Wong’s Essentials of Pediatric Nursing 9th Ed By Marilyn J. Hockenberry

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Wong’s Essentials of Pediatric Nursing 9th Ed By Marilyn J. Hockenberry

Chapter 02: Community-Based Nursing Care of the Child and Family

 

MULTIPLE CHOICE

 

  1. Which term best describes the identification of the distribution and causes of disease, injury, or illness?
a. Nursing process
b. Epidemiologic process
c. Community-based statistics
d. Mortality and morbidity statistics

 

 

ANS:  B

Epidemiology is the science of population health applied to the detection of morbidity and mortality in a population. It identifies the distribution and causes of diseases across a population. Nursing process is a systematic problem-solving approach for the delivery of nursing care. Morbidity and mortality statistics, along with natal rates, may provide an objective picture of a community’s health status.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   18

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A community nurse at the health department is trying to identify how many new cases of acquired immunodeficiency syndrome (AIDS) disease have occurred in the city this past year. Which statistic should the nurse examine?
a. Mortality
b. Morbidity
c. Incidence
d. Prevalence

 

 

ANS:  C

Incidence will provide the number of cases of a particular disease process. Mortality statistics specify the number of deaths from a given cause. Morbidity statistics specify the prevalence of specific illnesses in a population at a particular time.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   18

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is collecting subjective and objective information about target populations to diagnose problems based on community needs. This describes which step in the community nursing process?
a. Planning
b. Diagnosis
c. Assessment
d. Establishing objectives

 

 

ANS:  C

The nursing process stages are similar, whether the client is one child or a population of children. The assessment phase of the nursing process focuses on collecting subjective and objective data. Planning is the development of community-centered goals and objectives. Diagnosis is the identification of problems specific to the community.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   19

TOP:   Integrated Process: Communication and Documentation

MSC:  Area of Client Needs: Safe and Effective Care Environment: Management of Care

 

  1. A nurse is establishing several health programs, such as bicycle safety, to improve the health status of a target population. This describes which step in the community nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation

 

 

ANS:  D

The nurse working with the community to put into practice a program to reach community goals is the implementation phase of the community nursing process. Planning involves designing the program to meet community-centered goals. The evaluation stage would determine the effectiveness of the program. During the assessment phase, the nurse would identify the resources necessary and the barriers that would interfere with implementation.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   19

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Safe and Effective Care Environment: Management of Care

 

  1. A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of prevention is the nurse demonstrating?
a. Primary
b. Secondary
c. Tertiary
d. Health promotion

 

 

ANS:  B

Secondary prevention focuses on screening and early diagnosis of disease. Vision and hearing testing are screening tests to detect problems. Primary prevention focuses on health promotion and prevention of disease or injury. Tertiary prevention focuses on optimizing function for children with a disability or chronic disease. Health promotion is focused on preventing disease or illness.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   19

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A community health nurse is collecting assessment data by interviewing community leaders. What type of assessment is this community nurse conducting?
a. Subjective
b. Windshield survey
c. Objective
d. Statistical

 

 

ANS:  A

Subjective information indicates what community members say are their most important needs. Interviewing community leaders would be a subjective assessment. Objective information is data that the nurse collects either by direct observation or through written sources. A windshield tour is one method of direct observation. Statistics would be objective information gathering.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   19

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which interventions by a community can be classified as primary prevention interventions? (Select all that apply.)
a. Administering immunizations
b. Teaching a child with asthma how to use an inhaler
c. Conducting scoliosis screening exams
d. Teaching a community parenting class
e. Conducting assessments at a well-child care clinic

 

 

ANS:  A, D, E

Primary prevention focuses on health promotion and prevention of disease or injury. Examples of primary prevention activities include well-child care clinics; immunization programs; safety programs (bike helmets, car seats, seat belts, childproof containers); nutrition programs; environmental efforts (clean air programs); sanitation measures (chlorinated water, garbage removal, sewage treatment); and community parenting classes. Teaching a child how to use an inhaler is tertiary prevention and conducting scoliosis screening exams is secondary prevention.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   19

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

Chapter 08: Health Promotion of the Newborn and Family

 

MULTIPLE CHOICE

 

  1. Which is the most critical physiologic change required of the newborn?
a. Closure of fetal shunts in the heart
b. Stabilization of fluid and electrolytes
c. Body-temperature maintenance
d. Onset of breathing

 

 

ANS:  D

The onset of breathing is the most immediate and critical physiologic change required for transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. This affects the fetus’s adjustment to extrauterine life. Closure of fetal shunts in the heart, stabilization of fluid and electrolytes, and body-temperature maintenance are important changes that must occur in the transition to extrauterine life, but breathing and the exchange of oxygen for carbon dioxide must come first.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   186

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is a function of brown adipose tissue (BAT) in the newborn?
a. Provides ready source of calories in the newborn period
b. Insulates the body against lowered environmental temperature
c. Protects the newborn from injury during the birth process
d. Generates heat for distribution to other parts of body

 

 

ANS:  D

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

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   186

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which characteristic is representative of the newborn’s gastrointestinal tract?
a. Stomach capacity is approximately 90 ml.
b. Peristaltic waves are relatively slow.
c. Overproduction of pancreatic amylase occurs.
d. Intestines are shorter in relation to body size.

 

 

ANS:  A

Newborns require frequent small feedings because their stomach capacity is approximately 90 ml. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats. Newborn’s intestines are longer in relation to body size than those of an adult.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   187

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of stool?
a. Meconium
b. Transitional
c. Miliaria
d. Milk stool

 

 

ANS:  A

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

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   187

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse documents this finding and continues to monitor the newborn because, in term newborns, the first meconium stool occurs within how many hours of birth?
a. 6 to 8
b. 8 to 12
c. 12 to 24
d. 24 to 48

 

 

ANS:  D

The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to 7 days in very low–birth-weight newborns. Although it may occur earlier, the expected range is the first 24 to 48 hours of life.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   187

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is doing an assessment on a newborn. Which is characteristic of a newborn’s vision at birth and an expected finding during the assessment?
a. Ciliary muscles are mature.
b. Blink reflex is absent.
c. Tear glands function.
d. Pupils react to light.

 

 

ANS:  D

Although at birth the eye is still structurally incomplete, the pupils do react to light. The ciliary muscles are immature, limiting the eyes’ ability to focus on an object for any length of time. The blink reflex is responsive to minimal stimulus. The tear glands do not begin to function until ages 2 to 4 weeks.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   188

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The Apgar score of a newborn 5 minutes after birth is 8. Which is the nurse’s best interpretation of this?
a. Resuscitation is likely to be needed.
b. Adjustment to extrauterine life is adequate.
c. Additional scoring in 5 more minutes is needed.
d. Maternal sedation or analgesia contributed to the low score.

 

 

ANS:  B

The Apgar reflects the newborn’s status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 6 indicate moderate difficulty. The Apgar score is not used to determine the newborn’s need for resuscitation at birth. All newborns are rescored at 5 minutes. The newborn does not have a low score.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   189

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
a. The newborn’s length and weight are the most accurate indicators of gestational age.
b. The newborn’s Apgar score and the mother’s estimated date of confinement (EDC) are combined to determine gestational age.
c. The newborn’s posture at rest and arm recoil are two physical signs used to determine gestational age.
d. The newborn’s chest circumference compared to the head circumference is the determinant for gestational age.

 

 

ANS:  C

With the newborn quiet and in a supine position, the degree of flexion in the arms and legs and the arm recoil can be used to help determine gestational age. Length, weight, and the chest/head circumference reflect the newborn’s size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborn’