy because they can crossthe placenta, possibly resulting in fetal birth defects or hypoglycemia. DIF: Cognitive Level: Comprehension REF: Page 103 OBJ: 5 TOP: Diabetes Mellitus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. A pregnant woman comesto the clinic stating thatshe has been exposed to hepatitis B. She is afraid thather infant will also contract hepatitis B. What will the nurse explain to this woman? a. The infant will be given a single dose of hepatitisimmune globulin after birth. b. The infant will be able to use the antibodiesfrom the immunizations given to the patient before delivery. c. The infant will not have hepatitis B because the virus does not passthrough the placental barrier. d. The infant will be immune to hepatitis B because of the mothersinfection. ANS: A The infant will be given immune globulin immediately after birth fortemporary immunity followed by hepatitis B vaccine. Immunization is not recommended for women who are pregnant.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 53 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 110 OBJ: 5 TOP: Hepatitis B KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 13. What willthe nurse begin with when asking a patient about drug use during a prenatal history? a. Do you smoke, drink alcohol, or use drugs? b. Do you ever use prescription orstreet drugs? c. What over-the-counter and prescription drugs have you taken in the past 3months? d. We need to know if you take drugsso we can help your baby. ANS: C Screening for drug use should begin in a nonthreatening way by asking about prescription and OTC medications and how the information can help provide safe and appropriate prenatal care. DIF: Cognitive Level: Application REF: Page 114 OBJ: 6 TOP: Interviewing Relative to Drug Use KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. The nurse assesses a pregnant woman for pregnancy-induced hypertension. Whatisthe firstsign of fluidretention suggestive of this complication? a. Abdominal enlargement b. Facialswelling c. Sudden weight gain d. Swelling of the feet and ankles ANS: C Sudden, excessive weight gain isthe firstsign of fluid retention;facialswelling and swelling ofthe feet, legs, and hands follow weight gain. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 97 TOP:Hypertension KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. A patient with gestational hypertension is exhibiting all ofthe signs below. Whatshould the nurse reportimmediately? a. Diarrhea b. Urticaria c. Blurred vision d. Backache ANS: C Visual disturbancesindicate worsening pregnancy-induced hypertension andmust be reported promptly for effective intervention to prevent preeclampsia and convulsion. DIF: Cognitive Level: Application REF: Page 97 TOP:Hypertension KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 16. A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the homehealth nurse make the first priority? a. Activity restriction b. Balanced nutrition c. Increased fluid intake to ensure adequate hydration d. Instruction aboutthe effect of diuretics ANS: A Bed restreducesthe flow of blood to skeletal muscles, making more blood available to the placenta and enhancing fetal oxygenation.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 54 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 98 TOP:Hypertension KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 17. The nurse is caring for a pregnant woman diagnosed with preeclampsia. What willthe nurse explain is theobjective of magnesium sulfate therapy for this patient? a. To prevent convulsions b. To promote diaphoresis c. To increase reflex irritability d. To act as a saline cathartic ANS: A Magnesium sulfate is a central nervoussystem depressant given to preventseizures. DIF: Cognitive Level: Knowledge REF: Page 98 TOP: Magnesium Sulfate KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 18. The nurse is caring for a pregnant woman receiving an intravenousinfusion withmagnesium sulfate. Whatis the most appropriate nursing intervention? a. Countrespirations and report a rate of lessthan 12 breaths/min. b. Countrespirations and report a rate ofmore than 20 breaths/min. c. Check blood pressure and report a rate of lessthan 100/60 mm Hg. d. Monitor urinary output and report a rate of lessthan 100mL/hr. ANS: A Excessive magnesium sulfatemay cause respiratory depression. DIF: Cognitive Level: Application REF: Page 99 OBJ: 4 TOP: Magnesium Sulfate KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 19. What drug willthe nurse plan to have available forimmediate IV administration whenever magnesiumsulfate is administered to a maternity patient? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline) ANS: C Calcium gluconate reversesthe effects ofmagnesium sulfate and should be available forimmediate use when a woman receives magnesium sulfate. DIF: Cognitive Level: Comprehension REF: Page 99 TOP: Calcium Gluconate KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 20. A woman who is 35 weeks pregnant has a total placenta previa. She asksthe nurse, Will I be able to delivervaginally? What explanation by the nurse is the most appropriate? a. Yes, you can deliver vaginally until 36 weeks. b. A vaginal delivery can be attempted, butif bleeding occurs, a cesarean section will be done. c. A cesarean section is performed when themother has a total placenta previa. d. There is no reason why you cannot have a vaginal delivery. ANS: C A cesarean delivery is done for a partial ortotal placenta previa. DIF: Cognitive Level: Application REF: Page 96INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 55 NURSINGTB.COM TOP: Placenta Previa KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse teaches a woman who is 8 weeks pregnant about how rubella can affectthe developing fetus.What can result from maternal rubella during pregnancy? a. Facial abnormalities b. Mentalretardation c. Liverfailure d. Limb deformities ANS: B Rubella can have devastating effects on the developing fetus. Some effects ofrubella on the embryo orfetus include microcephaly, mental retardation, cardiac defects, cataracts, and deafness. DIF: Cognitive Level: Knowledge REF: Page 110 TOP: Rubella KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. Whatsymptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis? a. Frequency and urgency of urination b. Nausea and weight loss c. Burning sensation when voiding d. Tendernessin the flank area ANS: D Pyelonephritisis a particularly seriousinfection in pregnancy. Signs and symptomsinclude high fever, chills, flank pain or tenderness, nausea, and vomiting. DIF: Cognitive Level: Comprehension REF: Page 113 TOP: Pyelonephritis KEY: Nursing Process SNteUp:RDSIaNtaGCToBl.lCecOtMion MSC: NCLEX: Physiological Integrity: Reduction of Risk 23. The nurse is caring for a prenatal patient diagnosed with a placenta previa. Whatisthe best position for thispatient? a. Flat on her back with kneesflexed to help prevent hemorrhage b. On herside to preventsupine hypotension c. In the semi-Fowlers position to preventsupine hypotension d. In the knee-chest position to reduce pressure on the placenta ANS: B The prenatal patient with placenta previa is best placed on herside with a pillow forsupport. This position not only reduces stress on the placenta but also reduces the possibility of supine hypotension. DIF: Cognitive Level: Application REF: Page 95 TOP: Placenta Previa KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 24. The young prenatal patient with gestational diabetesmellitus(GDM)says, I amfrightened thatI will haveto deal with insulin injections for the rest of my life. What is the best response by the nurse? a. After delivery your doctor will prescribe oral hypoglycemicmedication to control your disease. Pills are so much simpler than insulin injections. b. Have you considered an insulin pump? c. After a while those insulin injections wontseem so bad. d. It will most likely resolve 6 weeks orso after the baby is born. ANS: D GDM usually resolves by 6 weeks after delivery. DIF: Cognitive Level: Application REF: Page 103INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 56 NURSINGTB.COM TOP: GDM KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 25. The nurse is preparing a pregnant patientfor an abdominal ultrasound at 8 weeks gestation. Whatintervention will the nurse implement before this diagnostic test? a. Instruct the patient to take nothing by mouth aftermidnightthe night before the test. b. Initiate an IV. c. Encourage the patient to drink 1 to 2 quarts of water before the test. d. Instruct the patient to remove all jewelry. ANS: C Ultrasound uses high-frequency sound wavesto visualize structures within the body; the examinationmay usea transvaginal probe or an abdominaltransducer; abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination). DIF: Cognitive Level: Application REF: Page 86 OBJ: 2 TOP: Diagnostic Tests KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care MULTIPLE RESPONSE 26. The nurse is caring for amacrosomic newborn of a diabetic patient. What complications willthe nurseassess for in the newborn? (Select all that apply.) a. Meconium ileus b. Diarrhea c. Hypoglycemia d. Muscle tremors e. Urine retention ANS: C NURSINGTB.COM The fetus responds to the hyperglycemia from the mothers blood and produces increased insulin. This insulinmay cause hypoglycemia in the infant after it is no longer exposed to the mothers blood. DIF: Cognitive Level: Application REF: Page 103 OBJ: 5 TOP: Hypoglycemia in Macrosomic Infant KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 27. The nurse educates prenatal patients aboutthe threat of TORCH infections. Which infections are includedin this classification? (Select all that apply.) a. Toxoplasmosis b. Toxemia c. Cytomegalovirus d. Rubella e. Herpessimplex ANS: A, C, D, E The TORCH infections are toxoplasmosis,rubella, cytomegalovirus, and herpessimplex. DIF: Cognitive Level: Knowledge REF: Page 109 TOP: TORCH Infections KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 28. The nurse emphasizesto a patient with a high-risk pregnancy thatthe impact ofsuch a pregnancy mightresult in which problems? (Select all that apply.) a. Disruption offamily roles b. Financial pressures c. Excessive attachmentto infantINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 57 NURSINGTB.COM d. Frustration with activity restriction e. Alteration in child care practices ANS: A, B, D, E High-risk pregnanciesmay produce problemssuch as disruption offamily roles,financial pressures, delayed attachment to the infant, alteration in child care practices, and frustration with activity restriction. DIF: Cognitive Level: Comprehension REF: Page 118 TOP: Impact ofHigh-Risk Pregnancies KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 29. A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). Whatshould the ED nurse offer the patient? (Select all that apply.) a. Privacy b. An opportunity to hold the infant c. Materials aboutsupport groups d. A memento (footprint orlock of hair) e. A warm beverage ANS: A, B, C, D The patientshould be offered privacy, an opportunity to hold the infant,support group information, and a memento. A warm beverage is not a priority at this time. DIF: Cognitive Level: Application REF: Page 118 TOP: Stillborn Infant KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 30. What would the nurse include in a teaching plan forthe pregnant patient who hasiron deficiency anemiaand has been placed on iron supplements? (Select all that apply.) a. Citrusfruits enhance absorption of iron. b. Bran productssupportiron deficiency. c. Milk will disguise the taste of the iron. NURSINGTB.COM d. The iron therapy will continue for about 3 months. e. Tea should be avoided while taking iron. ANS: A, D, E Calcium, bran, and milk interfere with the absorption of iron. Vitamin C helps with the absorption of iron,the therapy usually lasts 3 months, and the tannic acid in tea does interfere with the absorption of iron. DIF: Cognitive Level: Application REF: Page 108 TOP: Iron Deficiency Anemia KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 31. The nurse takesinto consideration thatthe patient with placenta previa is atrisk for postpartum infectionfor what reasons? (Select all that apply.) a. Vaginal organisms can invade the placenta. b. The undernourished placenta becomes necrotic. c. The amniotic fluid can become infected. d. The placenta is an excellent growth medium. e. Themisplaced placenta weakensthe uterine wall. ANS: A, D Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the nutrient-rich environment ofthe placenta. The weakmusculature of the lowersegment of the uterus will causepostpartum hemorrhage rather than infection. DIF: Cognitive Level: Comprehension REF: Page 94 TOP: Infection with Placenta Previa KEY:Nursing Process Step: PlanningINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 58 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 59 NURSINGTB.COM 32. The nurse is obtaining history and physical information on a new patient attending herfirst prenatal visit. Afterrecording current height, weight, and BMI, itis determined thatthe patient is obese. What complicationsrelated to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH Incompatibility c. Hypertension d. Pre-eclampsia e. Infection ANS: A, C, D The obese woman who is pregnant has a high risk for developing complications during pregnancy such as gestational diabetes, hypertension, cardiac problems, pre-eclampsia, and respiratory problems. DIF: Cognitive Level: Comprehension REF: Page 109 TOP: Obesity KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection 33. A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she isbattered by her husband. She is assessed to havemultiple bruises at variousstages of healing. What nursingactions are appropriate for the nurse to implement? (Select all that apply.) a. Tellthe husband that authorities will be notified immediately. b. Provide privacy forthe assessment. c. Determine if children are being hurt. d. Communicate in a non-judgmental way. e. Determine factorsthatincrease the risk of injury. ANS: B, C, D, E The woman being assessed for abuse istaken to a private area. The nurse determines whether there are factorsthatincrease the risk forsevere injuries or homicide,such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abNuUseRrSoIuNtsGidTeBt .CheOhMome. The nurse also determines whether children are being hurt. It is vital thatthe abuser not find outthat the woman has reported the abuse orthatsheintends to leave. DIF: Cognitive Level: Application REF: Page 116 OBJ: 7 TOP: Battering KEY:Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Injury Prevention COMPLETION 34. The nurse cautions that the consumption of as few as alcoholic drink(s) during pregnancy can lead to the loss of fetal brain cells. ANS: two Studies have shown that even asfew astwo alcoholic drinks consumed during pregnancy can cause loss of fetal brain cells. A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of liquor. DIF: Cognitive Level: Comprehension REF: Page 116 OBJ: 5 TOP: Fetal Alcohol Syndrome KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 35. The nurse explainsthat is a procedure in which an incompetent cervix issutured closed toprevent its opening when the fetus presses against it. ANS: cerclageINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 60 NURSINGTB.COM Cerclage isthe procedure thatsuturesthe cervix closed to preventits opening when the fetus presses against it. DIF: Cognitive Level: Knowledge REF: Page 89 TOP: Cerclage KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 36. isthe leading cause of perinatal infections thahave a high mortality rate. ANS: Group B streptococcus(GBS) Group B streptococcus(GBS) is a leading cause of perinatal infectionsthat have a high neonatal mortality rate. The organism can be found in the womans rectum, vagina, cervix, throat, or skin. DIF: Cognitive Level: Knowledge REF: Page 112 TOP: Perinatal Infections KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Antepartum andNewborn Care 37. A(n) consists of a group of five fetal assessments: fetal heart rateand reactivity (theNST), fetal breathing movements,fetal bodymovements, fetal tone (closure of the hand), and volume of amniotic fluid. ANS: biophysical profile A biophysical profile consists of a group of five fetal assessments:fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amnioticfluid. DIF: Cognitive Level: Knowledge REF: PageN8U7 RSINGTB.COM OBJ: 2 TOP: Diagnostic tests KEY:Nursing Process Step:Data Collection MSC:NCLEX:Heath Promotion and Maintenance: Prenatal CareINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 61 NURSINGTB.COM Chapter 06: Nursing Care of Mother and Infant During Labor and Birth MULTIPLE CHOICE 1. What doesthe nurse note whenmeasuring the frequency of a laboring womans contractions? a. How long the patientstatesthe contractionslast b. The time between the end of one contraction and the beginning of the next c. The time between the beginning and the end of one contraction d. The time between the beginning of one contraction and the beginning of the next ANS: D The frequency of contractionsisthe elapsed time from the beginning of one contraction to the beginning of thenext contraction. DIF: Cognitive Level: Comprehension REF: Page 126 TOP: Frequency of Contractions KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Why isthe relaxation phase between contractionsimportant? a. The laboring woman needsto rest. b. The uterinemusclesfatigue withoutrelaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progressestoward delivery atthese times. ANS: C Blood flow fromthemotherinto the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus. DIF: Cognitive Level: Comprehension REF: Page 127 OBJ: 6 TOP: Interval KEY: Nursing Process SNtUepR: SNIN/AGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What contraction duration and interval doesthe nurse recognize could resultin fetal compromise? a. Duration shorterthan 30 seconds, interval longerthan 75 seconds b. Duration shorterthan 90 seconds, interval longerthan 120 seconds c. Duration longerthan 90 seconds, intervalshorter than 60 seconds d. Duration longerthan 60 seconds, intervalshorter than 90 seconds ANS: C Persistent contraction durationslongerthan 90 seconds or contraction intervalslessthan 60 secondsmay reduce fetal oxygen supply. DIF: Cognitive Level: Comprehension REF: Page 128 OBJ: 9 TOP: Contraction/Fetal Compromise KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 4. Vaginal examination revealsthe presenting partisthe infants head, which is well flexed on the chest. Whatis this presentation? a. Vertex b. Military c. Brow d. Face ANS: A In the vertex presentation, the fetal head isthe presenting part. The head isfully flexed on the chest. DIF: Cognitive Level: Comprehension REF: Page 128 OBJ: 9 TOP: Fetal PositionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 62 NURSINGTB.COM KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 5. What doesmeconium-stained amniotic fluid indicate when the infantisin a vertex presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in themother ANS: A Green-stained amniotic fluidmeansthatthe fetus passed the firststool before birth, and itis an indicator of fetal compromise. DIF: Cognitive Level: Comprehension REF: Page 143 TOP: Meconium-Stained Amniotic Fluid KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 6. Itis determined thatthe presenting part of the fetusisthe buttocks. At delivery the fetuss hips are flexed andthe knees are extended. How would the nurse record this presentation? a. Complete breech b. Frank breech c. Double footling d. Buttocks presentation ANS: B When a fetus presentsin a frank breech position,the legs are flexed atthe hips and extend toward the shoulders. DIF: Cognitive Level: Application REF: Page 129 OBJ: 9 TOP: Components of the Birth ProcesNs URSINGTB.COM KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 7. At a prenatal visit, a primigravida asksthe nurse how she will know herlabor hasstarted. The nurse knowsthat what indicates the beginning of true labor? a. Contractionsthat are relieved by walking b. Discomfortin the abdomen and groin c. A decrease in vaginal discharge d. Regular contractions becoming more frequent and intense ANS: D In true labor, contractions gradually develop a regular pattern and become more frequent, longer, andmore intense. DIF: Cognitive Level: Application REF: Page 137 OBJ: 7 TOP: Initiation of Labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. While discussing labor and delivery during a prenatal visit, a primigravida asksthe nurse when she shouldgo to the hospital. What is the nurses most informative response? a. When you feel increased fetal movement b. When contractions are 10 minutes apart c. When membranes have ruptured d. When abdominal or groin discomfort occurs ANS: C Rupturedmembranes are an indication thatthe woman should go to the hospital or birthing center.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 63 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 134 TOP: Admission to the Hospital or Birth Center KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 9. The nurse is caring for a woman in the firststage of labor. What will the nurse remind the patient aboutcontractions during this stage of labor? a. They getthe infant positioned for delivery. b. They push the infant into the vagina. c. They dilate and efface the cervix. d. They get the mother prepared for true labor. ANS: C The firststage of labor describesthe time from the onset of labor until full dilation of the cervix. DIF: Cognitive Level: Comprehension REF: Page 150 OBJ: 6 TOP: First Stage of Labor KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthingcoach and the nurse, what does the nurse assess as the most likely explanation for the womans change in behavior? a. Labor has progressed to the transition phase. b. She lacked adequate preparation forthe labor experience. c. The woman would benefitfrom a differentform of analgesia. d. The contractions have increased frommild tomoderate intensity. ANS: A If a woman suddenly loses control and becomNesUiRrrSitIaNbGleT,Bsu.CspOeMct that she has progressed to the transition stage of labor. DIF: Cognitive Level: Analysis REF: Page 150 OBJ: 6 TOP: Transition KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Whatisthe function of contractions during the second stage of labor? a. Align the infantinto the proper position for delivery b. Dilate and efface the cervix c. Push the infant out of the mothers body d. Separate the placenta from the uterine wall ANS: C The contractions push the infant out of the mothers body asthe second stage of labor ends with the birth of theinfant. DIF: Cognitive Level: Knowledge REF: Page 150 OBJ: 6 TOP: Second Stage of Labor KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 12. What marksthe end of the third stage of labor? a. Full cervical dilation b. Expulsion ofthe placenta andmembranes c. Birth of the infant d. Engagement of the head ANS: BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 64 NURSINGTB.COM The third stage of labor extendsfrom the birth of the infant untilthe placenta is detached and expelled.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 65 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 151 OBJ: 6 TOP: Third Stage of Labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Why should the nurse encourage the mother to void during the fourth stage of labor? a. A full bladder could interfere with cervical dilation. b. A full bladder could obstruct progress of the infant through the birth canal. c. A full bladder could obstructthe passage of the placenta. d. A full bladder could predispose the mother to uterine hemorrhage. ANS: D A full bladderimmediately after birth can cause excessive bleeding because it pushesthe uterus upward and interferes with contractions. DIF: Cognitive Level: Comprehension REF: Page 151 OBJ: 6 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 14. The nurse observesthe patient bearing down with contractions and crying out, The baby is coming! Whatis the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the womans partnerto locate a registered nurse. d. Assist with deep breathing to slow the labor process. ANS: B If birth appearsto be imminent,the nurse should notleave the woman and should summon help with the call bell. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 135 TOP: Imminent Birth KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse observes on the fetal monitor a pattern of a 15-beatincrease in the fetal heartrate thatlasts 15 to20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression ofthe umbilical cord c. Compression ofthe fetal head d. Uteroplacental insufficiency ANS: A Accelerationsin the fetal heartrate suggestthat the fetusis well oxygenated. DIF: Cognitive Level: Analysis REF: Page 141 TOP: Fetal Accelerations KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Physiological Adaptation 16. Whatisthe most appropriate statement from the nurse when coaching the laboring woman with a fullydilated cervix to push? a. Atthe beginning of a contraction, hold your breath and push for 10 seconds. b. Take a deep breath and push between contractions. c. Begin pushing when a contraction starts and continue forthe duration of the contraction. d. Atthe beginning of a contraction,take two deep breaths and push with the second exhalation. ANS: D When the cervix isfully dilated,the woman should take a deep breath and exhale atthe beginning of aINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 66 NURSINGTB.COM contraction, and then take another deep breath and push while exhaling.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 67 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 148 TOP: Instructionsfor Pushing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. Whatisthe most important nursing intervention during the fourth stage oflabor? a. Monitorthe frequency and intensity of contractions. b. Provide comfort measures. c. Assessfor hemorrhage. d. Promote bonding. ANS: C Immediately after giving birth, every woman is assessed forsigns of hemorrhage. DIF: Cognitive Level: Comprehension REF: Page 153 TOP: Postdelivery Hemorrhage KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 18. One hour postdelivery the nurse notesthe newmother hassaturated three perineal pads. Whatisthe mostappropriate nursing action? a. Check the fundusfor position and firmness. b. Reportto the doctor immediately. c. Change the pads and chartthe time. d. Time how long ittakesto soak one pad. ANS: A Increased lochiamay indicate hemorrhage. The fundus should be assessed forfirmness. One pad an hour is an acceptable rate for immediate postdelivery. DIF: Cognitive Level: Application REF: Page 153 TOP: Nursing Postdelivery Hemorrhage KEYN: UNRurSsIiNngGTPBro.CceOsMs Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. While caring for a laboring woman,the nurse notices a pattern of variable decelerationsin fetal heart ratewith uterine contractions. What is the nurses initial action? a. Stop the oxytocin infusion. b. Increase the intravenousflow rate. c. Reposition the woman on herside. d. Start oxygen via nasal cannula. ANS: C Repositioning the woman isthe firstresponse to a pattern of variable decelerations. Ifthe decelerations continue, then oxygen should be administered and/orthe flow rate of oxygen should be increased. DIF: Cognitive Level: Application REF: Page 142 OBJ: 9 TOP: Variable Decelerations KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 20. How should the nurse intervene to relieve perineal bruising and edema following delivery? a. Place an ice pack on the area for 12 hours. b. Place a warm pack on the perineal area for 24 hours. c. Administer aspirin to relieve inflammation. d. Change the perineal pad frequently. ANS: A An ice pack can be placed on the mothers perineum to reduce bruising and edema for 12 hoursfollowed by a warm pack after the first 12 to 24 hours after delivery. DIF: Cognitive Level: Application REF: Page 156INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 68 NURSINGTB.COM TOP: Ice Pack/Bruising KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. At 1 and 5 minutes of life, a newborns Apgarscore is 9. What doesthe nurse understand that a score of 9indicates? a. The newborn willrequire resuscitation. b. The newbornmay have physical disabilities. c. The newborn will have above average intelligence. d. The newborn isin stable condition. ANS: D Apgar scoring is a system for evaluating the infants need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highestscore being 10. A score of 9 indicates that the newborn is stable. DIF: Cognitive Level: Comprehension REF: Page 157 OBJ: 10 TOP: Care of the Infant After Birth KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. The husband of a woman in labor asks, What doesit mean when the baby is at minus 1 station? Aftergiving an explanation, whatstatement by the husband indicates that teaching was effective? a. Fetal head is above the ischialspines. b. Fetal head is below the ischialspines. c. Fetal head is engaged in themothers pelvis. d. Fetal head is visible atthe perineum. ANS: A Station describesthe level of the presenting partin the pelvis. Itis estimated in centimetersfrom the level ofthe ischial spines. Minus stations are above thNe UisRchSiIaNlGspTiBne.Cs.OM DIF: Cognitive Level: Comprehension REF: Page 132 OBJ: 1 TOP: Mechanisms of Labor KEY:Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse formulates a nursing diagnosisfor a woman in the fourth stage of labor. What isthe mostappropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fearrelated to the probable need for cesarean delivery. c. Dysuria related to prolonged labor and decreased intake. d. Risk forinjury related to hemorrhage. ANS: D In the fourth stage of labor, a priority nursing action isidentifying and preventing hemorrhage. DIF: Cognitive Level: Application REF: Page 153 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Nursing Diagnosis MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 24. The nurse is caring for a patient who is not certain ifshe isin true labor. How mightthe nurse attempt tostimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warmfluidsto drink b. By helping the patient to ambulate in the room c. By seating the patient uprightin a straight-back chair d. By positioning the patient on herrightINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 69 NURSINGTB.COM sideANS: BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 70 NURSINGTB.COM Ambulation willstimulate effacement and intensify contractionsifthe patientisin true labor. DIF: Cognitive Level: Application REF: Page 137 OBJ: 5 | 7 TOP: Differentiating Between True and False Labor KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 25. Whatisthe best nursing action to implement when late decelerations occur? a. Reposition the patient to supine b. Decrease flow ofintravenous(IV) fluids c. Increase oxygen to 10 L/minute d. Prepare to increase oxytocin drip ANS: C Themajor objective of care forlate decelerationsisto increasematernal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension. DIF: Cognitive Level: Application REF: Page 143 TOP: Late Decelerations KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 26. Whatisthe nurse primarily concerned aboutmaintaining in the initial care of the newborn? a. Fluid intake b. Feeding schedule c. Thermoregulation d. Parental bonding ANS: C Thermoregulation is necessary to keep heat loNssUmRiSnIiNmGaTl Ban.CdOoMxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia. DIF: Cognitive Level: Comprehension REF: Page 156 TOP: Thermoregulation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 27. A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. Whatisthe primary concern regarding complicationsforthis patient during laborand birth? a. Eclampsia b. Placental abruption c. Congestive heartfailure d. Uterine rupture ANS: D Nursing care for women who plan to have a VBAC issimilar to that for women who have had no cesarean births. The main concern isthatthe uterine scar willrupture, which can disrupt the placental blood flow and cause hemorrhage. Observation forsigns of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous cesarean birth. DIF: Cognitive Level: Comprehension REF: Page 149 TOP: VBAC KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 28. The physician performs an amniotomy on a laboring woman. What will be the nurses priority assessmentimmediately following this procedure? a. Fetal heartrate b. Fluid amount c. Maternal blood pressureINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 71 NURSINGTB.COM d. Deep tendon reflexes ANS: A The FHR should be assessed for at least 1 full minute after themembranesrupture and must be recorded and reported. Marked slowing ofthe rate or variable decelerationssuggeststhatthe fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amountshould be assessed and recorded butis not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes. DIF: Cognitive Level: Application REF: Page 143 TOP: Rupture of Membranes KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease MULTIPLE RESPONSE 29. While caring for an Arab woman in labor,the nurse should provide culturalsensitivity through whichinterventions? (Select all that apply.) a. Provide for extreme modesty. b. Assign amale caregiver. c. Arrange forthe husband/partner to participate in labor. d. Provide adequate pain control. e. Respect protective amulets. ANS: A, D, E Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and religious amulets. The husband isin attendance but not as a participant. Arabs preferfemale caregivers. If a male isin attendance, then the husband will remain in the room as long as the male is there. DIF: Cognitive Level: Application REF: Page 123 OBJ: 2 TOP: Cultural Considerations KEY:Nursing Process Step: Planning NURSINGTB.COM MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 30. What are the advantages of a freestanding birth center? (Select all that apply.) a. Home-like setting b. Designed for high-risk pregnancies c. Lower costs d. Attended by certified obstetricians e. Immediate emergency access ANS: A, C Advantages of a freestanding birth centerinclude a homelike setting and lower costs because the center doesnot require expensive departments such as emergency or critical care. Freestanding birth centers are not designed for high-risk patients, are not attended by certified obstetricians, and do not have immediate emergency access. DIF: Cognitive Level: Comprehension REF: Page 122 TOP: Free-Standing Birth Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 31. What do late decelerationsindicate? (Select allthat apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression ANS: A, B, CINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 72 NURSINGTB.COM This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. ProlongedINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 73 NURSINGTB.COM decelerations indicate cord compression and early decelerations indicate head compressions. DIF: Cognitive Level: Comprehension REF: Page 141 TOP: Late Decelerations KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 32. A pregnant woman arrives atthe emergency department(ED) and reportsshe isin labor. After a thoroughexamination and diagnostic testing, itis determined to be false (prodromal) labor. Whatsigns and symptoms would lead the nurse to suspect false (prodromal) labor? (Select all that apply.) a. Leaking of vaginal fluid b. Contractions intensify with ambulation c. Pink spotting d. Painlesstightening of abdominal muscles e. Cervix thick and not effaced ANS: D, E Painlesstightening of abdominal muscles(Braxton-Hicks contractions) and cervix thick and not effaced lend to the determination offalse (prodromal) labor. Leaking of vaginal fluidmay indicate rupture of membranes and is a sign of true labor. Contractionsthatintensify with ambulation and pink spotting (bloody show) are signs of true labor. DIF: Cognitive Level: Comprehension REF: Page 137 OBJ: 7 | 8 TOP: False Labor KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Health Promotion and Maintenance: Prenatal Care COMPLETION 33. Afterthe pregnant woman is admitted to the laborsuite, the nurse assessesthe position of the infant asROA; this meansthat the infants head is . ANS: right occiput anterior NURSINGTB.COM Right occiput anterior meansthat the infantsright occiputistoward the anterior aspect of themothers body. DIF: Cognitive Level: Knowledge REF: Page 131 OBJ: 9 TOP: Fetal Position KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 34. The nurse explainsthat the four Ps of the birth process are , , , and . ANS: powers, passenger, passage, psyche The fourinterrelated components of the process oflabor and birth, called the four Ps, are powers, passenger, passage, and psyche. DIF: Cognitive Level: Knowledge REF: Page 122 TOP: Four Ps of the Birth Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. Afterthe membranes have ruptured,the nurse should assessthe fetal heartrate (FHR) for minute(s). ANS: 1INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 74 NURSINGTB.COM The FHR is checked for 1 full minute to ensure that the infant is notin distressfrom cord compressionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 75 NURSINGTB.COM resultantfrom the lost buoyancy. DIF: Cognitive Level: Application REF: Page 143 TOP: Assessment After Membrane Rupture KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 36. The nurse may assistthe health care providerin determining the fetal position and presentation by abdominal palpations called . ANS: Leopoldsmaneuver The nursemay assistthe health care providerin determining the fetal position and presentation by abdominal palpations called Leopolds maneuver. DIF: Cognitive Level: Knowledge REF: Page 136 TOP: Leopolds Maneuver KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection 37. A nursing studentis observing prenatal examsin the office setting. The health care providerinforms thestudent thatthe fetal position is LSA. The student interpretsthis as a presentation. ANS: breech LSA isthe abbreviation for Left SacrumAnterior. Thisis a breech presentation. DIF: Cognitive Level: Comprehension REF: Page 131 OBJ: 6 TOP: Presentation KEY:Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and MainteNnaUnRc Se: INPGreTnBat .CalOCMare 38. Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor. Place the seven mechanisms oflabor in sequential order. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Extension b. Engagement c. Descent d. Flexion e. Expulsion f. Internal rotation g. Externalrotation ANS: C, B, D, F, A, G, E The process by which a normal vaginal delivery is accomplished requiresthe infanttomake the descent into the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled. DIF: Cognitive Level: Comprehension REF: Page 133 OBJ: 6 TOP: Mechanisms of Labor KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 76 NURSINGTB.COM Chapter 07: Nursing Management of Pain During Labor and Birth MULTIPLE CHOICE 1. A nurse isteaching a childbirth preparation class. The group is discussing individual expression oflabor pain. Whatstatement is accurate about a patients expression of pain? a. Itreducesthe patients perception of pain. b. Itisintensified by the vertex position of the fetus. c. Itisinfluenced by culture. d. It can be completely controlled by nonpharmacologicaltechniques. ANS: C Culture influences how women feel about birth and whatis an acceptable response to pain. DIF: Cognitive Level: Comprehension REF: Page 168 TOP: Cultural Influences on Pain KEY: Nursing Process Step:N/AMSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What chemicalsubstance(s) produced in the body acts as a natural pain reliever? a. Endorphins b. Morphine c. Codeine d. Atropine ANS: A Endorphins are natural body substancesthat are similartomorphine andmay explain why laboring women need smaller doses of analgesia. DIF: Cognitive Level: Knowledge REF: Page 167 TOP: Endorphins KEY: Nursing Process StepN: NUR/ASINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A nurse instructs a womanslabor coach to comfort her by firmly pressing on herlower back. What is thistechnique? a. Sacral pressure b. Distraction c. Effleurage d. Conscious relaxation ANS: A Sacral pressure refersto firmpressure againstthe lower back to relieve some ofthe pain of back labor. DIF: Cognitive Level: Knowledge REF: Page 167 OBJ: 6 TOP: Nonpharmacological Pain ManagementKEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 4. A woman who is 6 cm dilated hasthe urge to push. What will the nurse instruct the woman to do during thecontraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing. ANS: C If a laboring woman feelsthe urge to push before the cervix isfully dilated,then she istaught to blow in short breaths to avoid bearing down. DIF: Cognitive Level: Application REF: Page 170INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 77 NURSINGTB.COM TOP: Stair-Step Breathing Pattern KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Several hoursinto labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth.What does the nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation ANS: D Hyperventilation issometimes a problem if a woman is breathing rapidly. DIF: Cognitive Level: Comprehension REF: Page 171 OBJ: 4 TOP: Hyperventilation KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 6. Whatisthemost appropriate nursing action to take when a laboring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 liters via mask. d. Notify the doctor. ANS: A Measuresto combat hyperventilation include breathing into cupped hands or a paper bag or holding breath fora few seconds. All of these techniques decrease PCO2. DIF: Cognitive Level: Application REF: Page 171 OBJ: 4 TOP: Nonpharmacological Pain ManaNgeUmReSnINt GTB.COM KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 7. A woman in the transition phase of laborrequests a narcotic analgesicmedication for pain relief. Whatshould the nurse explain regarding giving a narcotic analgesic medication at this stage of labor? a. It can cause medication given at laterstagesto be ineffective. b. It will have no complicationsfor themother or infant. c. Itmay resultin respiratory depression to the newborn. d. It willspeed up labor and increase pain. ANS: C The risk of narcotic analgesicsisthatthey crossthe placenta and can cause fetalrespiratory depression. DIF: Cognitive Level: Comprehension REF: Page 171 OBJ: 7 TOP: Opioids KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 8. What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions? a. Offer warm liquidsto the patient. b. Encourage the patient to pant. c. Engage the patientin conversation. d. Assistthe patient to the knee-chest position. ANS: B Panting relaxesthe abdominal wall and distractsthe patient. It would not be helpfulto offerfluids or to attemptconversation during contractions. Walking intensifies contractions. DIF: Cognitive Level: Application REF: Page 170 TOP: Panting KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 78 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 9. A woman in labor willreceive general anesthesia priorto cesarean section. The nurse remindsthe patientthat food and fluids need to be restricted forseveral hours priorto delivery. What will this prevent? a. Nausea and vomiting b. Vomiting and aspiration c. Abdominal cramping d. Intestinal obstruction ANS: B Themajor adverse effect of general anesthesia is aspiration ofstomach contents. DIF: Cognitive Level: Comprehension REF: Page 173 OBJ: 7 TOP: General Anesthesia KEY:Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Reduction of Risk 10. What assessmentshould be taken immediately afterthe anesthesiologist administers an epidural block to alaboring woman? a. Bladderfor distention b. Blood pressure c. Sensation in the lower extremities d. Intravenousfluid flow rate ANS: B Blood pressure is checked every 5 minutes when the epidural block isfirst begun. Bladder assessmentis also important but not an initial assessment. DIF: Cognitive Level: Application REF: Page 173 OBJ: 6 TOP: Epidural Block KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Reduction of Risk 11. A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia? a. Reduced fetal heartrate b. Long, intense contractions c. Sudden leg cramps d. Bladder distention ANS: D A side effect of an epidural block is urine retention because the anesthesia interferes with the womans ability tohave an urge to void. The patient may have to be catheterized. DIF: Cognitive Level: Knowledge REF: Page 173 OBJ: 7 TOP: Epidural Block KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 12. Which narcotic antagonistis used to reverse narcotic-induced respiratory depression? a. Hydroxyzine (Vistaril) b. Phenobarbital c. Naloxone (Narcan) d. Nitrous oxide ANS: C Naloxone (Narcan) is used to reverse respiratory depression caused byINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 79 NURSINGTB.COM narcotics.DIF: Cognitive Level: Knowledge REF: Page 172INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 80 NURSINGTB.COM TOP:Narcotic Antagonist KEY:Nursing Process Step: N/A MSC:NCLEX: Physiological Integrity: Reduction of Risk 13. The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. Whatnursing action will be included in this plan to prevent the associated side effect of thistype of anesthesia? a. Restrict oral fluids. b. Keep legsflexed. c. Walk with assistance assoon as possible. d. Lie flat forseveral hours. ANS: D The woman would be advised to remain flatforseveral hours after the block to decrease the chance of postspinal headache. DIF: Cognitive Level: Application REF: Page 173 OBJ: 7 TOP: Subarachnoid Block KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Reduction of Risk 14. A woman requests a pudendal block to manage herlabor pain. Whatstatement by the woman indicates aneed for further explanation about the pudendal block? a. Imhaving a contraction. Can I get the pudendal block now? b. Ill get the pudendal block right before I deliver. c. The nurse midwife will insertthe needlesinto my vagina. d. Ittakes a few minutes after the medicine is administered tomake me feel numb. ANS: A The pudendal block does not block pain from contractions and is given just before birth. DIF: Cognitive Level: Comprehension REF: PNaUgeRS1I7N3GTB.COM OBJ: 7 TOP: Pudendal Block KEY:Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 15. An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, Please giveme somethingfor the pain. I cant take the pain! What is the priority nursing diagnosis? a. Pain related to uterine contractions b. Knowledge deficitrelated to the birth experience c. Ineffective coping related to inadequate preparation forlabor d. Risk forinjury related to lack of prenatal care ANS: A Themost important issue forthis woman, atthistime, is effective painmanagement. DIF: Cognitive Level: Analysis REF: Page 177 OBJ: 3 TOP: Pain as a Priority KEY:Nursing Process Step:Nursing Diagnosis MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 16. The nurse who encouragesthe gate control theory of pain control would advise a woman in labor and herpartner to use which nonpharmacological method of pain management? a. Slow abdominal breathing b. Guided relaxation c. Listening to music d. Massage ANS: DINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 81 NURSINGTB.COM According to the gate controltheory,stimulating large-diameter nerve fiberstemporarily interferes withINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 82 NURSINGTB.COM conduction ofimpulsesthrough small-diameterfibers. Massage is a technique thatstimulateslarge-diameter fibers and closes the gate. DIF: Cognitive Level: Analysis REF: Page 166 TOP:Gate Control KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 17. When a pregnant woman arrives atthe laborsuite,she tellsthe nurse thatshe wantsto have an epidural fordelivery. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous cesarean delivery c. History ofmigraine headaches d. History of diabetesmellitus ANS: A An epidural block is not used if a woman has abnormal blood clotting. DIF: Cognitive Level: Comprehension REF: Page 173 OBJ: 7 TOP: Epidural Block KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 18. The nurse coachesthe primigravida notto bear down untilthe cervix is completely dilated. What maypremature bearing down cause? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression ofthe cord ANS: B NURSINGTB.COM Bearing down against a cervix thatis not dilated can cause edema and laceration to the cervix. DIF: Cognitive Level: Comprehension REF: Page 170 TOP: Cervical Laceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. WhatistheDick-Readmethod of childbirth preparation based on? a. Mild sedation throughoutlabor b. Relaxation techniques c. Skin stimulation d. Deep massage ANS: B TheDick-Readmethod depends on the use ofrelaxation techniquesto reduce the discomforts of labor. DIF: Cognitive Level: Knowledge REF: Page 168 TOP: Dick-Read Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths perminute. Whatshould be the patientsrate while performing slow breathing? a. 9 b. 11 c. 15 d. 20 ANS: B The range ofrespirationsshould be no lower than half of the base rate and no more rapid than double theINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 83 NURSINGTB.COM baserate.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 84 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 167 OBJ: 5 TOP: Lamaze Method KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 21. Whatisthe least amount ofsensation that one perceives as pain? a. Tolerance b. Threshold c. Level d. Abatement ANS: B Pain threshold isthe least amount ofsensation that one perceives as pain. Thresholds are differentfor each individual. DIF: Cognitive Level: Knowledge REF: Page 166 TOP: Pain Threshold KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. The nurse is caring for a laboring patient who is notreporting pain. Whatsign would alert the nurse of theneed for pain relief? a. Frequently asking forice chips b. Facial grimacing c. Changing positionsin bed d. Covering herface with her hands ANS: B Facial grimacing may be an indicator of unexpressed pain. DIF: Cognitive Level: Comprehension REF: PNaUgeRS1I7N1GTB.COM TOP:Nonverbal Pain Expressing KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 23. A patient who received an epidural block asks why her blood pressure istaken so often. Whatisthe nursesbest response to explain the frequent blood pressure assessments? a. They ensure that unsafe levels of hypertension do not occur. b. They help assessfor the need for further pain relief. c. Theymonitor the progress of labor. d. They ensure adequate placental perfusion. ANS: D The hypotension that accompanies an epidural blockmay cause inadequate perfusion of the placenta, leadingto fetal hypoxia. DIF: Cognitive Level: Comprehension REF: Page 173 OBJ: 7 TOP: Disadvantage of Epidural Block KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 24. A laboring patientrequests hot and cold applications be applied to her abdomen for pain control. How willthis intervention act to control pain? a. By increasing endorphin production b. By facilitating effacement and dilation c. By producing increasing pain tolerance d. By stimulation oflarge nerve fibers ANS: D The gate controltheory explains how pain impulsesreach the brain forinterpretation. Itsupportsseveral nonpharmacological methods of pain control. According to thistheory, pain istransmitted through small-INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 85 NURSINGTB.COM diameter nerve fibers. However,the stimulation oflarge-diameter nerve fiberstemporarily interferes with the conduction of impulsesthrough small-diameterfibers. Techniquesto stimulate large-diameterfibers and closethe gate to painful impulsesinclude massage, palm and fingertip pressure, and heat and cold applications. DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 3 TOP: Nonpharmacological Pain Relief KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 25. When caring for the laboring patient, the nurse determinesthat the fetusislocated in the right occiputposterior (ROA). What will the nurse anticipate? a. Urinary retention b. Severe lower back pain c. A shorterlabor process d. Nausea ANS: B If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mothers sacrum, resulting in persistent and poorly relieved back pain (back labor). Laboris often longer with thisfetal position. DIF: Cognitive Level: Application REF: Page 168 TOP: Maternal Condition KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 26. Whattypicaltypes of classes are available to help expectant parents prepare for parenthood? (Select all thatapply.) a. Infant care b. Breastfeeding c. Gestational diabetes d. Sources offinancial aid e. Yoga NURSINGTB.COM ANS: A, B, C Prenatal classes include such topics as infant care, breastfeeding, gestational diabetes, exercising, and siblingand grandparent preparation. Yoga and financial information are nottraditional content for prenatal instruction DIF: Cognitive Level: Knowledge REF: Page 164 OBJ: 2 TOP: Prenatal Classes KEY:Nursing Process Step: Implementation MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 27. What breathing techniques would the nurse teach the prenatal patient to help herfocus during laborinorder to reduce pain? (Select all that apply.) a. Firststage breathing b. Abdominal breathing c. Fourth stage breathing d. Modified pace breathing e. Patterned paced breathing ANS: A, B, D, E Firststage breathing includesthe techniques ofmodified pace breathing and patterned paced breathing, whichare types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus and reduce pain perception. The fourth stage of labor is the womans recovery stage and does not require a breathing technique.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 86 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 170 TOP: Breathing Exercises KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 87 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 28. How doesthe pain of childbirth differfrom othertypes of pain? (Select allthat apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs narcotic relief. c. Position changesrelieve pain and facilitate delivery. d. Childbirth pain declinesfollowing birth. e. Childbirth pain isself-limited. ANS: A, C, D, E Childbirth pain differs from other types of pain because it is part of a normal, natural, and expected process,can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with narcotics in many cases. DIF: Cognitive Level: Comprehension REF: Page 166 TOP: Childbirth Pain KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 29. Which are nonpharmacological forms of pain relief? (Select allthat apply.) a. Skin stimulation b. Diversion and distraction c. Breathing techniques d. Exercise e. Yoga ANS: A, B, C Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain control. Although exercise and practices such as yoga and Pilates are beneficial, they are not means of pain control. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 167 OBJ: 5 TOP: Nonpharmacological Pain Control KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 30. Which position(s) and exercise(s) willthe nurse teach as beneficial in combating discomfort in the laterstages of pregnancy? (Select all that apply.) a. Leg lifts b. Pelvic rock c. Tailorsitting d. Sit-ups e. Shoulder curling ANS: B, C, E Pelvic rock, tailorsitting, and shoulder curling are beneficialto themusclesthat will have to adaptto the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial because they both increase intraabdominal pressure. DIF: Cognitive Level: Comprehension REF: Page 165 OBJ: 6 TOP: Helpful Exercises KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. The nurse is providing a conference on nonpharmacological pain control methods. What major advantagesof nonpharmacological pain control methods willthe nurse include in the presentation? (Select allthat apply.) a. They sedate themother. b. They do notslow labor. c. They do not dullthe excitement of the birth experience.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 88 NURSINGTB.COM d. They do not have the potentialto cause allergic reactions.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 89 NURSINGTB.COM e. They do not have to be delayed until laboris well established. ANS: B, C, D, E Allthe optionsmentioned are benefits of nonpharmacological pain control methods with the exception of sedating the mother. DIF: Cognitive Level: Knowledge REF: Page 168 TOP: Advantages of Nonpharmacological Pain ControlKEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 32. The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.) a. Assessleg movement and sensation before ambulating. b. Administer antibiotic as ordered. c. Observe forsigns ofimpending birth. d. Provide sacral pressure as needed. e. Assessfetal position frequently. ANS: A, C To preventthe risk forinjury related to epidural anesthesia the nurse should assesfor movement, sensation,and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positionsregularly, and observe forsignsthat birth may be near: increase in bloody show, perineal bulging,and/or crowning. DIF: Cognitive Level: Application REF: Page 179 TOP: Epidural Anesthesia KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk NURSINGTB.COM 33. The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to providepatient education. What will the nurse include in the educational plan? (Select all that apply.) a. Onset isslow. b. Duration isshort. c. Administration is bymouth. d. No known side effects. e. Itis not the same drug assufentanil. ANS: B, E Fentanyl has a rapid onset and short duration of action. Fentanyl,sufentanil, and alfentanil are notthe same drugs. Fentanyl can cause respiratory depression butlessthan meperidine. Itis not administered by mouth. DIF: Cognitive Level: Comprehension REF: Page 172 OBJ: 8 TOP: Narcotic Analgesia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of RiskCOMPLETION 34. The amount of pain a person is willing to endure isreferred to as . ANS: pain tolerance Pain tolerance isthe amount of pain a person is willing to endure. Pain threshold isthe point at which pain is perceived. Pain threshold isrelatively consistentfrom person to person, but pain tolerance differs greatly. DIF: Cognitive Level: Knowledge REF: Page 166 TOP: Pain Tolerance KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 90 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. Themassage technique thatstimulatesthe large-diameterfibersin order to block impulsesfromthe small-diameter fibersis . ANS: effleurage Effleurage stimulatesthe large-diameterfibers and blocksthe pain impulsesfromthe small-diameterfibers. DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 6 TOP: Effleurage KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 36. The , also called the psychoprophylactic method, isthe basis of mostchildbirth preparation classes in the United States. ANS: Lamazemethod The Lamazemethod, also called the psychoprophylacticmethod, isthe basis of most childbirth preparation classes in the United States. DIF: Cognitive Level: Knowledge REF: Page 168 TOP: Childbirth Preparation KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Basic Care and Comfort NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 91 NURSINGTB.COM Chapter 08: Nursing Care of Women with Complications During Laborand Birth MULTIPLE CHOICE 1. What nursing assessmentshould be reported immediately after an amniotomy? a. Fetal heartrate isregular at 154 beats/min. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternaltemperature is 37.8 C. ANS: C Amniotic fluid should be clear. Green fluid indicatesthe fetus has passed meconium, which is associated with fetal compromise. DIF: Cognitive Level: Application REF: Page 184 TOP: Obstetric ProceduresAmniotomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. A woman 2 weeks past her expected delivery date isreceiving an oxytocin infusion to induce labor andbegins to have contractions every 90 seconds. What is the nurses initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findingsto the physician. c. Turn her on herleftside and reassessthe contractions. d. Administer oxygen bymask. ANS: A Oxytocin is discontinued if signs of fetal compNrUomRS isIeNoGrTeBx. cCeOssMive uterine contractions occur. DIF: Cognitive Level: Application REF: Page 185 TOP: Obstetric ProceduresInduction of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. What nursing care should be provided to a woman with a third-degree laceration immediately after delivery? a. Warm compressesto the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hipsto prevent edema ANS: B Ice is applied to the perineum to reduce bruising and edema. DIF: Cognitive Level: Application REF: Page 188 TOP: Obstetric ProceduresLacerations KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 4. Afterseveral hours of labor, a nursing assessmentrevealsthat a womans cervix is 5 cm dilated butcontractions are becoming shorter and less frequent. What isthis labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False ANS: BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 92 NURSINGTB.COM The woman with labor dysfunction related to decreased uterinemuscle tone beginslabor normally, butINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 93 NURSINGTB.COM contractions diminish afterthe active phase. DIF: Cognitive Level: Comprehension REF: Page 195 OBJ: 5 TOP: Abnormal Labor KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A labor dysfunction due to decreased uterinemuscle tone occursin a patient who is dilated to 5 cm withmembranes intact. What action by the physician will the nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency cesarean section. ANS: A Medicaltreatmentfor hypotonic labor dysfunction includes an amniotomy as the firstremedy if the membranes are intact. DIF: Cognitive Level: Comprehension REF: Page 184 OBJ: 2 | 5 TOP: Abnormal Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 6. An infant is delivered with the use offorceps. Whatshould the nurse assessforin the newborn? a. Loss of hairfrom contact with forceps b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation ANS: C NURSINGTB.COM Pressure fromforcepsmay injure the infantsfacial nerve, which is evidenced by facial asymmetry. DIF: Cognitive Level: Application REF: Page 189 TOP: Obstetric ProceduresForceps Delivery KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 7. A newmotheris distressed and tearful aboutthe elevated dome over her infants posteriorfontanelle. Thenurse responds, This condition will resolve itself in a few days. What is the cause? a. Prolonged pressure againstthe partially dilated cervix b. Small leak offluid through the posterior fontanelle c. Pressure ofthe forceps during delivery d. The effect of the vacuum extractor ANS: D The chignon is due to the effect of the vacuum extractor and will disappearin a few days. DIF: Cognitive Level: Comprehension REF: Page 189 TOP: Chignon KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wontinduce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? Whatisthe lowest Bishop score the patientshould have prior to induction? a. 6 b. 8 c. 10 d. 12INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 94 NURSINGTB.COM ANS: A The Bishop score evaluatesthe suitability ofthe patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG). DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 2 TOP: Bishop Scoring for Vaginal Delivery KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 9. A woman is having a difficultlabor because the fetusis presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legssupported and give her a backmassage b. Supine with legs bent atthe knee c. Standing with support d. Sitting up and leaning forward on the over-bed table ANS: D A position that favorsfetal rotation and descent and thatis helpful forthe woman with back laboristo sit or kneel leaning forward on a support. DIF: Cognitive Level: Application REF: Page 197 OBJ: 7 TOP: Abnormal Labor KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 10. The initial vaginal examination of a woman admitted to the labor unitrevealsthatthe cervix is dilated 9 cm. The panicked woman begsthe nurse, Please giveme something. Whatisthemost appropriate pain reliefintervention for a woman in precipitate labor? a. Get an orderfor an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractionNsU. RSINGTB.COM d. Tell her to bear with it because she is close to delivery. ANS: C The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractionsto help the woman focus and cope with each contraction. DIF: Cognitive Level: Application REF: Page 199 OBJ: 6 TOP: Abnormal Labor KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance 11. A woman who is 33 weeks pregnantis admitted to the obstetric unit because hermembranes rupturedspontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism ANS: A Infection ofthe amniotic sac, called chorioamnionitis,may cause prematurely ruptured membranes, or it maybe a consequence of rupture because the barrier to the uterine cavity is broken. DIF: Cognitive Level: Application REF: Page 200 TOP: Premature Rupture of Membranes KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. The nurse is administering terbutaline (Brethine)to a pregnant woman to prevent preterm labor. The nursewould assess for which adverse effect? a. Maternal tachycardiaINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 95 NURSINGTB.COM b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia ANS: A Maternaltachycardia isthe common negative side effect of terbutaline, which should be corrected with a doseof propranolol. DIF: Cognitive Level: Comprehension REF: Page 201 TOP: Preterm Labor KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 13. Which statementindicates a woman understands activity limitationsforthemanagement of preterm labor? a. After my shower in the morning, I do the laundry and straighten up the house; then I rest. b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day. c. I have a 2-year-old to care for, but I try to rest as much asI can. d. I getreally bored at home,so I go to the shopping mall for just a little while. ANS: B Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest. DIF: Cognitive Level: Comprehension REF: Page 202 TOP: Preterm Labor KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. A student nurse questionsthe instructor regarding what alteration should be made for the assessment of thefundus of a new postoperative cesarean section patient. What is the best response? a. The fundusis not assessed until the second postoperative day. b. The fundus is assessed by walking fingers fNroUmRSthIeNGsiTdeB.oCfOthMe uterus to the midline. c. The fundusis assessed only if large clots appear in lochia. d. The fundusis assessed only once every shift. ANS: B Assessment ofthe fundusfollowing a cesarean section is done as usual, but using especially gentle fundal massage. DIF: Cognitive Level: Comprehension REF: Page 191 TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. A pulsating structure isfelt during a vaginal examination of a woman in labor. How would the nurseposition the woman to prevent compression of a prolapsed cord? a. On her rightside with kneesflexed b. On her leftside with a pillow placed between herlegs c. On her back with her head lower than the rest of her body d. Supine with herlegs elevated and bent atthe knee ANS: C The Trendelenburg (head down) position displacesthe fetus upward to stop compression of the prolapsed cord. DIF: Cognitive Level: Application REF: Page 203 TOP: Emergencies During ChildbirthProlapsed Umbilical Cord KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 16. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby isINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 96 NURSINGTB.COM beautiful, butI was planning on a vaginal delivery. Instead I needed an emergency C-section. Whatisthe mostappropriate nursing diagnosis?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 97 NURSINGTB.COM a. Anxiety related to the development of postpartumcomplications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk forineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience ANS: D Women who have cesarean births usually need greatersupportthan those who have vaginal births. They mayfeel grief, guilt, or anger because the expected course of birth did not occur. DIF: Cognitive Level: Application REF: Page 191 TOP: Cesarean Section KEY:Nursing Process Step:Nursing DiagnosisMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. A pregnant womansmembranesruptured prematurely at 34 weeks. She will be discharged to her home forthe next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her obstetrician ifshe has a temperature above 37.8 C (100 F). c. Massage her breaststo promote uterine relaxation. d. Restin a side-lying Trendelenburg position with hips elevated. ANS: B For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combinesinformation aboutinfection and preterm labor. The woman shouldmonitor her temperatureand report a temperature greater than 37.8 C (100 F). DIF: Cognitive Level: Application REF: Page 200 TOP: Premature Rupture of Membranes KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. A woman who is 24 weeks pregnant is plaNceUdRoSnINaGnTinBtr.CavOeMnous infusion of magnesium sulfate. What side effectshould the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency ANS: C Magnesium sulfate isthe drug of choice forinitiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug. DIF: Cognitive Level: Knowledge REF: Page 201 TOP: Preterm Labor KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity 19. When a woman is admitted to the labor and delivery unit,she tellsthe nurse thatshe is anxious aboutdelivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a womans pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greatermuscle tension ANS: B Excessive anxiety reduces uterine blood flow,making uterine contractionsless effective, and creates muscle tension that counteracts the expulsion powers of contractions. DIF: Cognitive Level: Comprehension REF: Page 199 TOP: Factors ThatInfluence Labor Pain KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Health Promotion and MaintenanceINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 98 NURSINGTB.COM 20. During a strenuouslabor,the woman asksforsome pain remedy forthe sudden pain between her scapulaethatseems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest thatthe coach give her a back rub. ANS: B Sudden pain between the scapulae during a strenuouslaboris an indicator of uterine rupture. Thisshould be reported immediately. DIF: Cognitive Level: Application REF: Page 203 TOP:Uterine Rupture KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 21. What doesthe nurse explain is used to soften the cervix with a cervicalripening agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation ANS: A Prostaglandin gel isinserted in the cervix and the woman remainsin bed for 1 to 2 hours, beingmonitored for uterine contractions. DIF: Cognitive Level: Knowledge REF: Page 183 TOP: Cervical Ripening KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 22. The nurse is caring for a patient who is thrNeaUtRenSiInNgGpTreBt.eCrOmMlabor and has been given glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow fromplacenta. d. Relax the cervix. ANS: B Glucocorticoids assist with improving the lung maturity of a fetusthatis preterm. DIF: Cognitive Level: Comprehension REF: Page 201 TOP: Fetal Lung Maturity KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse arrives atthe start of a shift on the labor unit to find a census of four patientsin active labor.Which laboring patientshould the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-oldmultigravida with history of previous cesarean section c. 35-year-oldmultigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy ANS: C A precipitate birth is completed in lessthan 3 hours. Labor often begins abruptly and intensifies quickly,rather than having amore subtle onset and gradual progression. Contractions may be frequent and intense, often fromthe onset. If the womanstissues do not yield easily to the powerful contractions,she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth. DIF: Cognitive Level: Analysis REF: Page 199 TOP: Precipitate Birth KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 99 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Reduction of Risk 24. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What willthe nurse expectwhen caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use offrequent position changes ANS: D A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor. DIF: Cognitive Level: Comprehension REF: Page 195 TOP:Hypotonic LaborDysfunction KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 25. Whatsign(s) ofinfection should the nurse assessfor after an amniotomy? (Select allthat apply.) a. Oral temperature of 37 C (99.8 F) b. Increase of fetal heartrate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain e. Edematouslabia ANS: B Increase in the FHR above 160 beats/minute frequently precedes a womanstemperature elevation. Allthe other options are normal findings for late pregNnUanRcSyI.NGTB.COM DIF: Cognitive Level: Application REF: Page 184 TOP: Postamniotomy Care KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 26. What are the rationalesforlabor induction? (Select allthat apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency ANS: D, E Maternal diabetes and placental insufficiency are rationalesforinduction. The other options are contraindications for labor induction. DIF: Cognitive Level: Comprehension REF: Page 183 TOP: Rationalesfor LaborInduction KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 27. Which interventions could a nurse apply to help stimulate contractions? (Select allthat apply.) a. Encouraging the patient to sit upright b. Assisting the patientto ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration ANS: A, B, C Sitting upright, ambulating, and stimulating the nipplesmay encourage progression oflabor. OfferingINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 100 NURSINGTB.COM emotionalsupport and allowing patientto vent frustration are supportive to the patient but do notstimulate more effective labor. DIF: Cognitive Level: Application REF: Page 185 TOP:Hypotonic Labor KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. What complications of overstimulation of uterine contractionsmay occur? (Select allthat apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture ANS: A, B, E Themost common complications are impaired placental exchange and uterine rupture, but waterintoxication can occur due to fluid retention. DIF: Cognitive Level: Comprehension REF: Page 186 TOP: Complication ofOxytocin KEY: Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Physiological Adaptation 29. Howmightthe nurse instruct the patient to stimulate her nipplesin an attemptto increase the quality ofuterine contractions? (Select all that apply.) a. Place a warm,moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Pressthe palms of her hands down on her breasts. NURSINGTB.COM ANS: B, C, D Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions. DIF: Cognitive Level: Application REF: Page 185 TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological Adaptation 30. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor atterm. Whatconditions would contraindicate labor induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal cesarean incision d. Prolapsed cord e. Gestational diabetes ANS: B, D Laborinduction is contraindicated with placenta previa or a prolapsed umbilical cord. Gynecoid pelvisisthe most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labor induction. DIF: Cognitive Level: Comprehension REF: Page 183 TOP: Induction KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 31. A woman is preparing for administration of a cervicalripening agent. What nursing actions willthe nurseanticipate implementing? (Select all that apply.) a. Insert IV.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 101 NURSINGTB.COM b. Record a baseline fetal heartrate. c. Explain procedure to patient. d. Instruct patientto ambulate immediately afterward. e. Ensure a tocolytic is available. ANS: A, B, C The cervicalripening procedure should be explained to the woman and her family. A fetal heartrate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics(drugsthatreduce uterine contractions) are needed. Afterinsertion of the prostaglandin gel,the woman remains on bed restfor 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded. DIF: Cognitive Level: Application REF: Page 183 OBJ: 3 TOP: Cervical Ripening KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies COMPLETION 32. After an amniotomy,the umbilical cord becomes compressed. The nurse preparesthe patientfor aninstillation of a bolus of warm sterile saline into the uterus, which is called . ANS: amnioinfusion A warm saline bolusisinstilled in the uterusto floatthe fetusto relieve pressure on the cord. DIF: Cognitive Level: Knowledge REF: Page 182 TOP: Amnioinfusion KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: ReducN tU io R n S o I fN RG i T sk B.COM 33. is a lower-than-normal amount of amniotic fluid. ANS: Oligohydramnios Oligohydramniosis a lower amountthan normal of amniotic fluid.DIF: Cognitive Level: Knowledge REF: Page 182 TOP: Amniotic Fluid KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Reduction of Risk 34. A(n) is a narrow cone inserted into the cervix to ripen the cervix to increase uterinecontractions. ANS: laminaria A laminaria is a narrow cone inserted in the cervix that dilates and ripensthe cervix asit absorbs water. DIF: Cognitive Level: Knowledge REF: Page 184 TOP: Laminaria KEY:Nursing Process Step:N/A MSC: NCLEX: Physiological Integrity: Pharmacological TherapiesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 102 NURSINGTB.COM Chapter 09: The Family After Birth MULTIPLE CHOICE 1. The nurse is assessing a newborn. Whatsign of hypoglycemia doesthe nurse record? a. Increased nasal mucus b. Increased temperature c. Activemusclemovements d. High-pitched cry ANS: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry. DIF: Cognitive Level: Comprehension REF: Page 228 TOP: Signs ofHypoglycemia KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 2. What would the nurse expectto find when assessing the fundus of the uterusimmediately after delivery? a. Well-contracted with its upper border at orjust below the umbilicus b. Well-contracted with its upper borderthree orfourfingerbreadths above the umbilicus c. Relaxed with its upper borderlevel with the umbilicus d. Relaxed with its upper bordertwo or three fingerbreadths below the umbilicus ANS: A Immediately afterthe placenta is expelled,the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus. DIF: Cognitive Level: Comprehension REF: Page 209 TOP: Fundus Assessment KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: PhysiNolUoRgi Sc IaNlGATdBap.CtaOtiMon 3. Whatstatementmade by a newmotherindicatesshe needs additional information about breastfeeding? a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast. b. The baby needsto nurse atleast 5 minutes on the breastto get the hindmilk. c. The baby has been nursing every 2 to 3 hours. d. If the baby getsfussy between feedings, I give her a bottle of water. ANS: D Supplemental feedings offormula or watershould not be offered to a healthy newborn who is breastfeeding. DIF: Cognitive Level: Comprehension REF: Page 232 OBJ: 14 TOP: BreastfeedingSupplemental Feedings KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After delivery,the nurses assessmentreveals a soft, boggy uteruslocated above the level of the umbilicus.What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measuresthat encourage voiding. d. Position the patientflat. ANS: B A poorly contracted uterusshould bemassaged until firmto prevent hemorrhage. DIF: Cognitive Level: Application REF: Page 211 TOP: Boggy Uterus KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 103 NURSINGTB.COM 5. Whattype of lochia willthe nurse assessinitially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis ANS: B The initial vaginal discharge after delivery is called lochia rubra. Itisred and moderately heavy. Lochia rubra lasts for up to 3 days postpartum. DIF: Cognitive Level: Knowledge REF: Page 211 TOP: Lochia Rubra KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching,the nursewould include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. Itis normal forthe lochia to have a slightly foul odor. c. A change in lochia from pink to brightred should be reported. d. A decrease in flow will be noticed with ambulation and activity. ANS: C A return to brightred lochia rubra may indicate a late postpartum hemorrhage and must be reported. DIF: Cognitive Level: Application REF: Page 212 TOP:Hemorrhage KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Whatinstruction should the nurse teach the postpartumwoman about perinealself-care? a. Perform perineal self-care at least twice a dNayU.RSINGTB.COM b. Cleanse with warm waterin a squeeze bottle from front to back. c. Remove perineal padsfromthe rectal area toward the vagina. d. Use cool water to decrease edema of the perineum. ANS: B Cleansing fromfrontto back prevents contamination from the rectal area. DIF: Cognitive Level: Application REF: Page 213 TOP: Perineal Care KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. A postpartum woman is notimmune to rubella. What willthe nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed notto get pregnant untilshe receivesthe rubella vaccine. d. No intervention isindicated atthistime because the woman is not atrisk forrubella. ANS: A The woman who is notimmune to rubella isimmunized in the immediate postpartum period because there isno danger of her being pregnant. DIF: Cognitive Level: Comprehension REF: Page 218 TOP: Rubella KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 9. Which statementindicatesthe newmotheris breastfeeding correctly? a. I will alternate breasts when feeding the baby. b. I keep the baby on a 4-hourfeeding schedule. c. I let the baby stay on the first breast only 5 minutes.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 104 NURSINGTB.COM d. I put only the nipple in the babys mouth when I am breastfeeding. ANS: A Alternating breastsforfeeding increasesmilk production, particularly hindmilk, which has a higher protein andfat content. DIF: Cognitive Level: Comprehension REF: Page 233 OBJ: 14 TOP: Breastfeeding KEY:Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is counseling a lactating mother about diet. What would the nurse include with thisinformation? a. Consume 500more caloriesthan her usual prepregnancy diet. b. Eatlessmeat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more caloriesthan her usual prepregnancy diet. ANS: A Tomaintain nutrientstores while breastfeeding,themother needs 500 additional calories each day over her prepregnancy diet. DIF: Cognitive Level: Comprehension REF: Page 239 TOP: BreastfeedingMaternal Nutrition KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A woman asks aboutresumption of hermenstrual cycle after childbirth. Whatshould the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2months postpartum. c. Generally, a woman does not ovulate in theNfiUrsRtSfIeNwGcTyBcl.CesOaMfter childbirth. d. The return of menstruation is delayed when a woman does not breastfeed. ANS: B Menstrual periodsresume in about 6 to 8 weeksifthe woman is not breastfeeding. DIF: Cognitive Level: Comprehension REF: Page 214 TOP: Return of Menses KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological Adaptation 12. In whatsituation willthe physician order RhoGAM? a. An unsensitized Rh-negativemother has an Rh-positive infant. b. An Rh-negativemother becomessensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs. ANS: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant. DIF: Cognitive Level: Analysis REF: Page 218 TOP: RhoGAM KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 13. After birth,the nurse quickly dries and wraps the newborn in a blanket. How doesthis action prevent heatloss? a. Conduction b. Radiation c. Evaporation d. ConvectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 105 NURSINGTB.COM ANS: C Newbornslose heat quickly after birth asfluid evaporatesfrom their bodies. DIF: Cognitive Level: Comprehension REF: Page 225 OBJ: 2 TOP: Thermoregulation KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What willthe nursesinstructionsfor a new mother to care forthe infants umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaperlow to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off ANS: C Diaper placement below the umbilicalstump allowsfor drying by air circulation. DIF: Cognitive Level: Application REF: Page 227 OBJ: 2 TOP: Umbilical Cord Care KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. A newmotherstates her preference to formula feed her newborn. What willthe nurse planning dischargeinstructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously forseveral days. b. Stand in a warmshower, letting the waterspray overthe breasts. c. Expresssmall amounts ofmilk from the breastsseveral times a day. d. Massage the breasts when they ache. ANS: A NURSINGTB.COM When amother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement. DIF: Cognitive Level: Application REF: Page 239 TOP: Suppression of Lactation KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 16. On the second postpartum day, a mother bathed her newborn forthe first time. She tellsthe nurse, I dont think I did itright. What postpartum psychologicalstage isthis woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down ANS: B In phase 2,taking hold,themother beginsto initiate action and becomesinterested in caring for the infant. In doing so, she may become critical of her performance. DIF: Cognitive Level: Analysis REF: Page 221 OBJ: 6 TOP: Postpartum Psychological Stages KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation 17. A primipara tellsthe nurse, My afterpains get worse when I ambreastfeeding. What isthe most appropriatenursing response? a. Ill get you some aspirin to relieve the cramping that you feel. b. Afterpains aremore intense with yourfirst baby. c. Breastfeeding releases a hormone that causes your uterusto contract.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 106 NURSINGTB.COM d. A change of position when youre breastfeeding might help.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 107 NURSINGTB.COM ANS: C Breastfeeding mothersmay havemore afterpains because infantsuckling causesthe posterior pituitary to release oxytocin, which is a hormone that contracts the uterus. DIF: Cognitive Level: Application REF: Page 210 TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. A newmother has decided not to breastfeed her newborn. Whatinformation willthe nurse include whenplanning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple isfull of formula during the entire feeding b. Heating the infantformula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding ANS: A The nipple of the bottle should be keptfull of formula to reduce the amount of airthe infantswallows. DIF: Cognitive Level: Comprehension REF: Page 241 OBJ: 17 TOP: Formula Feeding KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Reduction of Risk 19. In the recovery room,the nurse checksthe newly delivered womansfundusfollowing a cesarean section.How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate fromthe symphysisto the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion.NURSINGTB.COM ANS: C The fundusis checked gently by walking the fingersfrom the side of the uterusto the midline. DIF: Cognitive Level: Application REF: Page 218 TOP: PostpartumCesarean Assessment KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 20. The nurse instructed a postpartum woman aboutstoring and freezing breast milk. Whatstatement by thewoman leads the nurse to determine that the teaching was effective? a. I can thaw frozen breastmilk in the microwave. b. Ill put enough breast milk for one day in a container. c. Breastmilk can be stored in glass containers. d. Breast milk can be keptin the refrigerator for up to 3 months. ANS: C Breastmilk can be safely stored in glass or clear hard plastic containers. DIF: Cognitive Level: Comprehension REF: Page 238 TOP: Storing Breast Milk KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. Whatshould the nurse implementforsecurity purposes when bringing the infantfrom the nursery to themother? a. Ask, Isthis your band number? b. Confirm roomnumber of mother. c. Ask themother to identify herself verbally. d. Check the band number of the infant with that of the mother.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 108 NURSINGTB.COM ANS: D The nurse should check the band number of the infant with that of the mother by asking the mother to verballyread the number. DIF: Cognitive Level: Application REF: Page 225 OBJ: 8 TOP: Security Identification Procedure KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. Below what blood glucose level isthe newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL ANS: D A blood glucose level of lessthan 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infantshould be fed to prevent a further drop. DIF: Cognitive Level: Comprehension REF: Page 228 TOP: Hypoglycemia KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Reduction of Risk 23. The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicatesthatthe woman hasunderstood the provided instruction? a. Patient correctly performed return demonstration. b. Patientindicated understanding by nodding head with instruction. c. Patient verbalizesI understand. NURSINGTB.COM d. Family member indicates patient understands procedure. ANS: A The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to rememberthat an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign ofunderstanding or agreement. DIF: Cognitive Level: Application REF: Page 209 TOP: Cultural Influences KEY:Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Cultural Awareness 24. A woman has given birth to an unresponsive newborn thatNICU staff are attempting to revive. The patientand her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action? a. Contactthe hospital chaplain. b. Requestthe couples clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn. ANS: C Ifthe condition of a newborn is poor,the parents may wish to have a baptism performed. The minister or priestis notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infantsforehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. Ifthere is any doubt as to whether the infant is alive, the baptism is given conditionally: If you are INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 109 NURSINGTB.COM capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. The physician is attending to the patients immediate health needs.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 110 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 222 TOP:Grieving Parents KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Grief and Loss 25. A woman required a cesarean section forsafe delivery of her newborn. She is planning to breastfeed andverbalized concern about pain. What is the best suggestion by the nurse? a. Considerformula feeding forthe firstfew days. b. Pumping breast milk would be best for now. c. Take painmedication 30 to 40 minutes prior to nursing. d. Use the football hold when breastfeeding. ANS: D The best answer isto encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding. DIF: Cognitive Level: Application REF: Page 233 OBJ: 12 TOP: Breastfeeding KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 26. Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Selectall that apply.) a. Thin,transparentskin b. Vernix only in the body creases c. Folded earsprings back slowly d. Breasttissue under the nipple e. Creases over entire sole ANS: A, C NURSINGTB.COM The only signs of preterm are the thin skin and the slowly responding ear. DIF: Cognitive Level: Application REF: Page 226 TOP:Gestational Age Assessment KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth and Development 27. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventionsshould be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to waterstream. c. Coverinfusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability. ANS: B, C, D, E The patientshould be evaluated for ambulatory ability, and the abdominal dressing and infusion site should becovered with a waterproof cover. The patientshould be provided a shower chair and positioned with her back to the water stream. DIF: Cognitive Level: Application REF: Page 218 OBJ: 5 TOP: Postpartum Shower KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 28. What postpartumexercisesshould the nurse teach a patient who had a vaginal delivery yesterday? (Selectall that apply.)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 111 NURSINGTB.COM a. Abdominal tightenersINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 112 NURSINGTB.COM b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D Exercisesfor postpartuminvolution such as abdominaltighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period. DIF: Cognitive Level: Comprehension REF: Page 217 TOP: Postpartum Exercises KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. While instructing a newmother on formula preparations,the nurse would include what types? (Select allthat apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cowsmilk e. Canned evaporatedmilk ANS: A, B, C Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infantsneeds and powdered formula thatismixed as needed. Cowsmilk and canned evaporated milk are unsuitablebecause they are nutritionally inadequate and stress the kidneys. DIF: Cognitive Level: Comprehension REF: Page 240 TOP: Formula Choices KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 30. The nurse isinstructing a woman at 6months postpartum on weaning herinfantfrom breastfeeding. Whatinterventions will the nurse suggest? (Select all that apply.) a. Omit newbornsfavorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfortfeeding. d. Formula will need to be provided to substitute forfeeding. e. Pump breastsin place of eliminated feeding. ANS: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infantsformula will need to be substituted. Themothershould not be instructed to pump in place of eliminatedfeeding or the breasts will continue to produce milk. DIF: Cognitive Level: Comprehension REF: Page 239 TOP: Weaning KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 31. The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse woulddocument this as a(n) amount of lochia. ANS: moderate A 6-inch stain on a pad worn for 2 hoursisregarded as a moderate amount of lochia discharge. DIF: Cognitive Level: Application REF: Page 211INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 113 NURSINGTB.COM OBJ: 2 TOP: Estimating Lochia Discharge KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 32. The nurse explainsthatthe three infectionsthat are contraindicationsto breastfeeding are , , and . ANS: human immunodeficiency virus(HIV), hepatitis B, hepatitis C Mothers who areHIV positive should not breastfeed because the virus can be transmitted through breast milk,as can the viruses that cause hepatitis B and C. DIF: Cognitive Level: Comprehension REF: Page 231 TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 33. The hormone responsible for milk production is . ANS: prolactin During pregnancy,the woman secretes high levels of prolactin,the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation. DIF: Cognitive Level: Knowledge REF: Page 232 TOP: Prolactin KEY:Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 34. The hormone responsible for milk let-down or ejection from the breastsis . NURSINGTB.COM ANS: oxytocin Themilk let-down reflex is caused by the hormone oxytocin. DIF: Cognitive Level: Knowledge REF: Page 232 TOP:Oxytocin KEY:Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. refersto changesthatthe reproductive organs, particularly the uterus, undergo after birth toreturn to their prepregnancy size and condition. ANS: Involution Involution refersto changesthatthe reproductive organs, particularly the uterus, undergo after birth to return totheir prepregnancy size and condition. DIF: Cognitive Level: Knowledge REF: Page 209 TOP: Puerperium KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 114 NURSINGTB.COM Chapter 10: Nursing Care of Women with Complications After Birth MULTIPLE CHOICE 1. Whatisthe firstsign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output ANS: B Tachycardia is usually the firstsign of inadequate blood volume. DIF: Cognitive Level: Knowledge REF: Page 248 OBJ: 2 TOP: Hypovolemic Shock KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Although the nurse hasmassaged the uterus every 15 minutes, itremainsflaccid, and the patient continues topass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction ANS: A Atony describes a lack of normal muscle tone. If the uterusis atonic, then muscle fibers are flaccid and will not compress bleeding vessels. DIF: Cognitive Level: Comprehension REF: PNaUgeRS2I5N0GTB.COM TOP: Atony KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Whatshould the nursesfirst action be when postpartum hemorrhage from uterine atony issuspected? a. Teach the patient how tomassage the abdomen and then get help. b. StartIV fluidsto prevent hypovolemia and then notify the registered nurse. c. Beginmassaging the fundus while another person notifiesthe physician. d. Ask the patient to void and reassessfundal tone and location. ANS: C When the uterusis boggy, the nurse should immediately massage it until it becomesfirm. DIF: Cognitive Level: Application REF: Page 250 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. Whatshould the nurses next assessment be? a. Fullness ofthe bladder b. Amount of lochia c. Blood pressure d. Level of pain ANS: A Bladder distention can cause uterine atony. The uterusismassaged to firmness and then the bladderis emptied. DIF: Cognitive Level: Application REF: Page 251INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 115 NURSINGTB.COM TOP: Bladder Distention KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 116 NURSINGTB.COM 5. Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling aboggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfate c. Oxytocin d. Bromocriptine ANS: C Oxytocin (Pitocin) isthemost common drug ordered to control uterine atony. DIF: Cognitive Level: Comprehension REF: Page 251 TOP: Oxytocin (Pitocin) for Hemorrhage KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A 4-week postpartum patient with mastitis asksthe nurse ifshe can continue to breastfeed. Whatis thenurses most helpful response? a. Stop breastfeeding untilthe infection clears. b. Pump the breaststo continue milk production, but do not give breastmilk to the infant. c. Begin all feedings with the affected breast untilthemastitisisresolved. d. Breastfeeding can continue unlessthere is abscessformation. ANS: D The woman withmastitis can continue to breastfeed unless an abscessforms. DIF: Cognitive Level: Application REF: Page 256 TOP: Mastitis and Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 7. A woman had a vaginal delivery two days aNgUoRaSndINiGs TprBe.pCaOriMng for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability ANS: A Increased temperature is a sign of infection. The other choices are normal in the postpartum period. DIF: Cognitive Level: Application REF: Page 254 TOP: Puerperal Infections KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lowerleg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartumhemorrhage d. Mastitis ANS: A The complaintsrelated to the leg are indicative of phlebitis. The othersigns are normal in the postpartum patient. DIF: Cognitive Level: Analysis REF: Page 253 TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 117 NURSINGTB.COM 9. Which statement indicatesto the nurse on a postpartum home visitthatthe patient understandsthe signs oflate postpartum hemorrhage? a. My discharge would change to red after it has been pink or white. b. IfI have a postpartum hemorrhage, I will have severe abdominal pain. c. Ishould be alert for an increase in brightred blood. d. I would pass a large clotthat wasretained from the placenta. ANS: A When the nurse teachesthe postpartum woman about normal changesin lochia, itisimportant to explain that areturn to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage. DIF: Cognitive Level: Comprehension REF: Page 252 TOP: Color Change in Lochia KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain theprobable treatment will involve? a. Anticoagulantsfor 6 weeks b. Application ofice to the affected leg c. Gentlemassage ofthe affected leg d. Passive leg exercisestwice a day ANS: A Anticoagulanttherapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism. DIF: Cognitive Level: Analysis REF: Page 253 TOP: Anticoagulant Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: PharmNaUcRolSoIgNicGaTlBT.hCeOraMpies 11. Whatstatement by the patientleadsthe nurse to determine a woman with mastitis understands treatmentinstructions? a. I will apply cold compressesto the painful areas. b. I will take a warm shower before nursing the baby. c. I will nurse first on the affected side. d. I will empty the affected breast every 8 hours. ANS: B Moist heat promotes blood flow to the area, comfort, and complete emptying ofthe breast. DIF: Cognitive Level: Comprehension REF: Page 256 TOP: Mastitis KEY:Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 12. What isthe bestresponse to a postpartum woman who tellsthe nurse she feelstired and sick all of the timesince I had the baby 3 months ago? a. Thisis a normal response forthe body after pregnancy. Try to get more rest. b. Ill bet you willsnap out of thisfunk realsoon. c. Why dont you arrange for a babysitterso you and your husband can have a night out? d. Letstalk aboutthisfurther. I am concerned about how you are feeling. ANS: D If a postpartum woman seems depressed, itisimportantto explore herfeelingsto determine ifthey are persistent and pervasive. DIF: Cognitive Level: Application REF: Page 257 OBJ: 6 | 7 TOP:Depression KEY:Nursing Process Step: ImplementationMSC:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 118 NURSINGTB.COM NCLEX: Psychosocial Integrity: Psychosocial AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 119 NURSINGTB.COM 13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on bothlegs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sitin a chair for meals. b. Monitor vitalsigns every 4 hours and report any changes. c. Tellthe woman to remain in bed with herlegs elevated. d. Assistthe woman with ambulation forshort periods of time. ANS: D Early ambulation and range-of-motion exercises are valuable aidsto prevent thrombusformation in the postpartum woman. DIF: Cognitive Level: Application REF: Page 253 TOP: Thrombus Prevention KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. Five days after a spontaneous vaginal delivery, a woman comesto the emergency room because she has afever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis ANS: C Fever after 24 hoursfollowing delivery issuggestive of an infection. Severe cramping and fever are manifestations of endometritis. DIF: Cognitive Level: Analysis REF: Page 254 OBJ: 2 TOP: Puerperal Infections KEY: Nursing Process Step: Data Collection NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating.She feels guilty because sometimesshe believes her infant is dead. What does the nurse recognize as the causeof this womans symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression ANS: B Major depression is a disorder characterized by deep feelings of worthlessness, guilt,serioussleep and appetitedisturbances, and sometimes delusions about the infant being dead. DIF: Cognitive Level: Analysis REF: Page 257 TOP: Major Depression KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and nowthat she is here, I cant believe how different my life is from what I expected. What is the best nursing response to the womans statement? a. How is your partner adjusting to the change? b. I hear thisfrom a lot of first-time mothers. c. Have you told anyone else about yourfeelings? d. Tell me how things are different. ANS: D The nurse may help the woman by being a sympathetic listener. The nurse should elicitthe newmothersINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 120 NURSINGTB.COM feelings about motherhood and her infant.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 121 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 257 TOP:Disorders of Mood KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complicationshould the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments ANS: B Delivering a large infant and a prolonged labor are risk factorsfor hematoma formation. DIF: Cognitive Level: Analysis REF: Page 251 TOP:Hematoma KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 18. A woman has had persistentlochia rubra for 2 weeks after her delivery and is experiencing pelvicdiscomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterinemassage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy ANS: C Medicaltreatmentforsubinvolution isselected to correctthe cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall. DIF: Cognitive Level: Knowledge REF: PageN2U52RSINGTB.COM TOP: Subinvolution oftheUterus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The 1-day postpartumpatientshows a temperature elevation, cough, and slightshortness of breath onexertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upperrespiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature. ANS: B Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication. DIF: Cognitive Level: Application REF: Page 253 TOP: Pulmonary Embolus KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 20. While caring for a postpartum patient who had a vaginal delivery yesterday,the nurse assesses a firm uterine fundus and a trickle of bright blood. How doesthe nursemostlikely feel and react to this finding? a. Concerned and reports a probable cervical laceration b. Attentive andmassagesthe uterusto expelretained clots c. Distressed and reports a possible clotting disorder d. Satisfied with the normal early postpartumfinding ANS: A The bright trickle of blood with a firm uterussuggests a cervical laceration.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 122 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 251INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 123 NURSINGTB.COM TOP: Laceration KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse assesses a positive Homanssign when the patientsleg isflexed and footsharply dorsiflexed.Where does the patient report that the pain is felt? a. Groin b. Achillestendon c. Top of the foot d. Calf of the leg ANS: D A pain in the calf of the leg when the leg isflexed and the footis dorsiflexed is a positive Homanssign. Homans sign is suggestive of a deep vein thrombosis. DIF: Cognitive Level: Comprehension REF: Page 253 TOP:Homans Sign KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. The newmother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL.What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to putthe patientin isolation. c. Have the infantremoved from the room and returned to the nursery. d. Assessthe patient further. ANS: D The patientshould be assessed furtherfor othersigns ofinfection because a white blood cell (WBC) count of 20,000 to 30,000 cells/dL is normal in the early postpartum period. DIF: Cognitive Level: Analysis REF: Page 25N4URSINGTB.COM TOP: Elevated WBC KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. A postpartumpatient experiences anaphylactic shock. Whatisthemost likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder ANS: C Anaphylactic shock is caused by allergic responsesto drugs administered. Cardiogenic shock may be caused by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders. DIF: Cognitive Level: Comprehension REF: Page 247 TOP: Shock KEY:Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A woman is prescribed Coumadin (warfarin)to treat deep vein thrombosis. What willthe nurse instructthis woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K ANS: D The antidote for warfarin overdose is vitamin K. DIF: Cognitive Level: Knowledge REF: Page 253 TOP:Warfarin KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 124 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 25. A nurse is discussing risk factorsfor postpartum shock with a childbirth preparation class. What willthe nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage ANS: B, C, D, E Hypertension is not a cause for postpartum shock; allthe other options can cause shock. DIF: Cognitive Level: Application REF: Page 247 TOP: PostpartumShock KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 26. The nurse assessesthe perineal pad placed on a 3-hour postdelivery patient and findsthatthere is no lochiaon it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundusthe size of a grapefruit b. A full bladder c. Retained placental fragments d. Vitalsignsindicative ofshock e. A soft, boggy fundus ANS: B, E Large clotsthatform in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterusthatis boggy. NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 250 TOP: Cessation of Lochia KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 27. The nurse instructsthe postpartum patientthat her nutritional intake should include which food(s)particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrusfruits d. Rice e. Cantaloupe ANS: A, C, E Legumes and foods containing vitamin C are conducive to healing. Starches are not. DIF: Cognitive Level: Comprehension REF: Page 255 TOP: Foods Conducive toHealing KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. What will the nurse teach a nursing mother to do to reduce the risk ofmastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breaststo ensure emptying. ANS: B, C, D, EINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 125 NURSINGTB.COM Nursing mothersshould take in about 3 liters of fluid a day. Allthe other options are interventionsto reduceINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 126 NURSINGTB.COM the risk of mastitis and milk accumulation in the breast. DIF: Cognitive Level: Comprehension REF: Page 256 TOP: Reduction ofthe Risk of Mastitis KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 29. A woman is diagnosed with a urinary tractinfection in the postpartum period. What foods can the nurseencourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples ANS: A, B, C, D Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine. DIF: Cognitive Level: Comprehension REF: Page 254 OBJ: 4 TOP: Urinary Tract Infection KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 30. A postpartumpatientis experiencing hypovolemic shock. Whatinterventions can the nurse anticipate?(Select all that apply.) a. Provision ofIV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion ANS: A, B, C, E NURSINGTB.COM Medical managementforthe patient experiencing hypovolemic shock includesstopping blood loss, giving IV fluidstomaintain circulating volume and replace fluids, giving blood transfusionsto replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given. DIF: Cognitive Level: Application REF: Page 248 TOP:Hypovolemic Shock KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseCOMPLETION 31. The nurse weighs a saturated perineal pad and findsitto weigh 15 grams. The nurse is aware that thisindicates a blood loss of mL. ANS: 15 The weight of 1 g in a perineal pad is equal to 1 mL of blood loss. DIF: Cognitive Level: Comprehension REF: Page 248 TOP:Weighing Perineal Pad KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 32. The nurse explainsthat a slower than expected return ofthe uterus to the nonpregnantstate is called . ANS: subinvolutionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 127 NURSINGTB.COM Subinvolution isthe term applied to the uterussslower than expected return to a nonpregnantstate. DIF: Cognitive Level: Knowledge REF: Page 252 TOP: Subinvolution KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 33. A(n) is a collection of blood within the tissues. ANS: hematoma A hematoma is a collection of blood within the tissues. DIF: Cognitive Level: Knowledge REF: Page 251 TOP: Hematoma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 128 NURSINGTB.COM Chapter 11: The Nurses Role in Womens Health Care MULTIPLE CHOICE 1. The nurse is preparing a community education program on preventive health care for women. What commonscreening test will the nurse plan on explaining to the women attending the program? a. Breast examination by a health professional b. Breast self-examination c. Breast biopsy d. Mammography ANS: D Mammography is a screening test used to detect breast cancer. DIF: Cognitive Level: Comprehension REF: Page 260 TOP: Mammography KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. The nurse reviewsthe procedure for breastself-examination (BSE) with a 25-year-old woman who has a family history of breast cancer. When reviewing the procedure, when willthe nurse indicate asthe best timefor a woman to perform a breast self-examination? a. A few days before her period b. During hermenstrual period c. On the last day of menstrual flow d. One week after the beginning of her period ANS: D The best time for BSE is 1 week after the beginning of the menstrual period. DIF: Cognitive Level: Knowledge REF: PageN2U60RSINGTB.COM TOP: Breast Self-Exam KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 3. A woman asksthe nurse,How do oral contraceptives prevent pregnancy? What willthe nurse explain aboutthe combination of estrogen and progesterone in oral contraceptives? a. Makes cervical mucus hostile to sperm b. Prevents ovulation c. Prohibitsimplantation of the egg d. Acts as a barrier by destroying sperm ANS: B Oral contraceptives contain a combination of estrogen and progesterone thatsuppresses ovulation. DIF: Cognitive Level: Comprehension REF: Page 271 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 4. Whatshould a woman expect after insertion of an intrauterine device (IUD)? a. Menstrual flow will be lighter. b. Menstrual cramps will be eliminated. c. A string should be feltin the vagina. d. The device should be changed every 2 years. ANS: C A woman should feel forthe string periodically, especially after her period,to confirm the presence of the IUD. DIF: Cognitive Level: Comprehension REF: Page 273INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 129 NURSINGTB.COM TOP: IUDs KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 130 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Whatinformation willthe nurse provide when educating a woman aboutthe correct use of a diaphragm? a. Use of a spermicidal cream orjelly is notrecommended. b. Leave in place for atleast 6 hours afterintercourse. c. Remove immediately afterintercourse for douching. d. Itis effective for up to 48 hoursif positioned properly. ANS: B To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to 24 hours. DIF: Cognitive Level: Comprehension REF: Page 273 OBJ: 5 TOP: Diaphragm KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 6. The nurse is providing sexual education to a group of high schoolstudents. What willthe nurse explain isthe most effective choice of birth control for preventing pregnancy and sexually transmitted diseases? a. Abstain fromsex. b. Use themale condom. c. Use the female condom. d. Use the barriermethod. ANS: A Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases. DIF: Cognitive Level: Comprehension REF: Page 271 TOP: Abstinence KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease NURSINGTB.COM 7. On day 13 of a 28-day cycle, a womans basal body temperature is 36.5 C (97.7 F). What will her temperaturemeasurementmostlikely be if ovulation takes place on day 14?a. 35.9 C (96.7 F) b. 36.3 C (97.3 F) c. 36.7 C (98.1 F) d. 37.1 C (98.9 F) ANS: C Atthe time of ovulation, body temperature will increase slightly, about 0.2 C (0.4 F). DIF: Cognitive Level: Analysis REF: Page 270 TOP: Ovulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse tells a woman who istrying to conceive to check her cervical mucusfor changes. What willshe expect the characteristic of cervical mucus to be a few days before ovulation? a. Cloudy and tacky b. Scant and thick c. Thin and white d. Clear and slippery ANS: D Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage ofsperm into the cervix. DIF: Cognitive Level: Knowledge REF: Page 270 TOP: Ovulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 131 NURSINGTB.COM 9. The nurse is discussing cervical mucus changes with a woman who wishesto use natural family planning methods. What information about cervical mucus at ovulation will the woman indicate to the nurse, demonstrating that learning hastaken place? a. Cervical mucus enhancesthe motility of the sperm. b. Cervical mucus indicates endometrial readiness for implantation. c. Cervical mucusfacilitatesmovement ofthe ovum through the fallopian tube. d. Cervical mucus provides vaginal lubrication during intercourse. ANS: A Around the time of ovulation,the slippery, clear cervical mucus enhances themotility of the sperm. DIF: Cognitive Level: Comprehension REF: Page 270 TOP: Cervical Mucus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. In the week before hermenstrual period, a woman experiencesirritability, anxiety, and difficultyconcentrating. What remedy might the nurse suggest to relieve these symptoms? a. Drink tea or hot chocolate before going to bed. b. Take a daily folic acid and vitamin C supplement. c. Include complex carbohydrates and fiberin the diet. d. Avoid exercise when symptoms occur. ANS: C A dietrich in complex carbohydrates and fiberisrecommended for premenstrual dysmorphic disorder. DIF: Cognitive Level: Application REF: Page 263 TOP: Premenstrual Dysmorphic Disorder KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation NURSINGTB.COM 11. The nurse explainsthatthe drug clomiphene (Clomid) is used in infertility treatment. Whatisthe primaryaction of clomiphene (Clomid)? a. Induces ovulation b. Reduces endometriosis c. Promotesimplantation of a fertilized ovum d. Inhibits excess prolactin secretion ANS: A Clomiphene (Clomid) induces ovulation. Itmay also increase spermproduction, although thisis an unlabeled use. DIF: Cognitive Level: Knowledge REF: Page 281 TOP: Clomid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. At herregular gynecological examination, a woman tellsthe nurse thatshe is concerned aboutosteoporosis. Whatsuggestion can the nurse make to this patient? a. Take a vitamin E supplement daily. b. Do isometric exercisesthat can be practiced every day. c. Includemore dairy products and green, leafy vegetablesin her diet. d. Try to limit herintake of caffeine. ANS: C Foodsrich in calcium includemilk, dairy products, and green, leafy vegetables. DIF: Cognitive Level: Application REF: Page 284 TOP: Prevention of Osteoporosis KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 132 NURSINGTB.COM 13. A 48-year-old woman tellsthe nurse, I missedmy period last month. Am I inmenopause? The nurseknows that at which point is a woman considered to be menopausal? a. Her periods have stopped for 1 year. b. Her periods have been irregular and lightfor 12 months. c. She hassymptoms of vasomotor instability. d. She experiencessymptoms of decreased estrogen,such as dyspareunia. ANS: A When a womansmenstrual periods have stopped for 1 year,she is considered menopausal. DIF: Cognitive Level: Comprehension REF: Page 283 TOP: Menopause KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The nurse is planning to teach a woman about perimenopause. What would the nurse include regardinglowered estrogen level? a. It prevent osteoporosis. b. It decreases vaginal lubrication. c. Itraisesthe level of low-density lipoproteins. d. Itraisesthe level of high-density lipoproteins. ANS: C Estrogen increasesthe amount of high-density lipoproteinsthat carry cholesterol frombody cellsto the liver for excretion. With lowered levels of estrogen, low-density lipoproteinsincrease, causing an increase in the incidence of heart attacks and strokes. DIF: Cognitive Level: Knowledge REF: Page 283 TOP: Menopause KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation NURSINGTB.COM 15. Whatside effect would the nurse instruct a woman to look for when starting hormone replacement therapy(HRT)? a. Fatigue b. Headache c. Weightloss d. Amenorrhea ANS: B Patientsinitiating HRT are reminded to have regularfollow-up care and report headaches, vision changes, symptoms of thrombophlebitis, and cardiac symptoms. DIF: Cognitive Level: Comprehension REF: Page 284 TOP: HRT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What will the nurse advise when a woman asks whatshe can do to reduce the discomfort of hotflashes? a. Aerobic exercise helps control hot flashes. b. Increase the amount of calcium and vitamin D in your diet. c. Dressin layers of cotton clothing. d. Drink plenty offluids, particularly caffeinated beverages. ANS: C Cotton allows easier passage of air than synthetic fabrics. Layering allowsthe woman to take off or put on clothes when symptoms occur. DIF: Cognitive Level: Application REF: Page 285 OBJ: 8 TOP: Prevention of Hot Flashes KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 133 NURSINGTB.COM 17. Which statementmade by the nurse would teach an adolescent using tampons how to preventtoxic shocksyndrome (TSS)? a. Super-absorbency tampons are effective for overnight absorption. b. Tamponsshould be changed at least every 4 hours. c. Glovesshould be worn when changing tampons. d. TSS can be prevented by using a pad for the first 2 days of menstrual flow. ANS: B Tamponsshould be changed every 4 hours because a blood-soaked tampon is an excellent environmentfor bacteria. DIF: Cognitive Level: Comprehension REF: Page 264 TOP: TSS KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 18. Whatstatement by aman considering a vasectomy indicates a need for furtherinformation? a. Sterility does not occurimmediately afterthe procedure. b. We will need to use some form of birth control for about a month afterward. c. The procedure involvesthe use oflocal anesthesia. d. Ill need to remain in the hospital for a few days. ANS: D A vasectomy takes about 20minutes and is performed on an outpatient basis under local anesthesia. DIF: Cognitive Level: Analysis REF: Page 277 TOP: Vasectomy KEY:Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. At her 6-week postpartum checkup, a woman states, I am wondering about birth control. I used oral contraceptives before, and Im breastfeeding noNwU.RCSaINnGI TusBe.CthOeMpill again? What is the nurses best response? a. You should know that oral contraceptivesincrease your milk production. b. Oral contraceptives can be taken once lactation is well established. c. You dont need to use any form of birth control aslong as you are breastfeeding. d. Oral contraceptives are contraindicated forthe lactatingwoman. ANS: B Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established.Women who breastfeed their infants usually will not ovulate for 10 weeks and do not need contraception untilthat time. DIF: Cognitive Level: Application REF: Page 272 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. A 17-year-old girl comesto the emergency department complaining ofsevere pain in herleft lowerquadrant. An ovarian cyst is suspected. The nurse knows that what confirms this diagnosis? a. Laparotomy b. Oophorectomy c. Transvaginal ultrasound d. Hysteroscopy ANS: C Diagnosis of an ovarian cyst ismade by transvaginal ultrasound. DIF: Cognitive Level: Analysis REF: Page 287 TOP:Ovarian Cysts KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 21. A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 134 NURSINGTB.COM Physical assessmentrevealsinflammation ofthe vagina and vulva, and vaginal discharge has a cottage cheese appearance. With what are these findings consistent? a. Candidiasis b. Trichomoniasis c. Bacterial vaginosis d. Chlamydia ANS: A The signs and symptoms of candidiasisinclude inflammation of the vagina and vulva and a cottage cheese appearance to the vaginal discharge. DIF: Cognitive Level: Analysis REF: Page 266 OBJ: 4 TOP: Candidiasis KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. The nurse is providing an informationalsession on oral contraceptives. Which of the following decreaseeffectiveness of oral contraceptives? a. Antihistamines for seasonal allergies b. Iron preparationsfortreatment of anemia c. Appetite suppressantsfor weightreduction d. Anticonvulsantsfortreatment of epilepsy ANS: D Anticonvulsants decrease the effectiveness of oral contraceptives. DIF: Cognitive Level: Comprehension REF: Page 272 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse is instructing a man consideringNaUvRaSsIeNctGoTmBy..CWOMhat instruction will the nurse provide to address the postoperative time period? a. Intercourse should be delayed for 6 weeks. b. Sperm willstill be ejaculated for a month. c. Erections will be difficult to maintain. d. Monthly sperm countsfor a year will be necessary. ANS: B Because sperm are distal to the severed vas deferens,sperm will be in the ejaculate for about a month. A spermcount after that period of time should be performed to confirm the absence ofsperm. Intercourse does not have to be delayed, but an alternate method of contraception should be used. Erections and sexual pleasure are notaffected by a vasectomy. DIF: Cognitive Level: Comprehension REF: Page 277 TOP: Vasectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A woman diagnosed with endometriosisreports painful intercourse. Whatisthe appropriate medical termfor the nurse to document when describing this symptom? a. Dyspnea b. Dysmenorrhea c. Dyspareunia d. Dysrhythmia ANS: C Dyspareunia isthe term for painfulsexual intercourse. Dyspnea isshortness of breath. Dysmenorrhea is painful menstruation. Dysrhythmia is irregular heart rhythm. DIF: Cognitive Level: Knowledge REF: Page 263 TOP:Dyspareunia KEY:Nursing Process Step:Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 135 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. The nurse is educating a woman diagnosed with Premenstrual Dysphoric Disorder(PMDD). What isthe best type of diet for the nurse to recommend? a. High protein, low fat b. High carbohydrate, high fiber c. Low calorie, low fat d. Low carbohydrate, high protein ANS: B Treatment of PMDD includes a dietrich in complex carbohydrates and fiber(to lengthen effects of the carbohydrate meal). DIF: Cognitive Level: Application REF: Page 263 TOP: PMDD KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 26. The nurse instructs a woman taking oral contraceptivesto report which possible side effects? (Select allthat apply.) a. Abdominal pain b. Weight gain c. Headache d. Eye or visual problems e. Speech disturbances ANS: A, C, D, E Thememory aid ACHES is helpful: Abdominal pain, Chest pain, Headaches, Eye problems, Speech disturbances. Weight gain is an expected sideNefUfeRcStIoNfGoTraBl.CcoOnMtraceptives. DIF: Cognitive Level: Comprehension REF: Page 272 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 27. What are anonymoussperm donorsscreened for? (Select all that apply.) a. Particular physical features b. Genetic defects c. Infections d. High-risk behaviors e. Nationality ANS: B, C, D Sperm donors are screened for genetic defects, infections, and high-risk behaviors. As an added precaution, thesperm are kept frozen for 6 months before the sample is used. DIF: Cognitive Level: Comprehension REF: Page 281 TOP: Sperm Donors KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 28. The nurse cautionsthat women with a history of which disorders are not candidatesfor HRT? (Select allthat apply.) a. Melanoma b. Estrogen-dependent breast cancer c. Hepatitis C d. Thromboembolic disease e. Hyperthyroidism ANS: A, B, C, DINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 136 NURSINGTB.COM Persons who are absolutely restricted from HRT are those withmelanoma, estrogen-dependent breast cancers,chronic liver disorders, thromboembolic disease, and seizure disorders. DIF: Cognitive Level: Comprehension REF: Page 284 TOP: HRT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 29. The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gottenworse lately. The nurse remindsthe patientthat which food(s) and drug(s) can increase incontinence? (Selectall that apply.) a. Antihypertensive drugs b. Coffee c. Alcohol d. Diuretics e. NSAIDs ANS: A, B, C, D Foods and drugsthatincrease the symptoms of urge incontinence are antidepressants, angiotensin converting enzyme (ACE) inhibitors, caffeine, alcohol, and diuretics. NSAIDs do not increase incontinence. DIF: Cognitive Level: Application REF: Page 287 TOP: Urge Incontinence KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 30. Whatmightthe nurse advise the woman with pelvic floor dysfunction to do forrelief of the associateddiscomfort? (Select all that apply.) a. Lie down with feet elevated. b. Practice Kegel exercises. c. Assume knee-chest position periodically. d. Perform leg lift exercises. e. Prevent constipation. NURSINGTB.COM ANS: A, B, C, E Elevating the feet, performing Kegel exercises, assuming the knee-chest position, and preventing constipation will reduce the pelvic discomfort of pelvic floor dysfunction. DIF: Cognitive Level: Application REF: Page 286 TOP: Pelvic FloorDysfunction KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What informationwill the nurse provide when educating this patient on alendronate (Fosamax)? a. Drink 8 oz. of water following dosage. b. Lay down for 30 minutes after taking. c. Thismedication has no known side effects. d. Avoid weight-bearing exercises. ANS: A Alendronate (Fosamax) may be prescribed. Esophageal and gastric irritation are common side effects of alendronate, and the woman should be instructed to drink 8 ounces of plain water and sit upright for 30 minutes aftertaking the drug and before eating ameal. Weight-bearing exercisessuch as walking, hiking,stair climbing, and dancing are advisable. High-impact exercises should be avoided. DIF: Cognitive Level: Comprehension REF: Page 284 TOP: Osteoporosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 32. The nurse is caring for a patient planning to undergo a uterine fibroid embolization. What information canthe nurse provide? (Select all that apply.)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 137 NURSINGTB.COM a. Itinvolveslaser destruction of fibroids. b. It hasfewer physiological effectsthan drug therapy. c. Itis nonsurgical. d. Itis associated withmore psychological effectsthan surgery. e. It has a faster recovery time than surgery. ANS: B, C, E Uterine fibroid embolization is a nonsurgical technique of treating uterine fibroids that involves fewer physiological effectsthan drug therapy,fewer psychological effectsthan surgery, and a faster recovery time than surgery. Myolysisisthe laser or electrosurgical destruction of fibroids, and it also preservesfertility. DIF: Cognitive Level: Comprehension REF: Page 287 TOP: Uterine Fibroid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential COMPLETION 33. The nurse outlinesthe process of ova being mixed with sperm and then the resulting embryos beingreturned to themothers uterus. This process of infertility treatmentis . ANS: in vitro fertilization The in vitro fertilization techniquemixes ova with sperm and depositsseveral of the resulting embryosin the mothers uterus. DIF: Cognitive Level: Knowledge REF: Page 282 OBJ: 6 TOP: In Vitro Fertilization KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 34. When intraabdominal pressure increasesfrom laughing orsneezing in a woman with a cystocele, results. ANS: stressincontinence When intraabdominal pressure increases,such as with laughing, coughing, orsneezing, a woman with a cystocele is said to have stress incontinence. DIF: Cognitive Level: Knowledge REF: Page 286 TOP: Cystocele KEY:Nursing Process Step:N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. isthe presence oftissue thatresembles endometrium outside the uterus. ANS: Endometriosis Endometriosisisthe presence oftissue thatresembles endometrium outside the uterus.DIF: Cognitive Level: Knowledge REF: Page 263 TOP: Endometriosis KEY:Nursing Process Step:N/A MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 138 NURSINGTB.COM Chapter 12: The Term Newborn MULTIPLE CHOICE 1. While inspecting a newborns head,the nurse identifies a swelling ofthe scalp that does not crossthe sutureline. How would the nurse refer to this finding when documenting? a. Molding b. Caputsuccedaneum c. Cephalohematoma d. Enlarged fontanelle ANS: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line. DIF: Cognitive Level: Comprehension REF: Page 286 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Whatisthe nurses bestresponse to a mother who is voicing concern about the molding of her 2-dayoldinfant? a. Molding doesnt cause any problems. Dont worry about it. b. Did you deliver vaginally or by cesarean section? c. The babys head conformed to the shape of the birth canal. It will go away soon. d. A traumatic delivery can cause molding. ANS: C The newborns headmay be out ofshape from molding. Thisrefersto the shaping of the fetal head to conformto the size and shape of the birth canal. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 286 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Whatsymptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heartrate c. Mucus draining from the nose d. Sternal or chestretractions ANS: D Sternalretractions are evidence thatthe newborn isin respiratory distress and should be reported immediately. DIF: Cognitive Level: Analysis REF: Page 292 TOP: Newborn AssessmentRespiratory KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When the newborns crib was moved suddenly,the nurse noticed that hislegsflexed and armsfanned out,and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of themusculoskeletalsystem d. A neurological abnormality ANS: A The Moro reflex is a normal neonatal reflex. Itis elicited when the infants crib isjarred. The infantresponds byINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 139 NURSINGTB.COM drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 140 NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 285 OBJ: 2 TOP: Newborn Reflexes KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A first-timemotherreportsthatshe is experiencing difficulty breastfeeding her newborn. Which neonatalreflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck ANS: B The rooting reflex causesthe infants head to turn in the direction of anything that touchesthe cheek in anticipation of food. DIF: Cognitive Level: Application REF: Page 285 OBJ: 2 TOP: Newborn Reflexes KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What willthe nurse expect when assessing the anteriorfontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangularshaped c. Smallerthan the posteriorfontanelle d. Open and diamond shaped ANS: D The anterior fontanelle is diamond shaped and located atthe junction of the two parietal and two frontal bones.It should not be raised or sunken, and it closesNbUeRtwSeINenG1T2Ba.CnOdM18 months of age. DIF: Cognitive Level: Comprehension REF: Page 286 OBJ: 3 TOP: Newborn AssessmentHead KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Whatstatementindicatesthe parent understandsthe guidelinesfor bathing a newborn? a. Ill use a mild soap to clean all of the body parts. b. I am going to add bath oil to the water to keep the babysskin soft. c. Ishould shampoo the head after washing the rest of the body. d. Ill wash from the feet upward and change the washcloth for the face. ANS: C The shampoo is done last because the large surface area of the head predisposesthe infant to heatloss. DIF: Cognitive Level: Comprehension REF: Page 298 OBJ: 8 TOP: Home CareBathing the Infant KEY:Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse ismeasuring the vitalsigns of a full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6 C (98 F) b. An apical pulse rate of 178 beats/min c. Respirations of 35 breaths/min d. Blood pressure of 80/50 mm Hg ANS: B The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of thisrangeINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 141 NURSINGTB.COM shouldbe reported.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 142 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 293 TOP: Newborn AssessmentVital Signs KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry ANS: A The stool of a breastfed infantis bright yellow,soft, and pasty. DIF: Cognitive Level: Application REF: Page 302 OBJ: 8 TOP: Newborn AssessmentGastrointestinal SystemKEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. Themother of a 2-week-old infant tellsthe nurse, I think the baby is constipated. Ive noticed she strainswhen she has a bowel movement. What is nurses most helpful response? a. Give the baby one serving of fruit per day. b. Increase the amount and frequency of herfeedings. c. Itsoundslike the baby is uncomfortable because she is constipated. d. Newbornsmightstrain with bowel movements because theirmuscles arentfully developed. ANS: D Straining in the newborn period is normal. Itresultsfrom underdeveloped abdominal musculature. No treatment is required. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 303 TOP: Newborn AssessmentGastrointestinal System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh ingrams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800 ANS: C In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight. DIF: Cognitive Level: Analysis REF: Page 294 OBJ: 3 TOP: Newborn AssessmentWeight KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The parents of a newborn girl express concern aboutthe infants vaginal discharge, which appearsto bebloody mucus. What does the nurse explain as the cause? a. Premature stimulation ofthe ovarian hormones by the pituitary system b. Cessation offemale sex hormonestransferred in utero from mother to infant c. The increased amount of circulating blood from the motherthroughout pregnancy d. Trauma to the genitalia during the birthINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 143 NURSINGTB.COM processANS: BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 144 NURSINGTB.COM Blood-tingedmucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth. DIF: Cognitive Level: Comprehension REF: Page 296 TOP: Newborn AssessmentGenitourinary KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Themother of a 2-week-old infant tellsthe nurse thatshe thinks he issleeping too much. Whatisthe mostappropriate nursing response to this mother? a. Tell me howmany hours per day your baby sleeps. b. Itis normal for newbornsto sleep most of the day. c. Newborns generally sleep 12 to 15 hours per day. d. You will find asthe baby gets older, he sleepsless. ANS: A Although itistrue that newbornssleep a great deal of any 24-hour period, the nurse mustfind out what the mother means by too much before giving any information. DIF: Cognitive Level: Application REF: Page 290 TOP:Discharge Planning KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. Which statementindicatesthe parents understand when to contactthe pediatrician or nurse practitioner? a. Infantrefuses a feeding b. Infant has an axillary temperature of 97 F c. Infant hasthree pasty, yellow-brown stoolsin 24 hours d. Infants diaper is not wet after 8 hours ANS: D Decreased or lack of voiding by the newborn sNhUoRulSdINbeGrTeBp.oCrOteMd to the pediatrician or nurse practitioner to prevent dehydration. DIF: Cognitive Level: Comprehension REF: Page 295 TOP:Discharge Planning KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. On what knowledge would the nurse base a response to a mother who questions, Do you think my babyrecognizes my voice? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infantsrespond to voice by increasing movements and sucking. c. Infantsinitially respond to low-pitched voices. d. Neonates can distinguish a mothers voice from othersoundsin the first days of life. ANS: D The ability to discriminate between a mothers voice and other voices may occur as early asin the first 3 daysof life. DIF: Cognitive Level: Knowledge REF: Page 286 OBJ: 8 TOP: Newborn AssessmentHearing KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant hadlost weight. What is the most appropriate intervention by the nurse? a. Do nothing because thisis a normal occurrence. b. Reportthe discrepancy to the pediatrician immediately. c. Decrease the interval between the infantsfeedings. d. Try feeding the infant a different type of formula.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 145 NURSINGTB.COM ANS: A Itistypical for the newborn to lose 5% to 10% of his or her birth weightin the first 3 to 4 days of life. No change in the plan of care is needed. DIF: Cognitive Level: Application REF: Page 294 OBJ: 3 TOP: Newborn AssessmentWeight KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. Parents express concern about the milia on the face and nose of theirinfant. Whatisthe nurses mosthelpful response when instructing the parents? a. Contact a pediatric dermatologistfortopical medication. b. Squeeze outthe whitematerial after cleansing the face. c. Wash the infantsface with a mild astringentseveraltimes a day. d. Leave themilia alone; it will disappearspontaneously. No treatment is needed. ANS: D Milia require no treatment. Thisskinmanifestation will disappearspontaneously. DIF: Cognitive Level: Application REF: Page 297 OBJ: 5 TOP: Newborn AssessmentSkin KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. The nurse is going to use a bulb syringe to clear mucusfrom a newborns nose and mouth. Whatis thenurses first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretionsfrom the nose before themouth. c. Depressthe bulb before inserting the syringe tip into themouth. d. Insert the tip into the back of the mouth to rNeaUcRhSmINuGcuTsB. .COM ANS: C The bulb is depressed, and then the tip isinserted into themouth and then the nose. The depression isslowly released, creating the suction. DIF: Cognitive Level: Application REF: Page 291 OBJ: 3 TOP: Newborn AssessmentRespiratory KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 19. Themother of a 4-day-old callsthe pediatricians office because she is concerned about herinfants skin.Which finding needs to be reported promptly to the childs pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infants body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infantsskin has a yellowish tinge. ANS: D Physiological jaundice becomes evident between the second and third days of life and lastsfor about 1 week. Evidence of jaundice is reported and the newborn is evaluated. DIF: Cognitive Level: Analysis REF: Page 297 TOP: Newborn AssessmentSkin (Jaundice) KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 20. What action doesthe nurse implementto protect newbornsfrominfection while in the nursery? a. Keep the newborn dressed warmly. b. Adjustroom temperature between 23.8 C (75 F) and 26.6 C (80 F).INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 146 NURSINGTB.COM c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care. ANS: C Handwashing isthemostreliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies. DIF: Cognitive Level: Application REF: Page 303 TOP: Preventing Infection KEY:Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. Which assessment of the newborn should be reported? a. Head circumference is 5 cmgreater than the chest circumference b. Hands and feet are warm with a blue color c. Temperature is 36.6 C (97.8 F) d. Head has a longer than normalshape to it ANS: A The circumference of the head should be lessthan 2 cm greaterthan that of the chest. All otherlisted assessments are within the norm. DIF: Cognitive Level: Analysis REF: Page 288 OBJ: 3 TOP: Newborn Assessment KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. Parents of a newborn are worried about dark areas overthe sacrumof the newborn. What doesthe nurseexplain this transitory skin discoloration is called? a. Epsteins pearls b. Milia c. Stork bites d. Mongolian spots NURSINGTB.COM ANS: D Bluish skin discoloration overthe sacral area of a newborn is a transitory condition called Mongolian spots. DIF: Cognitive Level: Comprehension REF: Page 297 TOP: Mongolian Spots KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological Adaptation 23. The pediatric clinic nurse receiveslab results on several newborn patients. Which of the following shouldbe brought to the physicians attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15 ANS: D A bilirubin of 15 is elevated and requiresfurther immediate investigation. DIF: Cognitive Level: Analysis REF: Page 297 OBJ: 3 TOP: Labwork KEY:Nursing Process Step: Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 24. The nurse is assessing Apgarscore on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. ColorINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 147 NURSINGTB.COM c. Heartrate d. Respiration e. Weight ANS: A, B, C, D The Apgarscore is a standardizedmethod of evaluating the newborns condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes. DIF: Cognitive Level: Application REF: Page 292 TOP: Apgar Score KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 25. What noninvasive forms of pain reliefmight a nurse implement with a newborn? (Select allthat apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling ANS: A, B, C, E Swaddling,rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants. DIF: Cognitive Level: Comprehension REF: Page 291 TOP:Noninvasive Pain Relief KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 26. The nurse reminds new parentsthat newbornsmust be protected from environmentsthat are too cold or toohot because of which aspects of the newbornsNpUhyRsSioINloGgTyB?.(CSOelMect all that apply.) a. Very little subcutaneousfat b. Lowmetabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts ANS: A, C Newborns have very little subcutaneousfat,which offerslittle insulation against cold.Newborns have ineffective sweat glands and cannot cool themselves through evaporation. DIF: Cognitive Level: Comprehension REF: Page 293 TOP: Environmental Thermal Stress KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. Which interventions would be included in the nursing care of the newly circumcised infant? (Select all thatapply.) a. Wash penis with warm water. b. Wipe with alcoholswab. c. Gently remove the yellow crustformation. d. Apply diaperloosely. e. Dress with simple bandage. ANS: A, D Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crustin place, and diapering loosely. DIF: Cognitive Level: Application REF: Page 296 OBJ: 7 TOP: Circumcision Care KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 148 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 28. The nurse is aware that a full-term infantis born with which reflexes? (Select allthat apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Grasping ANS: A, B, C, D, E All listed reflexes are presentin the full-term newborn. DIF: Cognitive Level: Knowledge REF: Page 285 OBJ: 2 TOP: Reflexes KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 29. The nurse takesinto consideration that newborns are especially prone to dehydration because of whichaspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimalrenal blood flow c. Inactive gastrointestinal (GI)tract d. Excessive fluid lossfrom the sweat glands e. Immature renaltubulesthat do not concentrate urine ANS: A, B, E The newborns glomeruli are small and have only one third of the blood circulation of an adult, and they are unable to effectively concentrate urine. TheGI tractis active. The infantssweat glands do not work effectively and allow very little fluid loss through sweat. DIF: Cognitive Level: Comprehension REF: PNaUgeRS2I9N5GTB.COM TOP: Dehydration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Growth and Development COMPLETION 30. The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to assessment. ANS: pain CRIES, PIPP,NIPS, andNPASS are all 10-point-scale pain assessment guidesforinfants.DIF: Cognitive Level: Comprehension REF: Page 290 OBJ: 3 TOP: Pain AssessmentGuides KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 31. The nurse advisesthe nursing mother thatthe immune globulin thatisfound in breast milk is . ANS: IgA IgA is an immune globulin thatisfound in breast milk. DIF: Cognitive Level: Knowledge REF: Page 303 TOP: IgA KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 149 NURSINGTB.COM 32. The nurse instructsthemother that when the neonates stool becomesloose and takes on a greenishyellowcolor,thisis normal stool. ANS: transition The transitionalstool haslostits dark greenmeconium color and gradually changesto a loose greenish-yellow stool with mucus. DIF: Cognitive Level: Comprehension REF: Page 302 OBJ: 8 TOP: IgA KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 33. Prancing movements of the legs,seen when an infantis held upright on the examining table, are termed the . ANS: dancing reflex Prancing movements of the legs,seen when an infantis held upright on the examining table, are termed the dancing reflex. DIF: Cognitive Level: Knowledge REF: Page 286 TOP: Reflexes KEY:Nursing Process Step: Assessment MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 34. Place the newborn phases of the sleep-wake statesin proper orderfrom firstto last. Put a comma and spacebetween each answer choice (a, b, c, d, etc.) a. Stability phase b. Firstreactive phase c. Sleep phase d. Second reactive phase ANS: B, C, D, A NURSINGTB.COM At birth the newborn passesthrough the phases ofsleep-wake states as part of the adjustment to life outside ofthe uterus: first reactive phase, sleep phase, second reactive phase,stability phase. DIF: Cognitive Level: Comprehension REF: Page 290 TOP: Sleep KEY:Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. Putthe steps of nasal bulb suctioning forthe newborn in the correct order from first to last. Put a commaand space between each answer choice (a, b, c, d, etc.) a. Clean bulb syringe. b. Release pressure. c. Insert narrow portion into nose. d. Compress ball of bulb syringe. e. Remove and empty into receptacle. ANS: D, C, B, E, A First the ball of the bulb syringe is compressed, and then the narrow portion is inserted into the nose. The pressure isreleased, and the syringe isremoved and emptied into the receptacle. The bulb syringe is cleanedINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 150 NURSINGTB.COM and stored at the end of the procedure.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 151 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 291 OBJ: 8 TOP: Bulb Syringe Suctioning KEY:Nursing Process Step: Implementation MSC: Safety and Infection Control: Safe Use of Equipment NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 152 NURSINGTB.COM Chapter 13: Preterm and Postterm Newborns MULTIPLE CHOICE 1. The nurse is assessing a preterm infant. To what doesthe infantslevel ofmaturation refer? a. Actualtime the fetusremained in the uterus b. Age on the Dubowitzscoring system c. Infants weight as compared to the gestational age d. Ability of the organsto function outside of the uterus ANS: D Level ofmaturation refersto how well developed the infantis at birth and the ability of the organsto function outside of the uterus. DIF: Cognitive Level: Knowledge REF: Page 312 TOP: Preterm Infant KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knowsthat thisinfant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heartfailure ANS: C The higherthe bilirubin level and the deeper the jaundice, the greater isthe risk for neurological damage. DIF: Cognitive Level: Comprehension REF: Page 319 TOP: Jaundice KEY: Nursing Process Step: DNaUtaRCSoINlleGcTtiBo.nCOM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 3. Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the firstfew days of life? a. Weak or absentsucking orswallowing reflex b. Inability to digestfood properly c. Refusalto take formula by mouth d. Need for a larger quantity of formula at each feeding ANS: A When the preterm infantssucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition. DIF: Cognitive Level: Comprehension REF: Page 320 TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What deficiency causes a preterm infantrespiratory distresssyndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant ANS: D The production ofsurfactant, necessary forthe absorption of oxygen by the lungs, is deficient in the preterm infant. DIF: Cognitive Level: Knowledge REF: Page 314INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 153 NURSINGTB.COM TOP: Respiratory Distress Syndrome KEY:Nursing Process Step: Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 154 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 5. How willthe nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting airinto the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents. d. Check serumglucose level. ANS: C When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach. DIF: Cognitive Level: Application REF: Page 320 TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse explainsto a patient in preterm labor that whatmay be ordered by the physician to accelerate fetallung maturity? a. Prostaglandins b. Oxytocin c. Magnesium sulfate d. Corticosteroids ANS: D Surfactant production can be increased by administering corticosteroidsto the mother before delivery. DIF: Cognitive Level: Comprehension REF: Page 315 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: ImplementationMSC: NCLEX: Health Promotion and MainteNnaUnRcSe:INGGroTwBt.ChOanMd Development 7. The apneamonitorindicatesthat a preterm infant is having an apneic episode. Whatisthemost appropriatenursing action in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infantsfeet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning. ANS: B Gently rubbing the infants back, ankles, orfeet may stimulate the infantto breathe. DIF: Cognitive Level: Application REF: Page 315 TOP: Preterm InfantApnea KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. What would the nurse assessforin a preterm infantreceiving an intravenousinfusion containing calciumgluconate? a. Seizures b. Bradycardia c. Dysrhythmias d. Tetany ANS: B The infantreceiving intravenous calcium gluconate should bemonitored for bradycardia. DIF: Cognitive Level: Application REF: Page 317 TOP: Hypocalcemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological TherapiesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 155 NURSINGTB.COM 9. Whatisthe rationale for placing a preterm infant born at 34 weeks of gestation in an incubator? a. The infant has a small body surface-to-weightratio. b. Heatincreasesthe flow of oxygen to the extremities. c. The infantstemperature control mechanism isimmature. d. Heat within the incubator facilitates drainage of mucus. ANS: C The preterm infantis atrisk for heat lossforseveralreasons, one of which isthatthe heatregulating center inthe brain is immature. DIF: Cognitive Level: Comprehension REF: Page 317 TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. What nursing action is appropriate to prevent possible retinopathy in a preterm infantrequiring oxygentherapy? a. Monitor arterial oxygen levels with a pulse oximeter. b. Position the head slightly lowerthan the body. c. Administer low concentrations of oxygen. d. Keep the infants eyes covered at alltimes. ANS: A Use of a pulse oximeterto carefully monitor arterial blood gasesin high-risk infants continuesto be a priority in the neonatal intensive care unit (NICU). DIF: Cognitive Level: Application REF: Page 318 TOP: Retinopathy of Prematurity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. When assessing a preterm infant, the nurseNoUbRsSerIvNeGsTnBas.CalOfMlaring, sternal retractions, and expiratory grunting. What do these findings indicate? a. Respiratory distresssyndrome b. Postmaturity syndrome c. Apneic episode d. Cold stress ANS: A Insufficient amounts ofsurfactant predispose the preterminfantto respiratory distress. The signsmanifested bythe infant are indicative of respiratory distress. DIF: Cognitive Level: Analysis REF: Page 313 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. What nursing action willthe nurse implementfor a preterm infant who is being gavage fed and has abloody stool? a. Assessfor abdominal distention. b. Decrease the amount of the next feeding. c. Institute enteric precautions. d. Get a culture of the nextstool. ANS: A Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilitiesinclude measuring the abdomen and listening to bowelsounds. DIF: Cognitive Level: Application REF: Page 320 TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and DevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 156 NURSINGTB.COM 13. Parents of a preterm infant come to theNICU every day to see their infant, who is being gavage fed. Whatwill the nurse teaching aboutstimulating the infant tell the parents? a. To bring in colorful pictures and toysto place in the incubator b. Thatstimulating the infant during feedingsincreasesintake c. To stroke the infant during feeding to increase intake d. Notto disturb the infant between feedings ANS: C During gavage feedings,stroking the infant gently can provide stimulation. DIF: Cognitive Level: Application REF: Page 320 TOP: Family Reaction KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. The nurse caring for an infant born at 36 weeks of gestation assessestremors and a weak cry. The nurse isaware that these symptoms indicate what? a. Respiratory distresssyndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure ANS: B The preterm infant, before 38 weeks,should be assessed for hypoglycemia because the infants glycogen stores are not adequate. DIF: Cognitive Level: Analysis REF: Page 317 TOP: Postterm Infant KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 15. The mother of a 4-month-old infant, born NprUemRSaItNurGelTyB, .aCsOksMthe nurse if her daughter will always be small for her age. What is the most appropriate nursing response? a. Preterm infants usually remain smallerthan term infantsthroughout childhood. b. Your daughter will be the same size as other children by the time she is 1 year old. c. Prematurity is associated with shortstature but does not affect weight gain. d. Ittakes abouttwo yearsforthe preterm infant to catch up to a full-term infant. ANS: D In the absence ofsevere birth defects and complications,the growth rate of the preterm newborn nearsthat ofthe term infant by about the second year. DIF: Cognitive Level: Application REF: Page 323 TOP: Preterm Infant KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. The nurse caring for a preterm infant will record the intake and output. The nurse is aware that whatis theoptimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr ANS: A The optimum output for a preterm infantis 1 to 3 mL/kg/hr. DIF: Cognitive Level: Comprehension REF: Page 319 TOP: Immature Kidneys KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristicmight theINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 157 NURSINGTB.COM nurse expect thisinfant to exhibit? a. Thin, long extremities b. Large genitalsforitssize c. Minimal vernix caseosa d. Loose, transparent skin ANS: D The growth and development of the fetus are abruptly halted by a preterm birth.One of the characteristics ofthe preterm infant is skin that is loose and transparent. DIF: Cognitive Level: Comprehension REF: Page 312 TOP: Preterm Infant KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. The nurse in a pediatricians office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knowsthatthe infantshould be evaluated in what month of achievementto adjust for the preterm birth? a. 1 b. 2 c. 3 d. 4 ANS: B The growth and development of a preterm infant are based on the current ageminusthe number of weeks before term that the infant was born. DIF: Cognitive Level: Analysis REF: Page 323 TOP: Preterm Infant KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 19. Themother of a postterm infant asks the nurse why the infant is being watched so closely. Whatis thenurses most appropriate response? a. The placenta does notfunction adequately asit ages. b. Infants born postmaturely are generally large. c. Delivery ofthe postterm infant ismore difficult. d. There isless amniotic fluid. ANS: A Fetal distressmay occurin the postterm infant because placental functioning becomesinadequate with maturity. DIF: Cognitive Level: Comprehension REF: Page 324 TOP: Postterm Infant KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 20. Whatsymptoms of cold stressmightthe nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature d. Increased respiratory rate and periods of apnea ANS: D Signs of cold stressinclude increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy. DIF: Cognitive Level: Comprehension REF: Page 317 OBJ: 5 TOP: Preterm Infant KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of RiskINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 158 NURSINGTB.COM 21. The nurse is caring for an infant born at 43 weeks. What would the physical assessmentreveal? a. Dry, peeling skin b. Minimal hair on the head c. Short,rough nails d. Abundantlanugo on the body ANS: A Loss of vernix caseosa leavesthe skin dry, causing peeling. DIF: Cognitive Level: Comprehension REF: Page 324 TOP: Postterm Infant KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. What term describesthe age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age ANS: B The gestational age isthe age based on the actual time in the uterus. DIF: Cognitive Level: Knowledge REF: Page 312 TOP: Gestational Age KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity:Growth and Development 23. How often willthe nurse caring for a preterm infantin an incubator record the temperature of the infant andthe incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours NURSINGTB.COM ANS: B DIF: Cognitive Level: Comprehension REF: Page 317 OBJ: 5 TOP: Thermoregulation KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 24. Why isthe postterm neonate atrisk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fatstores have been used in utero for nourishment ANS: D Fatstores have been used in utero for nourishment during the extended pregnancy. DIF: Cognitive Level: Comprehension REF: Page 324 TOP: Postterm Cold Stress KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. When assessing a neonate born at 38 weeks of gestation,the nurse records his weight as 8 pounds, 10ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. LateINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 159 NURSINGTB.COM pretermANS: CINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 160 NURSINGTB.COM Term infants over 4000 g (8.8 lb)may be classified aslarge for gestational age (LGA). For the preterm infant thisislessthan 38 weeks, for the term infantit is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks. DIF: Cognitive Level: Analysis REF: Page 311 OBJ: 1 TOP: Gestational Age KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. An infantreceivessurfactant via endotracheal (ET)tube at birth forsymptoms ofrespiratory distresssyndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. Atleast 1 month ANS: B In preterm newborns,surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours. DIF: Cognitive Level: Comprehension REF: Page 315 TOP: Respiratory Distress Syndrome KEY:Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 27. The nurse knowsthat a postterm infantmay experience which potential problems? (Select allthat apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia NURSINGTB.COM ANS: A, B, E The postterm infantshould be assessed closely forindication of asphyxia,seizures, and polycythemia. DIF: Cognitive Level: Comprehension REF: Page 324 TOP: Potential Problems of the Postterm Infant KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 28. The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what arepossible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma ANS: A, B, C The predisposing causes of preterm birth are numerous; inmany instancesthe cause is unknown. Prematuritymay be caused bymultiple births, illness ofthemother (e.g.,malnutrition, heart disease, diabetesmellitus, or infectious conditions), or the hazards of pregnancy itself, such as gestational hypertension, placental abnormalitiesthatmay result in premature rupture ofthe membranes, placenta previa (in which the placenta lies over the cervix instead of higher in the uterus), and premature separation of the placenta. Studies also indicate the relationships between prematurity and poverty, smoking, alcohol consumption, and abuse of cocaine and other drugs. Hyperemesis gravidarum and chloasma are not risk factorsfor preterm birth.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 161 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 312INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 162 NURSINGTB.COM TOP: Preterm Birth KEY:Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 29. The nurse assesses a preterm infantin the NICU. Whatsignsshould be reported to the physician? (Selectall that apply.) a. Paleness b. Transparentskin c. Superficialscalp veins d. Vomiting e. Bulging fontanelles ANS: A, D, E Paleness, vomiting, and bulging fontanelles can indicate complicationsin the preterm newborn. Transparent skin and superficial scalp veins are expected findings. DIF: Cognitive Level: Application REF: Page 322 OBJ: 4 TOP: Potential Problems of the Preterm InfantKEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 30. The nurse clarifiesthat a fetus has enough surfactant to breathe on its own at the age of weeks. ANS: 34 Surfactant beginsto appear at the age of 24 weeks and is adequate to support life atthe age of 34 weeks.DIF: Cognitive Level: Knowledge REF: Page 315 TOP: Surfactant KEY: Nursing Process Step: N Im U p R l S e I m N e G n T ta B ti . o C n OM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. The nurse providing stimulation to a preterm infantshould schedule stimulation not to conflict with . ANS: feeding Preterm babiesshould not be stimulated during feeding so they can focus on sucking and swallowing. DIF: Cognitive Level: Application REF: Page 323 TOP: Stimulation and Feeding KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 32. Assessment of altered skin integrity in the preterm infantismade difficult because of the immatureimmune system that cannot produce a(n) reaction. ANS: inflammatory The immature immune system cannot produce an inflammatory reaction to show redness orswelling. Without such symptoms, skin integrity is more difficult to assess in the preterm infant. DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 4 TOP: Skin Assessment KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 33. The nurse encouragesthe anxiousmother of a preterm infantto considerthe warming technique ofINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 163 NURSINGTB.COM holdingINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 164 NURSINGTB.COM the infant between her breasts with skin-to-skin contact under a blanket. Thistechnique isthe car emethod. ANS: kangaroo The kangaroo care method is when themother placesthe infant between her breastsforskin-to-skin contact, and then bothmother and infant are wrapped in a blanket as a warming technique. Thismethod also facilitatesmaternal-infant bonding. DIF: Cognitive Level: Knowledge REF: Page 320 TOP: Kangaroo Care KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 34. The nurse is aware thatthe preterm infant has an increased tendency to bleed due to deficient levels of . ANS: prothrombin Preterm infants have deficientlevels of prothrombin,which increasesthe tendency to bleed spontaneously. DIF: Cognitive Level: Knowledge REF: Page 318 TOP: Bleeding Tendency KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Reduction of Risk 35. The nurse explainsthat the is a tool used to determine the gestational age ofa neonate based on appearance and neuromuscular criteria. ANS: Ballard Score NURSINGTB.COM The Ballard Score is a standardizedmethod to determine gestational age based on external characteristics and neurological development. DIF: Cognitive Level: Knowledge REF: Page 313 OBJ: 1 TOP: Ballard Scoring System KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 36. Bronchopulmonary dysplasia isthe toxic response of the lung to therapy. ANS: oxygen Bronchopulmonary dysplasia isthe toxic response of the lung to oxygen therapy.DIF: Cognitive Level: Knowledge REF: Page 315 TOP: Bronchopulmonary Dysplasia KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Growth and DevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 165 NURSINGTB.COM Chapter 14: The Newborn with a Perinatal Injury or Congenital Malformation MULTIPLE CHOICE 1. What occurrence resultsfromobstruction within the ventricles of the brain orinadequate reabsorption ofcerebrospinal fluid? a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus ANS: D Hydrocephalusis characterized by an increase in cerebrospinal fluid in the ventricles of the brain. DIF: Cognitive Level: Knowledge REF: Page 329 TOP:Hydrocephalus KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for an infant with hydrocephalus. What nursing action ismost importantforthis nurse toimplement? a. Align the limbs. b. Support the head. c. Keep the head lower than the hip. d. Check intake and output. ANS: B The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the childNtoUpRrSeI vNeGntTiBn. jCurOyMto the neck. DIF: Cognitive Level: Application REF: Page 331 TOP:Hydrocephalus KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse observesthatthe infants anteriorfontanelle is bulging after placement of a ventriculoperitonealshunt. How should the nurse position this infant? a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In a semi-Fowlers position ANS: D Ifthe fontanelles are bulging,the child will be positioned in a semi-Fowlers position to promote drainage from the ventricles through the shunt. DIF: Cognitive Level: Application REF: Page 331 OBJ: 4 TOP: Hydrocephalus KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 4. What nursing action willthe nurse implement afterfeeding an infant with hydrocephalus? a. Position the infantsitting upright in an infantseat. b. Place the infant over the shoulder to burp. c. Leave the infantin a side-lying position. d. Stimulate the infant by rubbing itsfeet. ANS: C Because children with hydrocephalus are prone to vomiting,the child isfed and then positioned in the side-INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 166 NURSINGTB.COM lying position in a quiet atmosphere to reduce the incidence of vomiting. DIF: Cognitive Level: Application REF: Page 331 TOP: Feeding aHydrocephalic Child KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A newborn wasjust admitted to the neonatal intensive care unit with a meningomyelocele. Whatis thepriority preoperative nursing care of this newborn? a. Keep the sac dry. b. Diapersnugly. c. Position prone in an incubator. d. Move from side to side every hour. ANS: C The infant is placed prone in a humidified incubator, and the sac is covered with dressings ofsterile saline. The infants hips are kept lower than the lesion, and the infant is usually not in diapers. DIF: Cognitive Level: Analysis REF: Page 333 TOP: Myelodysplasia and Spina Bifida KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse is caring for a child who has had a ventriculoperitonealshunt(VP) for hydrocephalus andobserves an increasing abdominal girth. What is the most appropriate response? a. Elevate the childs head. b. Check bowelsounds. c. Record retention offeeding. d. Notify the charge nurse of possible malabsorption. ANS: D An increasing abdominal girth in a child withNaUVRPSsIhNuGnTtBm.CayObMe indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum. DIF: Cognitive Level: Application REF: Page 331 OBJ: 6 TOP: VP Shunt KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 7. The nurse is providing education to parents of a child with cleft palate. What willthe nurse instruct theparents to report immediately? a. Facial paralysis b. Earinfections c. Increasing intracranial pressure (ICP) d. Drooling ANS: B Children with cleft palate are atrisk of ear infections and dental disorders. Parentsshould be instructed to takethe child to the health care provider at the first sign of earache. DIF: Cognitive Level: Application REF: Page 336 TOP: Complication of Cleft Palate KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. Postoperative nursing care ofthe infantfollowing surgicalrepair of a cleft lip would include: a. Feeding the infant with a spoon to avoid sucking b. Positioning the infant on the abdomen to facilitate drainage c. Applying elbow restraintsto protect the surgical area d. Providing minimalstimulation to preventinjury to the incision ANS: C Elbow restraints are used postoperatively to prevent the infant fromdamaging the operative area.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 167 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 336 TOP: Cleft Lip and Palate KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. Which statement indicatesthat parents understand how to feed theirinfant who had a surgicalrepair for acleft lip? a. We are feeding the baby with a dropper for 2 weeks. b. We resumed bottle feeding after discharge. c. We started the baby on solid food yesterday. d. The baby is drinking well from a straw. ANS: A The infant isfed with a dropper untilthe incision is completely healed, about 1 to 2 weeks aftersurgery. DIF: Cognitive Level: Application REF: Page 336 TOP: Cleft Lip and Palate KEY:Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. An 18-month-old child had a surgicalrepair of a cleft palate and is now allowed to eat a regular diet. Whatnursing action is the most appropriate? a. Feed solid foods with the spoon atthe side of the mouth. b. Puree foods and offer them through a straw. c. Place small bites of food in the mouth with a tongue blade. d. Offersmall,frequent meals offingerfoods. ANS: A The primary concern with feeding isto protect the operative site. The child can be fed with a spoon, but onlythe side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of the mouth. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 336 TOP: Cleft Lip and Palate KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. When bathing an infant, whatsign doesthe nurse recognize as a sign of developmental hip dysplasia? a. Hypotonicity of the leg muscles b. One leg isshorter than the other c. Broadening and flattening of the buttocks d. Two skinfolds on the back of each thigh ANS: B When developmental hip dysplasia is present,the leg on the affected side will appearshorter than the leg onthe unaffected side. DIF: Cognitive Level: Comprehension REF: Page 338 OBJ: 8 TOP: Developmental Hip Dysplasia KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 12. A 3-month-old infantis diagnosed with developmental hip dysplasia. The nurse knowsthat whatis theusual treatment for an infant with this diagnosis? a. A Pavlik harness b. A body spica cast c. Traction d. Triple-diapering ANS: A In infants who aremore than 2 months of age, longer-termimmobilization with a Pavlik harnessisrequired.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 168 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 338 OBJ: 8 TOP: Developmental Hip Dysplasia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. After delivery, amother asksthe nurse about newborn screening tests. The nurse explainsthat whatis theoptimal time for testing for phenylketonuria? a. In the first 24 hours of life b. After 2 to 3 days c. At 4 to 6 weeks of age d. At 2 months of age ANS: B Blood testsfor phenylketonuria should be obtained 48 to 72 hours after birth. The newborn will have had enough time to ingest protein through feedings, and the chance of false-negative results will be reduced. DIF: Cognitive Level: Comprehension REF: Page 341 TOP: PKU KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. The nurse is advising parents aboutfeeding theirinfant with phenylketonuria. What formula and/or dietshould the nurse suggest? a. Lifelong high-protein diet b. A formula thatislow in the amino acid leucine c. A soy-based formula d. Substitute Lofenalac forsome protein foods ANS: D A synthetic food providing enough protein for growth and tissue repair, butlittle phenylalanine, issubstituted for natural protein foods. NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 341 TOP: PKU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. Parents of a 2-month-old infant with Down syndrome are attending a well visit atthe pediatric clinic. Whatshould they be instructed to provide special attention to in regard to the generalized hypotonicity of the child? a. Preventing hyperthermia b. Respiratory care c. Prevention of diarrhea d. Incontinence care ANS: B The child withDown syndrome has generalized hypotonicity, which causedmucus accumulation and respiratory problems. DIF: Cognitive Level: Application REF: Page 343 OBJ: 10 TOP: Down Syndrome KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 16. What would the nurse include when instructing parents about positioning theirtoddler who hasjust had abody spica cast applied? a. Prop the child upright with pillowsformeals. b. Use the bar between the legsto turn the child. c. Putthe child on her abdomen to sleep. d. Change the childs position frequently.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 169 NURSINGTB.COM ANS: DINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 170 NURSINGTB.COM The childs positionmust be changed frequently to relieve pressure and promote circulation. DIF: Cognitive Level: Application REF: Page 339 TOP: Developmental Hip Dysplasia KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity 17. The nurse is caring for an Rh-negative mother on the postpartum unit. Whatscenario indicatesthe need toadminister RhoGAM to this patient? a. She has had one Rh-negative child and is pregnant with an Rh-negative child. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative child. d. She is a primipara with an O-negative child. ANS: B The only woman with antibodies against the Rh-positive infantisthe Rh-negative woman who has had one Rh positive child and is now pregnant with another. DIF: Cognitive Level: Analysis REF: Page 344 TOP: Rh Concerns KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 18. Parents ask the nursery staff whatthe light doesfortheirjaundiced infant. Whatisthe nurses bestresponse? a. The lightincreasesthe infants metabolism. b. The lightstimulatesliverfunction. c. The light dilates blood vessels. d. The light breaks down bilirubin. ANS: D Severe jaundice can cause kernicterus, an accuNmUuRlSatIiNoGn ToBf b.CilOirMubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted. DIF: Cognitive Level: Application REF: Page 346 TOP: Hemolytic Disease of the Newborn KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. Parents of a newborn with a unilateral cleft lip are concerned about having the defectrepaired. The nurseexplains that a child with a cleft lip usually undergoes surgical repair at which time? a. Immediately after birth b. By 3 months of age c. After 12 months of age d. Variesin every case ANS: B A cleft lip isrepaired by 3 months of age when weight gain is established and the infant isfree of infection. DIF: Cognitive Level: Comprehension REF: Page 335 TOP: Cleft Lip KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 20. Phototherapy isinstituted for an infant. What isthemost appropriate nursing action forthe infant havingphototherapy? a. Cover the infants head with a hat. b. Dressthe infant lightly in a T-shirt. c. Keep the infants eyes covered. d. Reposition the infant atleast every 4 to 8 hours. ANS: CINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 171 NURSINGTB.COM The infants eyes are protected with patchesto prevent damage fromthe high-intensity lights. DIF: Cognitive Level: ApplicationREF: Page 346 OBJ: 12 TOP: Phototherapy KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse is caring for amacrosomic newborn whosemother has diabetes. Whatshould the nurse assessfor with this neonate? a. Hypoglycemia b. Erythroblastosis fetalis c. Intracranial hemorrhage d. Pancreatic failure ANS: A The newborn of a mother with diabetesis prone to hypoglycemia. DIF: Cognitive Level: Application REF: Page 351 TOP: Infant of aDiabetic Mother KEY: Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 22. What assessmentmade by the nurse would lead the nurse to suspect hip dysplasia? a. Asymmetrical gluteal folds b. Limited adduction ofthe affected side c. Foot turned inward d. Deep inguinal creases ANS: A The gluteal folds are asymmetrical because thNe UheRaSdINofGtThBe.fCeOmMur has slipped out of the acetabulum. There is also limited abduction of the affected side, and when the legs are flexed the affected leg seemsto be shorter. DIF: Cognitive Level: Comprehension REF: Page 337 OBJ: 8 TOP: Hip Dysplasia KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 23. The nurse is providing care to a child with Down syndrome. What body system hasthe highestrisk ofcongenital anomaly in a child with Down syndrome? a. Reproductive system b. Genitourinary system c. Cardiovascular system d. Gastrointestinal system ANS: C Down syndrome children are prone to deformities of the cardiovascularsystem. DIF: Cognitive Level: Knowledge REF: Page 343 TOP:Down Syndrome KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 24. The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is themost appropriate response? a. Cystic fibrosisis a chromosomal defect. b. Cystic fibrosisis ametabolic defect. c. Cystic fibrosisis amalformation present at birth. d. Cystic fibrosisis a blood disorder. ANS: BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 172 NURSINGTB.COM Inborn errors of metabolism include a number of inherited diseasesthat affect body chemistry. Theremay be an absence or a deficiency of a substance necessary for cell metabolism. The deficientsubstance is usually anenzyme. Almost any organ of the body may be damaged. Examples of inborn errors of metabolism includecystic fibrosis and phenylketonuria (PKU). In disorders of the blood, there is a reduced or missing blood component or an inability of a component to function adequately. Sickle cell disease, thalassemia, and hemophilia fall into this category. Chromosomal abnormalities numberin the thousands. Mostinvolve some type of mental retardation, and others are incompatible with life. The newborn with Turners syndrome or Klinefelters syndrome may have impaired physical growth and sexual development. Malformations at birthinclude several types of structural defects. DIF: Cognitive Level: Knowledge REF: Page 329 OBJ: 3 TOP: Classification of Birth Defects KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease MULTIPLE RESPONSE 25. What characteristics are typical in a child diagnosed with Down syndrome? (Select allthat apply.) a. Close-set eyes b. Simian creases c. Wide-spaced frontteeth d. Protruding tongue e. Curved,small fingers ANS: A, B, D, E Children with Down syndrome have close-set upturned eyes, simian creases in palms of hands, protruding tongues, and curved,small fingers. They also have a wide space between their first and second toe and a high incidence of heart defects. DIF: Cognitive Level: Knowledge REF: PageN3U43RSINGTB.COM OBJ: 10 TOP: Features of Down Syndrome KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. What willthe nurse include in the plan of care when caring for an infant with an intracranial hemorrhage?(Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often tomaintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe forincreased intracranial pressure. ANS: A, B, E These children should be kept positioned with the head elevated,fed slowly, andmonitored forincreased intracranial pressure. Children with intracranial hemorrhages are not stimulated and are kept in a quiet environment. DIF: Cognitive Level: Comprehension REF: Page 350 TOP: Topic: Intracranial Hemorrhage KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 27. What would be included in the plan of care for a child justreturned to the floorfrom surgery in which aclubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying. b. Check toesfor capillary refill. c. Circle with a pen any area of bleeding on the cast. d. Keep casted leg lowered. e. Observe forskin irritation.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 173 NURSINGTB.COM ANS: A, B, C, E The casted leg should be kept elevated. Allthe other options are necessary nursing interventionsfor a child who is freshly casted. DIF: Cognitive Level: Comprehension REF: Page 336 OBJ: 2 TOP: Repair of Clubfoot KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 28. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crack-addicted mother. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite ANS: A, B, C The neonate with abstinence syndrome will have tremors, be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite. DIF: Cognitive Level: Knowledge REF: Page 350 TOP:Neonatal Abstinence KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 29. Whatmanifestations ofincreasing ICP in the hydrocephalic child should the nurse be aware of? (Select allthat apply.) a. High-pitched cry b. Inequality of pupils c. Bulging fontanelles d. Diarrhea e. Hiccups NURSINGTB.COM ANS: A, B, C Increased ICP ismanifested by high-pitched cry, inequality of pupils, and bulging fontanelles. DIF: Cognitive Level: Knowledge REF: Page 331 OBJ: 14 TOP: Signs of ICP KEY: Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 30. The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defects. What interventions can the nurse suggest to this woman to help preventneural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid drug use. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the firsttrimester. ANS: A, C The use of drugs during early pregnancy and poor nutritionmay contribute to the development of a neural tubedefect. The American Academy of Pediatrics (AAP) recommends that all women of childbearing age take a dailymultivitamin that contains 0.4mg of folic acid and continue the intake offolic acid untilthe twelfth weekof pregnancy, when basic neural tube development is completed. Studies have shown that the intake of folic acid before conception dramatically decreasesthe occurrence of neuraltube defectssuch as spina bifida. Daily exercise and bed rest do not decrease the risk of neural tube anomalies. DIF: Cognitive Level: Comprehension REF: Page 333 OBJ: 5 TOP: Prevention of Neural Tube DefectsINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 174 NURSINGTB.COM KEY:Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 31. The nurse is caring for amacrosomic newborn of a woman diagnosed with gestational diabetesimmediately after birth. What assessmentfindings can the nurse anticipate? (Select all that apply.) a. High blood glucose levels b. Weight of 9 pounds or more c. Decreased subcutaneousfat d. Hypocalcemia e. Hyperbilirubinemia ANS: B, D, E Many newborn infants of diabetic mothers have serious complications. When the mother is hyperglycemic, large amounts of glucose are transferred to the fetus. After delivery the infant often has low blood glucose levels because ofthe abruptloss of maternal glucose and hypertrophy of the pancreatic islet cells, which resultsin a temporary overproduction of insulin. Hyperinsulinism, along with excess production of protein and fattyacids, often results in a newborn infant who weighs more than 4082 g (9 lb). These infants suffer from hypoglycemia, hypocalcemia, and hyperbilirubinemia. DIF: Cognitive Level: Comprehension REF: Page 350 OBJ: 15 TOP: Macrosomic Newborn KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 32. The home health nurse is educating parents on home phototherapy. What willthe nurse include whenproviding information to these parents? a. Coverthe infants eyes when under the light. b. Use a three-prong plug. c. Keep a diaper in place. d. Place the light source on an absorbent surfaNceU.RSINGTB.COM e. Expose as much skin as possible. ANS: B, C, E Parents should be instructed to use a three-prong plug for safety, keep a diaper in place, and expose as muchskin as possible. The light source should be placed on a nonabsorbent surface, not on carpet or in a crib. It isnot necessary to cover the infants eyes when under the light. DIF: Cognitive Level: Application REF: Page 348 OBJ: 13 TOP: Home Phototherapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention COMPLETION 33. When the CSF is obstructed in the subarachnoid space ratherthan in the ventricles, the resultinghydrocephalusis diagnosed as hydrocephalus. ANS: communicating Communicating hydrocephalus occurs when the CSF is obstructed in the subarachnoid space rather than in the ventricles. DIF: Cognitive Level: Comprehension REF: Page 329 TOP: Communicating Hydrocephalus KEY: Nursing Process Step: ImplementationMSC: NCLEX:Health Promotion and Maintenance: Growth andDevelopment 34. The nurse clarifiesto the parents of a child with spina bifida thattheir child has a portion of the spinalINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 175 NURSINGTB.COM cordin the sac in addition to the meninges. Thistype of spina bifida is known as a(n) .INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 176 NURSINGTB.COM ANS: meningomyelocele A spina bifida thatincludes a portion of the cord in the sac in addition to the meningesis classified as a meningomyelocele. DIF: Cognitive Level: Comprehension REF: Page 332 TOP: Meningomyelocele KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 35. The nurse demonstrates how to flush the ventriculoperitonealshunt by the use of the thatisin place behind the infants ear. ANS: pump A small pump is part of the VP shunt. The pump isin place behind the childs ear. The shunt can be pumped according to the physiciansinstructions to maintain flow from the ventriclesto the peritoneum. DIF: Cognitive Level: Comprehension REF: Page 330 TOP: Pumping the Shunt KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 36. The initial treatment for cleft lip is a surgical repair known as . ANS: cheiloplasty The initialtreatmentfor cleft lip is a surgicalrepair known as cheiloplasty. DIF: Cognitive Level: Knowledge REF: PageN3U35RSINGTB.COM TOP: Cleft Lip Repair KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk PotentialINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 177 NURSINGTB.COM Chapter 15: An Overview of Growth, Development, and Nutrition MULTIPLE CHOICE 1. What type of development isthe nurse assessing when an infant can lift his or her head before he orshe cansit? a. Specific to general b. Proximodistal c. Cephalocaudal d. Generalto specific ANS: C Cephalocaudal development proceedsfromhead to toe. DIF: Cognitive Level: Comprehension REF: Page 357 OBJ: 1 TOP: Cephalocaudal Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. Whatis a unique organization of characteristicsthat determines an individuals pattern of behavior? a. Environment b. Heredity c. Personality d. Experience ANS: C One definition of personality statesthatitis a unique organization of characteristicsthat determinesthe individuals typical or recurrent pattern of behavior. DIF: Cognitive Level: Knowledge REF: PageN3U64RSINGTB.COM TOP: Personality Development KEY:Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 3. An infants birth weight is 7 pounds, 8 ounces. What can the nurse project the weight to be at 6 months? a. 12 pounds b. 15 pounds c. 18 pounds d. 22 pounds ANS: B An infant usually doubles his or her birth weight by 5 to 6 months. DIF: Cognitive Level: Analysis REF: Page 357 OBJ: 4 TOP: Weight Prediction KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 4. What would the nurse furtherinvestigate when assessing patterns of growth in a child? a. Previous weight wasin the 75th percentile, and present weightisin the 25th percentile. b. Heightisin the 90th percentile, and weightisin the 75th percentile. c. Last weight wasin the 5th percentile, and present weightisin the 10th percentile. d. Weightisin the 50th percentile, and siblings weight atthe same age wasin the 75th percentile. ANS: A The child showing a difference oftwo or more percentile levelsfroman established growth pattern should undergo further evaluation. DIF: Cognitive Level: Analysis REF: Page 360INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 178 NURSINGTB.COM TOP:Growth KEY: Nursing Process Step:Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 179 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 5. A mother reportsthatshe and her husband have had one child together, but both have children frompreviousmarriagesliving in their home. The nurse will base the care planning on whattype of family? a. Nuclear b. Blended c. Alternate d. Extended ANS: B A blended family involvesthe remarriage of persons with children. DIF: Cognitive Level: Comprehension REF: Page 363 OBJ: 6 | 7 TOP: The Family KEY: Nursing Process Step: Planning MSC:NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The mother of a 7-month-old reports that the first lower central incisor has erupted. She asks the nurse, Howmany teeth will he have by his first birthday? The nurse explains that the infant will have how many teeth by 1year of age? a. 2 b. 4 c. 6 d. 8 ANS: C The 1-year-old infant usually has about 6 teeth, 4 above and 2 below. DIF: Cognitive Level: Knowledge REF: Page 384 TOP:Dentition KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and MainteNnaUnRcSe:INGGroTwBt.ChOanMd Development 7. At a well-baby visit, parents of a 6-month-old ask when to take the infant forthe first dental visit. What isthe nurses best response? a. If the teeth are brushed regularly, the child should see a dentist by 3 years of age. b. The first dental visitshould be arranged after the first tooth erupts. c. The child should have a dental examination when all deciduousteeth have erupted. d. A dental visit by 1 year of age isrecommended by the American Academy of Pediatric Dentistry. ANS: D The Academy of Pediatric Dentistry recommendsthatthe first dental visit occur by 1 year of age. DIF: Cognitive Level: Application REF: Page 384 TOP:Dentition KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. The nurse is planning anticipatory guidance for a caregiver of a preschool-age child. The nurse will explain that permanent teeth begin erupting at what age? a. 4 years old b. 6 years old c. 8 years old d. 10 years old ANS: B Permanentteeth do not erupt through the gums untilthe sixth year. DIF: Cognitive Level: Knowledge REF: Page 385 TOP: Dentition KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 180 NURSINGTB.COM 9. A mother asksthe nurse how much food should be offered to her 2-year-old. Whatis a good rule of thumbforserving size (in tablespoons) per year of age? a. 2 b. 3 c. 4 d. 5 ANS: A The rule of thumb forserving sizesisto offer 1 tablespoon of each food group per year of age. DIF: Cognitive Level: Comprehension REF: Page 384 TOP: Rule of Thumb for Serving Sizes KEY:Nursing Process Step: ImplementationMSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. An assessment of a childs nutritionalstatusrevealsthe child is alert, with shiny hair, firmgums, firm mucousmembranes, and regular elimination. How would this childs nutritionalstatus be described? a. Overnourished b. Undernourished c. Well nourished d. Borderline ANS: C Well-nourished children show steady gainsin height and weight and have shiny hair, firm gums and mucous membranes, and regular elimination. DIF: Cognitive Level: Analysis REF: Page 383 TOP: Nutrition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse encourages a Puerto Rican famiNlyUtRoSbIrNinGgTfBo.oCdOtMo a child because he is not eating the food served on his hospital tray. What can the nurse expect the child to eat? a. Dried beansmixed with rice b. Crisp vegetables c. Spaghetti and meatballs d. Wild berries,roots, and seeds ANS: A A common food choice of Americans of Puerto Rican descentis dried beans mixed with rice. DIF: Cognitive Level: Comprehension REF: Page 376 OBJ: 7 TOP: Feeding the Ill Child KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 12. The nurse observesthat a 2-year-old is able to use a spoon steadily at mealtime. What doesselffeedinghelp to develop in the toddler? a. Good nutrition b. A sense of independence c. Adequate height and weight d. Healthy teeth ANS: B By the end of the second year,toddlers can feed themselves. This helpsthem to develop a sense of independence. DIF: Cognitive Level: Comprehension REF: Page 372 OBJ: 2 TOP: Feeding the Healthy Child KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 181 NURSINGTB.COM 13. What activity would the nurse choose to meet Eriksons developmental task ofindustry when caring for a 7-year-old? a. Completing a 50-piece jigsaw puzzle b. Looking at a comic book c. Playing a game of I Spy with the nurse d. Coloring a picture in a coloring book ANS: A In the developmental period of late childhood, children are striving to develop a sense of industry. The completion of a jigsaw puzzle is industrious play. DIF: Cognitive Level: Analysis REF: Page 372 OBJ: 11 TOP: Personality Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. What doesthe nurse recognize as an example of Piagets concrete operational thinking? a. 2-year-old says, Its nighttime when hisroom is darkened. b. 4-year-old refersto the hospital asmy house. c. 5-year-old coloring a picture of a puppy says, Thisis my puppy. d. 7-year-old says, I am sick because I have germsin my chest. ANS: D The 7-year-oldsremark reflecting the cause and effect of germs and illnessis an example of operational thinking. All other options are examples of preoperationalthought, which is egocentric and symbolic. DIF: Cognitive Level: Analysis REF: Page 373 OBJ: 8 TOP: Cognitive Development KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and MainteNnaUnRcSe:INGGroTwBt.ChOanMd Development 15. The nurse has discussed with a mother the process of introducing solid foodsto her 6-month-old infant.Whatstatement by the mother leads the nurse to determine that learning hastaken place? a. I will give my infantrice cereal first. b. I will givemy infant yellow vegetablesfirst. c. I will give my infant egg yolksfirst. d. I will give my infant fruitsfirst. ANS: A Solid foods are usually introduced at about 6 months of age,starting with rice cereal, which isthe least allergenic. DIF: Cognitive Level: Comprehension REF: Page 379 OBJ: 9 TOP: Feeding the Healthy Child KEY: Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. Whatisthe best nursing action when an 8-year-old child comesto the school nurse with his central incisorin his hand and reports he knocked his tooth out on the water fountain? a. Give him an ice cube to suck on. b. Have him wash his mouth out with peroxide and water. c. Wrap the tooth in a clean tissue. d. Wash off the tooth and place it in a container of milk. ANS: D The tooth should be washed off and putin a container ofmilk to preserve itfor possible reimplantation. DIF: Cognitive Level: Application REF: Page 387INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 182 NURSINGTB.COM OBJ: 10 TOP: Loss of ToothINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 183 NURSINGTB.COM KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 17. Themother of a 7-month-old states, The baby is eating food now. Should I give him regularmilk,too? What is the nurses best response? a. You should give the baby low-fatmilk. b. Try the milk. See if he has any digestive problems. c. Continue breastmilk oriron-fortified formula until 1 year of age. d. Atthis age, infants can tolerate lactose-free orsoy-basedmilk. ANS: C Wholemilk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2 years of age. DIF: Cognitive Level: Application REF: Page 381 OBJ: 9 TOP: Nutrition and Health KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. When a small group of preschool-age children were playing house, each child was pretending to be a particularfamilymember. Whattype of play doesthe nurse recognize these children are participating in? a. Parallel b. Cooperative c. Symbolic d. Fantasy ANS: B In cooperative play, children play with each other, each taking a specific role. DIF: Cognitive Level: Analysis REF: Page 38N8URSINGTB.COM OBJ: 11 TOP: Play KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 19. When the nurse asks a 10-year-oldNative American if he isready to go to therapy, he does not answerimmediately. How does the nurse interpret this response? a. Indecision b. Considering the answer in silence c. Shyness with strangers d. Fear ofmedical personnel ANS: B Native Americans value silence. They need to sit and considermatters before replying to questions. DIF: Cognitive Level: Analysis REF: Page 371 OBJ: 7 TOP: Ethnic ConsiderationsAmerican IndianKEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. A mother tellsthe nurse, My 11-month-old son is not as active as my other children were atthis age. He isthe youngest of four and the older children love to dote on him. Which factor is influencing this childs language development? a. Heredity b. Sex c. Mothers health during pregnancy d. Ordinal position ANS: D Motor development of the youngest childmay be prolonged ifthe child is babied by othersin the family.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 184 NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 361 TOP: FactorsInfluencing Development KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. A mother tells her 4-year-old child that ballsshould be played with outside and notinside the house. Whyis the child likely to obey the rule? a. The child does not wantto be punished. b. The child wantsto please her mother. c. The child respects authority figures. d. The child believesthatfollowing the rulesisright. ANS: A According to Kohlberg, children in the preconventionalstage (4 to 7 years) are obedient to their parentsfor fear of punishment. DIF: Cognitive Level: Comprehension REF: Page 372 OBJ: 8 TOP: Moral Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. Whatshould the nurse avoid when demonstrating a bath procedure to parents of Vietnamese origin? a. Talking directly to the mother b. Exposing the childs genitals c. Touching the childs head d. Using cool water ANS: C The Vietnamese are very sensitive about anyone touching a childs head because thatis where consciousness lies. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 367 OBJ: 7 TOP: Ethnic ConsiderationsVietnamese KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 23. What doesthe nurse calculate the basal metabolic index (BMI) of an 8-year-old child who is 48 inchestall (1.2 meters) and weighs 100 pounds (45.4 kg) to be? a. 28.9 b. 32.4 c. 34.8 d. 37.6 ANS: B The formula for BMI calculation is weightin kg divided by heightinmeters(squared): 45.4 (weight in kg) divided by 1.4 (1.2 squared) = 32.4. A BMI of over 30 is classified as obese. DIF: Cognitive Level: Analysis REF: Page 383 OBJ: 9 TOP: Calculation of BMI KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 24. Whattoy is developmentally appropriate for the nurse to suggest to entertain a 5-year-old child? a. Jack-in-the-box b. Book of nursery rhymes c. Model airport with toy planes d. Model car construction kit ANS: C Atthis age children are into creative play. Themodel airport with toy planesisthemost developmentallyINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 185 NURSINGTB.COM appropriate. DIF: Cognitive Level: Application REF: Page 388 OBJ: 11 TOP: Play Activities KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 25. The nurse caring for a 4-year-old postoperative patientinstructs him to blow bubbles. What nursingintervention is the nurse most likely implementing by using this form of therapeutic play? a. Providing pain relief b. Encouraging deep breathing c. Decreasing risk of infection d. Maintaining body temperature ANS: B Play can also be therapeutic and aid in the recovery process. An example of therapeutic play isthe game of having the child blow bubbles to promote deep breathing. DIF: Cognitive Level: Application REF: Page 388 TOP: Therapeutic Play KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 26. Themother of a 7-year-old pediatric patient asksthe nurse about her childssleep requirement. Whatis themost accurate response by the nurse? a. 7 to 10 hours a night b. 5 to 7 hours a night with one daytime nap c. 11 to 13 hours a night d. 4 to 6 hours a night with two daytime naps ANS: C NURSINGTB.COM Sleep patterns vary with age. The neonate sleeps 8 to 9 hours per night and naps an equal amount of time during the day. The 2-year-old may sleep 10 hours during the night and have only one short daytime nap. The 7-year-old usually requires 11 to 13 hours ofsleep and rarely has a daytime nap. These patterns may be alteredby cultural practices. DIF: Cognitive Level: Comprehension REF: Page 359 TOP: Sleep KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention MULTIPLE RESPONSE 27. How do children differfromadults? (Select all that apply.) a. Highermetabolic rate b. Greatersurface area in relation to their weight c. Lessmature organ systems d. More fluid reserves e. Continuously changing growth and development pattern ANS: A, B, C, E Children are in a continuous growth and development pattern. Children have a greatersurface area and a highemetabolic rate. All of their organ systems are not mature. DIF: Cognitive Level: Comprehension REF: Page 354 OBJ: 3 TOP: Adult Versus Child KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 28. What approachesshould the nurse suggestforintroducing a toddler to new foods? (Select allthat apply.) a. Serve one food at a time.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 186 NURSINGTB.COM b. Avoid showing personal likes or dislikes. c. Offerfoodsin small amounts, lessthan a teaspoon. d. Entice the toddler to eat with sweets. e. Serve food warm. ANS: A, B, C, E Foodsshould be introduced in small, warm servings, one food at a time. Sweets and milk should not be offered until after solid food. DIF: Cognitive Level: Comprehension REF: Page 380 OBJ: 9 TOP: Solid Food KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 29. Which healthy snack foods would the school nurse suggestto a group of adolescents? (Select all thatapply.) a. Bubble gum b. Chocolate-covered peanuts c. Raw vegetables d. Cheese e. Dried fruits ANS: C, D Cheese and raw vegetables are acceptable healthy snacks. Bubble gum, chocolate-covered peanuts, and dried fruits all contain high amounts of sugar. DIF: Cognitive Level: Comprehension REF: Page 380 OBJ: 9 TOP: Healthy Snacks KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 30. The nurse suggeststo the parents of an obese 10-year-old that they use the Portion Plate for Kids placemat.How does this tool help with selection of portion sizes? (Select all that apply.) a. Cartoon characters eating healthy foods b. Tips on healthy food choices c. Portion measurement in tablespoons for common food d. Calorie valuesfor cup-size portions of common foods e. Familiar objectssuch as a deck of cardsto measure servings ANS: B, E The Portion Plate for Kidsis a placemat that uses common objectssuch as a deck of playing cards or a basebalto measure serving portions. DIF: Cognitive Level: Comprehension REF: Page 377 OBJ: 9 TOP: Portion Plate for Kids KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. An educational program is being presented to pediatric nurses on the relationship of play to childhooddevelopment. Whatinformation should be included in this presentation? (Select all that apply.) a. Art play should be used sparingly. b. Use of computer/video gamesis detrimental. c. Understanding of child/parentrelationships can be gained by observing play. d. Play encourages self-expression. e. Play provides a sense of accomplishment. ANS: C, D, E Artis an appropriate play activity at almost any age and provides an avenue for experimentation as well asforINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 187 NURSINGTB.COM creative expression and a feeling of accomplishment in the child. Observing the child at play can aid in assessing growth and development and understanding the childsrelationships with family members. Any planINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 188 NURSINGTB.COM of care for a hospitalized child of any age should include a play activity that either encourages growth and development or encouragesthe expression ofthoughts and feelings. Computer programs are popular with allage groups, providing problem-solving skills, manipulative skills, and opportunitiesfor new learning. DIF: Cognitive Level: Comprehension REF: Page 387 OBJ: 12 | 15 TOP: Play KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 32. Parents attending a well visit for their 11-year-old son verbalize concern over his computer use. When asked aboutit, the boy states, I play games on my computer for 1 hour a day. The nurse knowsthat computergames can provide what opportunities to childhood development? (Select all that apply.) a. Problem-solving skills b. Gross motor development c. Manipulative skills d. Learning opportunities e. Increased self-worth ANS: A, C, D Computer programs are popular with all age groups, providing problem-solving skills,manipulative skills, and opportunities for new learning. DIF: Cognitive Level: Comprehension REF: Page 388 TOP: Computer Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 33. The nurse includesin the care plan for a Hispanic family to encourage visitsfromthe , or for a healing ceremony. ANS: folk healer, curandero NURSINGTB.COM Hispanics have faith in the effect of the curandero and are soothed by the ceremonies. DIF: Cognitive Level: Knowledge REF: Page 365 OBJ: 7 TOP: Folk Healer or Curandero KEY:Nursing Process Step: Planning MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 34. The nurse assesses an unmet need in a hospitalized child who clingsto his mother asshe is aboutto leave.As described by Maslow,the basic needsthat may be unmet in this case are and . ANS: love, belonging The hospitalized child displaying these symptomsmay feel a loss of love and a lack of belonging to the family unit. DIF: Cognitive Level: Knowledge REF: Page 364 OBJ: 8 TOP: Maslows Hierarchy KEY:Nursing Process Step:Data Collection MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 35. The nurse cautions that children who are put to sleep with a bottle are atrisk for a dental problem called . ANS: nursing cariesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 189 NURSINGTB.COM The bactericidal effects ofsaliva decrease during sleep;therefore, when the saliva and themilk combine,they bathe the teeth in a mixture that encourages dental caries. DIF: Cognitive Level: Knowledge REF: Page 386 OBJ: 9 TOP: Nursing Caries KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 36. The correct term for the child aged 4 weeksto 1 year is . ANS: infant A child between the ages of 4 weeks and 1 year istermed an infant. DIF: Cognitive Level: Knowledge REF: Page 356 TOP: Infant KEY: Nursing Process Step:N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 37. refersto standing measurement, whereas referstomeasurement while the infant is ina recumbent position. ANS: Height, length Heightrefersto standing measurement, whereaslength refersto measurement while the infantisin a recumbent position. DIF: Cognitive Level: Knowledge REF: Page 357 TOP: Physical Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and MainteNnaUn Rc Se: INGGro TwBt .ChOanMd DevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 190 NURSINGTB.COM Chapter 16: The Infant MULTIPLE CHOICE 1. A mother callsthe pediatricians office because herinfantis colicky. Whatisthemost helpful measure thenurse can suggest to the mother? a. Sing songsto the infant in a soft voice. b. Place the infantin a well-litroom. c. Walk around and massage the infants back. d. Rock the fussy infantslowly and gently. ANS: D One technique the nurse can offer parents of a fussy infantisto rock the infant gently and slowly while being careful to avoid sudden movements. DIF: Cognitive Level: Application REF: Page 400 OBJ: 7 TOP: Colic KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. When doesthe posteriorfontanelle close? a. 2 to 3 months b. 3 to 6 months c. 6 to 9 months d. 9 to 12 months ANS: A The posteriorfontanelle closes between 2 and 3 months of age. DIF: Cognitive Level: Knowledge REF: Page 396 OBJ: 5 TOP: Fontanelle KEY: Nursing ProcesNsUSRteSpIN: DGaTtBa.CCoOlMlection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 3. At what age does an infants birth weighttriple? a. 9 months b. 1 year c. 18 months d. 2 years ANS: B The infant usually triples his or her birth weight by about 12 months of age. DIF: Cognitive Level: Knowledge REF: Page 400 OBJ: 3 TOP: Development and Care KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 4. What isthe earliest age at which an infantis able to sitsteadily alone? a. 4months b. 5months c. 8months d. 15 months ANS: C The infant can sit alone withoutsupport at about 8 months of age. DIF: Cognitive Level: Knowledge REF: Page 398 OBJ: 5 TOP: Sitting Alone KEY:Nursing Process Step:Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 191 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 192 NURSINGTB.COM 5. Whatisthe earliest age at which the infantshould be able to walk independently? a. 8 to 10 months b. 12 to 15 months c. 15 to 18 months d. 18 to 21 months ANS: B Forthe majority of children,the milestone of walking alone is achieved between 12 and 15months. DIF: Cognitive Level: Knowledge REF: Page 400 OBJ: 5 TOP: Walk Independently KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 6. The parent of a 3-month-old infant asksthe nurse, At what age do infants usually begin drinking from acup? What is the nurses most accurate response? a. 5months b. 9months c. 1 year d. 2 years ANS: A The infant can usually drink from a cup when it is offered at about 5 months. DIF: Cognitive Level: Comprehension REF: Page 397 TOP:Drink fromCup KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 7. What would the nurse expect a 4-month-old to be able to accomplish? a. Hold a cup. b. Stand with assistance. c. Lift head and shoulders. d. Sit with back straight. NURSINGTB.COM ANS: C Because developmentis cephalocaudal, of these choices, lifting the head and shouldersisthe one that the infant learnsto do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months. DIF: Cognitive Level: Comprehension REF: Page 397 OBJ: 3 TOP: Development and Care KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 8. Whatis an abnormal finding in an evaluation of growth and developmentfor a 6-month-old infant? a. Weight gain of 4 to 7 ounces per week b. Length increase of 1 inch in 2 months c. Head lag present d. Can sit alone for a few seconds ANS: C The infantshould be holding the head up well by 5 months of age. If head lag is present at 6 months,the child should undergo further evaluation. DIF: Cognitive Level: Analysis REF: Page 397 OBJ: 3 TOP: Head Control KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 193 NURSINGTB.COM 9. A parent brings a 6-month-old infantto the pediatric clinic for her well-baby examination. Her birth weightwas 8 pounds, 2 ounces. What will the nurse weighing the infant today would expect her weight to be? a. Atleast 12 pounds b. Atleast 16 pounds c. Atleast 20 pounds d. Atleast 24 pounds ANS: B Birth weight is usually doubled by 6 months of age. DIF: Cognitive Level: Application REF: Page 397 OBJ: 3 TOP: Development and Care KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. What willthe nurse advise a parentto do when introducing solid foods? a. Begin with one tablespoon of food. b. Mix foodstogether. c. Eliminate a refused food from the diet. d. Introduce each new food 4 to 7 days apart. ANS: D Only one new food is offered in a 4- to 7-day period to determine tolerance. DIF: Cognitive Level: Comprehension REF: Page 407 TOP: Solid Food KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 11. The nurse istalking with a parent abouttooth eruption. What teeth willthe nurse explain are the first deciduousteeth to erupt? a. Lower central incisors b. Upper central incisors c. Lower lateral incisors d. Upper lateral incisors NURSINGTB.COM ANS: A The first teeth to erupt, usually at about 7 months, are the lower central incisors. DIF: Cognitive Level: Knowledge REF: Page 398 OBJ: 5 TOP: Development and Care KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 12. The nurse is assessing developmentin a 9-month-old infant. What would the nurse expect to observe? a. Speaking in 2-word sentences b. Grasping objects with palmar grasp c. Creeping along the floor d. Beginning to use a spoon rathersloppily ANS: C The 9-month-old triesto creep, has developed pincer movement, and can grasp a spoon without keeping foodon it. DIF: Cognitive Level: Analysis REF: Page 399 OBJ: 3 TOP: Development and Care KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 194 NURSINGTB.COM 13. Whatstatementmade by a parentindicates correct understanding ofinfantfeeding?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 195 NURSINGTB.COM a. Ive beenmixing rice cereal and formula in the babys bottle. b. Iswitched the baby to low-fat milk at 9 months. c. The baby really likeslittle pieces of chocolate. d. I give the baby any new foods before he takes his bottle. ANS: D New solid foodsshould be introduced before formula or breast milk to encourage the infant to try new foods. DIF: Cognitive Level: Comprehension REF: Page 407 OBJ: 15 TOP: Nutrition Counseling KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. A motheris concerned because her 10-month-old islethargic. Whatisthe best action the nurse can advisethis mother to implement? a. Keep the infantsroom well lit. b. Rub the infantssoles vigorously. c. Offer the infant a pacifier. d. Handle the infantslowly and gently. ANS: D Some infantsrespond to stimulating environments by shutting down. Move and handle infantsslowly and gently. DIF: Cognitive Level: Application REF: Page 401 TOP: Lethargy KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 15. The nurse discusses child-proofing the home forsafety with the mother of a 9-month-old. Which statementmade by the mother would indicate an unsafeNbeUhRaSvIiNorG?TB.COM a. I put covers on all of the electrical outlets. b. In the car,she ridesin a front-facing carseat. c. There are locks on all of the cabinets in the house. d. I have a gate at the top and bottom of the stairs. ANS: B A rear-facing infant carseatshould be used for infants younger than 1 year of age. DIF: Cognitive Level: Analysis REF: Page 409 TOP: Infant Safety KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. The nurse observes a 10-month-old infant using herindex finger and thumb to pick up pieces of cereal.What does this behavior indicate the infant has developed? a. The pincer grasp b. A grasp reflex c. Prehension ability d. The parachute reflex ANS: A By 1 year, the pincer-grasp coordination ofindex finger and thumb is well established. DIF: Cognitive Level: Comprehension REF: Page 393 OBJ: 3 TOP: General Characteristics KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. A parentis concerned because herinfant has a diaperrash. Whatisthe best action the nurse would advisethe parent to implement?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 196 NURSINGTB.COM a. Use commercial diaper wipesto clean the area. b. Apply a protective ointment on the area. c. Change the infants diaperlessfrequently. d. Keep the diaper area covered all of the time. ANS: B A protective ointment can be applied when the skin in the diaper area appears pink and irritated. DIF: Cognitive Level: Application REF: Page 402 TOP:Diaper Rash KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 18. The mother of an infant born prematurely tells the nurse, The baby is irritable. She cries during diaper changes and feedings. Can you make some suggestions about whatIshould do to soothe her? Whatisthe mostappropriate recommendation to help this parent? a. Play the radio or TV while you feed the infant. b. Putthe infantin a room with sunlight. c. Wrap the infantsnugly when you hold them. d. Change the infants position quickly. ANS: C A strategy that may be helpful isto swaddle the infantsnugly in a light blanket with extremitiesflexed and hands near the face. DIF: Cognitive Level: Application REF: Page 400 OBJ: 7 TOP: Infant Care KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. Whatisthemost appropriate activity to recommend to parentsto promote sensorimotorstimulation for a 1- year-old? a. Ride a tricycle. b. Spend time in an infantswing. c. Play with push-pulltoys. d. Read large picture books. NURSINGTB.COM ANS: C Push-pulltoys are appropriate to promote sensorimotorstimulation for a 1-year-old child. DIF: Cognitive Level: Analysis REF: Page 410 OBJ: 18 TOP: Infant Safety KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 20. Which statementindicatesthemother of an 8-month-old understandsinfantsleep patterns? a. I put the baby in my bed untilshe falls asleep,then I put her in her crib. b. I let the baby skip an afternoon nap so thatshe will fall asleep earlier. c. I put the pacifier in the crib so thatshe can find it when she wakes up. d. I rock the baby back to sleep ifshe wakes up at night. ANS: C The parentshould assist the infant to develop self-soothing behaviorsso that the infant can get back to sleep onher own. DIF: Cognitive Level: Analysis REF: Page 402 TOP: Sleep Patterns KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 21. Howmightthe nurse demonstrate the parachute reflex with an infant?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 197 NURSINGTB.COM a. Lifting the infant high in the air above her headINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 198 NURSINGTB.COM b. Holding the infant in a football hold, cradling the head c. Seating the infant in a stroller in an upright position d. Thrusting the infant downward into the crib ANS: D The infant, when thrust downward in a prone position, will protectively extend the arms. DIF: Cognitive Level: Comprehension REF: Page 393 TOP: Parachute Reflex KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. Parents of a 6-month-old infant ask the nurse why itis necessary to offer iron-rich formula to their child.What is the correct response? a. The infant haslimited ability to produce red blood cells. b. The infant hasineffective digestive enzymes. c. The infant has exhaustedmaternal iron stores. d. The infant has need of the iron to support dentition. ANS: C Many pediatriciansrecommend iron-fortified formulas becausematernal iron stores decrease by 6months of age. DIF: Cognitive Level: Comprehension REF: Page 404 TOP: Iron Supplement KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 23. The nurse is assessing a 1-year-old infantin the pediatric office. Whatfinding should the nurse report to thephysician immediately? a. Respiratory rate of 60 breaths per minute b. Pulse rate of 100 beats per minute c. Minimal verbalization d. Fussy behavior NURSINGTB.COM ANS: A Respirations of a 1-year-old should be 20 to 40 breaths perminute. Increased respiratory rate can lead to distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal verbalization and fussy behavior are not emergency situations or abnormal for this age. DIF: Cognitive Level: Application REF: Page 400 OBJ: 2 TOP: 12-Month-Old Physical CharacteristicsKEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 24. A newmotheris voicing concern she is breastfeeding her newborn too frequently. How often does thenurse instruct this mother she should expect her newborn to feed? a. Every 2 to 3 hours b. Every 4 to 6 hours c. Every 6 to 8 hours d. Every 8 to 10 hours ANS: A Breastfed infantsmay require feedings at 2- to 3-hourintervals because breast milk ismore easily digested. A flexible butregularschedule that provides a rest period between feedingsis best forthe parent and infant. DIF: Cognitive Level: Application REF: Page 403 TOP: 12-Month-Old Physical Characteristics KEY: Nursing Process Step: Intervention MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 199 NURSINGTB.COM MULTIPLE RESPONSE 25. The nurse cautionsthat children who have unmet hunger needs will likely display which characteristic(s)?(Select all that apply.) a. Irritability b. Ineffective feeding patterns c. No predictable sleep-wake cycle d. Distrust e. Effective parent bonding ANS: A, B, C, D Children who experience frequent hunger do not have effective parental bonding. All other options are probable outcomes for a child who has unmet hunger needs. DIF: Cognitive Level: Comprehension REF: Page 404 OBJ: 3 TOP:Hunger KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 26. The nurse is preparing to outline principles of discipline for parents of an infant. What information shouldthe nurse include? (Select all that apply.) a. Firmly say No. b. Distractthe child to another activity. c. Bribe the child with a sweet treat. d. Remain consistent. e. Ignore the child until behaviorimproves. ANS: A, B, D Parental approval isimportantto the infant, and setting limits early isimportant (Anderson, 2008). Principlesof discipline for an infantinclude lowering the voice to say no firmly,removing the child from the situation, distraction, and consistency. NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 393 OBJ: 4 TOP: Discipline KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 27. Whatshould the teaching plan include aboutinfantfall precautions? (Select allthat apply.) a. Remove all unsteady furniture. b. Keep crib rails up and in locked position. c. Steady infant with hand when on changing table. d. Use tray attachment on high chair asrestraint. e. Keep infantseat on the floor. ANS: A, B, C, E The tray attachment to a high chairis an inadequate restraint. All other options are good precautionsto preventan infant from a fall. DIF: Cognitive Level: Comprehension REF: Page 409 TOP: Fall Prevention KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Reduction of Risk 28. The nurse is aware thatthe 7-month-old can signal feeding readiness by which action(s)? (Select all thatapply.) a. Pulling spoon toward mouth b. Biting atspoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement atsight of food e. Manipulating finger foodsINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 200 NURSINGTB.COM ANS: A, EINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 201 NURSINGTB.COM The 7-month-old pullsthe spoon toward his or her mouth and canmanipulate fingerfoods. The 7-month-old does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food. DIF: Cognitive Level: Comprehension REF: Page 404 OBJ: 3 TOP: Feeding Skills KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 29. The nurse is educating parents of a 2-month-old aboutimmunizations. Whatimmunizations against illnessshould their child receive? (Select all that apply.) a. Pertussis(whooping cough) b. Influenza c. Diptheria d. Tetanus e. Polio ANS: A, B, C, D, E The first DPT, polio, and flu immunizations are given atthe age of 2months. DIF: Cognitive Level: Knowledge REF: Page 396 OBJ: 6 TOP: Immunizations KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection 30. What willthe nurse take into consideration when educating parentsregarding infant nutrition? (Select allthat apply.) a. Cultural practices b. Sex of the infant c. Parental knowledge d. Infants developmental level e. Parent-child interaction NURSINGTB.COM ANS: A, C, D, E Parents have many concerns about feeding their infant during the first year of life. This is a period when readinessto receive nutrition education is usually high; therefore the nurse looksfor opportunitiesto provide accurate information. Assessment of parental knowledge; infant development, behavior, and readiness; parent-child interaction; and cultural and ethnic practicesisimportant. Sex of the infant does not enter into nutritionaleducation. DIF: Cognitive Level: Comprehension REF: Page 403 OBJ: 10 TOP:Nutrition KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. Parents of an infant informthe nurse they are planning home preparation ofsolid foods. What directionsshould the nurse provide? (Select all that apply.) a. Boil foodsin a large amount of water. b. Do not freeze foods. c. Add 1 teaspoon of salt per cup. d. Puree food in electric blender. e. Add sugarsparingly. ANS: D, E Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly. Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foodsmaybe frozen in ice cube trays and defrosted for use. DIF: Cognitive Level: Comprehension REF: Page 407INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 202 NURSINGTB.COM OBJ: 12 | 13 TOP: Nutrition KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 203 NURSINGTB.COM MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 32. The nurse explainsthatthe second process ofself-mobility an infantlearnsisseen at the age of 9 months,when the infant beginsto . ANS: creep At 7 monthsthe infant beginsto crawl, using arms and dragging trunk and legs. At 9monthsthe infant begins to creep, holding his or hertrunk above the floor. The nextself-mobility activity is cruising, where the child walks from one piece of furniture to the next before it begins to walk independently. DIF: Cognitive Level: Application REF: Page 395 OBJ: 3 TOP: Creeping KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 33. The nurse cautions parentsto place their infant in the position,rather than on his or herstomach, to reduce the risk of sudden infant death syndrome (SIDS). ANS: supine The supine orside-lying position has been found to reduce possible aspiration and is believed to reduce the riskof SIDS. DIF: Cognitive Level: Application REF: Page 401 TOP: Positionsfor Sleep KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk NURSINGTB.COM 34. is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant. ANS: Colic Colic is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant. DIF: Cognitive Level: Knowledge REF: Page 401 TOP: Colic KEY:Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. The nurse explains that an infants prehensile development is progressive and logical. Arrange the developmentin the orderfrom the simplestto the most complex. Put a comma and space between each answerchoice (a, b, c, d, etc.) a. Hands held open most of the time b. Grasps with thumb on one side and three fingers on the other c. Picks up toy with squeeze action d. Thumb and forefinger hold object e. Hands held closed most of the time ANS: E, A, C, B, D The development advancesfrom the newborns closed handsto the open star hands of the olderinfant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger. DIF: Cognitive Level: Analysis REF: Page 394INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 204 NURSINGTB.COM OBJ: 3 TOP: Prehensile Development KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 205 NURSINGTB.COM Chapter 17: The Toddler MULTIPLE CHOICE 1. Which behaviorreported by a parent of an 18-month-old toddler would the nurse report to the pediatricianas a cause for concern? a. Hastempertantrums b. Feedsselfsloppily c. Walks by holding onto furniture d. Speaksin shortsentences ANS: C By 18months, a toddlershould have been walking alone forseveral months. The toddler who walks holding onto furniture should be evaluated by a developmental specialist. DIF: Cognitive Level: Analysis REF: Page 413 OBJ: 2 TOP: Delayed Walking KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. What would the nurse assessing growth and development of a 2-year-old child expect to find? a. The child jumps with both feet. b. Twenty deciduousteeth have erupted. c. The child can hop on one foot. d. The child has a vocabulary of 900 words. ANS: A The 2-year-old can jump with both feet. The remaining achievements occur after 2 years of age. DIF: Cognitive Level: Comprehension REF: PNaUgeRS4I1N3GTB.COM OBJ: 2 TOP:Jumping KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 3. A parentremarks, My 18-month-old daughter carries her blanket around everywhere. Isthis normal? Whatis the best explanation a nurse who has an understanding of toddler development might give? a. She carries her blanket because she isritualistic. b. Carrying herfavorite blanketisself-consoling behavior. c. This behavior can be discouraged by offering new toysto the child. d. This could be indicative of emotional distress. ANS: B Favorite possessions and repetitive rituals are self-consoling behaviorsfor the toddler. DIF: Cognitive Level: Application REF: Page 412 OBJ: 6 TOP: Self Consoling KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 4. The nurse observed three toddlers playing side by side with dolls. Closer observation revealed that thechildren were not interacting with one another. What type of play is this? a. Solitary b. Parallel c. Associative d. Cooperative ANS: B Toddlers engage in parallel play. Children play nextto, but not with, each other.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 206 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 424INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 207 NURSINGTB.COM TOP: Play KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 5. Whatinstruction would the nurse include when planning anticipatory guidance for parents of a toddler? a. Adhere to a rigid schedule because the toddlerisritualistic. b. Limit-setting should include praise. c. Shoesshould fitsnugly atthe toe and arch. d. Dressthe toddler in pants with a zipperso that he orshe can learn to zip and unzip clothes. ANS: B Limit-setting should include praise as well as disapproval for undesired behavior. DIF: Cognitive Level: Application REF: Page 416 TOP: Limit Setting KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 6. Whatisthe best advice the nurse can offer a parent concerned because her 2-year-old is very active and doesnot eat much? a. Insist thatthe child eat one food on the plate. b. Help the child wind down with a quiet activity beforemealtime. c. Maintain a consistent eating schedule forthe family. d. Serve themeal with a variety of interesting plates, cups, and utensils. ANS: B Quiettime beforemeals provides an opportunity forthe active toddlerto wind down. DIF: Cognitive Level: Application REF: Page 419 TOP:Quiet Time KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 7. How would the nurse advise a parent who states, I never know how much food to feed my child? a. Serving sizesshould not exceed 1 teaspoon of each type of food. b. Food quantitiesmust be carefully measured to avoid overfeeding. c. Use 1 tablespoon of each food for each year of age as a guideline. d. A toddlershould eat three balancedmeals. Snacks are not necessary. ANS: C A tablespoon of each type of food for each year of age is a good guideline to follow when determining serving sizes. DIF: Cognitive Level: Application REF: Page 419 TOP: Food Portions KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 8. The nurse is discussing toilettraining with parents. What behavior by the child would identify toilet trainingreadiness? a. Willing to sit on the potty for 15 to 20 minutes b. Dry in the daytime for 4-hour periods c. Able to communicate that he orshe is wet d. Curious about bathroom activities ANS: C Children are ready for toilet training when they can communicate in some fashion thatthey are wet or need to urinate or defecate. DIF: Cognitive Level: Comprehension REF: Page 417 OBJ: 8 TOP: Toilet Independence KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 208 NURSINGTB.COM 9. Whatisthe most appropriate toy for the nurse to select for a normal 2-year-old child? a. Bicycle with training wheels b. Dump truck c. Wind-up toy d. Building block set ANS: B The 2-year-old enjoys playing with objectsthat can be pushed or pulled. DIF: Cognitive Level: Application REF: Page 424 TOP: Toys and Play KEY: Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 10. What could the nurse recommend to a childsmother to encourage a toddlerto practice independence? a. Offer a variety of itemsto choose from to stimulate his mind. b. Allow the child to determine his own daily routine. c. Offer him a choice between two items. d. Setthe routine herself, but discuss with hertoddler how he orshe would have done it differently. ANS: C The toddler can be allowed tomake choices asthe situation warrants, butthe number of choicesshould be limited because too many confuse the toddler. DIF: Cognitive Level: Application REF: Page 412 TOP:Offering Choices KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 11. On a home visit,the nurse notesthat the parentsrequire teaching intervention to protect the 15- month-oldchild who lives there. What observation would lead the nurse to this conclusion? a. The fireplace has a screen. NURSINGTB.COM b. The dining room table has a tablecloth on it. c. There are paintings on the wall. d. The kitchen floor is clean but notshiny. ANS: B A tablecloth presents a safety hazard because the curioustoddler willreach up and pull on it. The toddler couldbe injured if items on the table are moved when the tablecloth is pulled. DIF: Cognitive Level: Analysis REF: Page 421 OBJ: 10 TOP: Injury Prevention KEY:Nursing Process Step:Data Collection MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. What doesthe nurse consider as an appropriate snack for a 2-year-old child? a. Hot dog sections b. Grapes c. Popcorn d. Applesauce ANS: D Applesauce is a healthy and safe snack food for the toddler. The toddler is atrisk for choking on foodssuch as grapes, hot dogs, and popcorn. DIF: Cognitive Level: Analysis REF: Page 421 OBJ: 10 TOP: Injury Prevention KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 13. Which finding would concern the nurse assessing vitalsigns on a 2-year-old?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 209 NURSINGTB.COM a. Temperature of 37.1 C (98.8 F) b. Pulse at 100 beats/min c. Respirations of 36 breaths/min d. Blood pressure of 90/60 mm Hg ANS: C In the toddler period,the respiratory rate decreasesto 25 breaths/min. DIF: Cognitive Level: Analysis REF: Page 414 TOP: Vital Signs KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What would be an expected finding when assessing language developmentin a 2-year-old? a. A 900-word vocabulary b. Use oftwo-word sentences c. Use of pronouns and prepositions d. 100% ofspeech is understandable ANS: B The 2-year-old should be using two-word sentences. DIF: Cognitive Level: Analysis REF: Page 415 OBJ: 5 TOP: Speech Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 15. The nurse is planning to explain the use of time-outsto the parent of a 3-year-old. How manyminutes willthe nurse indicate is appropriate for a child of this age? a. 3 b. 6 c. 10 d. 15 NURSINGTB.COM ANS: A Timing fortime-outis usually based on 1 minute per year of age. DIF: Cognitive Level: Comprehension REF: Page 416 TOP:Guidance andDiscipline KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. The parent of a toddler tellsthe nurse, My daughters appetite has decreased. Thank goodnessshe loves todrink milk. What is the most appropriate response by the nurse? a. Has your daughter been sick recently? b. How much milk doesshe drink in a day? c. Hasshe become a fussy eater,too? d. Have you tried offering herfingerfoods? ANS: B Milk should be limited to 24 ounces a day. Too few solid foods can lead to dietary deficiencies of iron. DIF: Cognitive Level: Application REF: Page 419 TOP:Nutrition Counseling KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity 17. Howmany hoursshould toddlers be able to stay dry for the nurse to suggest they are ready to begin bladdetraining? a. 1 b. 2 c. 3INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 210 NURSINGTB.COM d. 4 ANS: B Ifthe toddlerismature enough to retain urine for 2 hours, bladdertraining can be effective. DIF: Cognitive Level: Comprehension REF: Page 418 TOP: Bladder Training KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. Parents tell the nurse they are frustrated with their toddlers recent behavior and refusal to agree with anything they ask of them. What doesthe nurse explain asthe term for when a toddler tests their own power? a. Negativism b. Dawdling c. Tantrums d. Food fads ANS: A By refusing to eat, dress, sleep, or anything else by saying No, toddlers test their own power to control. Because toddlers are also egocentric,they come to believe thattheir negativism is absolute. Thisis especially true if the adults give into it. DIF: Cognitive Level: Comprehension REF: Page 412 TOP:Negativism KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 19. The nurse is assessing a 3-year-old. Whatisthe expected weight gain for this age child? a. 2 timesthe birth weight b. 2.5 timesthe birth weight c. 3 timesthe birth weight d. 4 timesthe birth weight ANS: D NURSINGTB.COM The expected weight of a -year-old toddler isfour timesthe birth weight. DIF: Cognitive Level: Comprehension REF: Page 412 TOP:Weight Prediction KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 20. What guideline should an adult follow when speaking to a toddler? a. Be at eye level with the child. b. Hold by the shouldersto keep the childs attention. c. Seatthe child to focus on conversation. d. Speak in a firm strong voice. ANS: A Being at eye level is helpfulto hold the childs attention and is especially important when the child is frightened. DIF: Cognitive Level: Comprehension REF: Page 416 TOP: Conversing with Toddler KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. Why does day care forthe toddler differfrom that of the preschooler? a. Toddlers have a shorter attention span. b. Toddlers needmore group play. c. Toddlers are less prone to environmental dangers. d. Toddlersrequire less outdoorspace.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 211 NURSINGTB.COM ANS: AINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 212 NURSINGTB.COM Toddlers have a shorter attention span than preschoolers and are prone to investigate other opportunitiesin theenvironment that may put them in harms way. Toddlers are more interested in parallel play. DIF: Cognitive Level: Comprehension REF: Page 420 TOP: Day Care KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. A 16-month-old child is attending a well-child visit at a pediatric clinic. Which assessment would indicate the biggest cause for concern? a. Does not walk independently b. Prefersfinger feeding c. Limited to single words d. Is unable to climb steps ANS: A A child should be walking independently by 16months old. Itis normal for a child this age to prefer finger feeding and to be limited to single words. Many children do not climb steps until 24 months of age. DIF: Cognitive Level: Comprehension REF: Page 413 OBJ: 2 TOP: Development KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 23. When selecting a potty chair,the parents are encouraged to select one that has which characteristic(s)?(Select all that apply.) a. Small enough forthe childsfeet to touch floor b. Sturdy and stable c. Supportive of childs back and arms d. Made of plastic or fiberglass e. Capable of being taken apart easily NURSINGTB.COM ANS: A, B, C Potty chairsshould be small and sturdy and supportive ofthe childs back and arms. The composition is not important as long as it is stable. DIF: Cognitive Level: Comprehension REF: Page 418 TOP: Potty Chairs KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 24. The nurse suggests offering which food(s)to supportthe toddlers desire to self-feed? (Select allthat apply.) a. Pureed foods b. Finger foods c. Foodsserved cold d. Foodsin colorful dishes e. Foodsthat are varied and colorful ANS: B, D, E Fingerfoodsthat are varied and colorful and served in colorful dishes at amoderate temperature are all attractive. Foods can be chopped into small pieces but not pureed. DIF: Cognitive Level: Comprehension REF: Page 419 TOP: Self-Feeding KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 25. The nurse points outwhich physiological change(s) in the toddlerthatserve(s)as protection againstdisease? (Select all that apply.) a. Toughening of the skinINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 213 NURSINGTB.COM b. Increased capillary response for thermoregulation c. Stabilization of body temperature d. Elevation in white blood cell count e. Enlarged adenoids and tonsils ANS: A, B, C, E With the exception of an increased white blood cell (WBC) count, which is always pathological, the other options are all maturing changes that equip the toddler to better fight disease. DIF: Cognitive Level: Comprehension REF: Page 413 TOP: Physiological Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 26. Parents of a toddler are discussing the emotion of fear with the pediatric nurse. Whatinformation can thenurse offer regarding fear and the toddler? (Select all that apply.) a. Stressincreasesfear. b. Rituals help deal with fear. c. Teasing the child can decrease fear. d. Once fear islearned itis difficult to eliminate. e. Adultsshould openly share theirfears. ANS: A, B, D Once a fear has been learned, itis more difficultto eliminate. Clinging to favorite possessions and repetitive rituals are self-consoling behaviorsforthe toddler, particularly at bedtime and during separation from parents. Stressincreasesfear ofseparation. Adultsshould attemptto control their own fearsin the presence of young children. Respect and understanding should always be accorded to children who are afraid. Making fun of the fear or shaming the child in front of others is detrimental to self-esteem. DIF: Cognitive Level: Comprehension REF: Page 416 TOP: Fear KEY: Nursing Process Step: ImpleNmUeRntSaItNioGnTB.COM MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 27. The nurse assessing a 2-year-old issatisfied to see that the presentweight of the child is the birth weight. ANS: triple The birth weight has usually tripled by the time the child is 2 years of age. DIF: Cognitive Level: Comprehension REF: Page 412 TOP: Tripled Birth Weight KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 28. The nurse explainsthatwith the completion ofmyelination,the toddler will have the neuromuscularmaturity to attain or control. ANS: bowel, bladder With themature myelin,the toddleris able to translate neural impulses and respond in a significantmanner. With myelination, the toddler can now translate the feeling of a full bladder or bowel and respond by defecating or urinating at willhopefully in the bathroom. DIF: Cognitive Level: Comprehension REF: Page 413 TOP: Myelination KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 214 NURSINGTB.COM 29. The nurse recognizesthat when the toddler claims everything in the environment as mine, itis an exampleof the toddler trait of . ANS: egocentrism Toddlers are egocentric in thatthey perceive their world only asit appliesto them,such as MYmommy, MY dog, MY car, MY house, MY street. Asthey mature and havemore experience with the world,they come to a more realistic viewpoint. DIF: Cognitive Level: Comprehension REF: Page 424 OBJ: 2 TOP: Egocentrism KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 30. When the previously potty-trained 3-year-old wetsthe bed after admission to the hospital, the nurseassessesthis event is caused by a related to the new environment. ANS: regression Regression occurs when a situation causesthe person to go back to a lessmature manner of coping. Faced with the new situation, in this case a hospital admission,the toddlerrevertsto an earlier coping mechanism in whichpotty training has no part. The same regression frequently appears when a new infant is introduced to the family circle, or when a traumatic eventsuch as a death or divorce affects the family DIF: Cognitive Level: Comprehension REF: Page 418 TOP: Toddler Regression KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 31. The toddler isin Eriksonsstage of versus . NURSINGTB.COM ANS: autonomy;shame and doubt The toddlerisin Eriksonsstage of autonomy versusshame and doubt, which is based on a continuum of trust established during infancy DIF: Cognitive Level: Knowledge REF: Page 412 TOP: Eriksons Stages KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 32. is when toddlersincrease theirsense ofsecurity by making compulsiveroutines of simple tasks. ANS: Ritualism Ritualism is when toddlersincrease theirsense ofsecurity by making compulsive routines ofsimple tasks. DIF: Cognitive Level: Knowledge REF: Page 412 TOP: Ritualism KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 33. Putthe developmental milestonesin orderfrom first achieved to last achieved. Put a comma and spacebetween each answer choice (a, b, c, d, etc.) a. Jumps with both feet b. Holds a cup by the handle c. Socialsmile d. BabblesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 215 NURSINGTB.COM e. Understands no ANS: C, D, E, A, B Social smile: 2 months Babbles: 3 months Understands no: 9 months Jumps with both feet: 24 months Holds a cup by the handle: 36 months DIF: Cognitive Level: Analysis REF: Page 413 OBJ: 3 TOP: Physical Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 216 NURSINGTB.COM Chapter 18: The Preschool Child MULTIPLE CHOICE 1. Which statement best describesthe 3-year-old child? a. Boisterous,tattles on others b. Aggressive,shows off c. Helpful, wantsto assist with chores d. Talkative, inquisitive aboutthe environment ANS: C Three-year-old children are helpful and can assist in simple household chores. DIF: Cognitive Level: Comprehension REF: Page 431 TOP:Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis.What knowledge would act as the basis for the nurses response? a. This behaviorindicates a normal curiosity aboutsexuality. b. Masturbation suggeststhe boy has an excessive fear of castration. c. Itis usually a result of discomfort from a penile rash orirritation. d. The behavioris abnormal and the child should be referred for counseling. ANS: A Masturbation atthis age is common and indicatesthatthe preschooler has a normal curiosity aboutsexuality. DIF: Cognitive Level: Comprehension REF: Page 431 TOP: Masturbation KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and MainteNnaUnRc Se: INGGroTwBt .ChOanMd Development 3. A preschool-age child is asked, Why do trees have leaves? Which response would be an example ofanimism? a. So I can have shade over my sandbox. b. Because God made them that way. c. To hide behind when they are scared. d. Forthe squirrelsto play in. ANS: C Animism describesthe tendency of preschool children to attribute human characteristicsto nonhuman objects. DIF: Cognitive Level: Application REF: Page 428 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. Whattasks would be appropriate to expect of a 5-year-old? a. Setting the table with paper plates b. Washing the dirty knives c. Carrying glassesfrom the table to the sink d. Scrubbing outthe sink with cleanser ANS: A Parentsmust consider developmental level and safety when asking the 5-year-old child to help with chores. DIF: Cognitive Level: Application REF: Page 437 TOP:DevelopmentSafety KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 5. A 3-year-old child, while playing with hisfavorite toy in the playroom of the pediatric unit, is approachedINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 217 NURSINGTB.COM by another child who also wants to play with the same toy. What behavior willthe nurse anticipate from this child? a. Will play well with the other child b. Will give the toy up and then not play anymore c. Will become angry and a physicalresponsemight ensue d. Will ignore the toy and go on to something else ANS: C The 3-year-old child is egocentric and likely will become angry when others attemptto take his or her possessions. DIF: Cognitive Level: Application REF: Page 432 TOP: Display of Aggression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. A parentis concerned about her childrensreaction should their grandmother die. What understanding willguide the nurses response? a. Children are unlikely to notice their grandmothers absence if no one remindsthem. b. Young children often understand that other people die, but do not equate it with themselves. c. The childrensresponse will depend entirely on whether they have been acquainted with death before this. d. Children can understand the concept of a higher being much like adults can. ANS: B Between 3 and 4 years of age, the child becomes curious about death and dying. Theymay realize that others die, but they do not relate death to themselves. DIF: Cognitive Level: Comprehension REF: Page 432 TOP: Concept ofDeath KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 7. Whatisthemost appropriate intervention when dealing with occasional aggression in a 4-year-old child? a. Have the child take a time-outin the cornerfor 4 minutes. b. Spank the child at the time of the incident. c. Take away television privilegesforthe day. d. Send the child to hisroom for 30 minutes. ANS: A Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique. DIF: Cognitive Level: Application REF: Page 432 TOP: Limit Setting KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 8. A fatheris concerned about how long his preschool-age child will continue sucking histhumb. What is themost helpful response from the nurse? a. Most children willstop thumb-sucking naturally by school age. b. Over-the-countertreatmentsthat give a bad taste can be placed on the thumb to discourage the practice. c. Consistently touching the childsfingers whenever he sucks histhumb is most effective. d. Thumb-sucking is detrimentalto the eruption of the childsteeth and must be stopped assoon as possible. ANS: A Most children give up the habit of thumb-sucking by the time they reach school. DIF: Cognitive Level: Application REF: Page 435 TOP: Thumb-Sucking KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 9. How doesthe nurse characterize the play of 5-year-old children?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 218 NURSINGTB.COM a. Enjoying rough and tumble play b. Playing well-organized games c. Following rules d. Preferring inside activities ANS: C The 5-year-old wantsto play by the rules but cannot acceptlosing. The rules may be very strict or change as the game progresses. DIF: Cognitive Level: Comprehension REF: Page 429 OBJ: 13 TOP: Play KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 10. The nurse is discussing preschoolerssexual curiosity with the parent. Whatstatement by the mother leadsthe nurse to determine that the mother understands the information? a. Make up funny wordsfor body parts. b. Distract the child with a toy if they ask aboutsex. c. Answertheir questions when they ask. d. Tell them to ask you again when they are 6 year old. ANS: C Parentsshould provide sex education at the time the child asks aboutsex. DIF: Cognitive Level: Analysis REF: Page 431 TOP: Sexual Curiosity KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 11. Whattype of play ismost appropriate when planning care for a child withmoderate intellectualdeficiency? a. Exercise leg and arm muscles. NURSINGTB.COM b. Be educationally oriented to make up forlost time. c. Be adjusted tomental age rather than chronological age. d. Involve contactsports and aggressive physical activity with other children. ANS: C The nurse must considerthe childsmental age rather than her chronological age when selecting toysfor play. DIF: Cognitive Level: Application REF: Page 438 TOP: Play KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 12. Whatisthe nurses best advice to a parent about a preschoolersimaginary friend? a. Having imaginary friendsis a sign thatthe child haslow self-esteem. b. Itis common for preschoolersto have imaginary friends. c. Preschoolersinvent an imaginary friend when they feel overwhelmed. d. The best approach to dealing with an imaginary friend isto ignore them. ANS: B Imaginary friends are common and normal during the preschool period and servemany purposes,such asrelief from loneliness, mastery of fears, and acting as a scapegoat. DIF: Cognitive Level: Comprehension REF: Page 438 OBJ: 13 TOP: Imaginary Friend KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 13. Whatinterventionmightthe nurse suggest as helpful forthe child with enuresis? a. Applying an electric pad that gently shocksthe child b. Waking the child several times during the night to urinateINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 219 NURSINGTB.COM c. Decreasing fluid intake afterthe evening meal d. Increasing dietary fiberintake ANS: C If a child is experiencing enuresis, liquids after dinnershould be limited and the child should routinely void before going to bed. DIF: Cognitive Level: Application REF: Page 435 OBJ: 9 TOP: Enuresis KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. Whatshould the nurse suggest asthe most appropriate toy choice for a 3-year-old? a. A board game b. A small pet,such as a goldfish c. A large construction set d. Push-pulltoys ANS: C Large construction sets are suitable toysforthe preschool-age child. DIF: Cognitive Level: Application REF: Page 438 TOP: Play KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 15. The parent of a 3 -year-old child tellsthe nurse, My daughter pointsinstead ofspeaking whenever shewants me to getsomething for her, butshe understands me when I ask herto do something. Based on the parents comment, what does the nurse suspect? a. Age-appropriate language development b. An expressive language delay c. A receptive language delay d. A potential hearing deficit NURSINGTB.COM ANS: B An expressive language delay issuspected when the child understandsspoken language butis nottalking. DIF: Cognitive Level: Application REF: Page 432 OBJ: 3 TOP: Language Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. The parent of a 4 -year-old child tellsthe nurse, Bedtime is difficult. I cant get my son to go to bed at night.The nurse and the childs mother discuss options. What intervention is the most appropriate choice? a. Allow the child to put himself to bed when he istired. b. Let the child read in hisroom until he falls asleep. c. Establish a bedtime routine and use it consistently. d. Tire himoutwith physical activity before bedtime. ANS: C Parentsshould engage the child in quiet activities before bedtime and establish a ritualthatsignals readinessfor bedtime. DIF: Cognitive Level: Application REF: Page 431 TOP: Bedtime Habits KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. Whatfear is unique to the preschool period? a. Water b. Animals c. Bodily harmINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 220 NURSINGTB.COM d. Death ANS: C The fear of bodily harm, particularly the loss of body parts, is unique to thisstage. DIF: Cognitive Level: Knowledge REF: Page 432 TOP: Fear KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. A 4-year-old child tellsthe nurse she will not eat peas because they are green. Of whatisthis an example? a. Egocentrism b. Artificialism c. Animism d. Centering ANS: D The tendency to concentrate on a single outstanding characteristic of an object while excluding other featuresis known as centering. DIF: Cognitive Level: Application REF: Page 428 TOP: Centering KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 19. A 4-year-old child insists he has more money with a nickel than hisfather has with a dime. Whatisthis perception, as described in Piagets theory? a. Egocentrism b. Artificialism c. Animism d. Intuition ANS: D NURSINGTB.COM The intuitive stage, as described by Piaget, is prelogicalthinking thatis based on the outside appearance of objects. A nickel is larger than a dime and therefore more valuable. DIF: Cognitive Level: Comprehension REF: Page 428 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. What will children who are unable to expressthemselves with words often do? a. Become reclusive and introspective b. Develop other methods of verbal communication c. Engage inmore creative play d. Have tantrums and act out ANS: D Children with delayed communication skills will frequently have tantrums and act out when they are unable to make their needs known. DIF: Cognitive Level: Comprehension REF: Page 428 TOP: Tantrums KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 21. Which is an example of associative play? a. Two children playing house, one playing the role of the dad and the other playing themom b. Two children playing in a sand box, one building a wall and the other digging a hole c. Two children playing with sports-associated items, one with a football and the other with a bat d. Two children playing with a coloring book, one coloring pictures and the otherlooking at picturesANS: AINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 221 NURSINGTB.COM Associative play allowsthe preschoolersto use their enlarged vocabulary in play with other children to carryon conversations and describe scenarios for each to play. DIF: Cognitive Level: Analysis REF: Page 431 TOP: Associative Play KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. The nurse is educating a group of preschool parents aboutthe importance ofsafety. Which statement by aparent indicates the need for further education? a. I continue to provide a great deal of indirectsupervision formy child. b. My stairway is alwaysfree of clutter. c. I only leave my child in the carfor brief moments. d. Medications are keptin a locked cabinet. ANS: C Children must not play in or around the car or be left alone, even for a brief moment, in the car. Preschool children still require a good deal of indirect supervision to protect them from dangers that arise from their immature judgment or social environment. Stairways should be free of clutter and medications kept out ofreach. DIF: Cognitive Level: Comprehension REF: Page 437 TOP: Safety KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 23. Parents of a 5-year-old child tellthe nurse they are concerned abouttheir childsspeech development bystating, No one can understand him but us. What clinical classification of speech disorder does the nurse suspect? a. Global language delay b. Expressive language delay c. Language loss d. Articulation disorder NURSINGTB.COM ANS: D When parents are the only people to understand their preschool child, an articulation disorder issuspected. (SeTable 18-3.) DIF: Cognitive Level: Application REF: Page 430 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 24. What doesincluding play in the plan of care for a 5-year-old allow the child to do? (Select all that apply.) a. Exercise hisimagination b. Assume a role and act it out c. Offers an emotional outlet d. Avoid magical thinking e. Interact with other children ANS: A, B, C, E Benefits of play forthe preschoolerinclude exercising imagination, assuming a role and acting it out, offering an emotional outlet, and interaction with other children. Play employsthe use of magical thinking. DIF: Cognitive Level: Knowledge REF: Page 429 OBJ: 10 TOP: Purpose of Play KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 25. What developmental milestone(s) assistthe 5-year-old boy toward developing hissexual identity? (SelectINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 222 NURSINGTB.COM all that apply.) a. Beginsto be lessfocused on his mother b. Ignores both parentstotally c. Regressesto a more infantile level d. Forms a romantic attachmentto the mother e. Identifies with the parent of the same sex ANS: A, D, E Children of this age become lessfocused on the mother asthe central person and begin to identify with the parent of the same sex, forming a romantic attachment to the parent of the opposite sex. Thislittle boy mightsay, Im going to marry my mother. A little girl mightsay, Im going to marry my daddy. DIF: Cognitive Level: Application REF: Page 432 OBJ: 2 TOP: Romantic Attachment to Parent KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 26. Which bedtime preparation rituals are themost appropriate forthe nurse to suggest? (Select allthat apply.) a. Telling a story b. Placing a favorite toy in bed c. Placing a glass of water atthe bedside d. Turning on a night light e. Playing energetically ANS: A, B, C, D All options are soothing bedtime rituals except energetic playing, which would be stimulating and counterproductive to sleep. DIF: Cognitive Level: Comprehension REF: Page 431 TOP: Bedtime Habits KEY: Nursing Process SNtUepR:SIImNpGlTemB.eCnOtaMtion MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 27. The nurse points out what advantage(s) of a nursery school or preschool experience? (Select allthat apply.) a. Increasing self-confidence b. Fostering group cooperation c. Detecting adjustment problems d. Attainment oftoilettraining skills e. Playing experiences with other children ANS: A, B, C, E Nursery school increasesself-confidence, group cooperation,socialskills, and cooperative play.Objective observations by a nursery school instructor can detect early adjustment problems. The child is usually toilet trained prior to the start of preschool. DIF: Cognitive Level: Comprehension REF: Page 436 TOP: Advantages of Nursery School KEY: Nursing Process Step: ImplementationMSC: NCLEX:Health Promotion and Maintenance: Growth andDevelopment 28. Whichmajor developmentaltasks willthe nurse expect a child to accomplish by the end of the preschoolyears? (Select all that apply.) a. Development of parallel play b. Acceptance ofseparation c. Increased communication skills d. Consistent appetite e. Control of bodily functions ANS: B, C, EINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 223 NURSINGTB.COM Themajortasks ofthe preschool child include preparation to enterschool, development of a cooperative typeof play, control of body functions, acceptance ofseparation, and increase in communication skills, memory,INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 224 NURSINGTB.COM and attention span. Appetite remainsinconsistent. DIF: Cognitive Level: Comprehension REF: Page 427 TOP: Major Developmental Tasks. KEY: Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth and Development COMPLETION 29. When planning an activity for a 3-year-old, the nurse basesthe plan on the average attention span of minutes. ANS: 15 The average attention span of the preschooleris about 15minutes. DIF: Cognitive Level: Comprehension REF: Page 429 OBJ: 3 TOP: Attention Span of Preschooler KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 30. Play thatis designed to retrainmuscles orimprove eye-hand coordination is considered play. ANS: therapeutic Therapeutic play, whether at home orin a clinic orrehab center, is designed to retrainmuscles,strengthen muscles, or improve eye-hand coordination DIF: Cognitive Level: Knowledge REF: PageN4U39RSINGTB.COM TOP: Therapeutic Play KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. The gradualtransfer of behavioral control from the parentto the child is accomplished through . ANS: discipline Through discipline the parent gradually gives up behaviorself-controlto the child.DIF: Cognitive Level: Comprehension REF: Page 433 TOP:Discipline KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 32. is a preschoolersidea that the world and all of its contents are created by people. ANS: Artificialism Artificialism isthe beliefthat allthingsin the world have been created by people.DIF: Cognitive Level: Knowledge REF: Page 428 TOP: Artificialism KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 33. isseen in the play of children who pretend that an empty box is a fort;they create a mental image to stand for something that is not there. ANS:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 225 NURSINGTB.COM Symbolic functioning Symbolic functioning isseen in the play of children who pretend that an empty box is a fort; they create a mental image to stand for something that is not there. DIF: Cognitive Level: Knowledge REF: Page 428 TOP: Symbolic Functioning KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 34. Putthe stages ofseparation anxiety in order from firstto last. Put a comma and space between each answerchoice (a, b, c, d, etc.) a. Detachment b. Regression c. Despair d. Protest ANS: D, C, A, B The preschool childmay feel abandoned by the parents and continuesto be subjectto separation anxiety. Separation anxiety is manifested by the stages of protest, despair, detachment, and regression. DIF: Cognitive Level: Comprehension REF: Page 439 TOP: Separation Anxiety KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 226 NURSINGTB.COM Chapter 19: The School-Age Child MULTIPLE CHOICE 1. The nurse is assessing a school-age child. What willthe nurse expectin regard to physical development ofthis child? a. Growth of 3 to 6 inches per year b. Gain of 5 to 7 pounds per year c. Increase of head circumference by 1 inch per year d. A visual acuity of 20/20 by 9 years of age ANS: B During the school-age period,the average weight gain per yearis generally 5.5 to 7 pounds. DIF: Cognitive Level: Knowledge REF: Page 443 TOP: Physical Growth KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. Whatshould the nurse keep in mind when planning to teach a class on nutrition to fourth-grade students? a. School-age children can concentrate on only one aspect of a situation. b. School-age children can think abstractly. c. School-age children are egocentric in their thinking. d. School-age children think logically and concretely. ANS: D Piagetrefersto the thought process of this period as concrete operations, which involveslogicalthinking andan understanding of cause and effect. DIF: Cognitive Level: Comprehension REF: Page 442 OBJ: 3 TOP: Cognitive Development KEY:Nursing Process Step: Planning NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 3. Whattype ofrelationships are the preferred social interactionsforthe school-age child? a. Heterosexual interest groups b. Association with one bestfriend c. Rigidly organized groups with complex rules d. Same-sex peer groups ANS: D The preferred social interaction ofthe school-age child isin same-sex peer groups or cliques. DIF: Cognitive Level: Analysis REF: Page 443 TOP: Social DevelopmentPlay KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse is advising parents of a 10-year-old boy aboutthemost developmentally supportive experiencesfor their son. What is the best experience for this child according to Eriksons theory? a. Constant variety of activities b. Successful performance in Little League c. Feeling healthy and strong d. Having a girlfriend ANS: B The child who issuccessful in activities will feel positively about himself or herself. DIF: Cognitive Level: Analysis REF: Page 443 TOP: Psychosocial Development KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 227 NURSINGTB.COM MSC: NCLEX: Health Promotion and Maintenance: Growth and DevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 228 NURSINGTB.COM 5. The parents of an 8-year-old tellthe nurse the child wakesthe household crying out during his frequentnightmares. What is the nurses most helpful response to explain nightmares? a. They are a normal extension of the childsfear of mutilation. b. They are an abnormalresponse to repressed feelings. c. They are a common result of latentsexuality. d. They are a side effect of overactivity and stimulation. ANS: A The nightmares experienced by an 8-year-old are an extension of their characteristic fear ofmutilation. DIF: Cognitive Level: Comprehension REF: Page 452 OBJ: 3 TOP: Eight-Year-Old KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 6. Whatisthe bestsuggestion by the nurse for an appropriate toy for a hospitalized 6-year-old boy? a. Handheld video game b. MP3 player c. Adventure book d. Jigsaw puzzle ANS: A The 6-year-old child can performnumerousfeatsthatrequiremuscle coordination. Atthis age, the handheld video game will offer nonaggressive competition. DIF: Cognitive Level: Analysis REF: Page 452 OBJ: 3 TOP: Six-Year-Old KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 7. The nurse discusses preparation for school wNUithRSthINe GpaTrBen.CtsOoMf a 6-year-old girl who will soon be starting first grade. Whatstatement by the girlsfatherleadsthe nurse to determine thatthe parents understood the information? a. We should put a stop to herthumb-sucking. b. Well have a talk about whatschool islike. c. We will let her walk to the bus stop by herself. d. Well have hermeetsome children who will be in her class. ANS: D To prepare a child forschool, parents can arrange forthe child to meet other children who will be entering school with her. DIF: Cognitive Level: Application REF: Page 446 OBJ: 4 TOP: Parental Guidance for Starting School KEY: Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 8. A 9-year-old boy is often cranky and irritable, and hisschool performance has declined. Whatisthe mostprobable factor causing this behavior? a. He sleeps only 6 to 7 hours a night. b. He eats eggs every day. c. He has a new dog. d. He plays about 1 to 3 hours each evening. ANS: A The 9-year-old child requires about 10 hours ofsleep per night. DIF: Cognitive Level: Application REF: Page 449 TOP:Nine-Year-Old KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 229 NURSINGTB.COM 9. A parent asked the nurse,At what age are children capable of assuming more responsibility for personalbelongings? What is the nurses best response based on knowledge of growth and development? a. 6 years b. 7 years c. 9 years d. 12 years ANS: C The 9-year-old is dependable and assumesmore responsibility for personal belongings. DIF: Cognitive Level: Comprehension REF: Page 448 TOP: Nine-Year-Old KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 10. The school nurse is preserving a tooth that was knocked out on the school playground. What willthe nursebe especially careful to do? a. Wrap the tooth loosely in a clean cloth. b. Rinse the tooth with alcohol. c. Handle the tooth only by the crown. d. Place the tooth in a warmenvironment. ANS: C When a permanenttooth is avulsed,the tooth should be picked up by the crown to prevent any further damageto the root and placed in milk until the child can be examined by a dentist. DIF: Cognitive Level: Application REF: Page 447 OBJ: 7 TOP: Safety KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A parent states, My 7-year-old really wantNsUaRdSoIgN. GHTisB1.C0O-yMear-old brother has allergies to animal dander. I dont know what to do. What type of petshould the nurse suggest as the best choice? a. A small breed of dog because the large dogs produce more allergens b. An older unneutered dog that producesfewer allergensthan a younger one c. A cat because itrequiresless care and isless allergenic d. A poodle, which does notshed, making it a good choice for people with allergies ANS: D The poodle does not have a shed cycle and so it may be the least offensive petfor the allergic child. DIF: Cognitive Level: Analysis REF: Page 456 TOP: PetOwnership KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. When asked about her activities, a 10-year-old girlresponded, I like school. I play the flute in the schoolband, and I take tennislessons. What does the nurse know these activities will help this child develop? a. Initiative b. Industry c. Identity d. Intimacy ANS: B The school-age period isreferred to by Erikson asthe stage of industry. Successful participation in activities facilitates the childs sense of industry. DIF: Cognitive Level: Application REF: Page 442 TOP: Psychosocial Development KEY:Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and DevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 230 NURSINGTB.COM 13. A mother reportsthatshe has a new job and her 12-year-old child is home alone for a time afterschool.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 231 NURSINGTB.COM Which statement made by the parent alertsthe nurse to a potentially unsafe situation for this child? a. Itold him that he could invite a few friends afterschool. b. I put a list of emergency numbers nextto the telephone. c. Last week we made a first aid kit together. d. There is a neighbor available in case of an emergency. ANS: A Latchkey children are subjectto a higherrate of accidents. Permitting school-age children and theirfriends tobe home alone in an unsupervised environment is an unsafe situation. DIF: Cognitive Level: Application REF: Page 447 TOP: Latchkey Children KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. A motheris concerned because her 9-year-old boy has developed the habit of twitching his eyes andflipping his hair while communicating with anyone. What isthe best nursing response to this parent? a. Thismay indicate that he needs eyeglasses. b. Children sometimes do these thingsfor attention. c. This behaviorsuggestslow self-esteem. d. Tics appear when a child is understress. ANS: D The child cannot help such actions and should not be scolded forthem because they are mainly a result of tension. DIF: Cognitive Level: Application REF: Page 449 TOP: Nine-Year-Old KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 15. A seventh-grade girl tells the school nurseNthUaRtShIeNrGarTtBte.CacOhMer, a woman, is her hero. What is the most appropriate interpretation of the girls comment? a. The studentmay be exploring her career options. b. The commentis cause for concern aboutsexual abuse. c. The childmay have difficulty interacting with her peers. d. Hero worship is a normal phenomenon. ANS: D School-age children tend to admire theirteachers and adult companions. For the 11- to 12-year-old, hero worship is a normal phenomenon. DIF: Cognitive Level: Comprehension REF: Page 454 OBJ: 3 TOP: Social Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. Which stage of cognitive developmentis a 9-year-old child in according to Piaget? a. Formal operations b. Preoperational c. Concrete operations d. Sensorimotor ANS: C School-age children are in the concrete operationsstage of cognitive development. DIF: Cognitive Level: Knowledge REF: Page 442 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and DevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 232 NURSINGTB.COM 17. Whatstatement by an 11-year-old leadsthe nurse to determine he has moved from the mind set ofINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 233 NURSINGTB.COM egocentrism? a. I am a member of the best Cub Scout group in the world. b. I must do my homework before I can play. c. My dad can do anything! d. Im sorry. I betthat hurt your feelings. ANS: D The ability to see anothers point of view indicatesmoving away fromegocentrism into a more altruistic mindset. DIF: Cognitive Level: Analysis REF: Page 452 OBJ: 3 TOP: Increasing Understanding KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. A school-age child becomesfrustrated with a school assignment and says, I cant do this! Whatisthe mostdevelopmentally supportive response from the parent? a. Ask, Whatisitthat isso difficult? b. Allow the child to quitthe effort. c. Call in oldersiblingsto help. d. Finish the project forthem. ANS: A Helping the child focus on the problem thatis keeping him from mastery can limitfrustration.Quitting or having someone else finish is detrimental to the development of industry. DIF: Cognitive Level: Analysis REF: Page 442 TOP: Industry KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COM 19. Whatis best for the nurse to suggest to the parents of an overweight 9-year-old to help prevent obesity? a. Use wholemilk as a between-mealsnack because itis more filling than skim milk. b. Feed the child before familymealtimestomonitor intake more closely. c. Encourage the child to engage in physical activity for at least an hour a day. d. Remove allsweets and junk food from the house. ANS: C Regular physical activity reduces weight. DIF: Cognitive Level: Comprehension REF: Page 451 OBJ: 7 TOP: Prevention of Obesity KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 20. A parent confidesin the school nurse that her 8-year-old twins argue and bicker constantly. Whatis thebest response by the nurse? a. Express alarmatthe constant aggression. b. Voice concern and investigate referral for counseling. c. Inquire about what punitive action the parents have taken to stop it. d. Offerreassurance thatsuch behavioris normal for 8-year-olds. ANS: D Argumentative and competitive behavioris normal in 8-year-olds. DIF: Cognitive Level: Application REF: Page 448 TOP: Argumentative Behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The school nurse is planning sex education classesforschool-age children. Whatshould the nurse be sureINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 234 NURSINGTB.COM to do? a. Use simple terms. b. Avoid slang orstreet words and concepts. c. Keep topics on biological aspects ofsexual development. d. Limit questionsto keep content clear. ANS: A Using simple termsis essential butslang and street terms need to be clarified. Apply age-specific information across broad aspects of biological,social, and current attitudes. DIF: Cognitive Level: Application REF: Page 444 OBJ: 7 TOP: Sex Education KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. Parents ask the pediatric nurse how school lifemightinfluence their growing child. What area ofdevelopment will the nurse indicate that school affects the least? a. Moral development b. Social development c. Physical development d. Cognitive development ANS: C Physical developmentisthe least affected by school life. Moral development occurs asthey have experience with, and understand, rules and fairness in the school setting. Schools have a profound influence on the socialization of children, who bring to school whatthey have learned and experienced in the home. Successin school requires an integration of cognitive, receptive, and expressive (language) skills. DIF: Cognitive Level: Application REF: Page 445 TOP: Impact of School Life KEY: Nursing PrNocUeRssSISNteGpT:BP.lCanOnMing MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 23. What basic feeling wordsshould the nurse use in attempting to help a 7-year-old girl express her feelingsabout being in a new school? (Select all that apply.) a. Mad b. Glad c. Sad d. Scared e. Jealous ANS: A, B, C, D The words mad, glad,sad, and scared are basic feeling wordsthat can prompt a young child to better express his or her feelings. DIF: Cognitive Level: Application REF: Page 451 OBJ: 3 TOP: Expression of Feelings KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 24. The school nurse is preparing an educational program for new teachersregarding school-age children.What information is accurate for the nurse to include? (Select all that apply.) a. Participation in group activity increases b. Egocentricity prevails c. Thinking islogical d. Preference istoward family interaction e. Understand cause and effectINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 235 NURSINGTB.COM ANS: A, C, E Piaget refers to the thought processes of the school age period as concrete operations. Concrete operations involve logical thinking and an understanding of cause and effect. The egocentric view of the preschool child is replaced by the ability to understand the point of view of another person. Between 6 and 12 years of age, children prefer friends of their own sex and usually prefer the companyof their friends to that of their brothers and sisters. DIF: Cognitive Level: Comprehension REF: Page 442 TOP: Personality Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. The pediatric nurse is presenting school-age children with information on safety issuesto follow whengoing home alone. What guidelines should they be educated to follow? (Select all that apply.) a. Ask foridentification before letting someone in the house. b. Never acceptrides with strangers. c. Keep doorslocked. d. Do not enter house if door is ajar. e. Walk to and from school with friends. ANS: B, C, D, E Strangers should never be allowed in the house. Children should be instructed never to accept rides with strangers, to keep doorslocked, not to enter the house if the dooris ajar, and to walk to and from school with friends. DIF: Cognitive Level: Comprehension REF: Page 447 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 26. A 10-year-old child with disabilitiesis begging her parentsfor a dog. When atthe pediatric clinic,the parents inquire about possible benefits pet owNneUrsRhSiIpNmGaTyBp.CroOvMide to their child. What benefits of pet ownership should the nurse indicate? (Select all that apply.) a. Decrease the need for physicaltherapy b. Lower blood pressure c. Improve communication d. Foster trust e. Ease path to socialization ANS: B, C, D, E Studies have documented the positive influence of pet ownership on improving themedical and psychologicaloutcome after illness or surgery. Disabled children especially benefit from interacting with pets. The interaction with animals can lower blood pressure and heart rate, reduce loneliness and feelings of isolation,improve communication, foster trust, and motivate participation in physical therapy. Pets allow the ill child who feels separated from other people to feel companionship and acceptance. Shy children often find pet ownership eases the path to socialization with others who initiate contact because of the pet. DIF: Cognitive Level: Comprehension REF: Page 455 OBJ: 8 TOP: Pet Ownership KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 27. The nurse advisesthe parents of a 6-year-old to try and ensure atleast hours ofsleep daily for thechild. ANS: 11INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 236 NURSINGTB.COM The 6-year-old school-age child needs atleast 11 hours ofsleep.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 237 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 448 TOP: Sleep Needs KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 28. The nurse remindsthe parents who are trying to select a dog fortheir allergic child that the best selectionwould be a female dog that is and . ANS: young,spayed Young, neutered female dogs produce less allergens. DIF: Cognitive Level: Comprehension REF: Page 455 OBJ: 8 TOP: Pet Selection for Allergic Child KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 29. When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse cautioned the teacher to be alert forsymptoms of that can be carried by the reptiles. ANS: Salmonella Geckos can infect humans with Salmonella. DIF: Cognitive Level: Comprehension REF: Page 455 OBJ: 8 TOP: Salmonella KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 30. The pediatric nurse assessesthe 9-year-old child who has been diagnosed with diabetesto ensure that hedoes not come to believe that his disease is a fNorUmRSo I fNGTB.COM . ANS: punishment School-age childrenmay come to believe theirillnessis a form of punishmentfor bad behavior or bad thoughts. DIF: Cognitive Level: Comprehension REF: Page 443 TOP: Disease as Punishment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 31. The nurse explainsthat the term refersto a sex role thatincorporates both male andfemale traits. ANS: androgynous Sex rolesthatinvolvemale and female qualitieslead to better human functioning. DIF: Cognitive Level: Knowledge REF: Page 444 TOP: Sex Education KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 32. The nurse is aware that by the age of ,the first permanentteeth erupt. ANS: 6INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 238 NURSINGTB.COM Atthe age of 6,the first permanent teeth erupt: the 6-year molars.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 239 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 443 TOP: Eruption of Permanent Teeth KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 33. The maintainsthat every sex education program should present the topic from six aspects: biological,social, health, personal adjustment and attitudes, interpersonal associations, and establishment of values. ANS: Sexuality Information and Education Council oftheUnited States(SIECUS)DIF: Cognitive Level: Knowledge REF: Page 444 TOP: Sex Education KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 240 NURSINGTB.COM Chapter 20: The Adolescent MULTIPLE CHOICE 1. The nurse is assessing a 13-year-old boy. With what do physical changesin the pubertal male begin? a. Development of axillary and facial hair b. Enlargement of penis c. Enlargement of testicles d. Pigmentation ofthe scrotum ANS: C In boys, pubertal changes begin with enlargement ofthe testicles and internalstructures. DIF: Cognitive Level: Knowledge REF: Page 462 OBJ: 4 TOP: Physical Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 2. A 13-year-old boy states, The girlsinmy classtower overme. What would be the nurses most informativeresponse? a. It may seem that way because girls have a growth spurt 2 years earlier than boys. b. Perhaps your parents are not exceptionally tall. c. Boys usually experience a growth spurt 1 year earlierthan girls. d. You may feelshort, but you are actually average heightfor your age. ANS: A Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlierfor girlsthan for boys. DIF: Cognitive Level: Application REF: PageN4U6R3SINGTB.COM OBJ: 4 TOP: Physical Development KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 3. A parent commentsthat her adolescent daughterseemsto be daydreaming a lot. What doesthe nurseunderstand this behavior to indicate regarding their daughter? a. She is bored. b. She is not getting enough rest. c. She istrying to block outstress and anxiety. d. She ismentally preparing forrealsituations. ANS: D Daydreaming allows adolescentsto act outin theirimaginations what will be said or done in certain situations.This helps them to prepare for and cope with interactions with others. DIF: Cognitive Level: Comprehension REF: Page 468 TOP: DevelopmentDaydreams KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse is planning a safety program for high schoolstudents. To what willthe nurse relay that mostaccidental deaths in adolescence are related? a. Firearms b. Automobiles c. Drowning d. Diving injuries ANS: B The chiefsafety hazard forthe adolescentis automobiles.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 241 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 473 TOP: Safety KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 5. A 16-year-old excitedly tells his parentsthat he was offered a part-time job. Which response represents aneffective problem-solving approach for his parents? a. Yourstudies are too important for you to have a part-time job. b. When we wentto high school, academics were the adolescents priority. c. We want you to put your earningsin a savings account. d. How do you think you will manage yourschool work and a job? ANS: D An effective approach to help adolescentslearn to solve problemsisfor parentsto guide themin exploring alternatives. DIF: Cognitive Level: Application REF: Page 471 OBJ: 5 TOP: Parenting KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 6. The nurse is planning care of an adolescent. What psychosocialtask doesthe nurse understand is importantfor the adolescent to develop? a. A sense ofinitiative b. A sense ofindustry c. A sense of identity d. A sense of involvement ANS: C Psychosocial milestonesthatmust be accomplished during adolescence include the five Isimage ofself, identity, independence, interpersonal relationships, and intellectual maturity. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 459 OBJ: 5 TOP: Psychosocial Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 7. A 13-year-old girltellsthe school nurse thatshe is getting fat, especially in her hips and legs. What understanding by the nurse would best guide the response? a. Many adolescents are unaware of proper nutrition. b. Adolescents of this age become less active and should eatfewer calories. c. Puberty is often preceded by fat depositsin these areas. d. Assoon asmenarche occurs,she will lose this excess weight. ANS: C Secondary sexual characteristics become apparent beforemenarche. Fatis deposited in the hips,thighs, and breasts, causing them to enlarge. DIF: Cognitive Level: Application REF: Page 464 OBJ: 4 TOP: Physical Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 8. The school nurse is planning a program for girls about the physical changes of puberty. Toward what agegirl should this program be directed? a. 10 years b. 12 years c. 14 years d. 16 yearsANS:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 242 NURSINGTB.COM AINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 243 NURSINGTB.COM Because puberty can occurin girls as early as age 10 years, instruction must be given by that age. DIF: Cognitive Level: Comprehension REF: Page 460 TOP: Physical Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 9. Whatstatementmade by a parentindicates an understanding about helping a 13-year-oldmanage hisallowance? a. Iset amounts he can earn for particular chores. b. I give him a certain amount of money for each day. c. I put money into his bank account each month. d. I told him to ask me when he needs money. ANS: A Ifmoney issimply handed out asrequested, itis difficult to develop responsibility forfinances andmoney management. The older adolescent is able to get a job. The younger adolescent can earn money by doing particular chores. DIF: Cognitive Level: Comprehension REF: Page 467 OBJ: 8 TOP: DevelopmentResponsibility KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 10. What can the nurse suggests as a good dietary source ofzinc for an adolescent who is a vegetarian? a. Green, leafy vegetables b. Citrusfruits c. Nuts d. Enriched breads ANS: C NURSINGTB.COM Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sourcesinclude nuts, legumes, and wheat germ. DIF: Cognitive Level: Comprehension REF: Page 472 TOP:Nutrition KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 11. An adolescents parent comments, My son seemsso preoccupied with his appearance these days. Is thisnormal? What is the nurses best response? a. Itis his attemptto express hisindividualism. b. His preoccupation with hislooksis quite normal. c. He is probably troubled with his physical changes. d. Thisshowsthat he has a positive self-image. ANS: B Preoccupation with self-image is normal and accountsforthe constant primping of adolescents. DIF: Cognitive Level: Application REF: Page 462 OBJ: 14 TOP: Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 12. Whatfoods would be a healthy choice for an adolescent who justfinished playing in a strenuous sportsgame? a. A cheeseburger and soda b. A hot fudge sundae c. Two sausage and egg breakfastsandwiches and orange juice d. A bagel and skim milkINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 244 NURSINGTB.COM ANS: D A bagel provides a rapid supply of carbohydratesto the muscles, and skim milk provides a slow release of carbohydrates to the muscles. DIF: Cognitive Level: Comprehension REF: Page 472 TOP:Nutrition KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 13. When planning to answer a 16-year-old girls questions about menstruation, the nursemust considercognitive development. What is developed during adolescence according to Piaget? a. The ability to view a situation from multiple perspectives b. The ability to focus more on the pastthan presentsituations c. The ability to exercise concrete reasoning d. The ability to consider hypotheticalsituations ANS: D According to Piaget, in the formal operationsstage adolescents have the ability to think abstractly. DIF: Cognitive Level: Comprehension REF: Page 460 OBJ: 2 TOP: Cognitive Development KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 14. A girl tellsthe nurse thatshe and her best friend belong to the popular clique. She states, I love Katy Perry,and I want to be a singer. The nurse recognizes the girlsstatement as characteristic of what time period? a. Early adolescence b. Middle adolescence c. Late adolescence d. The entire adolescent period ANS: A NURSINGTB.COM Cliques of unisex friends, having a bestfriend, and hero worship are characteristics of the early adolescent. DIF: Cognitive Level: Comprehension REF: Page 462 OBJ: 10 TOP: Social Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 15. The nurse is leading a discussion group with parents of adolescents. One parent comments, My son cant doanything without checking with his friends first. My opinion doesnt count anymore. What knowledge in regardto this behavior would the nurse formulate as a response? a. Itis unusual for adolescent boys. b. Itis often more apparent in boysthan girls. c. Itis a normal phenomenon during adolescence. d. Itissuggestive of feelings oflow self-worth. ANS: C Parentsmay need help understanding thatthe adolescents exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family. DIF: Cognitive Level: Comprehension REF: Page 466 OBJ: 10 TOP: Peer Relationships KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 16. What does an adolescents peer group serve asrelated to development? a. Social outlet b. Association to blur personal identityINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 245 NURSINGTB.COM c. Platform for group thinkINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 246 NURSINGTB.COM d. Initialseparation from family ANS: D Being amember of a peer group and communicating with and seeking approval fromthis group are hallmarksof the first separation from the family. DIF: Cognitive Level: Comprehension REF: Page 462 OBJ: 10 TOP: PeerGroups KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 17. At whatstage isthe adolescent considered to be,according to Freudstheory? a. Conceptual b. Genital c. Glandular d. Pubertal ANS: B Freud describesthe adolescent period as genital. DIF: Cognitive Level: Knowledge REF: Page 460 OBJ: 2 TOP: Freud KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 18. The nurse using the PACE interview guide for persons atrisk forsubstance abuse arrives at a score of 2 foran adolescent patient. How would the nurse interpret this score? a. Nonindicative of potentialsubstance abuse b. Normal experimentation ofthe adolescent c. Need to schedule another PACE interview in 3 months d. Indication forreferral for counseling ANS: D NURSINGTB.COM The PACE guide recommendsthat a score of 2 or higher would suggestthe need for a referral for counseling about substance abuse. DIF: Cognitive Level: Analysis REF: Page 474 OBJ: 14 TOP: PACE Interview KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 19. What does adolescent acne result from? a. Ineffective sweat glands b. Oily skin c. Inadequate hygiene d. A poor diet ANS: B Adolescent acne isthe result of overactive sweat glands and oily skin. DIF: Cognitive Level: Comprehension REF: Page 460 TOP: Acne KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 20. The nurse suggeststhe use of I messagesto communicate a parentsfeeling to an adolescent. What is themost appropriate example of an I message? a. I feel frightened when you stay out past your curfew. b. I am your mother, and I insist that you observe your curfew. c. I am sick and tired of yourstaying outlate. d. I expect you to show me proper respect.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 247 NURSINGTB.COM ANS: A Thisisthe only statementthat associatesthe parentsfeelings aboutthe adolescent behavior thatis not aggressive or accusatory. DIF: Cognitive Level: Analysis REF: Page 471 OBJ: 14 TOP: I Statements KEY:Nursing Process Step: Implementation MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 21. A 13-year-old girltellsthe nurse she is concerned because she has not had herfirst menstrual period. Whatis the best initial response from the nurse? a. Your hormone levelsmay be irregular. b. Could you be pregnant? c. Age offirstmenstrual cycle varies. d. Do not worry about it. ANS: C Puberty is easily recognized in girls by the onset of menstruation. The first menstrual period is called the menarche. It commonly occurs about age 12 or 13 years, but this varies. It may occur as early as age 10 years or as late as age 15 years. DIF: Cognitive Level: Application REF: Page 464 TOP: Menstrual Cycle KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 22. The nurse is documenting the pediatricians assessment of a female patient. When assessing Tanners stagesof breast development there is elevation of papilla only. Whatstage of development willthe nurse document? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 NURSINGTB.COM ANS: A According to Tanners Stages of Sexual Maturity, Stage 1 (Preadolescent) is elevation of papilla only. DIF: Cognitive Level: Application REF: Page 463 OBJ: 7 TOP: Breast Development KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 23. The school nurse is educating high schoolstudents about guidelinesto be followed when participating insports. Which statement by a student alerts the nurse of the need for further information? a. I will eat carbohydrates before practice. b. I drink large amounts of fluid when working out. c. I wear protective gear every time I play sports. d. I avoid caffeine when participating in sports. ANS: B Fluidslost by sweat must be replaced by drinking small amounts offluid during a workout. Thirst is one guide for intake. Caffeine and alcohol deplete body water and are to be avoided. Carbohydrates that provide both energy and other nutrients are best for athletes. Protective gear should be worn by all team players in any contact sport. DIF: Cognitive Level: Application REF: Page 472 TOP: Sport Guidelines KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSEINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 248 NURSINGTB.COM 24. To whatisthe restlessnessseen in the adolescent considered to be attributed? (Select allthat apply.) a. Drive to be accepted by society as an individual b. Urge forindependence c. Establishment of a personal identity d. Intense libido e. Slowing of body changes ANS: A, B, C, D Allthe optionslisted are sources ofstressto the adolescent and are stimulantsto restlessness except option E: body changes are rapid. DIF: Cognitive Level: Comprehension REF: Page 459 TOP: Sources of Stress for the Adolescent KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 25. What are the best breakfast choices forthe nurse to point out priorto a big exam,to provide high levels ofalertness and increased memory? (Select all that apply.) a. Pancakes and syrup b. Coffee and chocolate-covered donuts c. Bacon and fried eggs d. Whole grain cereal and yogurt e. Oatmeal and sliced apples ANS: D, E Meals high in protein will break down into norepinephrine and increase alertness. Meals with a high sugar contentresult in a soothing sleepy response. Meals high in fats digestslowly and draw blood from the brain during the lengthy digestive process. DIF: Cognitive Level: Application REF: PageN4U7R2SINGTB.COM TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. The nurse considers whatrites of passage valued by the adolescentin American society? (Select all thatapply.) a. Attaining legal drinking age b. Selection of a career c. Religious affiliation d. Obtaining a driverslicense e. High school graduation ANS: A, D, E Rites of passage are socially recognizedmilestonesthatsignify adulthood. Legal drinking age, driverslicense, andmatriculation through high school are such signals. Religious affiliation and selection of a career path do not necessarily signal adulthood. DIF: Cognitive Level: Comprehension REF: Page 473 OBJ: 9 TOP: Rites of Passage KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 27. A mother confidesin the school nurse thatshe witnessed herson kissing another boy. Which conceptsshould guide the nurse to base a reply? (Select all that apply.) a. Homosexual behavior in adolescents is not uncommon. b. Homosexuality is amental disorder. c. Adolescents often desire to explore alternative lifestyles. d. Homosexualtendenciesshould be addressed with counseling. e. Parentsshould seek a support group for parents of gays.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 249 NURSINGTB.COM ANS: A, C Adolescentsmay experiment with an alternate sexual expression as part oftheirself-discovery. Homosexual activities are not uncommon in adolescence. DIF: Cognitive Level: Comprehension REF: Page 469 OBJ: 11 TOP: Homosexuality KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 28. The school nurse is discussing challenges ofthe adolescent years with a group of high schoolstudents inhealth class. What challenges toward adolescent development will the nurse include? a. Developing intimacy b. Maintaining dependence on parents c. Searching foridentity d. Adjusting to body changes e. Establishing future goals ANS: A, C, D, E Adolescentsface the challenges of developing intimacy,searching foridentity, adjusting to body changes and establishing goals for the future. Adolescents are striving for independence from parents. DIF: Cognitive Level: Comprehension REF: Page 459 OBJ: 3 TOP: Challenges KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 29. The nurse understandsthat as adolescentsstrive forindividuality,the strongest need of any adolescent insociety isthat of . ANS: conformity NURSINGTB.COM For all of the stressfrom coming of age as an individual in his own right,the adolescent also has an equal drive for conformity. DIF: Cognitive Level: Comprehension REF: Page 460 TOP: Conformity KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 30. The nurse knowsthat an adolescentmay find making a career choice difficult because there isless clarityin roles. ANS: gender The blurring of genderrolesin theUnited Stateswomen holding jobs as engineers, lawyers, and physicians; and men entering nursing and culinary pursuitshas caused confusion with the selection of a career path. DIF: Cognitive Level: Comprehension REF: Page 460 TOP: BlurredGender Roles KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 31. The nurse stressesthe need for using a sunscreen with a Sun Protection Factor(SPF) of at least . ANS: 15 A sunscreen with an SPF of atleast 15 isrecommended to block sun raysthat cause cancer.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 250 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 473 TOP: Sunscreen KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 32. isfrequently delayed in girls who are involved in activitiesthatrequire a lean body and ahigh level of physical activity. ANS: Menarche Menarche can be delayed in girls who are involved in such activities as dancing,running, gymnastics, or any activity that requires a lean body. DIF: Cognitive Level: Comprehension REF: Page 462 TOP: Menarche KEY: Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 33. The general appearance ofthe adolescent tends to be awkward,thatis, long-legged and gangling; thisgrowth characteristic istermed because different body partsmature at different rates. ANS: asynchrony The general appearance ofthe adolescenttendsto be awkward,thatis, long-legged and gangling;this growth characteristic is termed asynchrony because different body parts mature at different rates. DIF: Cognitive Level: Knowledge REF: Page 460 TOP: Physical Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 251 NURSINGTB.COM Chapter 21: The Childs Experience of Hospitalization MULTIPLE CHOICE 1. Which child would have themost difficulty in coping with separation from parents because ofhospitalization? a. 3-month-old child b. 16-month-old child c. 4-year-old child d. 7-year-old child ANS: B Separation anxiety occurs after age 6 months and ismost pronounced in the toddler. DIF: Cognitive Level: Comprehension REF: Page 481 OBJ: 3 TOP: Separation Anxiety KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. A 2-year-old child has been crying constantly for hismothersince he was hospitalized 3 days ago. What does this behavior suggest? a. The toddlerfeels abandoned by his mother. b. The child still has not adjusted to his hospitalization. c. The child is notseparated from his mother often. d. There is a poor mother-child bond. ANS: A Unlesstoddlers are extremely ill,their grief and sense of abandonment during hospitalization are obvious. DIF: Cognitive Level: Analysis REF: Page 48N1URSINGTB.COM OBJ: 3 TOP: Separation Anxiety KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. Which statement best correspondsto a preschoolers understanding of hospitalization? a. A germ made me getsick. b. I gotsick because I was mad at my brother. c. My tonsils are sick and they have to come out. d. I have a cast because I broke my leg. ANS: B The preschoolermay feel guilty, particularly if an accident happens as a result of mischief on his or her part. DIF: Cognitive Level: Application REF: Page 491 TOP: TheHospitalized Preschooler KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The parents of a hospitalized toddler are upset because she seemsmore interested in hertoys when theycome to visit her. In which stage of separation anxiety is the toddler? a. Protest b. Despair c. Denial d. Attachment ANS: C In the stage of denial or detachment, the child appearsto deny the need for the parents and becomes uninterested in their visits.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 252 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 481INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 253 NURSINGTB.COM OBJ: 3 TOP: Separation Anxiety KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nursemust make a room assignmentfor a 16-year-old with cystic fibrosis. Which roommate would bethe most appropriate for this patient? a. A 4-year-old child who had an appendectomy b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis c. A 15-year-old with type 1 diabetes mellitus d. To assign the adolescent to a private room ANS: C Adolescents usually do betterin rooms with one or more roommatesthan in single rooms. The adolescent would do best with a roommate who is closest to his or her age and also lives with a chronic illness. DIF: Cognitive Level: Application REF: Page 493 TOP: TheHospitalized Adolescent KEY:Nursing Process Step: PlanningMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The parents of a hospitalized 9-month-old infant ask if their preschool childmay visit his youngersibling. What understanding would assist the nurse most in formulating a response? a. Preschool children can be disruptive in the hospital environment. b. Seeing his youngersibling would probably frighten the preschooler and thusshould be avoided. c. The sibling could view the infant from the doorway but not enter the room to prevent the spread ofmicroorganisms. d. The preschooler needsto visit hisinfantsister to reassure himselfthatshe is allright. ANS: D Siblings are affected by a childs hospitalization. Their ability to cope isinfluenced by their age, experience, and intactness of the family. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 487 TOP: SiblingsParents Reaction to Hospitalization KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. A hospitalized toddler was drinking from a cup at home but now refusesto drink from anything except hisfavorite bottle. What is the most likely reason for this behavior? a. He is dealing with the anxiety of hospitalization by regressing. b. He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital. c. He is attempting to refocusthe attention of the adults around him to avoid further painful procedures. d. He is exhibiting normal behaviorfor his age, as children often stop new behaviors after they believe theyhave mastered them. ANS: A Hospitalization isfrustrating fortoddlers. They show their displeasure when illnessrestrictssatisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital. DIF: Cognitive Level: Comprehension REF: Page 484 OBJ: 1 TOP: Regression KEY:Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 8. A nurse encourages a school-age child to draw a picture after a painful procedure. What isthe best rationalefor this nursing intervention? a. Attempting to re-establish rapport b. Providing a way for the child to express hisfeelings c. Encouraging quiet play d. Distracting the child from thinking aboutthe painINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 254 NURSINGTB.COM ANS: B Aftertreatments, the nurse should encourage children to draw and talk abouttheir drawings orto act out their feelings through puppet play. DIF: Cognitive Level: Comprehension REF: Page 492 TOP: The Hospitalized School-Age Child KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. What isthe bestsuggestion by the nurse when parents ask, When isthe best time to begin to prepare a 5-year-old for surgery and hospitalization? a. Assoon asthe surgery isscheduled b. About 2 weeks before surgery c. About 4 days before surgery d. On the night before admission to the hospital ANS: C Parentsshould prepare children for procedures and hospitalization a few daysin advance. DIF: Cognitive Level: Application REF: Page 487 TOP: The Nurses Role inHospital AdmissionPreparing the ChildKEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. Themother of a 3-year-old tellsthe nurse thatshe will be in to visit tomorrow around 12:00 PM. The nextmorning, the child asks the nurse, When is my mommy coming? What isthe nurses best response? a. Your mommy will be here around noon. b. Your mommy will be here when you have lunch. c. Mommy will be here very soon. d. Your mommy is coming in 4 hours. ANS: B NURSINGTB.COM The toddler and preschooler do not understand time yet. They understand time relationshipsthrough activitiesin their experience, such as naptime and mealtimes. DIF: Cognitive Level: Application REF: Page 489 OBJ: 10 TOP: The Hospitalized Toddler/PreschoolerKEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. A 13-year-old girl has been hospitalized for the past week. When discussing the girlsfeelings about herillness, what would the nurse expect the girl to express as her biggest concern? a. Invasive procedures b. Loss of control c. Appearance d. Separation fromher boyfriend ANS: C Illness during early adolescence (12 to 15 years) isseen mainly as a threat to body image. DIF: Cognitive Level: Comprehension REF: Page 492 TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. The nurse noticesthat themother of a child with cerebral palsy corrects and redoes many of the things thenurse does for her child. What is the nurses most appropriate response to this mother? a. Would you like to do all of your childs care? b. Im doing the very best job that I can with your child. c. Why dont you go have a cup of coffee? You are going to be exhausted if you dont take a break.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 255 NURSINGTB.COM d. Id love for you to share with me some of the special things you do for your child. ANS: D The person who cares daily forthe child with a chronic illness can provide information that will best guarantee continuity of care between the home and the hospital. DIF: Cognitive Level: Application REF: Page 486 OBJ: 5 TOP: The Parents Reaction KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. Themother of a hospitalized toddlerstates, He cries when I visit. Maybe Ishould juststay away. What is the nurses best response? a. Perhaps you are right. He only gets upset when you have to leave. b. Itisimportant that you are here. Thisis a common reaction in children when they are separated from theirparents. c. It might be easier for your child if you would stay with him, butthis decision is up to you. d. We take good care of him and he seemsfine when you are not here. ANS: B During the second stage ofseparation anxiety (despair), the child is quiet, is not crying, and issad and depressed. The child will revert to protest when the parent arrives for a visit. DIF: Cognitive Level: Application REF: Page 481 OBJ: 3 TOP: Separation Anxiety KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. Whatshould the nurse, preparing to collect an admission history from parents who have recently emigrated fromRussia, keep inmind? NURSINGTB.COM a. Eye-to-eye contactis considered disrespectful. b. Touching the childs headmeansthe nurse issuperior. c. Smiling isinappropriate in a serioussituation. d. Staring is a sign of the nursesrudeness. ANS: C In Russia, a smile indicates happiness and isinappropriate in a serious orsad situation. DIF: Cognitive Level: Comprehension REF: Page 486 TOP: Fostering Intercultural Communication KEY:Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 15. Which nursing action would facilitate rapport with a child and the childs parents during the admissionprocess? a. Directthe parentsto undressthe child. b. Answer questionsin a calm and matter-of-fact way. c. Perform assessments and ask questions as quickly as possible. d. Express concern aboutthe seriousness ofthe childs condition. ANS: B The nurse tries notto appearrushed. A matter-of-fact attitudemust bemaintained regardless of the childs condition. DIF: Cognitive Level: Application REF: Page 487 OBJ: 5 TOP: Nurses Role in Hospital Admission KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 256 NURSINGTB.COM 16. When a 2-year-old returns to her hospital room following a diagnostic procedure, her parents are not available, and the child is crying loudly. Which technique ismost appropriate to alleviate the childs distress? a. Rock the child gently to sleep. b. Play with the child using pop-up toys. c. Role play with the child to act out her feelings. d. Ask the child to draw a picture about herfeelings. ANS: B Distractionssuch as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toysmay help reduce anxiety and pain. DIF: Cognitive Level: Application REF: Page 490 TOP: TheHospitalized Toddler KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 17. A 4-year-old beginsto cry when hismother tells him itistime for his operation. The nurse understands thisis an expected reaction. On which particular fear of the preschooler does the nurse base this understanding? a. Loss of control b. Restricted mobility c. Unfamiliar routines d. Invasive procedures ANS: D The preschool-age child is afraid of bodily harm, particularly invasive procedures. DIF: Cognitive Level: Comprehension REF: Page 491 TOP: TheHospitalized Preschooler KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 18. What statement by the parent of a hospitalNizUedRStoINddGleTrBl.eCaOdsMthe nurse to determine the parent understands a hospitalized toddlers need for transitional objects? a. Thisstuffed animal makes him feelsecure. b. He insisted on bringing this dirty old blanket with him. c. Im going to buy him a big stuffed animal from the giftshop. d. Id like to get him some toysfrom the playroom. ANS: A The use of a transitional objectsuch as a blanket or a favorite toy promotessecurity. DIF: Cognitive Level: Application REF: Page 490 TOP: TheHospitalized Toddler KEY:Nursing Process Step: EvaluationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 19. An 8-year-old child will be hospitalized forseveral weeksin skeletal traction to treat a fractured femur. What doesthe nurse realize immobilization in this age-group can generate feelings ofin planning care of thischild? a. Loss of control b. Altered body image c. Shame and guilt d. Fear of bodily harm ANS: A Forced dependency in the hospital,such asimmobilization, can result in a feeling of loss of control and loss of security. DIF: Cognitive Level: Application REF: Page 492 TOP: The Hospitalized School-Age ChildINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 257 NURSINGTB.COM KEY:Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 258 NURSINGTB.COM 20. The nurse explainsto the parents of a hospitalized child thattheir child willreceive fentanyl for anupcoming procedure. What advantage of fentanyl will the nurse explain? a. Itisspecifically designed for children. b. It has a rapid onset. c. Itis nonaddicting. d. It has a long duration. ANS: B Fentanyl is a drug useful for all ages because of itsrapid onset and brief duration. DIF: Cognitive Level: Knowledge REF: Page 484 TOP: Fentanyl KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. The nurse sharesthe information and timelinesrecorded on the interdisciplinary outline of care for a child.What is this document? a. Clinical pathway b. Comprehensive nursing care plan c. Holistic care approach d. Incorporated cost analysis ANS: A This documentisthe clinical pathway, which is a broad outline of interdisciplinary plan of care with specific timelines. DIF: Cognitive Level: Comprehension REF: Page 488 TOP: Clinical Pathway KEY:Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 22. The anxious parent asks if there is a dangeNrUofRhSeINr 2G-TyBea.Cr-OolMd child becoming addicted to the opioid pain reliever. What is the nurses most helpful response? a. Although this drug is addictive,the doctormonitorsthe dose very carefully. b. Dont worry. Addicted children are very easy to wean off the drug. c. Addiction israre in children when opiates are given for pain. d. Addictive behaviors are easy to assess. The drug will be stopped ifthat happens. ANS: C Addiction israre in children. DIF: Cognitive Level: Comprehension REF: Page 484 TOP: Pain Relief KEY:Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention isappropriate for the nurse to implement? a. Involve the parents. b. Provide a simple explanation to the child. c. Letthe child examine the equipment. d. Suggest coping techniques. ANS: A It is appropriate to involve the parents when performing a procedure on an infant. Providng a simple explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate interventions for an infant. DIF: Cognitive Level: Application REF: Page 480 OBJ: 7 TOP: Age-Appropriate Interventions KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and ComfortINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 259 NURSINGTB.COM 24. The pediatric nurse is caring for child that weighs 15 kilograms and callsthe physician for an order for Acetaminophen for pain control. Whatisthemaximum amount ofmedication per dose the nurse anticipatesordering? a. 100mg b. 150mg c. 225mg d. 250mg ANS: C Acetaminophen is commonly used forthe relief ofmild tomoderate pain in infants and children. The maximum dose is 15 mg/kg/dose forinfants and children, with a maximum of 5 dosesin 24 hours. DIF: Cognitive Level: Analysis REF: Page 484 TOP: Age-Appropriate Interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 25. What willthe nurse include when documenting the discharge of a pediatric patient? (Select allthat apply.) a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation e. Instructionsthatwere given to physician ANS: A, B, C, D Information thatshould be included in the discharge note include time of discharge, adults accompanying the child and relationship to child, condition of the child, and method of transportation. It should also be documented that instructions were given to parents. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 494 OBJ: 12 TOP: Discharge Documentation KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 26. The nurse suggeststo parentsthatthey use the outpatientsurgical centerfortheir childs upcoming surgery.What advantage(s) does this type of facility have to offer? (Select all that apply.) a. Lower cost b. Lessincidence of health careassociated infections c. Reduction of parent-child separation d. Ample time forrecuperation at the facility e. Decreased emotional impact of illness ANS: A, B, C, E All optionslisted are advantages of outpatientservices with the exception ofrecuperating atthe facility. DIF: Cognitive Level: Comprehension REF: Page 479 OBJ: 2 TOP: Outpatient Facilities KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 27. What are the basic fears of a young child being hospitalized? (Select allthat apply.) a. Separation b. Permanentscarring c. Pain d. Cost e. Body intrusion ANS: A, C, EINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 260 NURSINGTB.COM Small children allshare the same basic fearsrelative to hospitalization, which are separation from family, pain, and body intrusion or mutilation. DIF: Cognitive Level: Comprehension REF: Page 481 TOP: Basic Fear KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 28. Whatinformation willthe nurse include when taking a developmental history? (Select all that apply.) a. Previous experience with hospitalization b. Cultural needs c. History ofillness d. Allergies e. Childs nickname ANS: A, B, E The developmental history has information about the child and the childs developmental and cultural needs andpersonal preferences. The information relative to history of illness or allergies would be covered in the medical history. DIF: Cognitive Level: Application REF: Page 488 TOP:Developmental History KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 29. The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are appropriate forthe nurse to implement? (Select all that apply.) a. Model desired behavior. b. Instruct patient not to yell. c. Use distractions. d. Explain the procedure in detail. e. Encourage the child to ask questions. ANS: A, C NURSINGTB.COM Whenever possible the parent should be involved in the preparation for and initiation of a treatment or procedure, and the child should be prepared according to his or her developmental level. For a toddler,model the behavior desired (i.e., opening the mouth), tell the child itis okay to yell if the treatment or procedure is uncomfortable, and use distractions. Explaining the procedure in detail and encouraging questions are appropriate interventions for an older child. DIF: Cognitive Level: Application REF: Page 490 TOP: Promoting a Positive Experience KEY:Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 30. Parents are preparing their child for admission to the pediatric unitfor minorsurgery. Whatshould theyexpect to see when visiting the pediatric unit? (Select all that apply.) a. Nurses wearing all white b. Formal atmosphere c. Availability of a playroom d. Dim lighting e. Colored bedding ANS: C, E The childrens hospital unit differs in many respects from adult divisions. The pediatric unit or hospital is designed tomeet the needs of children and their parents. A cheerful, casual atmosphere helpsto bridge the gapbetween home and hospital and isin keeping with the childs emotional, developmental, and physical needs. Nurses wear colorful uniforms, and colored bedspreads and wagons or strollers for transportation provide a more homelike atmosphere. The physical structure of the unit includes furniture of the proper height for theINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 261 NURSINGTB.COM child,soundproof ceilings, and colorschemes with eye appeal. Most pediatric departmentsinclude a playroom. DIF: Cognitive Level: Knowledge REF: Page 480INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 262 NURSINGTB.COM OBJ: 2 TOP: Health Care Delivery Settings/Pediatric UnitKEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care COMPLETION 31. When the preschooler who is hospitalized forsurgery to correct a poorly healed fracture says, My doctor isgoing to unscrew my bent arm and screw on a new one,the nurse should this misconception. ANS: correct All misconceptionsthat a youngster has about proceduresshould be corrected. DIF: Cognitive Level: Knowledge REF: Page 491 TOP: Misconceptions KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 32. A(n) is a person under the age of 18 who can legally sign for consentfor medical treatment for themselves or their children. ANS: emancipated minor A person under the age of 18 who is no longer under the care of his parents authority or a married minor or minorsin the military are considered emancipated minors who are accorded the rights of an adult. DIF: Cognitive Level: Knowledge REF: Page 493 TOP: Emancipated Minor KEY:Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care EnvironmNeUnRt: SCINoGorTdBin.CatOedMCare 33. providestrained workers who come into the home for brief periodsto relieveparents of the responsibility of caring for the child. ANS: Respite care Respite care providestrained workers who come into the home for brief periodsto relieve parents of the responsibility of caring for the child. DIF: Cognitive Level: Knowledge REF: Page 494 TOP: Respite Care KEY:Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment: Coordinated CareINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 263 NURSINGTB.COM Chapter 22: Health Care Adaptations for the Child and Family MULTIPLE CHOICE 1. Whatisthe best pulse location forthe nurse to use when assessing the pulse rate on a 12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral ANS: B Apical pulses are advised for children under age 5 years. DIF: Cognitive Level: Knowledge REF: Page 502 TOP: Physical Assessment KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse preparing to administermedication to a 2-month-old infant discoversthere is no ID bracelet onthe child. What should be the next action by the nurse? a. Give themedication after confirming the childs name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse,make a new bracelet, and give themedicine. d. Delay themedication untilthe admissions office can supply a new ID bracelet. ANS: C After confirmation ofthe childsidentity with the charge nurse and making a new bracelet,the medication canbe safely given. All patients should be identified before treatment. DIF: Cognitive Level: Application REF: Page 497 OBJ: 2 TOP: ID Bracelets KEY: Nursing ProcNeUssRSSt IeNpG: TImBp.CleOmMentation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. The nurse instructed an adolescentfemale about collecting a clean-catch urine specimen. What statementmade by the adolescent led the nurse to determine she understood the instructions? a. Ishould wash my perineumwith soap and water, then begin to urinate. b. I clean the perineum fromfront to back with an antiseptic wipe before I urinate. c. Ill collect the firststream of urine in a sterile container. d. I will discard the first void and collect a freshly voided specimen 30 minuteslater. ANS: B To obtain a clean-catch specimen,the perineum is cleansed with an antiseptic wipe from frontto back. DIF: Cognitive Level: Analysis REF: Page 508 TOP: Collecting Specimens KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. Which strategymightthe nurse use when administering oral medicationsto a young child who isreluctant? a. Mix themedication with chocolate milk. b. Tellthe child that the medication is candy. c. Give themedication quickly ifthe child is crying. d. Offerthe child fruitjuice after the medication isswallowed. ANS: D The nurse can offer a chaser of water, fruitjuice, or a carbonated beverage after the medication has been swallowed. Medicationsshould not be mixed with food or drinks with important nutrientssuch as milk because the child may develop distaste for it. DIF: Cognitive Level: Application REF: Page 512INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 264 NURSINGTB.COM TOP: Administering Oral Medications KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 265 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 5. A parenttellsthe nurse, Im notsure how to give this medicine to my infant. How would the nurse teach theparent to best administer an oral suspension? a. Pourthe medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infantsuck the nipple. c. Use an oralsyringe and placing themedication in the side of the infantsmouth. d. Administerthemedication with a dropper onto the back of the infantstongue. ANS: C An oralsyringe is a useful device for measuring small quantities ofmedicationsforinfants. The syringe is placed midway back, at the side of the mouth. DIF: Cognitive Level: Application REF: Page 513 TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle whenadministering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out ANS: A For children 3 years of age and older,the auricle is gently pulled upward and backward to straighten the canal. DIF: Cognitive Level: Application REF: Page 514 OBJ: 10 TOP: Administering Ear Drops KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 7. Why is a tympanic thermometer consideredmore accurate than othertypes of thermometers? a. The thermometer probe is blunt and wide. b. Ittakes a brief time to register. c. The tympanic membrane shares circulation with the hypothalamus. d. The tympanicmembrane and the brain have the same temperature. ANS: C The accuracy of the tympanic thermometeris attributable to the factthatthe tympanicmembrane and the hypothalamus share the same circulation. DIF: Cognitive Level: Knowledge REF: Page 506 TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? a. Discard the residual and increase the volume of feeding by the amount of residual. b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding. c. Refillthe syringe with formula afterit has completely emptied. d. Position the child on the rightside after a feeding. ANS: D To preventregurgitation and aspiration, the child is placed in the Fowlers position or on the rightside to promote gastric emptying after a gastrostomy tube feeding. DIF: Cognitive Level: Application REF: Page 526 OBJ: 13 TOP: Enteral Feedings KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 266 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Reduction of Risk 9. Which restraintismost appropriate forthe insertion of an intravenousline in a scalp vein of an infant? a. Mummy b. Clove hitch c. Jacket d. Elbow ANS: A A mummy restraint would be used to restrain an infant forinsertion of an intravenousline in a scalp vein. DIF: Cognitive Level: Comprehension REF: Page 499 OBJ: 12 TOP: Restraining the Infant KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. How often should a child who has a continuousintravenousinfusion should be assessed? a. Hourly b. Every 2 hours c. Every 3 hours d. Every 4 hours ANS: A The nursemust assess hourly an intravenousinfusion for complications,such asinflammation and infiltration. DIF: Cognitive Level: Knowledge REF: Page 516 TOP: Administering Parenteral Medications KEY: Nursing Process Step: Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk NURSINGTB.COM 11. The prescription for a 4-month-old is penicillinG150,000 unitsintramuscularly bid. The drug issupplied as a unit dose of 600,000 unitsin a 5-mL vial. Howmanymilliliters(mL)should the nurse provide?a. 1.25 b. 1.4 c. 1.6 d. 1.8 ANS: B 600,000_mL 5 mL 150,000 = 1.25 mL This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an infant. DIF: Cognitive Level: Analysis REF: Page 520 OBJ: 9 TOP: Administering Injections KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 12. Which intervention willthe nurse implement when suctioning a tracheostomy? a. Suction fortwo to three breaths. b. Clearthe catheter with water aftersuctioning forreuse. c. Apply suction for no more than 15 seconds. d. Establish a regularschedule forsuctioning. ANS: C Suctioning should be limited to 15 seconds. DIF: Cognitive Level: Application REF: Page 527INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 267 NURSINGTB.COM TOP: Respiration KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 13. What emergency action should be implemented for airway obstruction in the infant? a. Six to 10 midsternal thrusts b. Five back blowsfollowed by five chestthrusts c. Five chestthrustsfollowed by five back blows d. Abdominalthrusts untilthe object is expelled ANS: B Five back blowsfollowed by five chest thrustsisthe appropriate intervention for airway obstruction in the infant. DIF: Cognitive Level: Knowledge REF: Page 530 TOP: Management of Airway Obstruction KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 14. A 4-year-old askstearfully ifthe IM injection will hurt. Whatisthe nurses most effective response? a. No. It is over before you know it. b. Yes. It willsting a little. c. No. Would you like to see the syringe? d. Yes. Your mom and I are going to hold you to help you be still. ANS: B Truthful answers will give a child a realistic expectation and help establish trustin the nurse. DIF: Cognitive Level: Application REF: Page 515 TOP: Preparation for an IM Injection KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: CopinNgUanRdSIANdGaTpBta.tCioOnM 15. Where isthe bestsite for giving an IM injection to a 15-month-old child? a. Ventrogluteal muscle b. Dorsogluteal muscle c. Deltoid muscle d. Vastuslateralismuscle ANS: D The vastuslateralismuscle isfree of major blood vessels and nerves and can be used in children of any age. DIF: Cognitive Level: Application REF: Page 514 TOP: Administering Injections KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. Whatfactor doesthe nurse explain affectsthe infants physiologicalresponse to medications? a. Fastermetabolism in the liver b. Slowerintestinaltransit c. Immature kidney function d. Increased secretion of hydrochloric acid ANS: C Immature kidney function prevents effective excretion of drugsfrom the body in infantslessthan 1 year of age. DIF: Cognitive Level: Comprehension REF: Page 511 TOP: Physiological Responses to Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological IntegrityINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 268 NURSINGTB.COM 17. Whatintervention should the nurse implement aftertopical administration of hydrocortisone cream to thebuttocks and abdomen of an infant? a. Diaperthe infantsnugly with a disposable diaper. b. Coverthe area with a transparent dressing. c. Apply a cloth diaper. d. Place the infant on a plastic pad, undiapered. ANS: C Plastic coveringsincrease the absorption of drugs. The diapershould be cloth, orthe infantshould be left undiapered on a cloth pad. DIF: Cognitive Level: Application REF: Page 511 TOP: Rapid Absorption ofDrug KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 18. Which observation on entering the hospital room letsthe nurse know thatthere is a need forthe parentstoreceive safety education to prevent unintentional injury? a. The blanket is not tucked into the mattress. b. Diapers and wipes are stacked at the foot of the crib. c. The crib side islocked in the up position. d. Pillows are stacked on the bedside table. ANS: B Disposable diapers and suppliesmust be kept out of the infantsreach to prevent accidentalsuffocation. DIF: Cognitive Level: Analysis REF: Page 498 OBJ: 2 TOP: Essential Safety Measures KEY: Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control NURSINGTB.COM 19. A 9-year-old child is preparing for a lumbar puncture. What position willthe nurse explain the child will assume for this procedure? a. On yourstomach with your head turned to the side. b. On yourside, keeping the legs bent and the head arched back. c. On your back with yourlegs extended straight out. d. On yourside with the knees bent and the head close to the knees. ANS: D The child is positioned on his or herside with the knees flexed, and the head is brought down close to the flexed knees. DIF: Cognitive Level: Application REF: Page 510 OBJ: 8 TOP: Collecting SpecimensLumbar PunctureKEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse is caring for a 4-year-old child. What will the nurse expectthe childs daily urinary output to be? a. 400 to 500 mL b. 500 to 600 mL c. 600 to 700 mL d. 700 to 1000 mL ANS: C The average daily excretion of urine for a 4-year-old child is 600 to 700 mL. DIF: Cognitive Level: Knowledge REF: Page 510 OBJ: 4 TOP: Collecting SpecimensUrine Output KEY: Nursing Process Step: Data Collection MSC:NCLEX: Physiological Integrity: Basic Care and ComfortINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 269 NURSINGTB.COM 21. An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record theinfants urine output? a. 47 mL b. 44.5 mL c. 43.5 mL d. 40.5 mL ANS: B Urine outputis determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one milliliter of output. 47 2.5 = 44.5 grams = 44.5 mL of urine. DIF: Cognitive Level: Analysis REF: Page 524 OBJ: 4 TOP: Collecting SpecimensUrine Output KEY: Nursing Process Step: Data Collection MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 22. The nurse instructsthemother of a 2-year-old who istaking iron supplementsfor anemia thatsome foodsreduce the absorption of iron. What would be the best example provided by the nurse? a. Red meat b. Green, leafy vegetables c. Acidic fruitjuices d. Egg yolks ANS: D Egg yolks and starchesreduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement. DIF: Cognitive Level: Application REF: Page 525 OBJ: 2 TOP: Food/Drug Interactions KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The pediatric nurse completes an assessment on all patients assigned during evening shift atthe hospital.Which patient assessment requires immediate intervention? a. Toddler with an axillary temperature of 99 F b. School-age child with widening pulse pressure c. Infant pulse rate of 100 beats per minute d. Adolescent with a respiratory rate of 28 breaths perminute ANS: B A widening pulse pressure can indicate increased ICP;therefore itisthe priority. An axillary temperature of 99 F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments. DIF: Cognitive Level: Application REF: Page 502 OBJ: 5 TOP: Vitalsigns KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. A 15-year-old patientreturnsto the pediatric unitfollowing a lumbar puncture. What initial position willthe nurse maintain for this patient? a. Leftside-lying b. Supine c. Prone d. Semi-Fowlers ANS: B The adolescentmay avoid postlumbar puncture headache by lying flatforsome time. DIF: Cognitive Level: Application REF: Page 510INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 270 NURSINGTB.COM TOP: Lumbar Puncture KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 271 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 25. Informed consentfor a minor guaranteesthatthe parent orlegal guardian understands what aspect(s) of aprocedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be broughtfor damages d. Thatthe document must be signed and witnessed e. Thatinformation was given ANS: A, B, D, E The informed consent establishesthatthe patient, parent, orlegal guardian understandsthe purpose and risks ofthe procedure. It also establishesthatthe patient, parent, orlegal guardian understands what they have beentold; the document should be signed and witnessed. DIF: Cognitive Level: Comprehension REF: Page 497 TOP: Informed Consent KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 26. Which specific drug(s)should be checked with a second licensed nurse priorto administration? (Select allthat apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts e. Anticoagulants ANS: A, B, D, E NURSINGTB.COM Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a licensed nurse prior to administration. DIF: Cognitive Level: Comprehension REF: Page 518 TOP:Drug Administration KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 27. A 3-year-old patientis admitted to the pediatric unit with a fever of 103 F. Which actions will the nurseimplement? (Select all that apply.) a. Assessrectaltemperature every 4 hours. b. Administer Acetaminophen as ordered. c. Assessskin turgor. d. Restrictfluids. e. Assesslevel of consciousness. ANS: B, C, E When evaluating the degree of illnessin a febrile child,the nurse should assess and record response of the child to cuddling, alertness, hydration,sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environmentmay be acutely ill. Because dehydration is a common problem in infants and children,skin turgorshould be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients. DIF: Cognitive Level: Application REF: Page 503 OBJ: 6 TOP: Fever KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 28. Whatshould the nurse assessto determine the method oftransportation for a pediatric patient? (Select allthat apply.)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 272 NURSINGTB.COM a. Age b. Race c. Vitalsigns d. Distance to travel e. Level of consciousness ANS: A, D, E Themeans by which the child istransported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel. DIF: Cognitive Level: Comprehension REF: Page 499 TOP: Modes of Transportation KEY: Nursing Process Step: Data Collection MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION 29. The nurse issearching through several blood pressure cuffsto find a cuff thatisthe appropriate size for hersmall patient. The nurse selects a cuff that covers of the patients upper arm. ANS: two thirds Nomatter the age of the patient, forthe blood pressure cuff to provide an accurate reading itshould cover twothirds of the upper arm. A smaller cuff will give an inaccurately high reading and a larger cuff will give an inaccurately low reading. DIF: Cognitive Level: Application REF: Page 503 OBJ: 4 TOP: Selection of Blood Pressure Cuff KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: BasicN CU a R re SI aN ndGT C B o . mC fO oM rt 30. The nurse is aware thatfor the 3-month-old who has a surgery time of 2:30 PM, the start orderfor NPOshould be no earlier than . ANS: 8:30 AM Periods ofNPOshould not exceed 4 to 6 hoursfor pediatric clients because they can become dehydrated very quickly. DIF: Cognitive Level: Application REF: Page 520 TOP:NPOOrdersin Infants KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 31. The orderreads, Give ampicillin oralsuspension 400 mg POevery day. The vialreads, Ampicillin 125 mg/5 mL. The nurse will give a dose of mL. ANS: 16 DIF: Cognitive Level: Analysis REF: Page 520 TOP: Pediatric Dose Calculation KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 32. The physician has ordered phenytoin syrup 20mg PO bid for a child who weighs 15 pounds. The PDR statesthat 10 mg/kg/day isthe maximum daily dose. The safe daily dose of this medication is mg. ANS: 34INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 273 NURSINGTB.COM 15 pounds = 6.8 kilograms; 6.8 10 mg = 68 mg maximum daily dose, making the bid doses 34 mg each DIF: Cognitive Level: Analysis REF: Page 513 TOP:Dose Calculation KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 33. Afterinstilling nose drops,the nurse will keep the infantin the head down position for atleast seconds. ANS: 30 The retained position for 30 secondsto 1minute allowsthe nose dropsto enter deeply into the nostril. DIF: Cognitive Level: Comprehension REF: Page 513 OBJ: 10 TOP:Nose Drops KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 34. The nurse is aware that because of the function of the mist tentthat a child is atrisk for . ANS: hypothermia Children inmisttents are atrisk for hypothermia because of the high humidity and the cooled oxygen. These children should be dressed warmly and changed frequently. The bed linensshould be changed frequently as they absorb moisture from the tent as well. DIF: Cognitive Level: Comprehension REF: Page 529 OBJ: 14 TOP: Mist Tent KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: BasicNCUa Rre SIaNndGTC Bo .mCfOoMrt 35. An implies that the parent or legal guardian is capable of understanding information given to him or her, including the purpose and risks of the procedure, and voluntarily agreesto thaprocedure. ANS: informed consent An informed consentimpliesthatthe parent or legal guardian is capable of understanding information given tohim or her, including the purpose and risks of the procedure, and voluntarily agreesto that procedure. DIF: Cognitive Level: Knowledge REF: Page 497 TOP: Informed Consent KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 36. When obtaining a urine specimen on an infant,the adhesive ofthe urine collectoris placed between the and the . ANS: anus, perineum Begin by applying the urine collector to the tiny area of skin between the anus and the perineum. The narrow bridge on the adhesive patch keeps feces from contaminating the specimen and helps to position the collectorcorrectly. DIF: Cognitive Level: Knowledge REF: Page 509 OBJ: 7 TOP: Urine Specimen Collection KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection ControlINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 274 NURSINGTB.COM Chapter 23: The Child with a Sensory or Neurological Condition MULTIPLE CHOICE 1. A parent commentsthat herinfant has had several earinfectionsin the pastfew months. Why are infantsmore susceptible to otitis media? a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure. c. They have increased susceptibility to upperrespiratory tractinfections. d. The eustachian tube isshort,straight, and wide. ANS: D An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy accessto themiddle ear. DIF: Cognitive Level: Knowledge REF: Page 538 TOP: Otitis Media KEY: Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Whatstatement by a patientsmotherleadsthe nurse to determine she understandsinstructions aboutadministering an oral antibiotic for otitis media? a. I will continue using themedication untilsymptoms are relieved. b. I willshare the medicine with siblingsiftheirsymptoms are the same. c. I will give the medication with a glass of milk. d. I will administer prescribed doses until allthemedication is used. ANS: D Antibiotic therapy for otitismedia is continued until the prescribed amount has been completed, even if symptoms are alleviated. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 540 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. Which situation would cause the nurse to suspect a hearing impairment? a. 3-month-old infant with a positive Moro reflex b. 15-month-old toddler who is babbling c. 18-month-old toddler who isspeaking one-syllable words d. 24-month-old toddler who communicates by pointing ANS: D The child who is notmaking verbal attempts by 18monthsshould undergo a complete physical examination. DIF: Cognitive Level: Analysis REF: Page 540 OBJ: 3 TOP: Hearing Impairment KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 4. Whatisthe best way forthe nurse to communicate with a 10-year-old child who has a hearing impairment? a. Use gestures and signs asmuch as possible. b. Letthe childs parents communicate for her. c. Face the child and speak clearly in shortsentences. d. Recognize thatthe childs ability to communicate will be on a 6-year-old childslevel. ANS: C The nurse who facesthe child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 275 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 541INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 276 NURSINGTB.COM OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What would the nurse include when planning postoperative teaching for a child who has had atympanostomy with insertion of tubes? a. Keeping the infantflat after feeding b. Giving over-the-counter decongestants c. Avoiding getting waterin the ears d. Cleaning the ear canal with cotton-tipped applicators ANS: C After a tympanostomy, care should be taken to avoid getting waterin the ears. DIF: Cognitive Level: Comprehension REF: Page 540 TOP: Postoperative Care of Tympanostomy KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Reduction of Risk 6. What assessmentmade by the school nurse would lead to the suspicion ofstrabismus? a. Reddened sclera in one eye b. Child covers one eye to read the chalkboard c. Child complains of a headache d. Copioustears while watching TV ANS: B Indicators ofstrabismusinclude covering one eye to see,tilting the head to see, and missing objectsin attemptsto pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder. NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 543 OBJ: 4 TOP: Strabismus KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 7. Whatmightthe nurse explain as a common treatment for amblyopia? a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractorymusclesto rest c. Using glassesthat willslightly blurthe image forthe good eye d. Using corticosteroidsto treatinflammation of the optic nerve ANS: A Early detection and treatment are essential forthe child with amblyopia. Treatmentincludes patching the goodeye and using glasses to correct refractive errors. DIF: Cognitive Level: Knowledge REF: Page 543 TOP: Amblyopia KEY:Nursing Process Step: N/A MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. What assessment doesthe school nurse recognize asthe cardinalsign of a hyphema? a. Opacity of the lens b. A yellow-white reflex on the pupil c. A dark-red spot in front of the iris d. Inflamedmucousmembranes of the eyelids ANS: C A dark red spotin front of the irisis blood that has drained into the anterior chamber as the result of an injury. DIF: Cognitive Level: Knowledge REF: Page 545 TOP:Hyphema KEY:Nursing Process Step:Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 277 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 9. The nurse is planning to teach parents about prevention of Reyessyndrome. Whatinformation would thenurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parentsto have their children immunized against Reyessyndrome. c. Avoid giving salicylate-containing medicationsto a child who has viralsymptoms. d. Getthe child tested for Reyessyndrome if the child exhibitsfever, vomiting, and lethargy. ANS: C Prevention of Reyessyndrome includes educating parents not to give aspirin-containing medication to childrenwith viral symptoms. DIF: Cognitive Level: Application REF: Page 546 TOP: Reyes Syndrome KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. Whatsymptom leadsthe nurse caring for a 5-month-old with viral influenza to suspect the development ofReyes syndrome? a. Respirations drop from 18 to 14 breaths/min b. Falling asleep afterfeeding c. Sudden vomiting without effort d. Development of amacularrash ANS: C A child with a viral infection is atrisk for Reyessyndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal. DIF: Cognitive Level: Application REF: Page 546 TOP: Reyes Syndrome KEY: Nursing ProcessNSUtRepS:INDGatTaBC.CoOlleMction MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 11. What doesthe nurse explainsto parents of a child with febrile seizures? a. They occur when the body temperature exceeds 38.3 C (101 F). b. They can be prevented by anticonvulsantmedication. c. They usually lead to the development of epilepsy. d. They occur when the temperature rises quickly. ANS: D Febrile seizures occurin response to a rapid rise in temperature, often above 38.8 C (102 F). DIF: Cognitive Level: Comprehension REF: Page 552 TOP: Febrile Seizures KEY:Nursing Process Step:N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A parentreportsthat her child has begun to do poorly atschool and experiences episodes where he appearsto be staring into space. Of which type of seizure is this behavior a characteristic? a. Absence b. Akinetic c. Myoclonic d. Complex partial ANS: A Absence seizures are characterized by transientloss of consciousness where the child appearsto stare blankly,and may last only a few seconds. DIF: Cognitive Level: Comprehension REF: Page 553 OBJ: 10 TOP: Epilepsy KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 278 NURSINGTB.COM 13. An adolescent hasjust had a generalized seizure and collapsed in the school nurses office. When should thenurse should call 911? a. The seizure lasts more than 5 minutes. b. The child issleepy and lethargic after the seizure. c. The child fell atthe onset of the seizure. d. The child is confused and hasslurred speech after the seizure. ANS: A Ifthere are multiple seizures orifseizureslast more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency. DIF: Cognitive Level: Application REF: Page 553 OBJ: 10 TOP: Epilepsy KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. Whatis an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure? a. Guide the child to the floorif the child isstanding, and then go for help. b. Move objects out of the childsimmediate area. c. Stick a padded tongue blade between the childsteeth. d. Manually restrain the child. ANS: B During a generalized tonic-clonic seizure,the immediate area is cleared to protectthe child from injury. DIF: Cognitive Level: Application REF: Page 553 OBJ: 10 TOP: Epilepsy KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure thatlasted 90 seconds. What wouldthe nurse expect to assess after a generalized tNonUiRc-ScIlNonGiTcBse.CizOuMre? a. Restlessness b. Sleepiness c. Nausea d. Anxiety ANS: B Following a generalized tonic-clonic seizure,the childmay have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness. DIF: Cognitive Level: Comprehension REF: Page 553 OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What would the nurse include when creating a teaching plan thatincludesthe long-term administration ofphenytoin (Dilantin)? a. Themedication should be given on an empty stomach. b. Insomnia can be a significantside effect. c. Gumsshould bemassaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored. ANS: C Dilantin can cause gum overgrowth, which can beminimized by regularmassaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day. DIF: Cognitive Level: Comprehension REF: Page 556 OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. The nurse observesthatthe legs of a child with cerebral palsy crossinvoluntarily, and the child exhibitsINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 279 NURSINGTB.COM jerkymovements with his arms as he triesto eat. The nurse recognizesthat he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed ANS: C Spasticity is characterized by tension in certainmuscle groups, whichmakes voluntarymovements of muscles jerky and uncoordinated. DIF: Cognitive Level: Comprehension REF: Page 557 OBJ: 12 TOP: Cerebral Palsy KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. Which assessmentfinding in a child withmeningitisshould be reported immediately? a. Irregularrespirations b. Tachycardia c. Slight drop in blood pressure d. Elevated temperature ANS: A Irregularrespirationsin conjunction with slowing heartrate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure. DIF: Cognitive Level: Application REF: Page 549 TOP: Meningitis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity NURSINGTB.COM 19. The nurse observes a childs position issupine with his arms and legsrigidly extended and the handspronated. How does the nurse identify this posture? a. Correct anatomical position b. Decorticate c. Decerebrate d. Opisthotonos ANS: C In decerebrate posturing, arms are extended along the side ofthe body and hands are pronated. This posture indicates brainstem function only. DIF: Cognitive Level: Application REF: Page 563 OBJ: 15 TOP: Posturing KEY:Nursing Process Step: Data Collection MSC:NCLEX: Physiological Integrity: Physiological Adaptation 20. What willthe nurse teach parents when giving instructionsfor acute conjunctivitis? a. Apply cool compressesto the affected eye several times a day. b. Instilltopicalsteroid eye dropsfor 1 week. c. Clear drainage from the inner to the outer aspect of the eye. d. Keep the eye patched untilthe inflammation resolves. ANS: C Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (innerto outer direction). DIF: Cognitive Level: Application REF: Page 545 TOP: Conjunctivitis KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection ControlINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 280 NURSINGTB.COM 21. A child is broughtto the emergency department after he fell and hit his head on the ground. Which nursingassessmentsuggests the child has a concussion? a. Sleepy but easily arousable b. Complaining of a stiff neck c. Cannotremember what happened to him d. Pupilsreactsluggishly to light ANS: C A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. Itis accompanied often by a loss of memory ofthe eventsthat occurred immediately before, during, or after the injury. DIF: Cognitive Level: Analysis REF: Page 561 OBJ: 16 | 17 TOP:Head Injury KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A child is admitted to the hospital because she had a seizure. Her parentsreportthatfor the past few weeksshe has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect? a. Meningitis b. Reyessyndrome c. Brain tumor d. Encephalitis ANS: C The signs and symptoms of a brain tumor are related to itssize and location. Mosttumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures. DIF: Cognitive Level: Analysis REF: Page 551 TOP: Brain Tumor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: PhysiNolUoRgiScIaNlGATdBap.CtaOtiMon 23. The nurse urgesthemother of a 6-month-old to get her child inoculated withHaemophilusinfluenzae type B. What doesthisimmunization protect against? a. Encephalitis b. Influenza c. Bacterial meningitis d. Otitismedia ANS: C H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis. DIF: Cognitive Level: Knowledge REF: Page 549 OBJ: N/A TOP: Prevention of Meningitis KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 24. The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to reportthe probability of increasing intracranial pressure (ICP)? a. Temperature increase from 37.2 C (99 F) to 37.7 C (100 F) b. Increase in blood pressure with an attendant decrease in pulse c. Increase in respirations d. Equilateral pupils ANS: B Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 281 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 565INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 282 NURSINGTB.COM TOP: ICP KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 25. A child is diagnosed with nonparalytic strabismus. How willthis disorder most likely be corrected? a. Patching the unaffected eye b. Corrective lenses c. Lasertreatment d. Surgery ANS: B In nonparalytic strabismusthe refractory erroris usually corrected with eyeglasses. DIF: Cognitive Level: Comprehension REF: Page 544 OBJ: 5 TOP: Strabismus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 26. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharingmultiple approaches theyimplementin dealing with various challenges. Which of the following a statements by the parents alertsthe nurse that they need further instruction? a. We dress ourson every morning forschool. b. Ourson participatesin the SpecialOlympics every year. c. Ourson attends play therapy at a center close to home. d. We attend a support group once a week. ANS: A Thementally handicapped child needsto develop a sense of accomplishment. Caregiversshould nottake over projects because of their own need to assist or speed up the process. DIF: Cognitive Level: Application REF: Page 561 TOP: Cognitive Impairment KEY: Nursing PrNoUceRsSsISNteGpT:BIm.CpOleMmentation MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment 27. What would the nurse include in teaching when preparing to teach parents about air travel instructions toprevent barotrauma in infants? a. Using ear plugs during takeoff b. Omitting themeal just before takeoff c. Letting the infant nurse during descent d. Applying ear drops before takeoff ANS: C Encouraging an infant to swallow reducesthe pressure in the ears during descent. DIF: Cognitive Level: Comprehension REF: Page 542 TOP: Barotrauma KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease MULTIPLE RESPONSE 28. Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.) a. Hypersensitivity to noise b. Irritability c. Reddened ear canal d. Rolls head from side to side e. Temperature of 39.4 C (103 F) ANS: B, D, E Infantssignal earinfections by being irritable,rolling their headsfrom side to side,spiking a temperature, and pulling at or rubbing their ears.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 283 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 539 OBJ: 2 TOP: Indications of Ear Infection KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 29. Which aspect(s) of a childs development doesthe nurse caution parentsthat hearing impairment can affect?(Select all that apply.) a. Speech clarity b. Language development c. Immunity to disease d. Personality development e. Academic achievement ANS: A, B, D, E Allthe options, exceptimmunity to disease, are areasin which a hearing impairment could interfere with normal development. DIF: Cognitive Level: Comprehension REF: Page 540 TOP:Hearing Impairment KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 30. Whatintervention(s) would the nurse caring for a child with infectiousmeningitisinclude? (Select all thatapply.) a. Isolation precautions b. Provision of brightly litroom c. Observation forincreasing intracranial pressure d. Preparation forspinaltap e. Seizure precautions ANS: A, C, D, E NURSINGTB.COM All elements of nursing care listed in the options, except a brightly litroom, would be part of comprehensive care of a child with meningitis. DIF: Cognitive Level: Application REF: Page 550 TOP: Nursing Care of Child with Meningitis KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 31. What willthe nurse include then documenting a grand malseizure? (Select allthat apply.) a. Presence ofincontinence b. Current dose of antispasmodic medication c. Activity level priorto and following seizure d. Level of consciousnessfollowing seizure e. Length ofseizure ANS: A, C, D, E Documentation on a seizure should include LOC following episode, activity priorto and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary. DIF: Cognitive Level: Application REF: Page 552 TOP:Documentation of Seizure KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 32. The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information willthe nurse include? (Select all that apply.) a. Encourage books with large type. b. Wordsin booksshould be closely spaced.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 284 NURSINGTB.COM c. Provide adequate lighting without glare.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 285 NURSINGTB.COM d. Be sure desks and chairs are adequate height. e. Instruct child to squint when reading. ANS: A, C, D Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height. DIF: Cognitive Level: Comprehension REF: Page 545 TOP:Decorticate Posturing KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 33. The nurse is performing a neurological assessment on a 10-month-old infant using a modified GlasgowComa Scale. Whatscore will the nurse give if the child is babbling? a. 1 b. 2 c. 3 d. 4 ANS: D If babbling,the 10-month-old infantreceives a score of 4 for responses. DIF: Cognitive Level: Application REF: Page 566 OBJ: 18 TOP: Neurological Monitoring/Infants KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 34. An 8-year-old near-drowning victim isrushed into the ED. What priorities of care will be implemented? (Select all that apply.) a. Parental education regarding prevention b. Respiratory support c. Cardiovascular support d. Controlled rewarming e. Adequate cerebral oxygenation NURSINGTB.COM ANS: B, C, D, E Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parentsshould be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up. DIF: Cognitive Level: Comprehension REF: Page 566 OBJ: 19 TOP: Near-drowning KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 35. The sign thatsuggests possible damage to the cortex of the brain is posturing. ANS: decorticate Decorticate posturing is a flexorrigidity ofthe arms, wrists,fingers, and feet. This posture suggestsinjury to the brain cortex. DIF: Cognitive Level: Comprehension REF: Page 563 TOP:Decorticate Posturing KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 36. The nurse recordsthe finding of when the child withmeningitis criesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 286 NURSINGTB.COM outin pain when his head isflexed toward his chest. ANS: nuchalrigidity Stiffness ofthe neck resulting from inflamedmeningesis a sign of meningitis called nuchalrigidity.DIF: Cognitive Level: Comprehension REF: Page 549 TOP:Nuchal Rigidity KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 37. The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle isthe nerve. ANS: hypoglossal The hypoglossal (XII) nerve allowsthe infantto be able to suck and swallow. Itis also responsible fortongue movement. DIF: Cognitive Level: Knowledge REF: Page 548 OBJ: 7 TOP: Cranial Nerves KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 38. occurs when there is a change in the atmospheric pressure between the internal bodysystems and the surrounding environment. ANS: Barotrauma NURSINGTB.COM Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems andthe surrounding environment. DIF: Cognitive Level: Knowledge REF: Page 542 TOP: Barotrauma KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early DetectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 287 NURSINGTB.COM Chapter 24: The Child with a Musculoskeletal Condition MULTIPLE CHOICE 1. What would the nurse include in planning teaching to parents of a child with Legg-Calv-Perthes diseaseabout the long-term effects of this disease? a. There are no long-term effects. b. The disease isself-limited and requires no long-term treatment. c. Degenerative arthritismay develop laterin life. d. There isrisk of osteogenic sarcoma in adulthood. ANS: C Marked distortion of the head of the femurmay lead to an imperfect joint orto degenerative arthritis of the hiplater in life. DIF: Cognitive Level: Comprehension REF: Page 582 TOP: Legg-Calv-Perthes Disease KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. Whatintervention willthe nurse caring for a child in Bucksskin traction implement? a. Position in high Fowlers position. b. Assist the child to be pulled up in bed. c. Keep childs heel on the bed surface. d. Maintain childsfeet againstthe foot of the bed. ANS: B Bucks traction is a type of skin traction that relies on the childs weight as counterbalance. The child must bekept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bedsurface or the foot of the bed. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 574 TOP: Bucks Traction KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 3. What willthe nurse include when caring for a child in Bucks extension? a. Positioning the child with hipsflexed 90 degrees at alltimes b. Keeping the weightsin contact with the floor c. Checking forskin irritation from traction equipment d. Releasing the weights on a schedule ANS: C The skin exposed to frequentfrictionmay break down. DIF: Cognitive Level: Application REF: Page 577 OBJ: 6 TOP: Traction KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 4. The nurse isreviewing the characteristics of Ewingssarcoma. Which statement ifmade by the nurseindicates correct understanding of this disease? a. Amputation isthe accepted treatment. b. The disease issensitive to radiation and chemotherapy. c. Metastasisisrare. d. The disease ismore prevalent among toddlers and preschoolers. ANS: B Ewingssarcoma issensitive to radiation therapy and chemotherapy. Amputation of the affected extremity isnot recommended. This cancer occursin school-age children and does metastasize.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 288 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 583INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 289 NURSINGTB.COM TOP: Ewings Sarcoma KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 5. What characteristicmanifestation doesthe nurse caring for a child with Duchennesmuscular dystrophydocument? a. Ambulates by holding onto furniture b. Exhibits atrophy ofthe calf muscles c. Fallsfrequently and is clumsy d. Has delayed fine-motor development ANS: C Frequentfalling and clumsiness are clinical manifestations of Duchennesmuscular dystrophy. DIF: Cognitive Level: Knowledge REF: Page 581 TOP:Duchennes Muscular Dystrophy KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. The child has a temperature of 38.8 C (102 F) and abdominal pain. What type ofjuvenile rheumatoid arthritis do these findings suggest? a. Psoriatic b. Enthesitis c. Systemic d. Acute febrile ANS: C The systemic formof juvenile rheumatoid arthritisis associated with an elevated temperature, erythrocyte sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash. DIF: Cognitive Level: Application REF: PageN5U8R3SINGTB.COM TOP:Juvenile Rheumatoid Arthritis KEY: Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse is providing instructions about how to treat a sprained ankle. Whatstatement by themother doesthe nurse recognize as indicative of a need for additional teaching? a. Apply warm compressesto the ankle forthe first 24 hours. b. Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off. c. Wrap the ankle in an Ace bandage forsupport. d. Keep the leg elevated when sitting. ANS: A Heatis not a treatmentforsofttissue injuries. The principles ofmanaging softtissue injuries are rest, ice, compression, and elevation. DIF: Cognitive Level: Application REF: Page 573 OBJ: 4 TOP: Soft Tissue Injury KEY:Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 8. How does Russelltraction provide adequate skin traction? a. Subluxatesthe tibia b. Does notinterfere with range of motion c. Preventsthe knee fromflexing d. Supplies continuous pull in two directions ANS: D Russelltraction isskin traction,similarto Bucks, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM,the patient can change position without disrupting the continuous pull in two directions.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 290 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 574 TOP: Russell Traction KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is checking for capillary refill on a child in Bryantstraction. How long doesit take forthe toe to regain color if adequate perfusion is assessed? a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds ANS: A Capillary refill in 3 seconds orlessis determined to be indicative of adequate perfusion. DIF: Cognitive Level: Comprehension REF: Page 577 OBJ: 8 TOP: Fracture KEY: Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The parent of a child with osteomyelitis asks why his child isin somuch pain. What will the nurse respond causes the pain experienced with osteomyelitis? a. Pressure ofinelastic bone b. Purulent drainage in the bone marrow c. The cast applied on the extremity d. Circulatory congestion of the skin ANS: B Osteomyelitisis an infection ofthe bone. Inflammation produces an exudate that collects under the marrowand cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain. DIF: Cognitive Level: Comprehension REF: PNaUgeRS5I8N0GTB.COM OBJ: N/A TOP: Osteomyelitis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A child hospitalized fortreatment of osteomyelitis complainsthat he istired of being sick and wants toknow when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy willprobably last? a. 2 weeks b. 6 weeks c. 2months d. 3months ANS: B Because osteomyelitisis an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks. DIF: Cognitive Level: Application REF: Page 580 OBJ: 1 TOP: Osteomyelitis KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. Whatfinding would the nurse assessing the neurovascularstatus of a child in Russelltraction reportimmediately? a. Skin thats warm to the touch b. Capillary refill lessthan 3 seconds c. Ability to wiggle toes d. Bluish coloration ofskin ANS: DINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 291 NURSINGTB.COM Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 292 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 577 OBJ: 7 | 8 TOP: Neurovascular Assessment KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 13. A 13-year-old girl is diagnosed with functionalscoliosis. What doesthe nurse explain asthe cause of this spinal curvature defect? a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele ANS: B Functionalscoliosis usually is caused by poor posture, and it is not a spinal disease. DIF: Cognitive Level: Comprehension REF: Page 584 OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. Whatintervention is appropriate for a nurse assessing a preadolescent child forscoliosis? a. Ask the child to bend forward at the waist and observe the childs back for asymmetry. b. Observe the gait while the child is walking forward heel to toe. c. Have the child flex the knees and look for uneven knee height. d. Look atthe childsshoulders and hips while fully clothed. ANS: A The nurse looks atthe back asthe child bendsforward for general body alignment and asymmetry. DIF: Cognitive Level: Application REF: Page 584 OBJ: 13 TOP: Scoliosis KEY: Nursing ProcesNsUSRteSpI:NDGaTtaB.CCoOllMection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. What nursing action willsignificantly decrease the risk ofserious complicationsfor a child in Bryants traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child isrestrained from rolling over. d. The childs buttocks are resting on the bed. ANS: A The nurse caring for a child in tractionmust be alertfor Volkmannsischemia, which occurs when circulation is obstructed. DIF: Cognitive Level: Application REF: Page 576 TOP: Traction: VolkmannsIschemia KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 16. Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoidarthritis? a. Wearing splints at nightto prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warmtub bath the evening before d. Sleeping with two pillows under the head ANS: B Application ofmoist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness. DIF: Cognitive Level: Application REF: Page 583 TOP:Juvenile Rheumatoid Arthritis KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 293 NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 17. Whatinstruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace? a. Wearthe brace directly againstthe skin. b. Wearthe brace overregular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping. ANS: C A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protectsthe skin. DIF: Cognitive Level: Application REF: Page 584 TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. Which observationmay cause the nurse to considerthe possibility of child abuse when amothersays thather young child fell down the basement stairs? a. Red, green, and yellow bruises on his body b. Bruises are dispersed on his head, arms, and legs c. A broken armlast year, and the child being described as accident-prone d. Themotheris very anxiousfor herson to get medical attention ANS: A As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred atthe same time. The nursemust consider whetherthe bruisesmatch the caretakers explanation ofwhat happened. DIF: Cognitive Level: Analysis REF: Page 589 OBJ: 15 TOP: Child Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and MainteNnaUnRcSe:INPGreTvBen.CtiOoMn and Early Detection of Disease 19. A 6-year-old sustained a fractured femur and was putin Russelltraction 2 days ago. She screamsin painwhen she raises herself onto the bedpan. Which nursing diagnosistakes highest priority forthis child? a. Pain resulting from tissue trauma b. High risk forimpaired skin integrity resulting fromimmobility c. Altered growth and developmentrelated to separation from family d. Altered urinary elimination related to immobility and traction ANS: A Although all ofthese nursing diagnoses are relevant to the child in traction, pain resulting frommuscle spasm and tissue trauma is the highest priority. DIF: Cognitive Level: Analysis REF: Page 579 OBJ: 7 TOP: The Child with a Fracture in TractionKEY: Nursing Process Step: Nursing Diagnosis MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 20. What would the nurse consider an abnormal finding on amusculoskeletal assessment of a 4-year-old child? a. Hasinward-turned knees while standing b. Walks on the toes c. Appearsto have flat feet d. Swings his arms when walking ANS: B Toe walking after 3 years of agemay indicate a muscle problem. DIF: Cognitive Level: Analysis REF: Page 571 TOP: Assessment of the Musculoskeletal SystemKEY:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 294 NURSINGTB.COM Nursing Process Step: Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 295 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 21. Why does a childsfracture heal more rapidly than the adults? a. A childs bones are less porousthan adult bone. b. A childs bones are covered by a thicker periosteum. c. A childs bones are not affected by bone overgrowth. d. A childs bones have faster callusformation. ANS: D Callusformsmore rapidly in the child than the adult. DIF: Cognitive Level: Knowledge REF: Page 574 TOP: Differences Between the Child and Adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. On entering the room of a child in Buckstraction, the nursemakes all of the following observations. Whichobservation requires a nursing intervention? a. Childs heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys. ANS: A Buckstraction is dependent on the child as a counterweight. The heelsshould be elevated above the level of the foot of the bed. DIF: Cognitive Level: Application REF: Page 574 TOP: Bucks Traction KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: BasicNCUaRreSIaNndGTCBo.mCfOoMrt 23. Approximately how old doesthe nurse assess a large green bruise on the thigh of a 4-year-old to be? a. 2 days b. 4 days c. 6 days d. 8 days ANS: C Bruises heal in variousstagesthat are indicated according to color; after 5 to 7 days bruise are green. DIF: Cognitive Level: Comprehension REF: Page 589 OBJ: 15 TOP: Child Abuse KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. Whattype offracture would be the most likely to alert the nurse to the possibility of physical abuse? a. Stressfracture b. Compound fracture c. Spiral fracture d. Greenstick fracture ANS: C A spiral fracture of the femuris caused by a forceful twisting motion. When the history of an injury does not correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity. DIF: Cognitive Level: Comprehension REF: Page 574 TOP: Fractures/Child Abuse KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 296 NURSINGTB.COM 25. Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast? a. Risk for altered peripheral tissue perfusion b. Risk for altered urine elimination c. Knowledge deficit d. Risk forinfection ANS: A Casting can lead to compromised tissue perfusion caused by increased pressure fromedema orswelling pressing on the tissues. Neurovascular checks are an assessment priority. DIF: Cognitive Level: Application REF: Page 576 OBJ: 9 TOP: Casting KEY:Nursing Process Step:Nursing Diagnosis MSC:NCLEX: Physiological Integrity: Reduction of Risk Potential 26. A child issentto the school nurse for assessment because she comesto school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do thesefinding indicate? a. Sexual abuse b. Physical abuse c. Physical neglect d. Emotional abuse ANS: C Physical neglectisthe failure to provide forthe basic physical needs of the child, including food, clothing, shelter, and basic cleanliness. DIF: Cognitive Level: Comprehension REF: Page 587 TOP: Child Abuse Triggers KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation NURSINGTB.COM 27. Which assessment performed by a nursing student performing a neurovascular check alertsthe instructorthat further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils ANS: D Neurovascular checksinclude assessment of pain, pulse,sensation, color, capillary refill, andmovement. Pupils are assessed with a neurological check. DIF: Cognitive Level: Comprehension REF: Page 577 TOP:Neurovascular Assessment KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 28. Whatfactor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficitrelative to child care ANS: A, C, D, E All options except high self-esteem are possible triggersfor a parentto become abusive. DIF: Cognitive Level: Comprehension REF: Page 587 OBJ: 15 TOP: Child Abuse TriggersINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 297 NURSINGTB.COM KEY:Nursing Process Step:Data Collection MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 29. The nurse demonstrates which similarities among alltraction devices? (Select allthat apply.) a. Pullthe limb into extension b. Decreasemuscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb ANS: A, B, D, E Tractions are designed to immobilize and pull limbsinto extension. Traction can also align broken bones and decreasemuscle spasm. Although some traction devicesmay relieve pain, manymay actually cause pain. DIF: Cognitive Level: Comprehension REF: Page 574 OBJ: 7 TOP: Traction KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 30. The nurse performing a neurovascular check on a limb in traction would report and document whichfinding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equalto uncasted limb. b. Patientis aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend. ANS: C, D The limb should be warm, and capillary refillshould be lessthan 3 seconds. DIF: Cognitive Level: Comprehension REF: PNaUgeRS5I7N7GTB.COM OBJ: 8 TOP: Neurovascular Assessment KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 31. How doesthe pediatric skeletalsystem differfrom that ofthe adult? (Select allthat apply.) a. Lowermineral content b. More ossification c. Open epiphyses d. Less porosity e. Greaterstrength ANS: A, C, E The childsskeletalsystem haslessmineral content, greater porosity, open epiphyses, greater bone strength,and a thicker periosteum. DIF: Cognitive Level: Comprehension REF: Page 570 OBJ: 2 TOP: Skeletal Differences KEY: Nursing Process Step:N/AMSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 32. The nurse explainsthat Bryants traction isreserved for children who weigh lessthan pounds. ANS: 30 Bryantstraction is a skin traction used in the treatment of orthopedic disorders of young children who weigh lessthan 30 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 298 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 574 TOP: Bryants Traction KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 33. The nurse remindsthe adolescent boy with Ewingssarcoma that he is prohibited from vigorous weight-bearing activities during treatment with radiation to reduce the risk of a(n) fracture. ANS: pathological The bone haslostitsintegrity because of the cancer and radiation. Excessive or vigorous weight bearing can cause a pathological fracture of the compromised bone. DIF: Cognitive Level: Application REF: Page 583 TOP: Ewings Sarcoma KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 34. The child with Duchennes muscular dystrophy must push on hislegs and walk up the leg in order to rise toa standing position. The nurse recognizesthis characteristic behavior as maneuver. ANS: Gowers Gowers maneuver is a unique way ofrising from the floor by walking up the leg in order to get the upper body erect. DIF: Cognitive Level: Knowledge REF: Page 581 TOP:Duchennes Muscular Dystrophy KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. The nurse recognizesthe signs of NURSINGTB.COMsyndrome in a child in 90-90 traction when the toes are pale and edematous and have a very slow capillary refill. ANS: compartment When a limb isin traction or has been cast, the caregiver must check for adequate perfusion of the limb. Compartmentsyndrome occurs when the attendant edema from the injury orthe traction compromisesthe circulation. This is an emergency and must be corrected before permanent damage can occur. DIF: Cognitive Level: Comprehension REF: Page 577 TOP: Compartment Syndrome KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 36. A nurse assessing welts on the body of a 2-year-old Vietnamese child should considerthe skin lesionsmight be the result of the cultural practice of . ANS: coining Some Vietnamese place heated coins on the body to cure disease. This practice leaves weltsthat are sometimesmistaken for child abuse. DIF: Cognitive Level: Comprehension REF: Page 589 TOP: Cultural Practices: Coining KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 37. is a condition in which neck motion islimited and the cervicalspine is rotatedbecause of shortening of the sternocleidomastoid muscle.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 299 NURSINGTB.COM ANS: Torticollis Torticollis(tortus,twisted, and collium, neck) is a condition in which neck motion islimited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle. It can be either congenital or acquired and can also be either acute or chronic. DIF: Cognitive Level: Knowledge REF: Page 583 TOP: Torticollis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 300 NURSINGTB.COM Chapter 25: The Child with a Respiratory Disorder MULTIPLE CHOICE 1. What willthe nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcusthat the treatment is most likely to be? a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until hissore throatis gone d. Streptococcus immunization ANS: B When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished. DIF: Cognitive Level: Comprehension REF: Page 596 TOP: Acute Pharyngitis KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 2. Which initial intervention willthe nurse suggestto the parents of a child experiencing laryngealspasm? a. Take the child outside in the cool air. b. Bring the child directly to the emergency department. c. Take the child to the bathroom and turn on a hotshower. d. Have the child drink plenty of fluids. ANS: C The child experiencing laryngealspasm should be placed in a high-humidity environment,such asthe bathroom with a hotshower running. The humidity liquefies secretions and reducesspasm. DIF: Cognitive Level: Application REF: PageN5U9R8SINGTB.COM TOP: Croup Syndromes KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse would observe a child forfrequentswallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate? a. Bleeding fromthe surgicalsite b. Pain atthe incision area c. Sore throatfrom postnasal drip d. Potential vomiting ANS: A Hemorrhage isthemost common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing. DIF: Cognitive Level: Comprehension REF: Page 604 TOP: Tonsillitis and Adenoiditis KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 4. What isthe best choice forfluid replacement that the nurse can offer a child who hasjust had atonsillectomy? a. A popsicle b. Chocolatemilk c. Orange juice d. Cola drink ANS: A Small amounts of clearliquids can be offered to the child. Synthetic fruitjuices are not asirritating as natural juices. A popsicle is usually well-tolerated.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 301 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 604 TOP: Tonsillitis and Adenoiditis KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. When auscultating breath sounds of an infant with respiratory syncytial virus,which assessment would thenurse immediately report? a. Respiration rate decrease from 40 to 32 breaths/min b. Heartrate decrease from 110 to 100 beats/min c. Quiet chestfromprevious assessment of wheezing d. Oxygen saturation of 90% ANS: C A quiet chest after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration. DIF: Cognitive Level: Analysis REF: Page 600 TOP: Respiratory Syncytial Virus (RSV) KEY: Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthmaattack, expect to find? a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds atlung bases ANS: C The child experiencing an acute asthma attack wheezes as airmovesin and out of the narrowed airways. The expiratory wheeze is most pronounced. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 605 OBJ: 12 TOP: Asthma KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Whatisthe best intervention for the nurse caring for a child experiencing an acute asthma attack? a. Offer plenty offluids, particularly carbonated beverages. b. Place the child in a humidified cool misttent with oxygen. c. Administersedatives as ordered to decrease anxiety. d. Position the child with armsresting on the overbed table. ANS: D This position is comfortable and allowsmaximum use ofthe accessory musclesfor breathing. Sedatives would mask symptoms ofincreasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea. DIF: Cognitive Level: Comprehension REF: Page 609 TOP: Asthma KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 8. Whatshould the nurse explain to the parent of a child with exercise-induced asthma about when to inhaleCromolyn? a. Before exercise to prevent attacks b. Atthe initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day ANS: A Anti-inflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing fortheINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 302 NURSINGTB.COM attack in progress. They are meant to be used as prophylactic therapies.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 303 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 609 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is the nurses best response based on the understandingof CF? a. Only one parent carriesthe CF gene. b. Both parents are carriers of the CF gene. c. The inheritance pattern ismultifactorial. d. The resultis probably a geneticmutation. ANS: B Cystic fibrosisis an inherited disease. Both parents must be carriers of the CF gene forthe child to have the disease. DIF: Cognitive Level: Comprehension REF: Page 611 TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. Which statementindicatesthatthe childs parents understand how to perform respiratory therapy? a. We do her postural drainage before the aerosoltherapy. b. We give herrespiratory treatments when she is coughing a lot. c. We give the aerosol followed by postural drainage beforemeals. d. She needsrespiratory therapy every day when she has an infection. ANS: C Postural drainage forthe child with CF is done following nebulization. Therapy is bestscheduled before meals or at least 1 hour after eating to prevent vomiting. NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 615 TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 11. What willthe nurse teach the child with cystic fibrosisto take in orderto facilitate digestion and absorptionof nutrients? a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Saltsupplements ANS: A An oral pancreatic enzyme is given to the child with everymeal and with snacksto replace the pancreatic enzymes that the childs body cannot produce. DIF: Cognitive Level: Knowledge REF: Page 615 TOP: Cystic Fibrosis KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. How would the nurse advise a mother to clear the nostrils when herinfant has a cold? a. Clearthe nasal passages after the infant has a feeding. b. Use over-the-counter nose drops to clear passages. c. Remove nasalsecretions with a bulb syringe. d. Instillsaline nose drops after clearing away secretions. ANS: C The nasal passages can be cleared by instilling a few drops ofsaline into the nose and then suctioning the secretions with a bulb syringe.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 304 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 596 TOP: Nasopharyngitis KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity 13. The nurse offers a variety of fluidsto a 5-year-old asthmatic child to compensate for the fluid loss throughdyspnea. Which fluids are most appropriate? a. Room temperature water b. Carbonated beverages c. Iced fruitjuice d. Cold milk ANS: A Roomtemperature fluids are the best. Carbonated and iced beveragesincrease spasm. Milk stimulates mucus production. DIF: Cognitive Level: Application REF: Page 609 TOP: Asthma KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 14. The asthmatic child who has been taking theophylline complains ofstomachache and tachycardia and issweating profusely. What does the nurse recognize as the cause of these symptoms? a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity ANS: D The symptoms described are the signs of theophylline toxicity. DIF: Cognitive Level: Analysis REF: Page 60N7URSINGTB.COM OBJ: 11 TOP: Asthma KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Whatsignificant information would the nurse include? a. Wrapping the infantsnugly for rest periods b. Positioning the infant prone forsleep c. Sitting the infant up in an infantseat d. Placing infants on their backs orsidesforsleep ANS: D The American Academy of Pediatricsrecommendsthat all healthy infants be placed in the supine orside-lying position on a firm mattress to prevent SIDS. DIF: Cognitive Level: Comprehension REF: Page 619 OBJ: 17 TOP: Sudden Infant Death Syndrome KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity 16. An infantis hospitalized with RSV bronchiolitis. Whatisthe priority nursing diagnosis? a. Fatigue related to increased work of breathing b. Ineffective breathing pattern related to airway inflammation and increased secretions c. Risk forfluid volume deficitrelated to tachypnea and decreased oral intake d. Fear and/or anxiety related to dyspnea and hospitalization ANS: B An ineffective breathing pattern isthe priority nursing diagnosisfor an infant hospitalized with RSV infection. DIF: Cognitive Level: Analysis REF: Page 599 OBJ: 5 TOP: Respiratory Syncytial Virus(RSV)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 305 NURSINGTB.COM KEY:Nursing Process Step:Nursing Diagnosis MSC: NCLEX: Physiological Integrity 17. The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding wouldindicate the child is experiencing increased respiratory obstruction? a. Restlessness b. Tachycardia c. Brassy cough d. Expiratory wheezing ANS: A Restlessnessis a primary sign ofincreased respiratory obstruction. DIF: Cognitive Level: Analysis REF: Page 597 OBJ: 5 TOP: Acute Croup KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The teaching plan forthe use of a dry powder inhalerforthe treatment of asthma should include thewarning to rinse the mouth after inhaling the powder. What does this prevent? a. Discoloration oftooth enamel b. Halitosis c. Irritation of oral membranes d. Candidiasis ANS: D Inhalant powders can cause candidiasis(yeast) infection of the mouth. DIF: Cognitive Level: Comprehension REF: Page 609 TOP: Candidiasis KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: PharmNaUcRolSoIgNicGaTlBth.CerOaMpies 19. The nurse is caring for a 3-year-old who suffered a smoke inhalation injury. How long isthis patient at thehighest risk for pulmonary edema after exposure? a. 2 hours b. 4 hours c. 18 hours d. 72 hours ANS: D Pulmonary edema appearsin a child with smoke inhalation injury 6 to 72 hours after exposure. DIF: Cognitive Level: Comprehension REF: Page 601 TOP: Smoke Inhalation KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. Which isthe most appropriate nursing action when planning care for a child with cystic fibrosis? a. Provide chest physiotherapy beforemeals every day. b. Assess weightmonthly. c. Administer pancrease with protein food at mealtime. d. Ensure high-protein, high-calorie diet. ANS: D The maintenance of adequate nutrition is essential. The diet is high in protein and calories. Chest physiotherapy should be done betweenmeals. Pancreatic enzyme powdershould be given with applesauce or other nonstarch, nonfat, nonprotein food. Children with cystic fibrosis should be weighed daily. DIF: Cognitive Level: Application REF: Page 615 TOP: Cystic Fibrosis KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 306 NURSINGTB.COM 21. The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to preventthisfrom happening with the child they are currently expecting. What willthe nurse explain asthe bestway to prevent BPD? a. Maternal intake of folic acid b. Exercise c. Prevention of preterm birth d. Provision of oxygen therapy to the newborn ANS: C Bronchopulmonary dysplasia (BPD) is a fibrosis, or thickening, of the alveolar walls and the bronchiolar epithelium. It occurs in premature infants (less than 32 weeks) who have abnormal or arrested lung development and receive ventilation and oxygen for more than 28 daysto survive. Respiratory distressin the newborn is the major reason why oxygen and ventilators are used for prolonged periods. The main cause of respiratory distressin the newborn is prematurity. Therefore the prevention of preterm birthsisthe best way toprevent BPD. DIF: Cognitive Level: Knowledge REF: Page 618 TOP: Bronchopulmonary Dysplasia KEY:Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention MULTIPLE RESPONSE 22. The nurse describesthe allergic salute as a cluster of whatsignsrelated to chronic allergy? (Select all thatapply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva NURSINGTB.COM ANS: A, B, C, E The allergic salute does notinclude a productive cough. DIF: Cognitive Level: Comprehension REF: Page 604 OBJ: 9 TOP: Allergic Salute KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse would suggestthe parents of an asthmatic child to encourage participation in which sport(s)?(Select all that apply.) a. Swimming b. Gymnastics c. Baseball d. Cross-country skiing e. Distance running ANS: A, B, C Sportsthatrequire bursts of energy rather than long-term output of energy are suitable pursuitsfor asthmatics.Swimming, gymnastics, and baseball fit this criterion. DIF: Cognitive Level: Comprehension REF: Page 609 TOP: Sports Activities Suitable for Asthmatics KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. The nurse reports which assessmentsthatsuggest a meconium ileusin a newborn? (Select allthat apply.) a. Abdominal distention b. VomitingINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 307 NURSINGTB.COM c. HiccoughingINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 308 NURSINGTB.COM d. Jaundice e. Absence ofstool ANS: A, B, E Distended abdomen, vomiting, and absence ofstool are the signsindicating meconiumileusin the newborn. DIF: Cognitive Level: Comprehension REF: Page 603 TOP: Meconium Ileus KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 25. What would the nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select allthat apply.) a. Inhale deeply through nose withmouth closed. b. Make exhalation twice aslong asinhalation. c. Use medicated inhaler priorto performing breathing exercise. d. Exhale through mouth asif whistling. e. Exhale forcefully. ANS: A, B, D The technique requiresthat breath be inhaled through the nose and exhaled through pursed lipsin a nonforcefumanner. The exhalation should be twice as long as the inhalation. DIF: Cognitive Level: Comprehension REF: Page 609 TOP: Pursed-Lip Breathing KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. A toddlermustmaintain bed restforthe diagnosis of pneumonia. What actions willthe nurse implement?(Select all that apply.) a. Maintain strict bed rest. b. Consider age. c. Assess developmental level. d. Implementlight play activities. e. Provide hypnoticmedication as ordered. NURSINGTB.COM ANS: B, C, D Confinementto bed for a child does not alwaysresult in physical rest. In pediatrics, bed rest means providing play therapy that promotesminimal activity. The nurse should considerthe age and developmental level of the child and the activity level involved in the play when designing appropriate activities and guiding parents in the home care of their child. DIF: Cognitive Level: Application REF: Page 595 TOP: Bed Rest KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk Potential 27. The school nurse suspects a first grade student hassinusitis. Which symptomsmightlead the nurse to thissuspicion? (Select all that apply.) a. Child reportstooth pain. b. Severe wheezing is auscultated on inspiration. c. Child reports, I have had a cold for 2 weeks. d. Nurse observes periorbitalswelling. e. Halitosisis present. ANS: A, C, D, E The proximity of the sinus to the tooth roots often results in tooth pain when the sinus is infected. The maxillary and ethmoid sinuses are most often involved in childhood sinusitis. Therefore the signs and symptoms of sinusitis in children are different from those in adults, depending on the age of the child and which sinusisfully developed. An acute sinusitisissuspected when an upper respiratory infection lastslongerINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 309 NURSINGTB.COM than 10 days, with a daytime cough. Halitosis is often present. Untreated sinusitis can lead to periorbital cellulitis. Severe wheezing is not indicative of sinusitis.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 310 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 597 TOP: Sinusitis KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. The nurse is caring for a 4-year-old child diagnosed withH. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.) a. Harsh cough b. Restlessness c. Edematous epiglottis d. Child insists on lying down e. Drooling ANS: B, C, E H. influenzae type B and most often occurs in children 3 to 6 years of age. It can occur in any season. The course is rapid and progressive. The onset of epiglottitis is abrupt, and the child presents with classic symptoms. The child insists on sitting up, leansforward with the mouth open, and droolssaliva because of the difficulty in swallowing. The child appears wide-eyed, anxious, and restless, and he orshemay emit a froglike croaking sound on inspiration. Cough is absent. Inspection of the throat shows an enlarged, reddened edematous epiglottis much like a beefy-red thumb. However, the examining tongue blade may trigger a laryngospasm and result in sudden respiratory arrest. DIF: Cognitive Level: Comprehension REF: Page 598 TOP: Epiglottitis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. What willthe nurse discourage when providing education to parents of a child with asthma? (Select all thatapply.) a. Stuffed toys b. Pet ownership c. Gymnastics d. Basketball e. Cotton blankets NURSINGTB.COM ANS: A, D Use ofstuffed toysis discouraged due to potential allergens. Basketball might not be welltolerated because of the constant physical exertion. Certain pets are encouraged, gymnasiticsis usually welltolerated, and cotton blankets are recommended for children with asthma. DIF: Cognitive Level: Comprehension REF: Page 607 TOP: Asthma KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention COMPLETION 30. The nurse explainsthat the can sense the oxygen concentration in the blood andsignal the brainstem to increase respiration. ANS: chemoreceptors Chemoreceptors can sense the oxygen concentration ofthe blood and signalthe brainstem to increase and deepen respirations to keep an adequate supply of oxygen in the circulating volume. DIF: Cognitive Level: Knowledge REF: Page 594 TOP: Chemoreceptors KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. Afterthe 3-month-old child with respiratory syncytial virusis given a protocol of antiviral medications,the nurse explainsthatroutine immunizations will need to be delayed for months.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 311 NURSINGTB.COM ANS: 9 After a protocol of antiviral medications,the routine immunizationsshould be delayed because the antiviral medications affect the integrity of the immunizations. DIF: Cognitive Level: Knowledge REF: Page 600 TOP: Respiratory Syncytial Virus(RSV) KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 32. The nurse reviews Accolate and Zyflo, which are ; they are capableof blocking the inflammatory response as well as providing bronchodilation. ANS: leukotriene modifiers The leukotrienemodifiers are capable of blocking the inflammatory response and can also provide bronchodilation. DIF: Cognitive Level: Knowledge REF: Page 607 OBJ: 12 TOP: Leukotriene Modifiers KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 33. Place the three stages ofsmoke inhalation injury in the correct order(first to last). Put a comma and spacebetween each answer choice (a, b, c, d, etc.) a. Bronchopneumonia b. Pulmonary insufficiency c. Pulmonary edema ANS: B, C,A NURSINGTB.COM Smoke inhalation injurymay cause carbonmonoxide poisoning. Poisonoussubstancesinhaled fromburning material may also cause pathological disturbance. There are three stages of inhalation injury: 1. Pulmonary insufficiency in the first 6 hours 2. Pulmonary edema from 6 to 72 hours 3. Bronchopneumonia after 72 hours, whichmay cause atelectasis DIF: Cognitive Level: Knowledge REF: Page 601 TOP: Smoke Inhalation KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 312 NURSINGTB.COM Chapter 26: The Child with a Cardiovascular Disorder MULTIPLE CHOICE 1. What doesthe nurse explain that a ventricularseptal defect will allow? a. Blood to shuntleft to right, causing increased pulmonary flow and no cyanosis b. Blood to shuntrightto left, causing decreased pulmonary flow and cyanosis c. No shunting because of high pressure in the left ventricle d. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume ANS: A Pulmonary blood flow isincreased when a ventricularseptal defect exists. The blood shiftsfromleft to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis. DIF: Cognitive Level: Comprehension REF: Page 626 TOP: Congenital HeartDisease KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Which assessment would lead the nurse to suspect that a newborn infant has a ventricularseptal defect? a. A loud, harsh murmur with a systolic thrill b. Cyanosis when crying c. Blood pressure higher in the armsthan in the legs d. A machinery-likemurmur ANS: A A loud, harshmurmur combined with a systolic thrill is characteristic of a ventricularseptal defect. DIF: Cognitive Level: Comprehension REF: Page 626 TOP: Congenital HeartDisease KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: PhysiNolUoRgi Sc IaNlGATdBap.CtaOtiMon 3. Whatfinding would the nurse expect whenmeasuring blood pressure on all four extremities of a child withcoarctation of the aorta? a. Blood pressure higher on the rightside b. Blood pressure higher on the leftside c. Blood pressure lowerin the armsthan in the legs d. Blood pressure lowerin the legsthan in the arms ANS: D The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal tothe coarctation. DIF: Cognitive Level: Comprehension REF: Page 627 TOP: Congenital HeartDisease KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A father asks why his child with tetralogy of Fallotseemsto favor a squatting position. Whatisthe nursesbest response? a. Squatting increasesthe return of venous blood back to the heart. b. Squatting decreases arterial blood flow away from the heart. c. Squatting is a common resting position when a child istachycardic. d. Squatting increasesthe workload of the heart. ANS: A The squatting position allowsthe child to breathe more easily because systemic venousreturn isincreased. DIF: Cognitive Level: Comprehension REF: Page 627INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 313 NURSINGTB.COM TOP: Congenital HeartDisease KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 314 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. An infantis experiencing dyspnea related to patent ductus arteriosus(PDA). What doesthe nurse understandregarding why dyspnea occurs? a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion. b. Blood isshunted pastthe pulmonary circulation, causing pulmonary hypoxia. c. Blood isshunted past cardiac arteries, causing myocardial hypoxia. d. Blood is circulated through the ductusfrom the pulmonary artery to the aorta, bypassing the leftside of theheart. ANS: A When PDA is present, oxygenated blood recyclesthrough the lungs, overburdening the pulmonary circulation. DIF: Cognitive Level: Comprehension REF: Page 626 OBJ: 4 TOP: Congenital Heart Disease KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. Which isthemost appropriate nursing action related to the administration of digoxin (Lanoxin)to an infant? a. Counting the apicalrate for 30 seconds before administering themedication b. Withholding a dose if the apical heartrate islessthan 100 beats/min c. Repeating a dose if the child vomits within 30 minutes ofthe previous dose d. Checking respiratory rate and blood pressure before each dose ANS: B As a rule, if the pulse rate of an infant is below 100 beats/min,the medication is withheld and the physician is notified. DIF: Cognitive Level: Application REF: Page 630 TOP: Congestive Heart Failure KEY: NursingNPUrRocSeIsNsGSTteBp.C: IOmMplementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. A child develops carditisfromrheumatic fever. Which areas of the heart are affected by carditis? a. Coronary arteries b. Heartmuscle and the mitral valve c. Aortic and pulmonic valves d. Contractility ofthe ventricles ANS: B The tissuesthat coverthe heart and heart valves are affected. The heart muscle may be involved and themitral valve is frequently involved. DIF: Cognitive Level: Knowledge REF: Page 632 TOP: Rheumatic Fever KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. Which comment made by a parent of a 1-month-old would alertthe nurse aboutthe presence of a congenitalheart defect? a. He is always hungry. b. He tires out during feedings. c. He isfussy forseveral hours every day. d. He sleeps all the time. ANS: B Fatigue during feeding or activity is common tomost infants with congenital cardiac problems. DIF: Cognitive Level: Application REF: Page 629 OBJ: 3 TOP: Congenital Heart Disease KEY:Nursing Process Step:Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 315 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 9. The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asksthe nurse, How does Kawasaki disease affectmy childs heart and blood vessels?On what understanding isthe nurses responsebased? a. Inflammation weakens blood vessels, leading to aneurysm. b. Increased lipid levelslead to the development of atherosclerosis. c. Untreated disease causesmitral valve stenosis. d. Altered blood flow increases cardiac workload with resulting heartfailure. ANS: A Inflammation of vessels weakensthe walls of the vessels and often resultsin aneurysm. DIF: Cognitive Level: Comprehension REF: Page 635 TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse explained how to position an infant with tetralogy of Fallotif the infantsuddenly becomescyanotic. Which statement by the father leads the nurse to determine he understood the instructions? a. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest. b. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body. c. If the baby turns blue, I will immediately put the baby upright in an infantseat. d. If the baby turns blue, I will put the baby in supine position with his head elevated. ANS: A In the event of a paroxysmal hypercyanotic ortetspell, the infantshould be placed in a knee-chest position. DIF: Cognitive Level: Application REF: Page 628 OBJ: 4 TOP: Tetralogy of Fallot KEY:Nursing Process Step: Evaluation NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 11. The parent of a 1-year-old child with tetralogy of Fallot asksthe nurse, Why do my childsfingertipslook like that? On what understanding does the nurse base a response? a. Clubbing occurs as a result of untreated congestive heartfailure. b. Clubbing occurs as a result of a left-to-rightshunting of blood. c. Clubbing occurs as a result of decreased cardiac output. d. Clubbing occurs as a result of chronic hypoxia. ANS: D Clubbing ofthe fingers developsin response to chronic hypoxia. DIF: Cognitive Level: Comprehension REF: Page 627 OBJ: 4 TOP: Tetralogy of Fallot KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A child has an elevated antistreptolysinO(ASO)titer. Which combination ofsymptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful,tenderjoints and carditis c. Erythemamarginatum and arthralgia d. Chorea and elevated sedimentation rate ANS: B The presence oftwomajorJones criteria would indicate a high probability ofrheumatic fever. DIF: Cognitive Level: Application REF: Page 632INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 316 NURSINGTB.COM OBJ: 6 TOP: Rheumatic FeverINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 317 NURSINGTB.COM KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 13. An infant with congestive heartfailure isreceiving digoxin (Lanoxin). What doesthe nurse recognize as a sign of digoxin toxicity? a. Restlessness b. Decreased respiratory rate c. Increased urinary output d. Vomiting ANS: D Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse. DIF: Cognitive Level: Comprehension REF: Page 630 TOP: Heart Failure KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 14. Through what doesthe infant born with hypoplastic left heartsyndrome acquire oxygenated blood? a. The patent ductus arteriosus b. A ventricularseptal defect c. The closure of the foramen ovale d. An atrialseptal defect ANS: D Because the rightside of the heart musttake over pumping blood to both the lungs and systemic circulation,the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs. DIF: Cognitive Level: Knowledge REF: Page 628 TOP: Hypoplastic Left Heart Syndrome KEYN: NUuRrSsIinNgGPTrBo.cCeOssMStep: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A child with rheumatic fever beginsinvoluntary, purposelessmovements of herlimbs. What doesthe nurserecognize that this indicates? a. Seizure activity b. Hypoxia c. Sydenhams chorea d. Decreasing level of consciousness ANS: C Asthe effects ofrheumatic fever affectthe central nervoussystem,the child may develop Sydenhams chorea, manifested by involuntary, purposeless movements of the limbs. DIF: Cognitive Level: Knowledge REF: Page 632 TOP: Sydenhams Chorea KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Physiological Adaptation 16. How long should a 4-year-old child recovering fromrheumatic fever need to receivemonthly injections ofpenicillin G? a. 1 year b. 2 years c. 5 years d. 10 years ANS: C Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections(about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 to preventfurther bouts of rheumatic fever.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 318 NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 633 TOP: Prophylaxisfor Rheumatic Fever KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 17. Whatis accurate aboutthe characteristics of high-density lipoproteins(HDLs)? a. They have high amounts oftriglycerides. b. They have only small amounts of protein. c. They have little cholesterol. d. They aid in steroid production. ANS: C HDLs have low amounts oftriglycerides, large amounts of proteins, low amount of cholesterol, and are excreted via the liver. They have no role in the production of steroids. DIF: Cognitive Level: Knowledge REF: Page 634 TOP:High-Density Lipoproteins KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 18. Whatshould the school nurse recommend when encouraging a heart-healthy diet for a child with highcholesterol? a. A fat intake reduction of 5-10% of total calories b. A fatintake reduction of 10-15% of total calories c. A fatintake reduction of 15-20% of total calories d. A fatintake reduction of 25-35% of total calories ANS: D For a child with increased cholesterol a fatreduction of 25-35% of total calories with lessthan 75 saturated fat and less than 200 mg of cholesterol per day is advised. DIF: Cognitive Level: Knowledge REF: PageN6U34RSINGTB.COM TOP:Heart-Healthy Diet KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 19. The nurse is planning a hypertension-prevention program. Whatshould be the main focus of the nursewhen presenting information? a. Pharmacological treatment b. Surgical interventions available c. Patient education d. Reduction of aerobic exercise ANS: C Themain focus of a hypertension-prevention program is patient education. DIF: Cognitive Level: Knowledge REF: Page 634 TOP:Hypertension Prevention KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 20. A pediatric patientisscheduled for a noninvasive procedure to determine if his heart isstructurally normaland to localize a murmur. What diagnostic test does the nurse anticipate? a. Barium swallow b. Chest x-ray c. Electrocardiogram d. Echocardiogram ANS: D Echocardiography is a noninvasive procedure thatlocalizesmurmurs and determinesiftheheart isstructurally normal. DIF: Cognitive Level: Knowledge REF: Page 625INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 319 NURSINGTB.COM OBJ:N/A TOP: Diagnostic Tests KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease MULTIPLE RESPONSE 21. How would the nurse caring for an infant with congestive heartfailure (CHF)modify feeding techniquesto adapt for the childs weakness and fatigue? (Select all that apply.) a. Feeding more frequently with smallerfeedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose waterforformula e. Offering high-caloric formula ANS: A, B, C, E Infants with CHF fatigue easily. Feeding can be givenmore frequently in smaller amountsthrough a soft, large-holed nipple. Formulas with a denser caloric content can be offered. The childmay be encouraged tonurse if he or she is held. DIF: Cognitive Level: Application REF: Page 630 TOP: Feeding Infant with CHF KEY:Nursing Process Step:ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. What are the fourstructural heart anomaliesthatmake up the tetralogy of Fallot? (Select the four thatapply.) a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventralseptal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta ANS: A, B, D, E NURSINGTB.COM The four anomaliesthat comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus,stenosis of pulmonary artery, and dextroposition of the aorta. DIF: Cognitive Level: Knowledge REF: Page 627 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological Adaptation 23. What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.) a. Spontaneous cyanosis b. Dyspnea c. Weakness d. Dry cough e. Syncope ANS: A, B, C, E Indicators of a paroxysmal hypercyanotic episode or a tet episode are spontaneous cyanosis, dyspnea, weakness, and syncope. DIF: Cognitive Level: Comprehension REF: Page 627 TOP: Tet Spells KEY: Nursing Process Step: Data Collection MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 24. Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select allthat apply.) a. Atrialseptal defects(ASDs) b. Tetralogy of Fallot c. Dextroposition of aortaINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 320 NURSINGTB.COM d. Patent ductus arteriosus e. Ventricularseptal defects(VSDs) ANS: A, D, E The congenital heart defectsthat cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus. DIF: Cognitive Level: Comprehension REF: Page 628 TOP: Congenital HeartDefects KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. A 16-year-old patientis diagnosed with primary hypertension. Whatrisk factors doesthe nurse mentionwhen providing education on this diagnosis to the patient and his family? (Select all that apply.) a. Heredity b. Stress c. Congenital defect d. Obesity e. Poor diet ANS: A, B, D, E Primary, or essential, hypertension impliesthat no known underlying disease is present. Nevertheless, heredity,obesity,stress, and a poor diet and exercise pattern can contribute to any type of hypertension. DIF: Cognitive Level: Comprehension REF: Page 625 TOP: Primary Hypertension KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 26. The nurse takes into consideration that theNmUoRsS tI cNoGmTmBo.CnOcoMngenital heart defect is the defect. ANS: ventricularseptal VSDs are themost common congenital heart defect. DIF: Cognitive Level: Knowledge REF: Page 633 TOP: VSDKEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. The nurse explainsthatthe difference between the systolic blood pressure reading and the diastolic bloodpressure reading is called the . ANS: pulse pressure The pulse pressure isthe difference between the diastolic pressure and the systolic pressure. DIF: Cognitive Level: Knowledge REF: Page 626 TOP: Pulse Pressure KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. Because the diagnosis ofrheumatic feveris difficult, an aid used to identify the presence ofrheumatic feveis the . ANS: Jones criteria The Jones criteria identify a cluster ofsymptoms and divide them into major criteria andminor criteria. TheINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 321 NURSINGTB.COM formula formaking the diagnosis ofrheumatic fever isto identify twomajor criteria in the patient, or one major and two minor criteria. DIF: Cognitive Level: Knowledge REF: Page 627 TOP: Jones Criteria KEY:Nursing Process Step: N/AMSC: NCLEX: N/A 29. is designed to serve the metabolic needs during intrauterine life and also topermitsafe transition to life outside the womb. ANS: Fetal circulation Fetal circulation is designed to serve the metabolic needs during intrauterine life and also to permitsafe transition to life outside the womb. DIF: Cognitive Level: Knowledge REF: Page 632 TOP: Fetal Circulation KEY:Nursing Process Step:N/A MSC: NCLEX: N/A 30. Systemic blood pressure increases with age and is correlated with and throughoutchildhood and adolescence. ANS: height; weight Systemic blood pressure increases with age and is correlated with height and weightthroughout childhood and adolescence. Significant hypertension is considered whenmeasurements are persistently at or above the 95th percentile for the patients age and sex. DIF: Cognitive Level: Knowledge REF: PageN6U33RSINGTB.COM TOP: Hypertension KEY:Nursing Process Step:Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 31. is a systemic disease involving the joints, heart, central nervoussystem (CNS),skin, and subcutaneous tissues. It belongs to a group of disorders known as collagen diseases. ANS: Rheumatic fever(RF) Rheumatic fever(RF) is a systemic disease involving the joints, heart, central nervoussystem (CNS),skin, and subcutaneous tissues. It belongs to a group of disorders known as collagen diseases DIF: Cognitive Level: Knowledge REF: Page 631 TOP: Rheumatic Fever KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 322 NURSINGTB.COM e 640 Chapter 27: The Child with a Condition of the Blood, Blood-Forming Organs, or Lymphatic System MULTIPLE CHOICE 1. The nurse isteaching the parents of a young child with iron deficiency anemia about nutrition. What foodwould the nurse emphasize as being a rich source of iron? a. An egg white b. Cream of Wheat c. A banana d. A carrot ANS: B Good nutritionalsources ofiron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried fruits, beans, nuts, and whole-grain breads. DIF: Cognitive Level: Comprehension REF: Page 640 TOP: Iron Deficiency Anemia KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. Which statement by amothermay indicate a cause for her 9-month-oldsiron deficiency anemia? a. Formula isso expensive. We switched to regularmilk right away. b. She almost never drinks water. c. She doesntreally like peaches or pears,so we stick to bananasforfruit. d. I give her a piece of bread now and then. She likesto chew on it. ANS: A Because cows milk contains very little iron, infantsshould drink iron-fortified formula for the first year of life. NURSINGTB.COM DIF: Cognitive Level: Application REF: Pag TOP: Iron Deficiency Anemia KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 3. What willthe nurse administer with ferroussulfate drops when providing themto a child on the pediatricunit? a. Withmilk b. With orange juice c. With water d. On a fullstomach ANS: B Vitamin C aidsin the absorption of iron, whereasfood andmilk interfere with the absorption of iron. DIF: Cognitive Level: Application REF: Page 640 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. What isthe result of a deficiency of factorIX? a. Thalassemia b. Idiopathic thrombocytopenic purpura c. Hemophilia A d. Christmas disease ANS: D Christmas disease, or hemophilia B, is caused by the deficiency offactorIX. DIF: Cognitive Level: Knowledge REF: Page 646 TOP: Christmas Disease KEY:Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 323 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A 2-year-old child has been diagnosed with hemophilia A. Whatinformation should the nurse include in ateaching plan about home care? a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b. Childrens aspirin in lowered dosesmay be given forjoint discomfort. c. A firm, dry toothbrush should be used to clean teeth atleast twice a day. d. Do not permitinteractive play with other children. ANS: A When bleeding occurs,the traditional approach isto follow RICErest, ice, compression, and elevation. DIF: Cognitive Level: Application REF: Page 646 TOP:Hemophilia KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 6. What will the nurse teach the parents of a child with a low platelet count to avoid? a. Ibuprofen b. Aspirin c. Caffeine d. Prednisone ANS: B Aspirin interferes with plateletfunction and should be avoided to prevent the risk of prolonged bleeding. DIF: Cognitive Level: Application REF: Page 647 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. What should the nurse closely assess in a chNilUdRrSecINeiGvTinBg.CaOtrMansfusion? a. Fever b. Lethargy c. Jaundice d. Bradycardia ANS: A The child receiving a blood transfusion is observed forsigns of a transfusion reaction including chills, itching, fever, rash, headache, and back pain. DIF: Cognitive Level: Comprehension REF: Page 650 OBJ: 16 TOP: Blood Transfusion KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 8. On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. What isthe priority nursing intervention? a. Assessing neurologicalstatus b. Inserting an intravenousline c. Monitoring vitalsigns during platelettransfusions d. Providing family education about how to prevent bleeding ANS: A When platelets are low,the greatest dangerisspontaneousintracranial bleeding. Neurological assessments are therefore a priority of care. DIF: Cognitive Level: Application REF: Page 647 TOP: Leukemia KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 324 NURSINGTB.COM 9. An adolescentis diagnosed withHodgkins disease. Lymph nodes on both sides of her diaphragm have beenfound to be involved, including cervical and inguinal nodes. Which disease stage is this? a. I b. II c. III d. IV ANS: C Lymph node regions on both sides of the diaphragm are consistent with a diagnosis ofstage III Hodgkins disease. DIF: Cognitive Level: Application REF: Page 651 OBJ: N/A TOP: Hodgkins Disease KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. Which type of crisis is the child most likely experiencing? a. Aplastic b. Hyperhemolytic c. Vaso-occlusive d. Splenic sequestration ANS: C Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm. DIF: Cognitive Level: Application REF: Page 642 OBJ: 8 TOP: Sickle Cell Disease KEY: Nursing Process Step: Data Collection NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Which statementmade by a parentindicates an understanding of healthmaintenance of a child with sicklecell disease? a. Ishould givemy child a daily iron supplement. b. Itisimportant for my child to drink plenty of fluids. c. He needsto wear protective equipment if he plays contactsports. d. He shouldntreceive any immunizations until he is older. ANS: B Prevention of dehydration, which can triggerthe sickling process, is a priority goal in the care of a child with sickle cell disease. DIF: Cognitive Level: Application REF: Page 644 TOP: Sickle Cell Disease KEY:Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. A newly married couple isseeking genetic counseling because they are both carriers of the sickle cell trait.How can the nurse best explain the childrens risk of inheriting this disease? a. Every fourth child will have the disease;two others will be carriers. b. All of their children will be carriers, just asthey are. c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier. d. The risk levels oftheir children cannot be determined by thisinformation. ANS: C The sickle cell gene isinherited from both parents; therefore each offspring has a one in four chance of inheriting the disease.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 325 NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 643INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 326 NURSINGTB.COM OBJ: 7 TOP: Sickle Cell Disease KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 13. A child with thalassemiamajorreceives blood transfusionsfrequently. Whatis a complication of repeatedblood transfusions? a. Hemarthrosis b. Hematuria c. Hemoptysis d. Hemosiderosis ANS: D As a result ofrepeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues. DIF: Cognitive Level: Comprehension REF: Page 645 TOP: Thalassemia KEY: Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A child hasjust been diagnosed with acute lymphoblastic leukemia. Whatisthe result of an overproductionof immature white blood cells in the bone marrow? a. Decreased T-cell production b. Decreased hemoglobin c. Increased blood clotting d. Increased susceptibility to infection ANS: D An overproduction of immature white blood cellsincreasesthe childssusceptibility to infection. DIF: Cognitive Level: Comprehension REF: Page 648 TOP: Leukemia KEY: Nursing Process Step: NDUatRaSCINolGleTcBti.oCnOM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The child receiving a transfusion complains of back pain and itching. Whatisthe bestinitial action by the nurse? a. Notify the charge nurse. b. Disconnect intravenous lines immediately. c. Give diphenhydramine (Benadryl). d. Clamp off blood and keep line open with normalsaline. ANS: D If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse. DIF: Cognitive Level: Application REF: Page 650 TOP: Blood Transfusion KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy? a. Use commercial mouthwash. b. Clean teeth with a softtoothbrush. c. Avoid use of a Water-Pik. d. Inspectthemouth weekly for ulcerations. ANS: B A softtoothbrush reduces capillary damage andmucousmembrane breakdown and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection. Water-Pik is useful for toughening gums. DIF: Cognitive Level: Application REF: Page 650INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 327 NURSINGTB.COM TOP: Leukemia KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 17. A 6-year-old with leukemia asks, Who will take care of me in heaven? Whatisthe bestresponse by thenurse? a. Who do you think will take care of you? b. Your grandparents and God willtake care of you. c. Your mom will know more aboutthat than I do. d. Why are you asking me that? ANS: A This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed responsesshut off communication. The asking of a why question is nottherapeutic asit callsforjustification. DIF: Cognitive Level: Application REF: Page 650 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. The nurse is dealing with a preschool-age child with a life-threatening illness. Whatshould the nurseremember the childs concept of death is at this age? a. Thatit isfinal b. Only a fear ofseparation from her parents c. That a person becomes alive again soon after death d. An understanding based on simple logic ANS: C The preschooler views death asreversible and temporary. DIF: Cognitive Level: Comprehension REF: Page 656 OBJ: 19 TOP: Nursing Care of the Dying ChiNldURSINGTB.COM KEY: Nursing Process Step: Data Collection MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 19. The nurse notesthat a 4-year-old childs gums bleed easily and he has bruising and petechiae on hisextremities. Which lab value is consistent with these symptoms? a. Platelet count of 25,000/mm3 b. Hemoglobin level of 8 g/dL c. Hematocritlevel of 36% d. Leukocyte count of 14,000/mm3 ANS: A The normal platelet countis 150,000 to 400,000/mm3. Thisfinding is very low, indicating an increased bleeding potential. DIF: Cognitive Level: Analysis REF: Page 647 TOP: Idiopathic Thrombocytopenic Purpura KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse, caring for a child receiving chemotherapy, notesthatthe childs abdomen isfirmand slightlydistended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest? a. Peripheral neuropathy b. Stomatitis c. Myelosuppression d. Hemorrhage ANS: A Peripheral neuropathymay be signaled by severe constipation resulting from decreased nerve sensationsinINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 328 NURSINGTB.COM theINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 329 NURSINGTB.COM bowel. DIF: Cognitive Level: Analysis REF: Page 650 TOP: Leukemia KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 21. The nurse finds an adolescent withHodgkins disease crying. The adolescentsays, I am so scared. Whatis the most appropriate nursing response to this comment? a. I understand how you mustfeel. b. You shouldnt feel that way. c. Isthisthe strongest feeling youve had today? d. Tell me whats got you scared. ANS: D The nurse should encourage the adolescent to express herfeelings and concerns. DIF: Cognitive Level: Application REF: Page 656 TOP: Adolescent with CancerFear of Death KEY:Nursing Process Step: Implementation MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 22. Themostrecent blood countfor a child who received chemotherapy last week shows neutropenia. What isthe priority nursing diagnosis for this child? a. Risk forinfection b. Risk for hemorrhage c. Altered skin integrity d. Disturbance in body image ANS: A The child with neutropenia is at risk for infectNioUnR. SINGTB.COM DIF: Cognitive Level: Application REF: Page 649 OBJ: 15 TOP: Chemotherapy: Neutropenia KEY:Nursing Process Step:Nursing Diagnosis MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 23. Whatimportant focus of nursing care forthe dying child and the family should the nurse implement? a. Nursing care should be organized to minimize contact with the child. b. Adequate oral intake is crucial to the dying child. c. Familiesshould bemade aware that hearing isthe lastsense to stop functioning before death. d. Itis best forthe family if the nursing staff provides all of the childs care. ANS: C Hearing isintact even when there is a loss of consciousness. DIF: Cognitive Level: Analysis REF: Page 656 TOP:Dying Child KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 24. The nurse is presenting information on the congentital disorder of hemophilia A. What fact willthe nurseinclude? a. Itisseen in males and females equally. b. Itistransmitted by symptom-free females. c. Itis a sex-linked dominant trait. d. Itis a defective gene located on the Y chromosome. ANS: B Hemophilia A affectsmostlymales who received the sex-linked recessive traitfroma symptom-free female. The defective gene is on the X chromosome.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 330 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 646 TOP: Hemophilia A KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. A child is diagnosed with iron deficiency anemia. What willthe nurse explain can occurif this disorder goes untreated? a. Hemorrhage b. Heart failure c. Infection d. Pulmonary embolism ANS: B Untreated iron deficiency anemias progressslowly, and in severe casesthe heart muscle becomestoo weak to function. If this happens, heart failure follows. DIF: Cognitive Level: Comprehension REF: Page 640 TOP: Iron Deficiency Anemia KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 26. The nurse is caring for a child with a low platelet count. Whatskin assessments would alertthe nurse tobleeding? (Select all that apply.) a. Petichiae b. Purpura c. Ecchymosis d. Hematoma e. Lymphadenopathy ANS: A, B, C, D NURSINGTB.COM The reduction or destruction of plateletsin the body interferes with the clotting mechanism. Skin lesionsthat are common to these disorders include petechiae, a bluish, nonblanching, pinpoint-sized lesion; purpura, groups of adjoining petechiae; ecchymosis, an isolated bluish lesion largerthan a petechia; and hematoma, a raised ecchymosis. Lymphadenopathy is an enlargement of lymph nodes that is indicative of infection or disease. DIF: Cognitive Level: Comprehension REF: Page 647 TOP: Manifestations of Bleeding KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.) a. She will feel less neglected by the parents. b. She can make amendsfor past hostilitiesto her brother. c. She will feel increased helplessness. d. She can express her feelingsthrough care. e. She can experience being supportive of her parents and brother. ANS: A, B, D, E All options are potential benefitsto including the sibling in the care of a dying child except increased helplessness. She would feel less helpless. DIF: Cognitive Level: Comprehension REF: Page 655 OBJ: 21 | 25 TOP: Siblings KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 28. Whatshould be included in the nursing care of a 12-year-old child receiving radiation therapy forHodgkins disease? (Select all that apply.) a. Application ofsunblockINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 331 NURSINGTB.COM b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger e. Preparation for premature sexual development ANS: A, B, C, D Sun block should be applied to skin afterradiation to prevent burning. Low energy levels produce anorexia and angerinmany young patients. Radiation delaysthe development ofsecondary sex characteristics and menses. DIF: Cognitive Level: Application REF: Page 651 TOP: Effects of Radiation KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. What are the classic symptoms ofthalassemiamajor(Cooleys anemia)? (Select all that apply.) a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Renal failure ANS: A, B, C, D All ofthe options are classic signs of thalassemiamajor exceptrenal failure. DIF: Cognitive Level: Comprehension REF: Page 645 TOP: Thalassemia Major KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 30. How hassynthetic recombinant antihemophilic factorimproved themanagement of hemophilia? (Select allthat apply.) a. Eliminates the need for frequent transfusionNsURSINGTB.COM b. Can be administered by family at home c. Prevents hemorrhage d. Reduces cost of care of the hemophiliac e. Reducesrisk of HIV and hepatitis A and B transmission ANS: A, B, D, E The drug can be given at home by the family. Because it supplies the missing factor, transfusions are notnecessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatlyreduced because hospitalizations and transfusions are not asfrequently required. The drug does not preventhemorrhage; it makes hemorrhage manageable. DIF: Cognitive Level: Comprehension REF: Page 646 TOP: Hemophilia A KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 31. The family of a child receiving chemotherapy forleukemia should be taught to focus on which aspect(s) ofthe childs care? (Select all that apply.) a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration d. Continuing with scheduled immunizations e. Reporting exposure to infectious diseases ANS: A, B, C, E Support groups are helpful for emotional support and realistic tips on care. The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the drugs. Because the drugssuppressthe bone marrow, children are atrisk for infection, and the suppression will not allow the antibody response needed for immunization.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 332 NURSINGTB.COM DIF: Cognitive Level: Analysis REF: Page 650 OBJ: 15 | 21 TOP: Chemotherapy KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 32. The nurse explainsthatthe COPP medicalregimen forthe treatment of Hodgkins disease uses acombination of which drugs? (Select all that apply.) a. Vincristine b. Cyclophosphamide c. Methotrexate d. Prednisone e. Procarbazine hydrochloride ANS: A, B, D, E The COPP medical regimen includes the combination of cyclophosphamide, vincristine (Oncovin), prednisone and procarbazine hydrochloride. DIF: Cognitive Level: Knowledge REF: Page 651 TOP: COPP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 33. A school-aged child isliving with a chronic disease process. How would the nurse anticipate chronic illness will effect growth and development? (Select all that apply.) a. Delayed bonding with parents b. Delayed toilet training c. Impaired sense of belonging d. Decreased feelings ofindependence e. Impaired speech development ANS: C, D NURSINGTB.COM A school-age child is in the stage of industry versus inferiority. A chronic illness might experience loss of grade level in school because ofillness and inability to participate or compete can lead to sense of inferiority. Sense of independence and accomplishment can be lost. Being differentfrom peersmay impede childs sense of belonging. DIF: Cognitive Level: Comprehension REF: Page 654 TOP: Chronic Illness/Growth and Development KEY:Nursing Process Step:Data Collection MSC:NCLEX: Psychosocial Integrity:Grief and Loss COMPLETION 34. The nurse showsslides ofred blood cellsfrom a child with sickle cell disease, noting thatin addition to theirsickle shape,the cells contain the abnormal element of . ANS: hemoglobin S Hemoglobin S isthe abnormal hemoglobin thatmakesred blood cellsfragile and causesthe walls of the cells to collapse, giving them the characteristic sickle shape. DIF: Cognitive Level: Knowledge REF: Page 642 TOP: Sickle Cell Disease KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Physiological Adaptation 35. The nurse confirmsthatsickle celltrait can be distinguished from sickle cell disease by a lab test called . ANS:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 333 NURSINGTB.COM electrophoresis The hemoglobin electrophoresis is a blood test to check for different types of hemoglobin in the blood. Hemoglobin isthe substance in red blood cellsthat carries oxygen. Electrophoresis uses an electrical current to separate normal and abnormal types of hemoglobin in the blood. Hemoglobin types have different electrical charges and move at different speeds. The amount of each hemoglobin type in the current is measured. An abnormal amount of normal hemoglobin or an abnormal type of hemoglobin in the blood may mean that a disease is present. A person with sickle cell disease has abnormal hemoglobin S cells. DIF: Cognitive Level: Knowledge REF: Page 642 TOP: Electrophoresis KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 36. To prevent ,the nurse warmsthe blood thatis to be given as atransfusion through a central line. ANS: cardiac arrhythmias Cold blood entering the heart via a central line can trigger an irregular heartbeat.DIF: Cognitive Level: Comprehension REF: Page 650 OBJ: 16 TOP: Blood Transfusion KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 37. The rate of RBC production isregulated by . ANS: erythropoietin NURSINGTB.COM Erythropoietin is a glycoprotein hormone that controls erythropoiesis orred blood cell production. DIF: Cognitive Level: Knowledge REF: Page 638 TOP: Components of Blood KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 38. Place the stages of dying in the usual order as detailed by Kbler-Ross(1975). Put a comma and spacebetween each answer choice (a, b, c, d, etc.) a. Bargaining b. Acceptance c. Denial d. Anger e. Reaching outto help others f. Depression ANS: C, D, A, F, B, E The stages of dying as detailed by Kbler-Ross (1975)denial, anger, bargaining, depression, acceptance, and reaching outto help otherscan be applied to parents and siblings as well asto the sick child. (Nurses may also respond with similarfeelings.) Itisimportantto accept and support each participant at whateverstage has beenreached and to refrain from directing progress. DIF: Cognitive Level: Comprehension REF: Page 656 TOP: Stages ofDying KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Psychosocial Integrity: End of Life ConceptsINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 334 NURSINGTB.COM Chapter 28: The Child with a Gastrointestinal Condition MULTIPLE CHOICE 1. Which finding in a newborn issuggestive oftracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the firstfeeding c. Palpablemassin the sternal area d. Visible peristalsis across abdomen ANS: B After birth, a newborn with tracheoesophageal fistula will vomit and choke when the firstfeeding is introduced. DIF: Cognitive Level: Comprehension REF: Page 660 TOP: Esophageal Atresia KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. A child is broughtto the pediatric clinic because he has been vomiting forthe past 2 days. What acidbaseimbalance would the nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis ANS: D Hydrochloric acid and sodiumchloride fromthe stomach are lostfrom persistent vomiting. Thisresultsin alkalosis. DIF: Cognitive Level: Comprehension REF: PNaUgeRS6I6N6GTB.COM OBJ: 9 TOP: Acid-Base Balance KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. On the second day of hospitalization for a 3-month-old broughtin fortreatment for gastroenteritis, the nursemakes all ofthe assessmentslisted below. Which assessmentfinding indicatesineffectiveness of treatment? a. Weight loss of 4 ounces b. Drymucous membranes c. Decreased skin turgor d. Depressed fontanelle ANS: A Weightlossisthemostsignificantindicator of dehydration because an infants weight comprises 77% water. DIF: Cognitive Level: Application REF: Page 672 OBJ: 9 TOP: Dehydration KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Why are rapid respirations a possible cause of dehydration? a. They preventthe child fromdrinking. b. They increase circulation, thus increasing urine production. c. They cause evaporation offluid on the mucous membranes. d. They often lead to vomiting. ANS: C Rapid respirations cause increased insensible fluid loss.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 335 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 672 TOP:Dehydration KEY:Nursing Process Step:Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 336 NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Which isthemost appropriate intervention for a 3-month-old infant who has gastroesophagealreflux? a. Position the infant in the crib on his or her abdomen, with the head elevated. b. Administermedication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infantin an infantseat after feedings. ANS: A Afterfeedings,the infantis placed in a prone position to avoid increased intraabdominal pressure. DIF: Cognitive Level: Application REF: Page 667 TOP: Gastroesophageal Reflux KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse isinterviewing parents of an infant with pyloric stenosis. What would the nurse expect the parentsto report? a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation ANS: B Vomiting isthe outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting. DIF: Cognitive Level: Comprehension REF: Page 661 TOP: Pyloric Stenosis KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease NURSINGTB.COM 7. A motherreportsthat her child has been scratching the anal area and complaining of itching. What doesthe nurse suspect based on thisinformation? a. Pinworms b. Giardiasis c. Ringworm d. Roundworm ANS: A With pinworms,the nurse or parent may notice thatthe child scratchesthe anal area and complains of itchiness. The other choices do not cause this reaction. DIF: Cognitive Level: Application REF: Page 678 TOP:Worms KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 8. The nurse isteaching a parent about pyrvinium (Povan).What would be included in regard to potential sideeffects? a. Diarrhea b. Skin rash c. Red stool d. Metallic taste ANS: C The nurse should advise parentsthat pyrvinium stains clothing and turnsstoolsred. DIF: Cognitive Level: Knowledge REF: Page 678 TOP:Worms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological TherapiesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 337 NURSINGTB.COM 9. Whatinstruction willthe nurse give to parents about preventing the spread and reinfection of pinworms? a. Keep childrens nailsshort. b. Dress child in loose-fitting underwear. c. Clean the bathroom with bleach solution. d. Wash bed linensin cold water. ANS: A One intervention to preventthe furtherspread of pinwormsisto keep the childsfingernailsshort. Pinwormsare not spread from person to person. DIF: Cognitive Level: Comprehension REF: Page 678 TOP: Worms KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. A motherreportsthat her 2-year-old child experiences constipation frequently. Which food would thenurse recommend to include in the childs diet? a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt ANS: C Dietarymodificationsfor constipation include eating more high-roughage foodssuch as whole-grain breads and cereals. DIF: Cognitive Level: Comprehension REF: Page 670 TOP: Constipation KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. What description of a childs stool characteNriUstRicSIlNeaGdTsBth.CeOnuMrse to suspect intussusception? a. Currantjelly b. Black and tarry c. Green liquid d. Greasy and foul-smelling ANS: A Bowel movements of blood andmucusthat contain no feces(currantjelly stools) are common about 12 hours after the onset of the obstruction. DIF: Cognitive Level: Comprehension REF: Page 665 TOP: Intussusception KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 12. Whatisthe treatment of choice for a child with intussusception? a. A barium enema b. Immediate surgery c. IV fluids until the spasmssubside d. Gastric lavage ANS: A A barium enema isthe treatment of choice forintussusception because the passage of the barium frequentlyun-telescopes the bowel. Surgery is scheduled only if reduction is not achieved. DIF: Cognitive Level: Knowledge REF: Page 665 TOP: Intussusception KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity 13. Parents ask the nurse how theirinfant developed a Meckels diverticulum. What condition, willthe nurseexplain, is present causing this diagnosis?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 338 NURSINGTB.COM a. The yolk sac remains connected to the intestine. b. There isinflammation ofthe ileocecal valve. c. A pouch forms when the vitelline ductfailsto disappear. d. There is a weaknessin the abdominal wall. ANS: C Ifthe vitelline ductfailsto disappear completely after birth, a blind pouchmay form. DIF: Cognitive Level: Knowledge REF: Page 665 TOP: Meckels Diverticulum KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 14. An infantis admitted to the hospital with severe isotonic dehydration. For whatisthis child atthe highestrisk? a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock ANS: D Shock isthe greatestthreatto life in isotonic dehydration. DIF: Cognitive Level: Comprehension REF: Page 673 TOP:Dehydration KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. A child is brought to the emergency department because he ingested an unknown quantity of acetaminophen (Tylenol). What doesthe nurse expectthis child to receive following gastric lavage? a. Activated charcoal b. N-acetylcysteine c. Vitamin K d. Syrup of ipecac NURSINGTB.COM ANS: B Gastric lavage isfollowed byN-acetylcysteine (Mucomyst),the antidote for acetaminophen. DIF: Cognitive Level: Comprehension REF: Page 679 TOP: Acetaminophen Poisoning KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. The nurse is planning a parent education program aboutlead poisoning prevention. What will be includedregarding primary sources of lead in the community? a. Increased lead content of air b. Use of aluminum cookware c. Deteriorating paintin older buildings d. Inhaling smog ANS: C The primary source of lead is paintfrom old, deteriorating buildings. DIF: Cognitive Level: Knowledge REF: Page 682 TOP: Lead Poisoning KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. A frightenedmother callsthe pediatricians office because her child swallowed dishwashing detergent.What is the most appropriate action? a. Induce vomiting by giving the child syrup ofipecac. b. Take the child to the local emergency department.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 339 NURSINGTB.COM c. Give the child activated charcoal mixed with juice.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 340 NURSINGTB.COM d. Give the childmilk to soothe affectedmucous membranes. ANS: B Inducing vomiting is no longerrecommended because it may pose additional problems. The child should be taken immediately to the nearest emergency department along with the packaging of the ingested substance. DIF: Cognitive Level: Application REF: Page 678 OBJ: 13 TOP: Poisoning KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 18. A child has been diagnosed with ascariasis(roundworm). Which statementmade by hermother that maysuggest a cause for her condition? a. Ive been airing outthe house on these nice breezy days. b. My child often goes out to the garden and pulls up a carrot to eat. c. She runs barefootso much I have to wash her feet at least twice a day. d. We justremodeled our bathroom at home. ANS: B The child can ingestroundworm eggsfromcontaminated soil. DIF: Cognitive Level: Comprehension REF: Page 678 TOP: Worms KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 19. What doesthe nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky,frothy d. Loose,foul-smelling ANS: C NURSINGTB.COM Celiac disease causesmalabsorption. Stoolsthat are large, bulky, and frothymay indicatemalabsorption. DIF: Cognitive Level: Comprehension REF: Page 663 TOP: CeliacDisease KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse hasreviewed dietary restrictionsfor celiac disease with concerned parents. Which grain will thenurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice ANS: D Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. These children will have a lifelong restriction of wheat, oats, barley, and rye. DIF: Cognitive Level: Knowledge REF: Page 663 TOP: Celiac Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. A 7-month-old infantis admitted to the hospital with a diagnosis of acute gastroenteritis. What will be thenursess priority goal of the infants care? a. Preventfluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Preventskin breakdown. d. Prevent malabsorption.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 341 NURSINGTB.COM ANS: A The priority goal of care in gastroenteritisis preventing fluid and electrolyte imbalance. DIF: Cognitive Level: Application REF: Page 666 TOP:Gastroenteritis KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. The nurse isspeaking to the parent of a 3-year-old child who hasmild diarrhea. What dietary modificationwould the nurse advise? a. Softfoods with rice, bananas, toast, and applesauce b. Small amounts of clearfluidssuch as gelatin c. An oralrehydrating solution,such as Pedialyte d. Chicken soup because itis high in sodium ANS: C An oralrehydrating solution isrecommended to replace fluids and electrolyteslostfrom frequent bowel movements. DIF: Cognitive Level: Application REF: Page 668 TOP: Diarrhea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. What would the nurse expect to find in a child admitted to the hospital for nonorganic failure to thrive? a. Cry to be picked up b. Be limp like a rag doll c. Be responsive to cuddling d. Weigh in the 10th percentile for age ANS: B Some children with failure to thrive have rag-NdoUllRlSimINpGnTesBs.C(hOyMpotonia) and appear wary of their caregivers. DIF: Cognitive Level: Comprehension REF: Page 675 TOP: Failure to Thrive KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 24. Which nursing interventions will be implemented forthemother of a 10-month-old infant with nonorganicfailure to thrive? a. Pointing out errorsthat the nurse observes when the motheris caring for the infant b. Discussing negative characteristics ofthe infant with the mother c. Having the nurse provide asmuch of the infants care as possible d. Teaching themother aboutthe developmental milestonesto expectin the nextfewmonths ANS: D The nurse can increase parents knowledge of growth and development by providing anticipatory guidance about normal developmental milestones. DIF: Cognitive Level: Application REF: Page 675 OBJ: N/A TOP: Failure to Thrive KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 25. Which statement by amothermay indicate a cause of hersons vitamin C deficiency? a. We get ourfruitsfrom homemade preserves. b. We use milk from our own goats. c. We grow all our own vegetables. d. Were not big meat eaters. ANS: A Vitamin C is destroyed by heat.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 342 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 676 TOP: Scurvy KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 26. The nurse isinstructing amother how to administer oral nystatin suspension prescribed to treat thrush.What will the nurse include? a. Pourthe prescribed amountinto a nipple and have the infantsuck the medication. b. Squirtthe prescribed dose into the back of the mouth and have the infantswallow. c. Give themedicationmixed with a small amount of juice in a bottle. d. Use a sterile applicatorto swab themedication on the oral mucosa. ANS: D An appropriate way to administer nystatin isto moisten a sterile applicator with themedication and then swabit on the inside of the mouth. DIF: Cognitive Level: Application REF: Page 677 TOP: Thrush KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 27. Why are infantsmore vulnerable to fluid and electrolyte imbalancesthan adults? a. They have a smallersurface area than adultsin proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body waterin infantsis extracellular. d. Infants have a lower metabolic turnover of water. ANS: C A greater percentage of body wateris contained in the extracellular compartment of children under 2 years of age. DIF: Cognitive Level: Knowledge REF: PageN6U72RSINGTB.COM TOP: Dehydration KEY: Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. An infantis admitted to the hospital with severe dehydration. Laboratory resultsshow pH 7.32, PaCO2 40,HCO3 21. How does the nurse interpret these values? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A A pH lower than 7.35 indicates acidosis. If the childs pH fallsin the same line asthe HCO3,the problem is metabolic (see Table 27-4). DIF: Cognitive Level: Analysis REF: Page 674 OBJ: 9 TOP: Fluid and Electrolyte Imbalance KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying. Whatisthe most appropriate nursing action? a. Delay feeding the child for 6 hours. b. Offerregularformula thinned with water. c. Give small amounts ofregularformula thickened with cereal. d. Allow 1 ounce of glucose water atfrequentintervals. ANS: D Small oral feedings of glucose water are given afterrecovery fromanesthesia. Feedings are gradually increasedto larger amounts of regular formula.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 343 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 661 TOP: Postoperative Pyloric Stenosis KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. The nurse is caring for an 18-pound child who has had one stool of diarrhea. The nurse knowsthat thechild needs to consume how many milliliters of oral fluid to make up for the fluid loss? a. 18 b. 36 c. 64 d. 81 ANS: D The formula for oral fluid replacement is 10 mL/kg. 18 pounds = 8.1 kg 10 = 81 mL. DIF: Cognitive Level: Analysis REF: Page 671 TOP:Oral Fluid Replacement KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. Which statement made by a parent alertsthe nurse to the need for additional education about poisonprevention? a. I keep the poison control center phone number easily accessible. b. All medication is kept out ofreach in a locked cabinet. c. I keep a bottle of syrup of ipecac handy. d. Our garden isfree from marigolds. ANS: C Traditionally, syrup of ipecac was the treatment of choice to remove some types of poisons from a childs system and parents were advised to keep a supply on hand in the home. However,the American Academy ofPediatrics (AAP) revised this policy in 2003. Parents are now advised to call the poison control center andbring the container of the substance ingested tNoUthReShINosGpTitBal.CeOmMergency department as quickly as possible because stomach lavage israrely effective 1 hour or more after ingestion. Ipecac syrup should not be keptin the home. Uncontrolled vomiting can cause serious complications. DIF: Cognitive Level: Comprehension REF: Page 679 TOP: Poison Control KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 32. Which assessment would the nurse reportto the physician immediately? a. 2-month-old with a urine output of 150 mL in 24 hours b. 3-year-old with a urine output of 650 mL in 24 hours c. 8-year-old with a urine output of over 1000 mL in 24 hours d. 14-year-old with a urine output of 800 mL in 24 hourse ANS: A The urine output of a 2-month-old should be between 400 and 500mL/24 hours. DIF: Cognitive Level: Application REF: Page 673 TOP: Dehydration KEY: Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Adaptation: Physiological Integrity MULTIPLE RESPONSE 33. Whatinterventions willthe nurse performwhen feeding a child with pyloric stenosis? (Select all thatapply.) a. Give a formula thinned with water. b. Burp the infant before and during feeding. c. Give the feeding slowly. d. Refeed ifthe infant vomits. e. Position infant on leftside afterfeeding.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 344 NURSINGTB.COM ANS: B, C, D Children with pyloric stenosis are given formula thickened with cereal; the infantis burped before and during feeding to getrid of any gasin the stomach; the infantisfed slowly and refed if vomiting occurs. The infant is positioned on the rightside to allow the weight of the feeding to stay in the stomach against the pyloric valve. DIF: Cognitive Level: Application REF: Page 661 TOP: Pyloric Stenosis KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 34. What assessment(s) would lead a nurse to suspectHirschsprungs disease in a 1-month-old infant? (Selectall that apply.) a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis ANS: A, B, C, D, E All options are significantindicators ofHirschsprungs disease. DIF: Cognitive Level: Comprehension REF: Page 664 TOP:Hirschsprungs Disease KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 35. Whatsign(s) indicate(s)moderate dehydration? (Select allthat apply.) a. 10% weightloss b. Dry mucous membranes c. Normal anterior fontanel d. Increased urinary output e. Lethargy NURSINGTB.COM ANS: A, B, C The child thatismoderately dehydrated will have lost 10% of his body weight, will have drymucous membranes, normal (nonsunken) anteriorfontanelle, decreased urine output, and will be irritable. DIF: Cognitive Level: Comprehension REF: Page 673 OBJ: 9 TOP: Moderate Dehydration KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 36. A child is broughtinto the ED with suspected appendicitis. Whatsigns and symptoms doesthe nurseexpect to assess? (Select all that apply.) a. Leftlower quandrant pain b. Guarding c. Rebound tenderness d. Decreased C-reactive protein e. Pain on lifting thigh when supine ANS: B, C, E With appendicitis on examination, characteristic tendernessin the rightlower quadrant known as McBurneys point will occur. Other diagnostic signs include guarding (tightening of the abdominal muscles or rigidity of the abdomen on palpation);rebound tenderness(pressing the RLQ with rapid release of pressure causes severepain); pain on lifting the thigh while in the supine position is caused by muscle irritation. C-reactive protein levels will be increased after 12 hours if any infection is present. DIF: Cognitive Level: Comprehension REF: Page 676 OBJ: 1 TOP: Appendicitis KEY:Nursing Process Step: Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 345 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 346 NURSINGTB.COM 37. Parents have adopted a child with the diagnosis of kwashiorkor. Whatismostlikely to be observed whenassessing this child? (Select all that apply.) a. Hyperactivity b. White streak in hair c. Edematous abdomen d. Slowed growth e. Thick, oily hair ANS: B, C, D Kwashiorkormeans, in native dialect, the disease of the deposed baby when the next one is born, indicating that the child no longer breastfeeds because a sibling is born and takes over the breast of the mother. Oral intake then is deficient in protein. The child failsto grow normally. Themuscles become weak and wasted. There is edema ofthe abdomen thatmay become generalized. Diarrhea,skin infections, irritability, anorexia, and vomiting may be present. The hair becomes thin and dry. Because protein is the basis of melanin, a substance that provides color to hair, melanin becomes deficient. This is the reason the earliest sign of this proteinmalnutrition is a white streak in the hair of the child (depigmentation). The child looks apathetic and weak. DIF: Cognitive Level: Comprehension REF: Page 676 TOP:Nutritional Deficiencies KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 38. The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for an infant with gastroenteritis,recognizesthat this confirmsthe process that is part of this disease. ANS: inflammatory NURSINGTB.COM The ESR elevatesin the presence of an inflammatory response. DIF: Cognitive Level: Comprehension REF: Page 666 TOP:Gastroenteritis KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 39. The nurse explainsthat because beverages cause diuresis,they are not good choicesfor fluid replacement in a child who is dehydrated. ANS: caffeinated Cola or other caffeinated drinks cause diuresis and will further dehydrate an already dehydrated child. DIF: Cognitive Level: Knowledge REF: Page 668 TOP:Dehydration KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 40. The nurse explainsthatrickets, a deficiency disease that causes bony deformities, is caused by theinadequate supply of vitamin . ANS: D Rickets is caused by a deficiency of vitamin D. DIF: Cognitive Level: Knowledge REF: Page 676 TOP: Rickets KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 347 NURSINGTB.COM 41. The nurse reminds parents of a child allergic to cows milk thatthey should avoid foodsthatlist as part of their contents. ANS: casein Food labelsthatlist casein contain cowsmilk. DIF: Cognitive Level: Comprehension REF: Page 666 OBJ: 2 TOP: Casein KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 42. The nurse explainsthemedically accepted definition of constipation isfewer than bowel movementsin a 2-week period. ANS: seven Themedically accepted definition of constipation isfewerthan seven bowel movementsin a 2-week period. DIF: Cognitive Level: Knowledge REF: Page 670 TOP: Constipation KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 43. Hernias are successfully repaired by the surgical operation called a . ANS: herniorrhaphy Hernias are successfully repaired by the surgical operation called a herniorrhaphy. Thisis a relatively simple procedure and is well tolerated by the child. MNoUstRcShIiNldGrTenB.aCreOMscheduled for procedures in same-day surgery units. The benefits of this method are both economic and psychological. DIF: Cognitive Level: Knowledge REF: Page 666 TOP:Hernias KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 348 NURSINGTB.COM Chapter 29: The Child with a Genitourinary Condition MULTIPLE CHOICE 1. The nurse discussed strategies with a parentto prevent a recurrence of urinary tractinfection in the child.Which statement made by the parent indicates a need for further teaching? a. My daughtershould wash and wipe the perineal area from front to back. b. I am only going to have my daughter wear cotton underwear. c. Itis acceptable to take frequent bubble baths. d. She needsto drink lots of fluids and void frequently. ANS: C Oilsin bubble bath and similar products are known to irritate the urethra. DIF: Cognitive Level: Comprehension REF: Page 692 OBJ: N/A TOP: Acute Urinary Tract Infection KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. When asked about correcting the hypospadias of a newborn,what doesthe nurse explain about thiscondition? a. No intervention is necessary asthe defect will correctitself overtime. b. Surgicalrepair of the hypospadiasis done before 18 months of age. c. Corrective surgery is usually delayed untilthe preschool age. d. Repairing the defect will increase the risk of testicular cancer. ANS: B Treatment of hypospadias consists ofsurgicalrepair and is usually performed before 18 months of age. DIF: Cognitive Level: Comprehension REF: PNaUgeRS6I9N0GTB.COM TOP: Hypospadias KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 3. What is an initialsign of nephrosisthat the nurse might note in a child? a. Raspberry-like rash b. Periorbital edema c. Temperature elevation d. Abdominal pain ANS: B The edema of nephrotic syndrome is generalized and notreadily noticed, even by the parents, but an early sign that can be assessed is periorbital edema. DIF: Cognitive Level: Knowledge REF: Page 692 TOP:Nephrotic Syndrome KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 4. Whatisitimportant to assessin a child receiving prednisone to treat nephrotic syndrome? a. Infection b. Urinary retention c. Easy bruising d. Hypoglycemia ANS: A Prednisone depressesthe immune response and increasessusceptibility to infection. Because steroidsmask signs of infection, the child must be assessed for more subtle symptoms of illness. DIF: Cognitive Level: Comprehension REF: Page 694INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 349 NURSINGTB.COM TOP:Nephrotic Syndrome KEY:Nursing Process Step: Data CollectionINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 350 NURSINGTB.COM MSC: NCLEX: Physiological Integrity 5. During a physical assessment of a hospitalized 5-year-old, the nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis.What action should the nurse implement? a. Forcibly push the foreskin down over the head of the penis. b. Place a warm compress on the penis. c. Notify the charge nurse. d. Wait a few hours and try again. ANS: C Notify the charge nurse of this occurrence of paraphimosis. The tightforeskin can impede blood flow to the penis; this should be remedied immediately. DIF: Cognitive Level: Application REF: Page 689 TOP: Paraphimosis KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 6. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. What isthe most appropriate nursing intervention for this child? a. Providing activitiesforthe child on restricted activity b. Feeding the child a protein-restricted diet c. Carefully handling edematous extremities d. Observing the child for evidence of hypotension ANS: A Although childrenmay feel well, activity islimited until hematuria resolves. DIF: Cognitive Level: Application REF: Page 695 TOP: Acute Glomerulonephritis KEY: NursinNgUPRroScIeNsGs TSBte.pC:OPMlanning MSC: NCLEX: Physiological Integrity: Reduction of Risk 7. Which urinary diversion procedure isthe least damaging to the body image ofthe adolescent? a. Urostomy b. Ileal conduit c. Nephrostomy d. Suprapubic placement ANS: B The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no external appliance, as is needed with the other diversion methods. DIF: Cognitive Level: Comprehension REF: Page 691OBJ: 10 TOP: Obstructive UropathyUrinary DiversionsKEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. Themother of a 5-year-old child taking prednisone for nephrotic syndrome tellsthe nurse he needsto getimmunizations to enter kindergarten. What does the nurse clarify about receiving immunizations while onprednisone? a. Can interfere with the treatment for nephrosis b. Require thatthe child have antibiotic coverage c. Can be given in smaller, divided doses d. Should be delayed ANS: D No vaccinations orimmunizationsshould be administered while the disease is active and during immunosuppressive therapy.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 351 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 694 TOP:Nephrotic Syndrome KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 9. Diuresis has not occurred on a child with nephrotic syndrome after amonth on corticosteroids. Whatprotocol can the nurse encourage to bring about diuresis? a. Ibuprofen, an anti-inflammatory agent b. Furosemide (Lasix), a diuretic c. Ciprofloxacin (Cipro), an antibiotic d. Cyclophosphamide (Cytoxan), an antisuppressant ANS: D A potent antisuppressantsuch as Cytoxan can bring about diuresis when corticosteroids have proven ineffective. DIF: Cognitive Level: Application REF: Page 694 TOP: Nephrotic Syndrome KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. Whatfoods doesthe nurse recommend the child with acute glomerulonephritis avoid to preventhyperkalemia? a. Dairy products b. Whole-grain cereals c. Organmeats d. Bananas ANS: D Bananas are very high in potassium and should be avoided. DIF: Cognitive Level: Comprehension REF: PNaUgeRS6I9N5GTB.COM TOP: AGN KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 11. Which physical assessmenttechnique willthe nurse omit when caring for a 2-year-old diagnosed withWilms tumor? a. Performing range-of-motion exercises on lower extremities b. Palpating the abdomen c. Assessing for bowelsounds d. Percussing ankle and knee reflexes ANS: B Palpation ofthe abdomen could disturb the tumor and cause the malignancy to spread. DIF: Cognitive Level: Application REF: Page 696 OBJ: 8 TOP: Wilms Tumor KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Reduction of Risk 12. Parents are speaking with the urologist abouttheirsons undescended testicle. Which statement by thechilds father causes the nurse to determine he understands the information presented? a. An undescended testicle can reduce fertility. b. The testicle usually descendsspontaneously during the firstmonth of life. c. Surgical correction reducesthe risk fortesticular tumors. d. The optimaltime to surgically correct the condition is at diagnosis. ANS: A Although orchiopexy improvesthe condition,the fertility rate among patients may be reduced even when only one testis is undescended.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 352 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 698 TOP: Cryptorchidism KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A parenttellsthe nurse that her child isscheduled for an x-ray of the bladder and urethra thatis done whilethe child is urinating. What is this test known as? a. Cystometrogram b. Cystoscopy c. Voiding cystourethrogram d. Intravenous pyelogram ANS: C An x-ray examination ofthe bladder and urethra before and during micturition is called a voiding cystourethrogram. DIF: Cognitive Level: Comprehension REF: Page 692 TOP:Diagnostic Procedures KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. A 6-year-old child with daytime enuresis complains of dysuria and urgency. What doesthe nurse recognizethese signs and symptoms indicate? a. Urinary tractinfection b. Nephrotic syndrome c. Acute glomerulonephritis d. Vesicoureteral reflux ANS: A Urinary frequency and pain during micturition are symptoms of acute urinary tractinfection. DIF: Cognitive Level: Comprehension REF: PNaUgeRS6I9N1GTB.COM TOP: AcuteUrinary TractInfection KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. Whatis an appropriate intervention forthe edematous child with reducedmobility related to nephroticsyndrome? a. Reach the child tominimize bodymovements. b. Change the childs position frequently. c. Keep the head of the childs bed flat. d. Keep edematous areasmoist and covered. ANS: B The child should be turned frequently to preventrespiratory tractinfection and to prevent pressure on delicateskin. DIF: Cognitive Level: Application REF: Page 694 TOP: Nephrotic Syndrome KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 16. Which statementmade by a parent of a child with nephrotic syndrome indicates an understanding ofdischarge teaching? a. I will make sure he gets his measles vaccine assoon as he gets home. b. He can stop taking hismedication next week. c. Ishould check his urine for protein when he goesto the bathroom. d. He should eat a low-protein diet forthe next few weeks. ANS: C The parentsshould be instructed to keep a daily record ofthe childs urinary proteins. DIF: Cognitive Level: Application REF: Page 692INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 353 NURSINGTB.COM TOP:Nephrotic Syndrome KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the childs history,what does the nurse recognize as the probable cause? a. Recovery fromGermanmeasles 2months ago b. Dysuria since the previous night c. A history of allergy d. A sore throat 2 weeks ago ANS: D Acute glomerulonephritis developsfrom1 to 3 weeks after a streptococcal infection, which causes an allergictype response that alters the effectiveness of the glomeruli. DIF: Cognitive Level: Comprehension REF: Page 694 TOP: Acute Glomerulonephritis KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The nurse is explaining to a 17-year-old female the actionsto prevent urinary tractinfection. Which is thebest beverage for the nurse to recommend to keep urine acidic? a. Milk b. Grape juice c. Apple juice d. Orange juice ANS: C Juicessuch as apple or cranberry helpmaintain acidity of urine. DIF: Cognitive Level: Comprehension REF: Page 693 OBJ: N/A TOP: Acute Urinary Tract InfectionNURSINGTB.COM KEY: Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 19. The 6-year-old scheduled for an orchiopexy shyly asksthe nurse, What are they going to do to me downthere? What is the nurses best response? a. They are going to fix you up down there. b. They will move yourtesticle from your abdomen to yourscrotum. c. What do you think your doctor is going to do? d. You shouldnt worry. Your doctor knows exactly whatto do. ANS: C Encourage the patient to talk about what he knows and whatfeelings he has aboutthe surgery. School-age children have a fear of bodily harm. DIF: Cognitive Level: Application REF: Page 698 TOP: Orchiopexy KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. What will the nurse caution the parents of a child who has had a nephrectomy that he will have to avoid? a. Contactsports b. Horseback riding c. Alcohol d. Diuretic medications ANS: A Children who have only one kidney should avoid contactsportsto preventinjury to thatremaining organ. DIF: Cognitive Level: Comprehension REF: Page 696 TOP: Postnephrectomy Instruction KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 354 NURSINGTB.COM MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 21. The parents of a newborn are concerned that theirsonsscrotumis enlarged and swollen on one side. Whatis the nurses best response? a. Itis very common in the newborn that one gonad islarger than the other. b. Birth trauma caused bruising to the scrotum. It will reduce in size in a few days. c. Itis a collection of fluid that will most likely correctitself in a year. d. The doctor will drain this collection of blood before your baby is discharged. ANS: C These signs are indicative of a hydrocele, a collection of fluid in the scrotum that usually correctsitself in a year. DIF: Cognitive Level: Comprehension REF: Page 697 TOP: Hydrocele KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. The nurse is providing information to parents of a child born with bilateral cryptorchidism. Whatinformation is accurate to include? a. Thisisthe most common form. b. Fertility will be unaffected. c. Surgical intervention is notrecommended. d. An inguinal herniamay be present. ANS: D When one or both testesfailto lowerinto the scrotum, the condition istermed cryptorchidism. The unilateral form is more common. Because the testes are warmer in the abdomen than in the scrotum, the sperm cells begin to deteriorate. If both testes are affected, sterility results. Inguinal hernia often accompanies this condition.Occasionally, a testis orthe testesspontaneously descend during the first year of life. An operation called an orchiopexy may be performed. NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 698 TOP: Cryptorchidism KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. An adolescentmale is admitted to the ED with severe acute scrotal pain. When documenting medicalhistory the nurse notes cryptorchidism at birth. What diagnosis does the nurse expect? a. Urinary tractinfection b. Nephrosis c. Torsion d. Phimosis ANS: C When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism. Acute scrotalpain may indicate a testicular torsion (twisting), which necessitates immediate surgery to preserve testicular function. DIF: Cognitive Level: Comprehension REF: Page 698 TOP: Torsion KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 24. A 7-year-old child has a BUNof 25 mg/dL. What isthe nurse aware thislab valuemightindicate? (Select all that apply.) a. Dehydration b. Renal disease c. Need forsteroid therapy d. DiabetesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 355 NURSINGTB.COM e. Pituitary malfunction ANS: A, B, C Increased BUNcan indicate dehydration,renal disease, and/or need forsteroid therapy. DIF: Cognitive Level: Analysis REF: Page 689 OBJ: 3 TOP: Diagnostic Tests KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk Potential 25. What willthe nurse caring for a newborn with exstrophy of the bladder include in the care? (Select all thatapply.) a. Diaperinfanttightly. b. Protectskin around bladder. c. Position infant on back. d. Prepare forsurgical closure. e. Cover exposed bladder with shield. ANS: B, C, D, E The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is constantly bathed with urine. These infants are diapered loosely, if at all. Surgical closure is done as quickly aspossible. DIF: Cognitive Level: Application REF: Page 690 TOP: Exstrophy ofthe Bladder KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 26. The nurse caring for a child with nephrotic syndrome is alertto which classic symptoms of this disorder?(Select all that apply.) a. Proteinuria b. Grossly bloody urine c. Hyperalbuminemia d. Fatigue e. Generalized edema NURSINGTB.COM ANS: A, B, D, E All optionslisted are those of nephrotic syndrome with the exception of hyperalbuminemia. The nephrotic child has hypoalbuminemia, as most of the protein has been spilled in the urine. DIF: Cognitive Level: Knowledge REF: Page 692 TOP:Nephrotic Syndrome KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 27. The nurse is aware that genitourinary surgery is especially stressful for preschool children. What factor(s)lend to this stress? (Select all that apply.) a. Theymay perceive the treatment as punishment. b. They are especially prone to separation anxiety. c. They are sexually curious and developmentally fixated on their genitals. d. They have a fear of castration. e. They fear death. ANS: A, B, C, D All options, exceptfear of death, are especially stressful for preschool children undergoing genitourinary surgery. Children in this age group do not have an understanding of the concept of death. DIF: Cognitive Level: Comprehension REF: Page 698 TOP: Topic: Impact of Surgery on Preschoolers KEY:Nursing Process Step: PlanningINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 356 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 357 NURSINGTB.COM 28. Whatspecial considerations are related to long-termprednisone therapy in preschoolers? (Select all thatapply.) a. Delayed immunization b. Hypertension c. Enlargement of the sex organs d. Alteration in nutrition e. Increased risk forinfection ANS: A, E Delayed immunization and greaterrisk forinfection are concernsrelative to long-term prednisone therapy. DIF: Cognitive Level: Comprehension REF: Page 694 TOP: Long-Term Prednisone Therapy KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Pharmacological Therapies COMPLETION 29. The nurse explainsthatthe device that measuresthe pressure and volume of the urine stream is called the . ANS: uroflowmeter The device thatspecificallymeasuresthe dynamics ofmicturition isthe uroflowmeter.DIF: Cognitive Level: Knowledge REF: Page 688 TOP:Uroflowmeter KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 30. The nurse uses a diagram to show how the ,the working unit of the kidney, filters and regulatesfluids. ANS: nephron NURSINGTB.COM The nephron isthe working unit of the kidney that filters and regulatesfluidsin the body. There are roughly 1 million nephrons in each kidney. DIF: Cognitive Level: Comprehension REF: Page 686 TOP: Nephron KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. When a childs ureter becomes completely obstructed from scarring,the nurse explainsthat urinarydiversion may be necessary to prevent the reflux back into the renal pelvis from causing . ANS: hydronephrosis Hydronephrosis occurs when the urine is unable to passthrough the ureter into the bladder;the urine refluxes back into the renal pelvis, causing dilation and swelling of the kidney. DIF: Cognitive Level: Comprehension REF: Page 690 TOP:Hydronephrosis KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 32. The strong urge to void, often despite the inability to do so, is known as . ANS: urgencyINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 358 NURSINGTB.COM Urgency isthe term that describesthe strong urge to void, often despite the inability to do so. DIF: Cognitive Level: Knowledge REF: Page 689 TOP: Urgency KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 33. The nurse ismeasuring ouput on an infant on the pediatric unit. When weighing the diaper and subtractingthe weight of the dry diaper, the nurse records 30 grams and documentsthis as mL. ANS: 30 Diapersmay be weighed on a gram scale before application and after removal (1 g = 1 mL).DIF: Cognitive Level: Analysis REF: Page 694 TOP:UrinaryOutput KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques 34. is a narrowing of the preputial opening of the foreskin, which preventsthe foreskinfrom being retracted over the penis. ANS: Phimosis Phimosisis a narrowing ofthe preputial opening of the foreskin, which preventsthe foreskin from being retracted over the penis. DIF: Cognitive Level: Knowledge REF: Page 689 TOP: Phimosis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 359 NURSINGTB.COM Chapter 30: The Child with a Skin Condition MULTIPLE CHOICE 1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-month-old. How isinfantskin different from adultskin? a. Less perfusion b. Greatermoisture c. More perspiration d. Greater absorption ANS: D The childsskin has a dramatically greater ability to absorb than doesthat of the adult. DIF: Cognitive Level: Comprehension REF: Page 700 OBJ: 2 TOP: Skin Comparison KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 2. Whatrisk isincreased with children who have been diagnosed with infantile eczema? a. Pneumonia b. Acne c. Sun sensitivity d. Asthma ANS: D Some children with eczema also develop asthma and hay fevertype allergies. DIF: Cognitive Level: Knowledge REF: Page 705 TOP: Infantile Eczema KEY: Nursing ProcessNSUtRepS: INPlGaTnnBi .nCgOM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 3. Whatisthe appropriate technique forthe application of a topicaltreatmentfor a child with eczema? a. Apply skin lotionsin a circularmotion. b. Apply prescribed ointments with a gloved hand. c. Apply asmuch and asfrequently asrelievesthe symptoms. d. Choose lanolin-based ointments. ANS: B The prescribed amount of ointment is usually applied to the skin by a gloved hand in long,smooth strokes.Lanolin-based preparations should be avoided because of a possible allergy to wool. DIF: Cognitive Level: Knowledge REF: Page 706 TOP: Infantile Eczema KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity 4. A 2-day-old infant is noted to have small pustules on herskin. Whatisthe best nursing action? a. Reportitimmediately because itmay be a staphylococcusinfection. b. Keep the affected area dry and clean. c. Teach the parents how to care forseborrheic dermatitis. d. Chartthe finding because it may be the beginning of a strawberry nevus. ANS: A A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn mustbe reported immediately. DIF: Cognitive Level: Application REF: Page 708 TOP: Staphylococcal Infection KEY: Nursing Process Step: ImplementationMSC:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 360 NURSINGTB.COM NCLEX: Physiological IntegrityINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 361 NURSINGTB.COM 5. The home health nurse discovers a family infected with pediculosis. Whatinformation can the nurse provideto the mother to start eradication of the lice? a. Coverthe hair with Vaseline. b. Apply a soda-vinegarsolution to the hair. c. Comb through the hair with a vinegar-watersolution. d. Shampoo the hair with dish detergent. ANS: C Combing a vinegar and watersolution through the hair with a fine-tooth comb and then shampooing is an initial step toward eradication. DIF: Cognitive Level: Application REF: Page 710 TOP: Tinea Capitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. A group of football playersistaking oral griseofulvin fortinea pedis. Whatshould the school nurse cautionthem to avoid? a. Citrusfruit and juice b. Eating shellfish c. Alcohol consumption d. Taking corticosteroids ANS: C Consumption of alcohol while taking griseofulvin will cause severe tachycardia. DIF: Cognitive Level: Comprehension REF: Page 709 TOP: Tinea Pedis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. What should the nurse suggest before a 17-NyeUaRr-SoIlNdGgiTrBl s.CtaOrtMs a protocol of isotretinoin (Accutane) for her acne? a. Get a prescription for oral contraceptives. b. Increase the dose ofthe presentmedication. c. Limitintake of chocolate, cola, and peanuts. d. Increase exposure to sunlight. ANS: A Oral contraceptives are often prescribed for adolescents with acne. Accutane can cause birth defects,so pregnancy should be prevented. DIF: Cognitive Level: Application REF: Page 704 TOP: Acne Vulgaris KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. A child had a burn, evidenced by pink skin and blistering. The child complains of pain and is crying. How does the nurse classify this burn when documenting? a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree ANS: B A second-degree superficial burn appears blistered,moist, and pink orred. The pain associated with this burn indicates tissue viability. DIF: Cognitive Level: Analysis REF: Page 712 OBJ: 9 TOP: Burns KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 362 NURSINGTB.COM 9. A child hassustained a second-degree deep thermal burn to the hand. What isthe best first action to take? a. Immerse the burned area in cold water. b. Apply ice to the burned area. c. Break any blistersthat are present. d. Apply petroleum jelly to the burned skin. ANS: A First-aid treatment of a second-degree deep thermal burn isimmersion ofthe burned area in water to haltthe burning process. DIF: Cognitive Level: Application REF: Page 712 OBJ: 9 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 10. Which allergy would contraindicate the use ofsilversulfadiazine (Silvadene) as a topical agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations d. Sulfa ANS: D The use of Silvadene cream on burnsis contraindicated ifthe patient has a sulfa allergy. DIF: Cognitive Level: Knowledge REF: Page 712 OBJ: 10 TOP: Burns KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity 11. What would help the child with a serious burn meet nutritional needs during the subacute phase ofrecovery? a. Decrease calories because the child will be NonUbReSdINreGsTt Ban.CdOwMill not need as many. b. Increase calories and protein to compensate for the healing process. c. Increase fatto replace the layer of fat nextto the burned skin. d. Decrease carbohydrates and starches because the pancreasisstrained by the healing process. ANS: B Frequentmeals and snacks high in calories, protein, and iron are needed to meet the increasedmetabolic needsof the child with burns. DIF: Cognitive Level: Comprehension REF: Page 714 OBJ: 13 TOP: Burns KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 12. Which statementmade by a parentindicates an understanding of the topical application of medications fora skin condition? a. I apply the medication after I give my child a bath. b. I rub the ointment in a circular motion over the rash. c. I increased the amount of cream because the rash was notimproving. d. I use powder and cornstarch to keep the skin dry. ANS: A Absorption oftopical medicationsis best when preparations are applied after a warm bath. DIF: Cognitive Level: Comprehension REF: Page 706 TOP: Topical Medications KEY:Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. On the first day following a severe burn,the bodysfluid reserves have left the circulating volume and entered the interstitialspace, causing massive edema. Whatshould the nurse monitor for very closely in theburn victim?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 363 NURSINGTB.COM a. Increasing intracranial pressure b. Reduced urine output c. Escharformation d. Fluid overload ANS: B With the fluid shift associated with severe burns,the nursemust be observantforthe reduction of urine, an indication of altered renal function. DIF: Cognitive Level: Application REF: Page 716 TOP: Burns KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 14. At a 2-month well-child visit, parents ask the nurse aboutthe red area on the infants neck. They tell thenurse that the mark appeared a few weeks after birth. What doesthe nurse recognize thisskin lesion as? a. A port wine nevus b. A strawberry nevus c. Exanthem d. Intertrigo ANS: B The strawberry nevusis a common hemangioma consisting of dilated capillariesin the dermalspace, which may not become apparent for a few weeks after birth. DIF: Cognitive Level: Comprehension REF: Page 701 OBJ: 3 TOP: Congenital Lesions KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A mother is concerned about what might hNaUveRcSaINusGeTdBa.CheOaMt rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infants neck and axilla. What doesthe nurse explain asthemost likelycause of this rash? a. Sun exposure b. Allergic reaction c. Infection d. Heat andmoisture ANS: D Miliaria, or prickly heatrash, is caused by excess body heat and moisture. DIF: Cognitive Level: Comprehension REF: Page 702 TOP: Skin Infections KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What isthe correct nursing response to a mother who asks, How can I getrid of the babys cradle cap? a. Rub baby oil on the infants head at night and shampoo the hair the next morning. b. Use a brush with firm bristlesto loosen the scales on the babys head several times a day. c. Wash the babys head every night with a dandruff-controlshampoo. d. Lubricate the babys head every morning with a small amount of olive oil. ANS: A Scalesmay be softened by applying baby oilto the head the evening before, and shampooing the hairin the morning. DIF: Cognitive Level: Application REF: Page 703 TOP: Seborrheic Dermatitis KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and ComfortINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 364 NURSINGTB.COM 17. Which statementmade by a parentindicatesthe need forfurther teaching aboutstrategiesto control itchingINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 365 NURSINGTB.COM forthe infant with eczema? a. Wool isthe best fabric for the infants clothing. b. Ishould avoid laundry detergents with fragrances. c. I put cotton gloves on the infants hands. d. The infantsfingernails are keptshort. ANS: A Clothing should bemade of cotton. Wool is avoided because of its allergy potential. DIF: Cognitive Level: Comprehension REF: Page 706 TOP: Infantile Eczema KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 18. What willthe nurse include when teaching about generalskin caremeasuresthat could help prevent acne? a. Eliminating chocolate, peanuts, and cola from the diet b. Washing the face with a cleansing productfrequently c. Planning indoor activitiesto avoid sun exposure d. Eating a balanced diet and getting sufficientrest ANS: D General hygienicmeasures of cleanliness,rest, and avoidance of emotionalstress may help prevent exacerbations. DIF: Cognitive Level: Comprehension REF: Page 704 TOP: Acne Vulgaris KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 19. The nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet. Whatisthe most appropriate nursing action? a. Report thissign immediately. b. Place a warmtowel overthe extremities. c. Gently sponge with cool water. d. Medicate for pain. NURSINGTB.COM ANS: D A purple flush indicatesthe return ofsensation and causes extreme pain. DIF: Cognitive Level: Application REF: Page 717 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 20. A child is broughtto the emergency department with burns on the face and chest. What isthe nurses firstpriority? a. Assessrespiratory status. b. Administer pain medication. c. Remove clothing. d. Insert a Foley catheter. ANS: A Airway assessment and establishing an airway are the initial priorities. DIF: Cognitive Level: Application REF: Page 713 TOP: Burns KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 21. An adolescent girl with acne is being treated with an antibiotic in addition to topical applications. Whatside effect does the nurse caution the girl to expect? a. Lessened effectiveness of oral contraceptivesINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 366 NURSINGTB.COM b. Urinary burning and frequencyINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 367 NURSINGTB.COM c. Breast engorgement d. Vaginitis ANS: D Antibiotic therapy can cause amonilial vaginitis. DIF: Cognitive Level: Comprehension REF: Page 704 TOP: Acne KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 22. The nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks.Which complication does the nurse document and report? a. Diverticulitis b. Stress diarrhea c. Curlings ulcer d. Perforated bowel ANS: C Curlings ulceris a complication of burn victimsresulting from the stress oftheirtrauma. DIF: Cognitive Level: Application REF: Page 714 TOP: Burns KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 23. A child is broughtto the emergency department with severe frostbite. Which body partsshould be warmedfirst? a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso ANS: D NURSINGTB.COM In extreme cases of exposure to freezing temperatures,the head and torso should be warmed before the extremities. DIF: Cognitive Level: Application REF: Page 717 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 24. An adolescentis atthe pediatricians office because he has been experiencing intense itching, particularly inthe axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. With what is this symptom associated? a. Scabies b. Pediculosis capitis c. Tinea corporis d. Eczema ANS: A Intense itching, especially at night, is characteristic ofscabies. DIF: Cognitive Level: Comprehension REF: Page 710 TOP: Scabies KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 25. Whatshould the nurse stressto the mother of a child with impetigo? a. The condition is caused by the herpessimplex virustype I. b. The crusts on the lesionsshould be left in place. c. The lesionsmay spread, butthe disease is not contagious.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 368 NURSINGTB.COM d. Small cuts and bitesshould be treated promptly.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 369 NURSINGTB.COM ANS: D Small cuts and bitesshould be treated promptly to preventthe invasions of the bacteria that cause impetigo. The crusts from the lesions should be gently removed. The disease is contagious. DIF: Cognitive Level: Comprehension REF: Page 708 TOP: Impetigo KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 26. The nurse is caring for a 3-year-old with severe burns. Whatisthe nurse aware isthe minimum adequatehourly urine output? a. 5 mL/hr b. 10 mL/hr c. 15 mL/hr d. 20 mL/hr ANS: D Theminimum acceptable hourly urine outputfor children over the age of 2 yearsis 20 to 30 mL/hr. DIF: Cognitive Level: Comprehension REF: Page 714 TOP:UrineOutput after Burn KEY:Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Physiological Adaptation 27. An adolescent patient at a pediatric clinic presents with a butterfly rash. What diagnosis doesthe nursesuspect? a. Tuberoussclerosis b. Eczema c. Psoriasis d. Systemic lupus erythematosus ANS: D NURSINGTB.COM Butterfly rash overthe nose and cheeks can be associated with photosensitivity and may be associated with systemic lupus erythematosus (SLE). DIF: Cognitive Level: Comprehension REF: Page 702 TOP: Skin Manifestations ofIllness KEY:Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. The nurse is documenting a description of a skin assessment. Whatterm can be used for an elevated, fluid-filled blister? a. Pustule b. Papule c. Wheal d. Vesicle ANS: D A vesicle is an elevated,fluid-filled blister(cold sore, chickenpox). DIF: Cognitive Level: Comprehension REF: Page 701 OBJ: 1 TOP: Skin Conditions KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. Whatshould the nurse keep inmind when providing care to the school-age child hospitalized with a burninjury? a. Hospitalization will be brief. b. Analgesicsshould be given immediately after dressing changes. c. Contact with peersshould bemaintained. d. Parents usually handle injury worse than the child.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 370 NURSINGTB.COM ANS: C A burn injury is taxing to the child and parents. It requires long periods of hospitalization and frequent readmissions. The accidentitself isterrifying forthe child but ismade even worse if caused by disobedience. Nurses encourage children to expresstheirfeelings. Analgesics are administered before painful procedures. The long-term patient requires diversions of various types. School tutors are requested, and contact is maintained with peers through cards or e-mail. DIF: Cognitive Level: Comprehension REF: Page 716 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 30. Parents of a child show the nurse that their child has a flatstrawberry nevus. Whatinformation can thenurse provide in educating the parents regarding strawberry nevus? (Select all that apply.) a. Itis a rare skin variation. b. Itis harmless. c. It gradually becomes raised. d. Laser treatment is available. e. Sometimesit can disappearspontaneously. ANS: B, C, D The strawberry nevusis a common hemangioma (consists of dilated capillariesin the dermalspace) that may not become apparent for a few weeks after birth. Although it is harmless and usually disappears without treatment, it is disturbing to parents, especially when it appears on the head or face. At first it is flat, but it gradually becomesraised. The lesions gradually blanch, with 60% disappearing spontaneously by 5 years of age and 90% disappearing by 9 years of age. Laser treatment or excision may be considered if the area becomes ulcerated. NURSINGTB.COM DIF: Cognitive Level: Knowledge REF: Page 700 OBJ: 3 TOP: Strawberry Nevus KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. What would the nurse teach parentsto do in orderto avoid diaperrash? (Select all that apply.) a. Use ointments. b. Keep perineumcovered at alltimes. c. Use disposable diapers. d. Avoid plastic bloomers or pants. e. Change diaperfrequently. ANS: A, C, D, E Keeping the skin dry and protected with emollients, leaving the area exposed to light and air periodically, changing the diaper frequently, and avoiding plastic pants will prevent diaper rash. DIF: Cognitive Level: Comprehension REF: Page 703 TOP: Avoiding Diaper Rash KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 32. The nurse speaking to a group of junior high schoolstudentsinformsthem that acne can be exacerbated bywhich drug(s)? (Select all that apply.) a. Steroids b. Phenytoin c. Phenobarbital d. Aspirin e. Oral contraceptivesANS:INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 371 NURSINGTB.COM A, B, CINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 372 NURSINGTB.COM Long-term use ofsteroids, phenytoin, phenobarbital, lithium, and vitamin B12 can cause acne. DIF: Cognitive Level: Knowledge REF: Page 704 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 33. Whatintervention(s) would the nurse preparing a teaching plan forthe care of a child with infantile eczemainclude? (Select all that apply.) a. Bathe the child using products with a lightfragrance. b. Use oatmeal and baking soda as bath additives. c. Add bath oil to bath water after the child hassoaked. d. Apply lanolin-based lotions after the bath. e. Bathe child several times a day. ANS: B, C Use of oatmeal, baking soda, and baking powder issoothing. Adding oilto the bath water after the child has soaked for a whilemakesthe oil application more effective. Items with any fragrance should be avoided as well as lanolin-based products. Many dermatologists advise minimal bathing. DIF: Cognitive Level: Comprehension REF: Page 706 TOP: Infantile Eczema KEY: Nursing Process Step: Planning MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 34. Which factor(s) activate the herpessimplex virustype I? (Select allthat apply.) a. Stress b. Sun c. Menses d. Fever e. Food allergies ANS: A, B, C, D NURSINGTB.COM The herpessimplex virustype I can be activated to cause a cold sore by exposure to stress,sun, initiation of menses, and fever. Food allergies do not activate the virus as a rule. DIF: Cognitive Level: Comprehension REF: Page 705 TOP:Herpes Simplex Type I KEY:Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 35. The nurse recognizesthe blisters and erythema of the hands of a person recovering fromfrostbite as theskin disorder called . ANS: chilblain After exposure to cold, blisters appear on the hands and feet that are similarto a burn. These are called chilblains. DIF: Cognitive Level: Knowledge REF: Page 717 TOP: Chilblain KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 36. The nurse differentiates a type of topical medication thatis an oil-based emulsion to be used on dry skin asa(n) . ANS: ointmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 373 NURSINGTB.COM Ointments are oil-based emulsionsthat are used on dry skin.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 374 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 708 OBJ: 6 TOP: Ointment KEY: Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 37. A 5-year-old boy is broughtto the emergency department with a second-degree burn of his entire right armand hand, anterior trunk and genital area, and front of right thigh. The nurse assesses the body surface area (BSA) percentage burn as %. ANS: 26 Using the Burn Size Estimation Table on page 695, the nurse can determine that for a 5-year-old child, the upper and lower arm = 5.5%, the hand = 2.5%, anterior trunk = 13%, genital area = 1%, and half of the thigh = 4%. Together this totals to 26% BSA burn. DIF: Cognitive Level: Analysis REF: Page 711 OBJ: 9 TOP: BSA Burn Estimation KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 38. The nurse recognizesthe characteristic circular hairless patches of tinea capitis, which is called . ANS: alopecia Alopecia isthe term to refer to hair loss. DIF: Cognitive Level: Knowledge REF: Page 709 TOP: Alopecia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physi Nol Uo R gi S c I a Nl GA T d B ap .C ta Oti Mon 39. The nurse assesses a major burn as a -thickness burn involving % or more of the body surface. ANS: full; 10 A full-thickness burn involving 10% or more of the body surface is considered a major burn. DIF: Cognitive Level: Knowledge REF: Page 711 OBJ: 9 TOP: Burns KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 40. Eczema indicatesthatthe infantis oversensitive to certain substances called , which enterthe body via the digestive tract, inhalation, direct contact, or injections. ANS: allergens Eczema is actually a symptom rather than a disorder. It indicates that the infant is oversensitive to certain substances called allergens, which enterthe body via the digestive tract(food), by inhalation (dust, pollen), by direct contact (wool,soap, strong sunlight), or by injections (insect bites, vaccines). DIF: Cognitive Level: Knowledge REF: Page 705 TOP: Eczema KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 375 NURSINGTB.COM Chapter 31: The Child with a Metabolic Condition MULTIPLE CHOICE 1. A nurse is planning to teach a family about Tay-Sachs disease. What willthe nurse relay aboutthe pattern ofinheritance for inborn errors of metabolism? a. They are usually autosomal recessive. b. They are usually autosomal dominant. c. They are usually X-linked recessive. d. They are usually multifactorial. ANS: A The pattern ofinheritance is generally autosomalrecessive. DIF: Cognitive Level: Knowledge REF: Page 720 TOP: Tay-Sachs KEY:Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. What occurs as a result of an inadequate secretion ofinsulin? a. Protein synthesisisincreased. b. Increased fat breakdown leadsto ketonemia. c. Serum glucose levels aremarkedly decreased. d. More rapid conversion and storage of carbohydratesto glucose occurs. ANS: B When insulin is deficient,the body cannot metabolize carbohydratesfor energy. The body is also unable to store and use fat properly. Incomplete fatmetabolism produces ketone bodiesthat accumulate in the blood. DIF: Cognitive Level: Comprehension REF: Page 722 TOP: Diabetes Mellitus KEY: Nursing ProcesNsUSRteSpI :NIGmTpBle.mCOenMtation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. On what understanding doesthe nurse plan the care of a child with a new diagnosis oftype 1 diabetesmellitus? a. There is an absolute deficiency ofinsulin. b. Insufficient quantities ofinsulin are produced by the pancreas. c. Oral hypoglycemic agents can control it. d. Insulin deficiency is caused by another disease affecting the pancreas. ANS: A Type 1 insulin-dependent diabetesmellitusis characterized by an absolute or complete deficiency of insulin. DIF: Cognitive Level: Comprehension REF: Page 723 OBJ: 5 TOP: Diabetes Mellitus KEY:Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A child receives a combination ofregular and NPH insulin at 8:00 AM. At 8:45 AM the breakfast trays have not yet arrived from the kitchen. What is the best action by the nurse? a. Notify the charge nurse. b. Give the patient a snack of graham crackers and milk. c. Ambulate the patient in the hall for a short time. d. Give the patient more insulin according to the sliding scale. ANS: B A child who receivesregularinsulin beforemealsmay have an insulin reaction if food is not eaten within 20 minutes. A snack of graham crackers and milk will prevent an episode of hypoglycemia. DIF: Cognitive Level: Application REF: Page 730INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 376 NURSINGTB.COM OBJ: 9 TOP: Prevention of Hypoglycemia KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 5. Although the child with type 1 diabetes had her prescribed insulin at 7:30 AM,the child is complaining of hunger and thirst and is drowsy at 10:30 AM. Whatshould the nurse do first? a. Walk the patientin the hall for 10 minutes. b. Allow the patient a short nap. c. Give her a cup of orange juice. d. Test her blood with a glucometer and give insulin according to the sliding scale. ANS: C The immediate remedy isto give orange juice to raise the blood glucose. Giving more sugar will increase the blood glucose in a hyperglycemic child. Walking exercise will use up even more glucose. The treatment for hyperglycemia is to give the patient more insulin. DIF: Cognitive Level: Application REF: Page 730 OBJ: 7 TOP: Hypoglycemia KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. Which commentmade by a school-age child indicatesthat he needsmore teaching about diabetes mellitusand exercise? a. I carry a piece of hard candy with me in case Istart to feelshaky. b. I make sure I have emergencymoney when I have soccer practice or a game. c. SometimesIskip my breakfast when I have a game in the morning. d. I play in soccer gamesthat are scheduled after dinner. ANS: C Blood glucose is high after meals. The child wNitUhRtySpINeG1TdBia.CbeOtMes mellitus who skips a meal before exercise is at risk for hypoglycemia. DIF: Cognitive Level: Comprehension REF: Page 727 OBJ: 9 TOP: Diabetes Mellitus KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Which statement made by a 7-year-old child with type 1 diabetesmellitusindicates a need for moreteaching? a. My pancreasissick and needsinsulin until it is well. b. I will need to take my insulin every day. c. I need to keep a piece of candy in my pocket in case Istart to feelshaky. d. My mom hasto give me insulin shotstwice a day. ANS: A The child with type 1 diabetesmellitus has an insulin deficiency and willrequire lifelong management ofthis disease. Insulin does not cure the pancreas. DIF: Cognitive Level: Comprehension REF: Page 726 TOP: Diabetes Mellitus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. Which general dietarymeasure should the nurse include in a teaching plan forthe child with type 1 diabetesmellitus? a. Control intake of carbohydrates and consume fewer calories. b. Focus on complex carbohydrates and eatfoods high in fiber. c. Obtainmost caloriesfromproteins and fats. d. Eat a diet low in fat and low in complex carbohydrates.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 377 NURSINGTB.COM ANS: B The nutritional needs of a child with diabetes mellitus are essentially the same as those of the nondiabetic child,with the exception ofthe elimination of concentrated carbohydratessuch assugar. Fiber has been shownto reduce blood glucose levels. DIF: Cognitive Level: Comprehension REF: Page 728 TOP: Diet KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A child with diabetesis broughtto the emergency department. He isflushed and drowsy, and hisskin is dry.Hisfatherstatesthatthe child has been feeling progressively worse since the morning. Whatisthis child most likely experiencing? a. Somogyi phenomenon b. Dawn syndrome c. Ketoacidosis d. Water intoxication ANS: C In ketoacidosis, the childsskin is dry, and the face isflushed. Patients appear dehydrated. They may perspire and be restless. The breath has a fruity odor, and there is no rest period between inspiration and expiration. DIF: Cognitive Level: Analysis REF: Page 725 OBJ: 7 TOP: Ketoacidosis KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A motherreportsthat her 4-month-old infantislethargic,sleeps 18 hours a day, and snores. The nurserecognizes these signs are characteristic of what? a. Hypothyroidism b. Hyperthyroidism c. Type 1 diabetes mellitus d. Tay-Sachs disease NURSINGTB.COM ANS: A The infant with hypothyroidism will appearsluggish, and the tongue will be enlarged, causing noisy respiration. DIF: Cognitive Level: Analysis REF: Page 721 TOP:Hypothyroidism KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 11. Whatis an important consideration forthe school-age child taking DDAVP for diabetesinsipidus? a. Observe forsigns of water deprivation. b. Restrict his physical education program. c. Arrange forthe child to use the bathroomwhen needed. d. Limitfluid intake other than during the lunch period. ANS: C The child with diabetesinsipidus needsliberal accessto bathrooms and waterfountains. Arrangementsmay have to be made with the school to allow access. DIF: Cognitive Level: Application REF: Page 721 OBJ: 4 TOP: Diabetes Insipidus KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 12. Which laboratory resultindicates goodmetabolic control for a child with type 1 diabetes mellitus? a. Glycosylated hemoglobin value of 8% b. Fasting blood glucose level lessthan 140mg/dLINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 378 NURSINGTB.COM c. Glucose tolerance testresult of 190 mg/dL d. No glucose or ketones presentin the urine ANS: A Glycosylated hemoglobin reflects glycemic levels over a period of months. Levels of 6% to 9% represent good metabolic control. DIF: Cognitive Level: Comprehension REF: Page 725 TOP:Hemoglobin A1c KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. What condition doesthe nurse suspect when a child with type 1 diabetes mellitus has hyperglycemia,diaphoresis, and headaches in the morning? a. Dawn phenomenon b. Somogyi phenomenon c. Honeymoon effect d. Ketoacidosis ANS: B The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level islowered to the point at which the bodys counter-regulatory hormones are released, producing the symptoms described. DIF: Cognitive Level: Analysis REF: Page 732 TOP: Somogyi Phenomenon KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity 14. What would be the most appropriate nursing response to a woman who says, My sister had a child withTay-Sachs disease, and I want to know if I could have a child with this condition? a. The disease israre. Itis unlikely that you would have a child with Tay-Sachs disease. b. A screening test can be done to determine ifNyUoRuSaIrNeGaTcBa.rCriOerMof the gene. c. The gene for Tay-Sachs disease istransmitted by the father. d. The cause of Tay-Sachs disease isthoughtto be an autoimmune response to a virus. ANS: B Carriers can be identified by screening tests. Tay-Sachs disease has an autosomalrecessive pattern of transmission. DIF: Cognitive Level: Comprehension REF: Page 720 OBJ: 2 TOP: Tay-Sachs Disease KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 15. Whatstatement by a parentleadsthe nurse to determine a parentis administering levothyroxine(Synthroid) correctly? a. Istopped giving themedication becausemy daughter waslosing her hair. b. I am using a different brand now because it costsless money. c. I dont give the medication on the weekends. d. I give the medication at 8:00 AM every day. ANS: D Synthroid should be given atthe same time each day, preferably in themorning. DIF: Cognitive Level: Comprehension REF: Page 721 TOP: Levothyroxine (Synthroid) KEY: Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. After a closed head injury, the unconscious 10-year-old child begins to excrete copious amounts of pale urine with an attendant drop in blood pressure (BP). Based on these symptoms, what doesthe nurse suspect hasdeveloped?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 379 NURSINGTB.COM a. Diabetesinsipidus b. Diabetesmellitus c. Hypothyroidism d. Hyperthyroidism ANS: A Diabetes insipidus can be acquired as the result of a head injury or tumor, and suppression of the posterior pituitary causes copious urine output with an attendant drop in BP. The child can become dehydrated veryquickly if some remedy is not applied. DIF: Cognitive Level: Analysis REF: Page 721 OBJ: 2 TOP: Diabetes Insipidus KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 17. The nurse isteaching the parents of a child with diabetesinsipidus about waterintoxication. The nursewould tell the parents to be alert for what symptom? For a. Polyuria b. Cough c. Weightloss d. Lethargy ANS: D Signs of waterintoxication include edema, lethargy, nausea, and central nervoussystem signs. DIF: Cognitive Level: Comprehension REF: Page 721 OBJ: 2 TOP: Diabetes Insipidus KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease NURSINGTB.COM 18. The parents of a child newly diagnosed with diabetes mellitustellthe nurse, Oursons body isresistant toinsulin. With what does the nurse recognize this description is consistent? a. Type 1, insulin-dependent diabetes mellitus b. Type 2, noninsulin-dependent diabetes mellitus c. Maturity-onset diabetes of youth d. Drug-induced diabetes ANS: B Type 2, noninsulin-dependent diabetes mellitusis caused by insulin resistance orfailure ofthe body to use the insulin. DIF: Cognitive Level: Comprehension REF: Page 723 TOP: Insulin Resistance KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Physiological Adaptation 19. What doesthe nurse instruct a 12-year-old to do when teaching how to administerinsulin? a. Make sure injection sites are 6 inches apart. b. Select an injection site that wasrecently exercised. c. Inject the needle at a 90-degree angle. d. Give the injection deep into themuscle. ANS: C Children often find it easierto learn to injectthe needle at a 90-degree angle. DIF: Cognitive Level: Application REF: Page 729 TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Pharmacological Therapies 20. The nurse discussed treatment of hypoglycemia with an adolescent. Which statement by the adolescentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 380 NURSINGTB.COM leadsthe nurse to determine the patient understood the instructions? a. When my blood glucose islow or if I begin to feel hungry and weak, I will eatsix LifeSavers. b. When my blood glucose islow or if I begin to feel hungry and weak, I will givemyself Lispro insulin. c. When my blood glucose islow or if I begin to feel hungry and weak, I will have a slice of cheese. d. When my blood glucose islow or if I begin to feel hungry and weak, I will drink a dietsoda. ANS: A The immediate treatment of hypoglycemia consists of administering sugarin some form such as orange juice, hard candy, or a commercial product. Cheese will eventually raise the blood glucose, but not as quickly as candy. DIF: Cognitive Level: Application REF: Page 732 TOP:Diabetes Mellitus KEY:Nursing Process Step: Evaluation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 21. Why doesthe nurse instruct an 11-year-old diabetic child to use the side of the fingerfor blood testing? a. It hasfewer capillaries. b. Itis easierto puncture. c. Itislesslikely to become infected. d. It hasfewer nerve endings. ANS: D The sides of the finger have fewer nerve endings andmore capillaries but are not easier to puncture than the fingertip. The risk for infection is remote for either site. DIF: Cognitive Level: Comprehension REF: Page 726 TOP: Finger Stick KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 22. What is the function of an insulin pump? NURSINGTB.COM a. Releasesinsulin as blood glucose rises b. Provides continuousinfusion of insulin c. Decreases need for painful glucosemonitoring d. Delivers a prescribed amount of insulin twice a day ANS: B The insulin pump thatis attached to a subcutaneoustube releases a continuousinfusion ofinsulin. DIF: Cognitive Level: Knowledge REF: Page 730 TOP: Insulin Pump KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse is preparing to administer a long-acting insulin. Which insulin is considered long acting? a. Lispro b. Aspart c. Glargine d. Regular ANS: C Insulin glargine is a long-acting insulin. Regularisshort acting. Lispro and Aspart are rapid acting. DIF: Cognitive Level: Knowledge REF: Page 730 OBJ: 10 TOP: Insulin KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 24. When discussing possible causes of diabetesin children,the nursementions chromosomal defects. Whichchromosomes are associated with diabetes? (Select all that apply.)INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 381 NURSINGTB.COM a. 6 b. 7 c. 12 d. 20 e. 21 ANS: A, B, C, D Defectsin chromosomes 6, 7, 12, and 20 and other genetic disorders are associated with diabetesmellitus syndrome. DIF: Cognitive Level: Knowledge REF: Page 723 TOP: Diabetes Mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. Which food sources are high in soluble fiber? (Select all that apply.) a. Raw fruits b. Cooked vegetables c. Beans d. Leanmeat e. Bran cereal ANS: A, C, E Foods high in soluble fiberinclude raw fruits, beans, and bran cereal. DIF: Cognitive Level: Comprehension REF: Page 728 TOP:Dietary Fiber Sources KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. What doesthe nurse remind the adolescent with diabetesthatsoluble fiberin the diet can reduce? (Select all that apply.) a. Blood glucose b. Serum cholesterol c. Incidence ofinfections d. Absorption ofsugar e. Insulin requirements NURSINGTB.COM ANS: A, B, D, E Soluble fiber can reduce blood glucose,serumcholesterol, absorption ofsugar, and insulin requirements. It hasno effect on infections. DIF: Cognitive Level: Comprehension REF: Page 728 TOP: Fiberin Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. Which process(es) doesthe nurse explain the endocrine system is primarily responsible for controlling?(Select all that apply.) a. Maturation b. Reproduction c. Stress response d. Sexual identity e. Growth ANS: A, B, C, E The endocrine system governsmaturation,reproduction,stressresponse, and sexual maturity. Sexual identityis a psychosocial response. DIF: Cognitive Level: Comprehension REF: Page 719 TOP: Endocrine System KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopmentINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 382 NURSINGTB.COM 28. The home health nurse ismonitoring an 8-month-old child with hypothyroidism taking levothyroxine(Synthroid). Which symptoms doesthe nurse recognize assigns of overdose? (Select all that apply.) a. Tachycardia b. Irritability c. Vomiting d. Weight gain e. Diaphoresis ANS: A, B, E Allthe options with the exception of weight gain and vomiting are indications of overdose of Synthroid. Weight loss is a symptom of overdose, however. DIF: Cognitive Level: Comprehension REF: Page 722 TOP: Levothyroxine (Synthroid) Overdose KEY:Nursing Process Step:Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 29. Whatmakes keeping diabetesin control in an adolescent difficult? (Select allthat apply.) a. Hormonal changes b. Developmental conflicts c. Preference forfast food d. Growth spurts e. Knowledge of disease ANS: A, B, C, D The adolescent who isin a growth spurt and filled with raging hormonesresents and deniesthe need to be dependent on a medication. Medication schedules and diet restrictions do not correlate well with the adolescents lifestyle of eating fast foods. Denial of disease is prevalent in the adolescent. DIF: Cognitive Level: Comprehension REF: PNaUgeRS7I3N3GTB.COM OBJ: 8 TOP: Diabetic Adolescent KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance:Growth andDevelopment 30. A child with diabetesmellitusis observed to have cold symptoms. Whatsigns and symptoms will alert parents of the possibility of ketoacidosis? (Select all that apply.) a. Chest congestion b. Ear pain c. Fruity breath d. Hyperactivity e. Nausea ANS: C, E Symptoms of ketoacidosis are compared with those of hypoglycemia. Signs and symptoms include a fruity odor to the breath, nausea, decreased level of consciousness and dehydration. Lab values include ketonuria, decreased serum bicarbonate concentration (decreased CO2 levels) and low pH, and hypertonic dehydration. DIF: Cognitive Level: Comprehension REF: Page 725 TOP: Ketoacidosis KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 31. The nurse is discussing insulin shock with parents of a child recently diagnosed with diabetes mellitus. What willthe nurse respond when the parents ask why children aremore prone to insulin reactions? (Select allthat apply.) a. The condition ismore unstable in children. b. Parents are often noncompliant.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 383 NURSINGTB.COM c. The activities are irregular. d. They are still growing. e. Sleep patterns are not established.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 384 NURSINGTB.COM ANS: A, C, D Children aremore prone to insulin reactionsthan adults because of the following:the condition itself ismore unstable in young people; they are growing; their activities are more irregular. DIF: Cognitive Level: Comprehension REF: Page 732 TOP: Insulin Shock KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseCOMPLETION 32. The nurse remindsthe parents of a diabetic with an insulin pump that the tubing of the pump should bechanged aseptically every hours. ANS: 48 The tubing of the insulin pump should be changed every 48 hours.DIF: Cognitive Level: Knowledge REF: Page 730 TOP: Insulin Pump KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 33. The nurse explainsthat the diagnosis of diabetesismade when the fasting blood glucose level is mg/dL on two separate occasions, and the history is positive forindication of the disease. ANS: 126 An elevated blood glucose level of 126mg/dL on two separate occasionsis groundsforthe diagnosis of diabetes mellitus when the history is positive fNoUr RthSeINdiGseTaBse.C.OM DIF: Cognitive Level: Comprehension REF: Page 723 TOP:Diagnosis ofDM KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 34. The nurse assessing a glycosylated hemoglobin (HbA1c) testis aware thatthistest can evaluate averageglucose levels over a period of to months. ANS: 3; 4 Glucose attaches to the red cells overthe life span ofthe cell and can be read as percentages. An HbA1c reading of 6% to 9% is normal; a reading of 12% or higher is indicative of DM. DIF: Cognitive Level: Knowledge REF: Page 725 TOP:Glycosylated Hemoglobin KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 35. Long-acting types of insulin are seldom given to children because of the danger of during sleep. ANS: hypoglycemia Long-acting types of insulin are seldom given to children because of the danger of hypoglycemia during sleep. DIF: Cognitive Level: Comprehension REF: Page 731 TOP: Insulin administration/Hypoglycemia KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 385 NURSINGTB.COM MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 386 NURSINGTB.COM Page 744 Chapter 32: Childhood Communicable Diseases, Bioterrorism, Natural Disasters and the Maternal-Child Patient MULTIPLE CHOICE 1. Which classification ofmedication wouldmake a childmostsusceptible to an opportunistic infection? a. Anticonvulsant b. Beta-adrenergic agent c. Antibiotic d. Corticosteroid ANS: D Steroids are immunosuppressive drugsthatmake the child very susceptible to opportunistic infections. DIF: Cognitive Level: Knowledge REF: Page 741 TOP: Effect of Steroids KEY:Nursing Process Step: Data Collection MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. An 8-year-old asksthe nurse how she got the antibodiesthat kept herfrom getting whooping cough. What isthe nurses best explanation? a. You received borrowed antibodiesfromanother person who had whooping cough. b. You were given a tiny case of whooping cough and then you made your own antibodies. c. An immunization strengthened antibodies you were born with. d. You received only temporary borrowed antibodies and you need to have anothershot every 5 years. ANS: B Vaccines contain live weakened or dead organisms notstrong enough to cause disease but they stimulate the body to develop an immune reaction and antibodies. This is active acquired immunity. NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: OBJ: 4 TOP: Vaccines KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. How would the nurse document a rash that has erythematous, circular raised lesions? a. Macular b. Papular c. Vesicular d. Pustular ANS: B A papule is a circular,reddened elevated area on the skin. DIF: Cognitive Level: Knowledge REF: Page 743 TOP: Rashes KEY:Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which finding would lead the nurse to delay the administration of DTaP for an infant? a. Diarrhea b. Temperature of 40.5 C (105 F) from the previousinoculation c. Teething d. Traveling to Europe in a week ANS: B A contraindication to giving theDTaP vaccine is a 40.5 C (105 F) temperature following the previous vaccination. DIF: Cognitive Level: Application REF: Page 747 TOP: Immunizations KEY: Nursing Process Step: ImplementationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 387 NURSINGTB.COM MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. Whattype of precautions are necessary when caring for a toddler with varicella? a. Contact b. Protective c. Airborne infection d. Large dropletinfection ANS: C Airborne-infection precautions are used for patients with conditionssuch astuberculosis, varicella, and rubella. Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room. DIF: Cognitive Level: Application REF: Page 738 OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. Which statement assuresthe nurse that parents understand how long a child who has varicella is contagious? a. My child should stay home from school for 6 days after the pox appear. b. My child can return to school when the rash fades. c. My child muststay away from other children until all of the lesions have healed. d. My child is contagious aslong as he has a fever. ANS: A The child with varicella is contagiousfor 6 days after the appearance of the rash. DIF: Cognitive Level: Comprehension REF: Page 738 OBJ: 2 TOP: Common Varicella KEY:Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care EnvironmNeUnRt:SSINafGetTyBa.CndOIMnfection Control 7. Which statementmade by a sexually active adolescent girl indicates an understanding of the prevention ofsexually transmitted diseases? a. I always douche afterintercourse. b. I think you can get a vaccination for STDs now. c. I insist that my partner wear a condom. d. I am protected because I take the pill. ANS: C The use of condomsto prevent STDsis not considered 100% effective butisrecommended forsexual intercourse. DIF: Cognitive Level: Comprehension REF: Page 755 OBJ: 9 TOP: Sexually Transmitted Diseases KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. Whatisthe priority nursing diagnosisfor a hospitalized infant who isHIV positive? a. Risk forinjury b. Altered nutrition c. Impaired skin integrity d. Risk forinfection ANS: D The infant who is HIV positive hasimpaired immunologic functioning and is at high risk for infection. DIF: Cognitive Level: Application REF: Page 758 OBJ: 10 TOP: Human Immunodeficiency VirusINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 388 NURSINGTB.COM KEY: Nursing Process Step: Nursing DiagnosisINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 389 NURSINGTB.COM MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. Themother of a newborn asked the nurse, When will my baby get the hepatitis B vaccine? When will thenurse explain the first dose of Comvax should be given to infants born to a hepatitis B-positive mother? a. Within 12 hours after birth b. Within 2 weeks after birth c. Within 1month after birth d. Within 2months after birth ANS: A The American Academy of Pediatricsrecommendsthat Comvax,the only thimerosal-free hepatitis B vaccine, should be used for infants born to HBsAg-positive mothers within 12 hours of birth. DIF: Cognitive Level: Knowledge REF: Page 749 OBJ: 4 TOP: Immunization Schedule KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A 10-year-old child is diagnosed with Hepatitis A. Whatisthe mostlikely way the child contracted this disease? a. Came in contact with infected blood b. Came in contact with dropletsin the air c. Was bitten by a mosquito or a tick d. Ate shrimp while in Mexico ANS: D Hepatitis A resultsfrom ingestion of contaminated water orshellfish. DIF: Cognitive Level: Comprehension REF: Page 739 OBJ: 3 TOP: Hepatitis A KEY: Nursing ProceNsUs RStSeIpN:GImTBpl.CemOeMntation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 11. An infantis hospitalized for RSV bronchiolitis. Which type of precautions would the nurse use when caring for the infant? a. Large-droplet infection precautions b. Airborne-infection precautions c. Contact precautions d. Protective precautions ANS: C Contact precautions are used when the condition transmits organisms via skin-to-skin contact orindirect touchof a contaminated fomite. DIF: Cognitive Level: Application REF: Page 742 OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response forthe nurse to make when the child asks,Why do you have to wear a gown and maskwhen you are in my room? a. Nurses and doctors wear gowns and masks because you have a condition that could be spread to others. b. The gown and mask are to protect you because you could get an infection very easily. c. Imwearing this because there are a lot of bacteria in the hospital. d. I might look scary but you wont need this after you have had medication for 24 hours. ANS: B Protective isolation is used for patients who are not communicable but have a lowered resistance and areINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 390 NURSINGTB.COM highlysusceptible to infection.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 391 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 743 TOP: Protective Isolation KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. The nurse is planning to administerimmunizations at a well-child visit when a parentreportsthe 18- monthold child is allergic to eggs. Which vaccine would be contraindicated? a. Influenza b. Inactivated polio vaccine c. Diphtheria,tetanus, acellular pertussis d. Hepatitis B ANS: A The influenza vaccine should not be given to children who are allergic to eggs. DIF: Cognitive Level: Knowledge REF: Page 745 TOP: Nurses Role in ImmunizationsAllergy KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. The nurse is preparing to administerimmunizations at a well-child clinic. Whichmethod of administrationwill the nurse implement? a. DTaP subcutaneously b. Hib vaccine prepared in a separate syringe c. Varicella intramuscularly d. Varicella 1 week after the MMR vaccine ANS: B Hib vaccinemust be given in a separate syringe from other vaccines administered atthe same time. DIF: Cognitive Level: Knowledge REF: PageN7U49RSINGTB.COM OBJ: 6 TOP: Hib KEY: Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 15. A child wassentto the school nurse because of a rash. The nurse noted the rash was present on the trunk,extremities, and face. The childs cheeks were bright red. With what is the nurse aware this type of rash is consistent? a. Measles b. Roseola c. Varicella d. Fifth disease ANS: D In fifth disease,the child has a generalized rash and the cheeks have a slapped-cheek appearance. DIF: Cognitive Level: Comprehension REF: Page 738 OBJ: 2 TOP: Fifth Disease KEY:Nursing Process Step:Data Collection MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. Whatstatementleadsthe nurse to determine that a childs parent understandsinformation related to tickbites? a. Ill have my son wear dark clothing on his hike. b. We should all get the Lyme disease vaccine before ourtrip. c. Ill get a prescription for amoxicillin to take with us. d. We will wearlong pants and long-sleeved shirtsin the woods. ANS: D People should keep skin covered by wearing protective clothing in wooded areasto prevent tick bites.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 392 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 740 OBJ: 4 TOP: Prevention of Tick Bites KEY:Nursing Process Step: Evaluation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 17. An adolescentistaking tetracycline for a sexually transmitted disease. What would the nurse stress whenproviding instruction about this medication? a. Finish all ofthe medication. b. Get plenty of fresh air and sunlight. c. Take themedication with food. d. Take an antacid if themedication causes an upsetstomach. ANS: A The nurse would teach the adolescent to take all of the prescribedmedication to avoidmaking the microorganism resistant to tetracyclines. DIF: Cognitive Level: Comprehension REF: Page 756 OBJ: 9 TOP: Sexually Transmitted Diseases KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. The nurse explainsto the parentsthat their child isin the prodromalstage of varicella. What does thismean? a. The child is now immune to varicella. b. The child has varicella but has not yet broken out. c. The child isinfected with varicella butis not contagious. d. The child does not have varicella but has been exposed to it. ANS: B The prodromal stage is the initial stage of the NcoUmRmSIuNnGicTaBbl.eCOdiMsease in which the child is infected and contagious but does not yet have outward signs of the disease. DIF: Cognitive Level: Comprehension REF: Page 741 TOP: Prodromal Period KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 19. Which is an example of an opportunistic infection? a. Measles b. Pneumocystis jiroveci c. Clostridium difficile d. Smallpox ANS: B Pneumocystisjiroveci isthemost common of opportunistic diseases. DIF: Cognitive Level: Knowledge REF: Page 757 TOP: Opportunistic Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 20. A child is admitted to the pediatric unit with a diagnosis of cellulitis on the right upper thigh. Patient history revealsthe child had a 2-cm laceration on the rightthigh priorto infection. When explaining the chainof infection, how does the nurse identify this laceration? a. Reservoir b. Portal of entry c. Portal of exit d. Cector ANS: BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 393 NURSINGTB.COM The chain of infection refersto the way in which organismsspread and infect the individual. A portal of entryINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 394 NURSINGTB.COM is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit isthe route by which the organisms exitthe body (e.g., feces or urine). A reservoir forinfection is a place thatsupportsthe growth oorganisms(e.g.,standing,stagnant water). A vector is an insect or animal that carries and spreads a disease. DIF: Cognitive Level: Comprehension REF: Page 741 TOP: Chain ofInfection KEY:Nursing Process Step: Data Collection MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection ControlMULTIPLE RESPONSE 21. Why would a female adolescent with STDsresistreporting the condition? (Select allthat apply.) a. She isreluctantto name contacts. b. She is embarrassed. c. She doubts confidentiality. d. She doesnt wantto take the medication. e. She dreadsthe pelvic examination. ANS: A, B, C, E Adolescents are uncomfortable aboutthe pelvic examination and require a lot ofsupport. Adolescents doubtthe confidentiality of the agency and are reluctant to name contacts. DIF: Cognitive Level: Comprehension REF: Page 755 OBJ: 9 TOP: Reporting STDs KEY:Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. Whatsources are examples of acquired immunity? (Select allthat apply.) a. Gamma globulin b. The disease c. Maternal antibodies d. The vaccine e. Immune globulin NURSINGTB.COM ANS: B, D Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination. Gamma globulin is simply a support to the immune system. Immune globulin is receiving the antibodies from some othersource, giving the person an immediate immunity but one that does not last. DIF: Cognitive Level: Knowledge REF: Page 742 TOP: Acquired Immunity KEY:Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 23. The well-child clinic nurse is preparing to give which immunizationsto a healthy 2-month-old? (Select all that apply.) a. DTaP b. Hib c. IPV d. MMR e. PCV ANS: A, B, C, E Allthe options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps, measles, rubella are not expected until the child is 1 year old. DIF: Cognitive Level: Knowledge REF: Page 749 OBJ: 6 TOP: Inoculations for a 2-Month-Old KEY: Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection ControlINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 395 NURSINGTB.COM 24. The nurse is explaining to a family about disaster preparedness. What willthe nurse instruct the family toprepare in a disaster kit in case of emergency? (Select all that apply.) a. Smalltelevision b. Vital documents c. Nonperishable food d. Pet food e. Blankets ANS: B, C, D, E The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or manmade disasters, such as bioterrorist attacks or bombings. The American Medical Association (AMA) office guidelinesfor preparing a family and community disaster plan state thatthe family should keep several days supply offood, water, petfood, warmclothing, blankets, copies of vital documents, and toiletries on hand. Abattery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential. DIF: Cognitive Level: Knowledge REF: Page 754 OBJ: 8 TOP: Disaster Preparedness KEY:Nursing Process Step: Planning MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 25. The nurse is assisting with an admission assessment of a child with scarletfever. Which actions willthe nurse expect to implement? (Select all that apply.) a. Obtain a throat culture. b. Encourage ambulation. c. Assessfor desquamation. d. Initiate droplet precautions. e. Administer isoniazid. ANS: A, C A diagnosis of scarlet fever would indicate thrNoUatRcSuI lNtuGreTBan.CdOaMssessment for desquamation. Bed rest with quiet activity is indicated. Droplet precautions would not be implemented for scarlet fever. Isoniazid is administered for tuberculosis. DIF: Cognitive Level: Application REF: Page 740 OBJ: 2 TOP: Scarlet Fever KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection ControlCOMPLETION 26. The nurse explainsthat the test determinesthe childssusceptibility to tuberculosis. ANS: Mantoux The Mantoux testis a screening test forthe susceptibility to TB. An intradermal injection is given and read 3 days later. An erythema and induration of more than 5 mm is considered a positive reading. DIF: Cognitive Level: Knowledge REF: Page 742 TOP: Mantoux KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 27. The nurse uses a diagram showing how the wood tick acts as a(n) in the transmission ofLyme disease. ANS: vector A vector is an insect or animalthat carries a communicable disease.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 396 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 741 TOP: Vector KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 28. The school nurse recognizesthe presence ofmacules, papules, vesicles, pustules, and scabs on the child asthe particularsign of the communicable disease of . ANS: varicella (chickenpox) Varicella hasthe distinctive sign ofshowing several types ofskin lesions at the same time. DIF: Cognitive Level: Comprehension REF: Page 738 OBJ: 2 TOP: Varicella KEY:Nursing Process Step: Data Collection MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 29. A parentis concerned because herson was exposed to varicella at preschool. The nurse would tell thisparentthatthe incubation period for varicella is days. ANS: 14 to 21 The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days.DIF: Cognitive Level: Knowledge REF: Page 738 OBJ: 2 TOP: Varicella KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 30. The nurse demonstrates proper hand hygiene pointing outthatthe processshould take a minimum of seconds. NURSINGTB.COM ANS: 15 Hand hygiene should take aminimum of 15 secondsto complete. DIF: Cognitive Level: Knowledge REF: Page 743 OBJ: 4 TOP: Hand Hygiene KEY:Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control 31. Children are generallymore vulnerable to biological warfare, because their arenot fully developed. ANS: immune systems The immune systems of children are notfully developed, which makesthem a vulnerable population. DIF: Cognitive Level: Comprehension REF: Page 753 TOP: Bioterrorism KEY: Nursing Process Step: Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 32. A is a worldwide high incidence of a communicable disease. An is a sudden increase of a communicable disease in a localized area. refersto a continuous incidenceof a communicable disease expected in a localized area. ANS: pandemic; epidemic; EndemicINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 397 NURSINGTB.COM A pandemic is a worldwide high incidence of a communicable disease. An epidemic is a sudden increase of a communicable disease in a localized area. Endemic refersto a continuousincidence of a communicable disease expected in a localized area. DIF: Cognitive Level: Knowledge REF: Page 741 TOP: Key Terms KEY:Nursing Process Step: N/A MSC:NCLEX: Safe, Effective Care Environment: Safety and Infection Control NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 398 NURSINGTB.COM Chapter 33: The Child with an Emotional or Behavioral Condition MULTIPLE CHOICE 1. A parent asksthe nurse to describe whatismeant by a learning disability. Which isthe nursesmost helpfulresponse? a. A childmay have difficulty with perception, language, comprehension, or memory. b. Itis characterized by inattention, impulsiveness, and hyperactivity. c. The childsintellectual ability limits hislearning. d. The child has difficulty learning because of brain damage. ANS: A Learning disability is an educationalterm. Children with learning disabilities may have average to aboveaverage intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization. DIF: Cognitive Level: Comprehension REF: Page 768 TOP: Learning Disability KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 2. What would be the appropriate response to an adolescent who states, This has been the worst day of my life? a. You should focus your mind on positive thoughts. b. Everybody has a bad day now and then. c. Youre young. What could be so terrible? d. Tell me aboutthe worst day of yourlife. ANS: D The nurse establishes a rapport with the adolescent by acknowledging his or herfeelings and giving the adolescent full attention. NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 773 OBJ: 6 TOP: Suicide KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im not going to talk aboutthat! Its none of your business, anyway! Leaveme alone! How doesthe nurse interpret the adolescentsbehavior? a. The adolescent is acting out and needsto be brought under controlso the conference can continue. b. The adolescent istrying to shift the focus of the conference away from himself, and the nurse needs torefocus. c. The adolescentis demonstrating thatthis problem requiresthe assistance of a psychiatrist. d. The adolescentisresponding to the discrediting of his parents, which causes anxiety. ANS: D Discrediting parentsthreatensthe childssecurity and creates anxiety. DIF: Cognitive Level: Analysis REF: Page 776 OBJ: 10 TOP: Children of Alcoholics KEY:Nursing Process Step:Data Collection MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 4. The nurse is answering phone calls at a localsuicide prevention hotline. Which statement would berecognized as the greatest risk of suicide? a. I just needed to talk to someone to keep myself fromthinking silly thoughts about killing myself. b. My parents arent home and wont be back for 4 hours. Thatshould be enough time for the pillsto work. Ivegot a hundred of them. c. My dad will be home first,so hell find me. So I think Ill use his gun. I hope he didnt lock the cabinet.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 399 NURSINGTB.COM d. My girlfriend is here withme. She toldme to call because I wastalking crazy about killing myself.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 400 NURSINGTB.COM ANS: B The risk of death increases when there is a definite plan of action,themeans are readily available, and the person has few resources for help and support. DIF: Cognitive Level: Analysis REF: Page 771 OBJ: 6 TOP: Suicide KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 5. A 15-year-old boy was previously active in a band and savedmoney to buy a special guitar. What would a nurse assess as an early sign of depression in this boy? a. He gives up the band to spend time with his girlfriend. b. He spends all of histime atthe library studying to qualify for the honorsociety. c. He gives his guitar away and spends histime listening to music in hisroom. d. He withdraws all of his money out of the bank to buy an expensive leather jacket. ANS: C A major depression is characterized by a prolonged behavioral change from baseline thatinterferes with school,family life, and age-specific activities,frequently signaled by giving prized possessions away. DIF: Cognitive Level: Analysis REF: Page 770 OBJ: 6 TOP: Depression KEY:Nursing Process Step: Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 6. A mother is concerned because her adolescent son is always in trouble for fighting at school and alwaysseems to be angry. She mentions that her husband drinks a bit. Which understanding will guide the nurses response? a. The boy is displaying antisocial behavior and should be evaluated formental illness. b. The boy is displaying one ofthe typical defense patterns of children of alcoholics and should receiveimmediate treatment. c. The mother is displaying her own anger witNhUhRerShINusGbTaBnd.CsOdMrinking, and she needs immediate intervention. d. The boy is only one member of the family affected by alcoholism, and all membersshould receiveimmediate intervention. ANS: D Early recognition of and intervention for children of alcoholics are paramount. This adolescentis using the coping pattern of acting-out behaviors to deal with the family situation. DIF: Cognitive Level: Comprehension REF: Page 776 OBJ: 10 TOP: Children of Alcoholics KEY:Nursing Process Step: Implementation MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 7. Whatisthemost appropriate classroom intervention for a child with attention deficit hyperactivity disorder(ADHD) for the school nurse to suggest? a. Seat the child in the back of the room to prevent distractionsfor other children. b. Pairthe child with a student buddy to offer remindersto pay attention. c. Divide work assignmentsinto shorter periods with breaksin between. d. Separate the child from othersto increase hisfocus on schoolwork. ANS: C The child with ADHD needs breaks between periods of work and study. DIF: Cognitive Level: Application REF: Page 769 OBJ: 12 TOP: Attention Deficit Hyperactivity DisorderKEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 8. How doesthe nurse describe a person who is bulimic? a. Severely underweightINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 401 NURSINGTB.COM b. Alternates binge eating with purging c. Introverted perfectionist d. Has extremely close family relationships ANS: B Bulimia is characterized by alternating binge eating and purge behavior. DIF: Cognitive Level: Comprehension REF: Page 770 OBJ: 13 TOP: Bulimia KEY:Nursing Process Step: Data CollectionMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 9. A 14-year-old girl with obsessive-compulsive disorder(OCD)tellsthe nurse other adolescentstease herbecause she washes her hands many times during the school day. For what does this disorder put the adolescent at greater risk? a. Anorexia nervosa b. Depression c. ADHD d. A learning disability ANS: B OCDisrelated to depression and other psychiatric disorders. Suicidal behavioris a high risk for adolescents with OCD. DIF: Cognitive Level: Comprehension REF: Page 767 OBJ: 5 TOP: Obsessive-Compulsive Disorder KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 10. Which statementmade by a parent of an adolescent with anorexia nervosa indicates an understanding of this condition? NURSINGTB.COM a. There really isnt anything to worry about. Dont they say you can never be too thin? b. My daughter just doesnt havemuch of an appetite. c. She isjusttrying to punish me for divorcing her father. d. She seemsto see herself asfat, even though her weightis below normal. ANS: D Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes. DIF: Cognitive Level: Comprehension REF: Page 769 OBJ: 13 TOP: Anorexia Nervosa KEY:Nursing Process Step: Evaluation MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 11. Whatis an appropriate nursing intervention for a hospitalized child who is autistic? a. Place the child in a location where she can watch all of the activity on the unit. b. Use the childs chronological age as a guide for communication. c. Keep the childsroom free of toys or objectsthatshe might wantto take home with her. d. Organize care to provide asfew disruptionsto the routine as possible. ANS: D During hospitalization,the nurse should provide a highly structured environment with few distractionsfor a child who is autistic. DIF: Cognitive Level: Application REF: Page 767 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 12. A nurse is planning to speak with a parentsupport group about childhood autism. What willthe nurseinclude?INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 402 NURSINGTB.COM a. Significantsigns of the disorder manifest by 1 year of age. b. The earliestsigns of autismare impulsivity and overactivity. c. Autism is usually diagnosed when the child goesto elementary school. d. Medications can cure childhood autism. ANS: A Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are significantsigns of dysfunction by 1 year of age. DIF: Cognitive Level: Comprehension REF: Page 767 TOP: Autism KEY: Nursing Process Step: Planning MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 13. An adolescent is brought to the emergency department after an automobile accident. When the nurse approachesthe adolescent, he becomes combative. The nurse notes hisspeech isslurred and his gait is ataxic.What does the nurse suspect the adolescent has used? a. Alcohol b. Cocaine c. Amphetamines d. PCP ANS: A Behavioralsigns of alcohol ingestion include slurred speech,short attention span, drowsiness, combativeness, and violence. DIF: Cognitive Level: Analysis REF: Page 774 OBJ: 8 TOP: Substance Abuse KEY:Nursing Process Step:Data Collection MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation NURSINGTB.COM 14. When the nurse is collecting a nursing history, an adolescentstatesthatshe hastried speed. For what doesthe nurse recognize this as the street name? a. Barbiturates b. Cocaine c. Methamphetamine d. Marijuana ANS: C Speed isthe street name formethamphetamine. DIF: Cognitive Level: Knowledge REF: Page 774 OBJ: 8 TOP: Substance Abuse KEY:Nursing Process Step:Data Collection MSC:NCLEX: Psychosocial Integrity: Coping and Adaptation 15. How would the nurse identify a member of the child guidance team who is a medical doctor with specialtraining in psychoanalytic theory? a. Psychiatrist b. Psychoanalyst c. Psychologist d. Counselor ANS: A The psychiatristis amedical doctor; the psychoanalyst may be amedical doctor or a psychologist. The psychologist is not a medical doctor, and neither is the counselor. DIF: Cognitive Level: Knowledge REF: Page 766 TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 403 NURSINGTB.COM 16. A young child on the pediatric unit cannot express himself well. Whattherapeutic interventionmight thenurse implement that allows children to act out their feelings? a. Arttherapy b. Play therapy c. Music therapy d. Bibliotherapy ANS: B Play therapy allows a young child to act out with dolls orfigures concerns that the child may be unable to adequately express verbally. DIF: Cognitive Level: Comprehension REF: Page 766 TOP: Play Therapy KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. The nurse explainsthat use ofstimulants will decrease hyperactivity in the autistic child. Whatis anegative aspect of stimulants? a. Sedating the child b. Impairing cognition c. Causing hypotension d. Creating fluid retention ANS: B Stimulantsthat decrease the hyperactivity in the autistic child also impair cognition andmay increase the potential of self-injuring behavior. DIF: Cognitive Level: Comprehension REF: Page 767 TOP: Autism KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies NURSINGTB.COM 18. A 9-year-old has been admitted to the hospital after huffing lighterfluid and isin a high euphoric state. Forwhatshould the nurse assess? a. Depressed respirations b. Severe vomiting c. Frightening hallucinations d. Elevation of temperature ANS: A Inhaling hydrocarbons depressesthe central nervoussystem, including respiratory rate and generalsensorium. DIF: Cognitive Level: Application REF: Page 775 TOP: Substance Abuse KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk 19. The pediatric nurse listensto a 9-year-old child read to his 6-year-old roommate. What action by 9-yearoldchild leads the nurse to question possible dyslexia? a. Becomes hyperactive and ceasesto read b. Readsthe word dog as God c. Makes up a story rather than reading the text d. Stutters as he reads ANS: B Dyslexics often transpose a word asthey read; for example,the word is dog, butit appears to the dyslexic child as the word God. DIF: Cognitive Level: Comprehension REF: Page 768 TOP: Dyslexia KEY:Nursing Process Step:Data Collection MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDiseaseINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 404 NURSINGTB.COM 20. How is a gateway substance defined? a. Recreational drug used occasionally b. Nonaddictive drug used daily c. Drug used to wean from stronger drugs d. Substance that can lead to use ofstronger drugs ANS: D A gateway drug is a substance that creates a high that can lead to the use ofstronger drugs. DIF: Cognitive Level: Knowledge REF: Page 773 OBJ: 8 TOP: Gateway Drugs KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. Which substance puts a person atthe greatestrisk for HIV and hepatitis B? a. Alcohol b. Opiates c. Cocaine d. Marijuana ANS: B The use of opiates coupled with sharing needles putthe user atrisk for HIV and hepatitis B. DIF: Cognitive Level: Comprehension REF: Page 774 OBJ: 8 TOP: OpiateUse KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 22. Whatrole hasthe child of an alcoholic assumed if he triesto do everything perfectly? a. Perfect child b. Super coper c. Flight d. Helper NURSINGTB.COM ANS: B Of the fourrolesfor the child of the alcoholic,the super coperis one who triesto do everything perfectly and feels overly responsible. The perfect child isthe child who triesto earn love by never causing any trouble. DIF: Cognitive Level: Comprehension REF: Page 776 OBJ: 10 TOP: Child of an Alcoholic KEY:Nursing Process Step:Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and AdaptationMULTIPLE RESPONSE 23. The nurse working with children fromdysfunctional families must be prepared to address what associatedproblem(s)? (Select all that apply.) a. Lack of trust b. Acting out c. Exaggerated self-confidence d. Blaming othersfor problems e. Depression ANS: A, B, E Children fromdysfunctional families exhibitlack of trust, act out, and show signs of depression. DIF: Cognitive Level: Comprehension REF: Page 766 TOP:Dysfunctional Families KEY:Nursing Process Step: PlanningMSC: NCLEX: Psychosocial Integrity: Coping and AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 405 NURSINGTB.COM 24. The nurse counsels parentsthat the early school years create nervoustension in the childmanifested bywhich abnormal behavior(s)? (Select all that apply.) a. Masturbation b. Food fads c. Stuttering d. Aggressive behavior e. Nonnutritive sucking ANS: C, D, E Stuttering, aggressive behavior, and finger orthumb sucking that appearsuddenly with no previous history area clue to increased nervous tension in the young school-age child. Masturbation and food fads are normal behavioral phenomena for the early school-age child. DIF: Cognitive Level: Comprehension REF: Page 767 TOP:Nervous Tension KEY:Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 25. The nurse statesthatthemembers of a mental health team for child guidance include which member(s)?(Select all that apply.) a. Psychiatrist b. Pediatrician c. Psychologist d. Dietitian e. Social worker ANS: A, B, C, E The traditional members ofthe child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team. DIF: Cognitive Level: Knowledge REF: PageN7U66RSINGTB.COM TOP: Members of the Child Guidance Team KEY: Nursing Process Step: Implementation MSC:NCLEX: Safe, Effective Care Environment: Coordinated Care 26. The school nurse cautions a group of parents aboutthe prevalence of children who get high by inhalinghydrocarbons and fluorocarbons. Which products contain these substances? (Select all that apply.) a. Glue b. Chlorine c. Cleaning fluid d. Copymachine toner e. Aerosolsprays ANS: A, C, E Although there aremany productsthat could be inhaled,themost frequently used products are glue, cleaning fluid, aerosol sprays, Freon,shoe polish, and gasoline products. DIF: Cognitive Level: Knowledge REF: Page 774 OBJ: 8 TOP: Inhaling Hydrocarbons KEY:Nursing Process Step: Implementation MSC:NCLEX:Health Promotion and Maintenance: Prevention and Early Detection ofDisease 27. The nurse is planning the care of an adolescent with anorexia nervosa. What characteristic(s) cause thisdisorder? (Select all that apply.) a. Discomfortrelative to emerging sexuality b. Fear of intimacy c. Pervasive high self-esteem d. EgocentricityINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 406 NURSINGTB.COM e. Inability tomeet developmental needsINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 407 NURSINGTB.COM ANS: A, B, D, E All options except pervasive high self-esteem are considered to be a cause of anorexia nervosa. Pervasive lowself-esteem also is considered a cause of anorexia nervosa. DIF: Cognitive Level: Comprehension REF: Page 769 TOP: AnorexiaNervosa KEY:Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 28. The nurse is assessing a 16-year-old female for characteristics of anorexia nervosa. Which assessmentfinding(s) would lead the nurse to suspect the possibility of this diagnosis? (Select all that apply.) a. Amenorrhea b. Severe weightloss c. Oily skin d. Hypertension e. Lanugo on back ANS: A, B, E The primary symptom of anorexia nervosa issevere weightloss. Adolescents who wish to be fashion models or actresses or who participate in sports, dance, or gymnastics activitiesmay be atrisk for developing an eatingdisorder. On physical examination, some of the following conditions may be evident: dry skin, amenorrhea, lanugo hair over the back and extremities, cold intolerance, low blood pressure, abdominal pain, and constipation. DIF: Cognitive Level: Comprehension REF: Page 769 TOP: AnorexiaNervosa KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Physiological Adaptation 29. A nurse is hired to work in a psychiatric facility on a unitspecializing in obsessive compulsive disorders (OCD). Which diagnoses might the nurse expect to encounter? (Select all that apply.) a. Trichotillomania b. Hoarding disorder c. Excoriation disorder d. Body dysmorphic disorder e. Oppositional defiant disorder NURSINGTB.COM ANS: A, B, C, D Oppositional defiant disorderis described as an ongoing pattern of anger-guided disobedience, a hostile or defiant response to authority and is not considered a form of OCD. DIF: Cognitive Level: Knowledge REF: Page 768 TOP:Obsessive Compulsive Disorder KEY: Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. A child is diagnosed with attention deficit hyperactivity disorder(ADHD). Which characteristics would the nurse assess in this child? (Select all that apply.) a. Social anxiety b. Impulsivity c. Hyperactivity d. Distractability e. Inattention ANS: B, C, D, E ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility. DIF: Cognitive Level: Knowledge REF: Page 768 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological AdaptationINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 408 NURSINGTB.COM COMPLETION 31. The nurse documents that every time the child is directed to discuss the relationship with her brother, shecomplains ofshortness of breath and beginsto have asthma-like symptoms. The nurse assessesthis behavior asa(n) reaction. ANS: psychosomatic A psychosomatic reaction is one in which a dysfunction ofthe body has an emotional or mental cause. DIF: Cognitive Level: Comprehension REF: Page 767 TOP: Psychosomatic Reaction KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 32. The nurse assists with the intervention of therapy, which provides a physical and social environment that is stable and therapeutic. ANS: milieu Milieu therapy is a modality of treatment offered to troubled children, in which they are placed in an environmentthatisstable and therapeutic so thattheir problemsmight be better expressed oridentified. DIF: Cognitive Level: Knowledge REF: Page 766 TOP: Milieu Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 33. Early childhood experiences are criticalto personality formation. Situationsthat disruptfamily patterns canhave a lasting impact on the child. These families are known as and can make children feel negatively aboutthemselves and the world. ANS: dysfunctional NURSINGTB.COM Early childhood experiences are critical to personality formation. Situations that disrupt family patterns canhave a lasting impact on the child. Children who come from these dysfunctional families may experience anyof the following: failure to develop a sense of trust (in their caregivers and environment), excessive fears, misdirected anger manifested as behavioral problems, depression, low self-esteem, lack of confidence, and feelings of lack of control over themselves and their environment. Cognitive Level: Knowledge DIF: Cognitive Level: Knowledge REF: Page 766 TOP: Suicide KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment 34. Putthe 5 steps of the SAFE-T program in the correct order. Put a comma and space between each answerchoice (a, b, c, d, etc.) a. Determine risk level b. Document and follow up c. Identify risk d. Identify protective factors e. Suicide inquiry ANS: C, D, E, A, BINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 409 NURSINGTB.COM The order of the SAFE-T program isto firstidentify risk (warning signs);second,INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 410 NURSINGTB.COM identify protective factors(coping strategies;support persons);third,suicide inquiry (identify plans);fourth, determine risk level (interventions); and last, to document and follow up. DIF: Cognitive Level: Comprehension REF: Page 773 TOP: Suicide KEY:Nursing Process Step:Data Collection |Nursing Process Step: Intervention | Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Crisis Intervention NURSINGTB.COMINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 411 NURSINGTB.COM Chapter 34: Complementary and Alternative Therapies in Maternity and Pediatric Nursing MULTIPLE CHOICE 1. A pregnant woman tellsthe nurse thatshe gotrelief from nausea when she had a therapy that involvespressure and massage on meridian sites. What type of therapy does this describe? a. Acupuncture b. Acupressure c. Aromatherapy d. Ayurveda ANS: B Acupressure usesfinger pressure and massage on the meridian sites. It can be used during pregnancy to controlnausea, backache, and pain. It has been useful for minor postpartum problemssuch as constipation. DIF: Cognitive Level: Knowledge REF: Page 783 OBJ: 2 TOP: Acupressure KEY:Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Which child should notreceive massage therapy? a. 15-year-old with a fractured femur b. 12-year-old with diabetes mellitus c. 8-year-old withDown syndrome d. 17-year-old with an eating disorder ANS: C Children withDown syndrome are prone particularly to cervicalspine anomalies andmay be injured by massage therapy. NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 782 TOP: Massage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A 12-year-old with rheumatoid arthritisfinds aromatherapy helpful forrelieving herjoint discomfort. Whichessential oil is useful for children with chronic pain? a. Lavender b. Ephedra c. Ginseng d. Kava-kava ANS: A Lavender, chamomile, and sandalwood essential oils are useful in aromatherapy for children with chronic pain. DIF: Cognitive Level: Knowledge REF: Page 784 OBJ: 2 TOP: Alternative Health PracticesAromatherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A pregnant woman wishesto use aromatherapy during herlabor and delivery. Whatisthemost appropriateessential oil for the nurse to recommend? a. Juniper b. Wintergreen c. Thyme d. Citrus ANS: D Citrusis one essential oilthat has been shown to be useful during labor and delivery.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 412 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 784 TOP: Aromatherapy KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A parent asksthe nurse,Whatis guided imagery? Which statementisthemost accurate response? a. Itis a technique where the patientfocuses on an image to relieve stress. b. Itinvolves using water to promote relaxation. c. The patient enters a hypnotic state ofsleep to promote relaxation. d. It helpsthe patientrecognize tension in themuscles with responses on an electronic machine. ANS: A In guided imagery, by focusing on a specific image,stressreduction and improved performance can result. DIF: Cognitive Level: Knowledge REF: Page 784 TOP:Guided Imagery KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. A woman taking St. Johns wort and ginseng daily isscheduled to have a hysterectomy in 3 weeks. Whatinstruction should the nurse provide? a. The herbs are not likely to cause any problems during the surgery. b. The St. Johns wort must be stopped priorto surgery, butshe can continue the ginseng. c. The ginseng should be stopped 1 week before surgery. d. She should discontinue taking both herbs 2 weeks before surgery. ANS: D Both St. Johns wort and ginseng can cause problems during surgery, and their use should be discontinued 2 weeks before surgery. DIF: Cognitive Level: Application REF: Page 781 OBJ: 6 TOP:Herbal Remedies KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC:NCLEX: Physiological Integrity: Reduction of Risk 7. Which herb can the nurse suggest to be used for discomforts associated with menopause,such as hotflashes? a. Evening primrose oil b. Echinacea c. Milk thistle d. Black cohosh ANS: D Black cohosh diminishes hotflashes by reducing luteinizing hormone. It also reducesjoint pain and other menopausal discomforts. DIF: Cognitive Level: Knowledge REF: Page 788 OBJ: 12 TOP: Herbal Remedies KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 8. A young mother asks, Isthere an alternativemedicine for children with asthma? Which formof alternativemedicine would be the most helpful for the nurse to suggest? a. Reflexology b. Rolfing c. Guided imagery d. Acupressure ANS: C The use of guided imagery has helped relieve some of the symptoms of asthma.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 413 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 779 TOP:Guided Imagery KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. Whatisthe difference between complementary therapy and alternative therapy? a. Complementary therapymust be administered by amedical doctor. b. Complementary therapy is administered with conventional therapy. c. Complementary therapy replaces conventional therapy. d. Complementary therapy is administered to a group of patients at the same time. ANS: B Complementary therapy is administered with conventionaltherapy,such asmassage withmuscle relaxantsfor low back pain. DIF: Cognitive Level: Comprehension REF: Page 779 TOP: CAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse uses a diagram to show the location of meridians. How willthe nurse explain the definition ofmeridians? a. They are lymph nodes. b. They are invisible pathwaysfor energy. c. They are linesthat divide the body into 10 zones. d. They are areas ofskin that are specifically innervated. ANS: B Meridians are invisible pathwaysthrough which energy travelsto effect acupuncture treatment. DIF: Cognitive Level: Knowledge REF: Page 783 OBJ: 8 TOP: Herbal Remedies: CAM KEY: Nursing Process Step: Implementation NURSINGTB.COM MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Which herbalremedy used by a patienttaking warfarin should the nurse reportto the physician? a. Angelica (dong quai) b. Chamomile c. Ginseng d. Kava-kava ANS: A Angelica prolongs prothrombin time and willsynergize the effect of the warfarin. DIF: Cognitive Level: Application REF: Page 785 OBJ: 4 TOP: Herbal Remedies KEY:Nursing Process Step:Data Collection MSC:NCLEX: Physiological Integrity: Reduction of Risk 12. Whatshould the nurse remind a parent who is considering homeopathic remediesfor treatment of herchilds asthma? a. Should be drunk with large amounts of fluid b. Can be taken with traditional Westernmedications c. Can be enhanced by drinking hot tea d. May containmercury, alcohol, or arsenic ANS: D Homeopathic remedies often contain mercury, alcohol, or arsenic and are taken sublingually. All Westernmedicationsshould be stopped when the homeopathic therapy is begun. Caffeine drinks are to be avoidedduring homeopathic treatment.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 414 NURSINGTB.COM DIF: Cognitive Level: Application REF: Page 784 TOP: Homeopathic Remedies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. The focus of acupressure isto restore the balance of what? a. Chi b. Shiatsu c. Yin and yang d. Ayurveda ANS: A Acupressure isfocused on the return of the balance of Chito control disease processes. DIF: Cognitive Level: Comprehension REF: Page 783 TOP: Acupressure KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. A breastfeeding mother tellsthe nurse she istaking large doses of vitamin C to keep up her energy. Whatshould the nurse warn that large doses of vitamin C can cause in an infant? a. Diarrhea b. Jaundice c. Colic d. Retinal damage ANS: C Vitamin C can be passed on to a breastfeeding child through breast milk and can cause colic. DIF: Cognitive Level: Comprehension REF: Page 786 TOP: Vitamin C KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: PharmNaUcRolSoIgNicGaTlBT.hCeOraMpies 15. The pregnant patient with a stasis ulcer asksifshe might be a candidate for hyperbaric oxygen therapy(HBOT). What is the nurses best response? a. Yes. Hyperbaric oxygen therapy should have no harmful effect on your baby. b. No. High amounts of oxygen in yoursystem will cause changesin your babys heart. c. Yes. Hyperbaric oxygen therapy is amuch better option than using antibiotics. d. No. Hyperbaric oxygen therapymay cause the placenta to separate from the uterine wall. ANS: B High concentrations of oxygen in themothers blood can cause closure of the ductus arteriosus and cause fetal death. DIF: Cognitive Level: Application REF: Page 788 TOP: HBOT KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 16. A patientis providing history information to the admitting nurse about treatment used for chronic pain. Thepatient reports she participates in a type of relaxation therapy that enables her to recognize tension in the muscles via responses on an electronicmachine and visual electromyography responses. Whattype of therapy does the nurse record on admission record? a. Guided imagery b. Biofeedback c. Hypnotherapy d. Chiropractic care ANS: B Biofeedback is a type ofrelaxation therapy that enablesthe patient to recognize tension in the muscles via responses on an electronicmachine and visual electromyography responses. The processis also used by traditional health care providers for drug addiction and chronic pain control.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 415 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 784 TOP: CAM Therapies KEY:Nursing Process Step:Data CollectionMSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE 17. What conditions would a nurse expectto see treated with hyperbaric oxygen therapy (HBOT)? (Select allthat apply.) a. Wounds b. Carbonmonoxide poisoning c. Hyperemesis gravidarum d. Decompression illness e. Pneumonia ANS: A, B, D Hyperbaric oxygen therapy (HBOT) uses an airtight enclosure to provide compressed air or oxygen under increased pressure. HBOT is used to revive children with carbonmonoxide poisoning,to aid wound healing, and to treat the diving syndrome known as decompression illness. HBOT is contraindicated during pregnancy, because the increased oxygen saturation can cause the ductus arteriosusto close, resulting in fetal death. DIF: Cognitive Level: Knowledge REF: Page 788 TOP: HBOT KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Reduction of Risk 18. Themother of a pediatric patient asksthe nurse aboutsafety concerns with using herbalsupplements withchildren. Which herbal products would the nurse educate this mother are safe to use in most of the pediatric population? (Select all that apply.) a. Ephedra b. Ginger c. Fish oil d. Chamomile e. Aloe vera NURSINGTB.COM ANS: B, C, D, E Ginger,fish oil, chamomile and aloe vera are safe herbal productsfor children. However,some herbs,such as ephedra, can be fatal to children. DIF: Cognitive Level: Knowledge REF: Page 786 OBJ: 11 TOP: Herbal Therapies KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Reduction of Risk 19. The nurse points outthatlight therapy is used in the treatment of patients with which disorder(s)? (Selectall that apply.) a. Digestive disorders b. Seasonal affective disorder c. Inflammatory diseases d. Stress disorders e. Jaundice ANS: B, E Lighttherapy has proven effective in the treatment of persons with seasonal affective disorders. Light therapyis also used in the treatment of jaundiced babies. DIF: Cognitive Level: Comprehension REF: Page 782 TOP: Light Therapy KEY:Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. What advantage(s) of alternative health care should the nurse outline when providing information toINTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 416 NURSINGTB.COM patients? (Select allthat apply.) a. Offering more patient control of health care b. Offering a variety of health care advisors c. Keeping patientsfrom having tomake decisions d. Using natural productsrather than chemical ones e. Incorporating cultural beliefs and practices ANS: A, B, D, E Alternative health care actually promotesthe patients decisionmaking in care. DIF: Cognitive Level: Comprehension REF: Page 779 OBJ: 5 TOP: CAM KEY:Nursing Process Step: Implementation MSC:NCLEX: Physiological Integrity: Basic Care and Comfort 21. Which approachesto care are combined with osteopathy? (Select allthat apply.) a. Manipulation therapy b. Aroma therapy c. Herbal application d. Pressure pointtherapy e. Traditional medicine ANS: A,D, E DIF: Cognitive Level: Knowledge REF: Page 782 OBJ: 9 TOP: Osteopathy KEY:Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 22. The practice of is a process of fascia pressure and stretching. ANS: rolfing NURSINGTB.COM Rolfing involves a process ofstretching and placing pressure on the fascia to improvemuscle and bone function. DIF: Cognitive Level: Knowledge REF: Page 782 TOP: Rolfing KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. While taking care of a Navajo child,the nurse welcomestheir folk healer, called a . ANS: singer TheNavajo recognize personsin theirtribe asfolk healers called singers. These persons performritesfor healing and well-being that are comforting to the Navajo. DIF: Cognitive Level: Knowledge REF: Page 780 TOP: Navajo Practices KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 24. The nurse clarifiesthat a person who is demonstrates sensitivity andrespect for different practices and philosophies. ANS: culturally competent The culturally competent nurse showssensitivity,respect, and an open attitude to the health care needs of othercultures.INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer) 417 NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: Page 780 TOP: Cultural Competency KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 25. The nurse explainsthat are areas ofskin that are innervated by the dorsal roots of thespinal cord, which are the basis of acupressure therapy. ANS: dermatomes Dermatomes are areas of the skin that are innervated by the dorsal roots of the spinal cord. Pressure in these areas is the basis of acupressure therapy. DIF: Cognitive Level: Knowledge REF: Page 783 OBJ: 8 TOP:Dermatomes KEY:Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 26. is an ancient practice thatinvolves concentrated fluid orthe essence ofspecific herbsthat are combined with steams or baths to inhale or bathe the skin. ANS: Aromatherapy Aromatherapy is an ancient practice thatinvolves concentrated fluid orthe essence ofspecific herbsthat are combined with steams or baths to inhale or bathe the skin. DIF: Cognitive Level: Knowledge REF: Page 784 TOP: Aromatherapy KEY:Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 27. In 1992 the National Institutes of Health (NNUIHR) Sc I rNeGat Te Bd . t ChOeMOffice of Alternative Medicine to evaluate the various CAM therapies. It has since been renamed the . ANS: National Center for Complementary and Alternative Medicine (NCCAM) In 1992 the National Institutes of Health (NIH) created the Office of Alternative Medicine to evaluate the various CAM therapies. It has since been renamed the National Center for Complementary and Alternative Medicine (NCCAM). This Centerserves as a public clearinghouse and resource forresearch concerning CAM therapies. DIF: Cognitive Level: Knowledge REF: Page 780 TOP:NIH KEY:Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Self-Car [Show More]

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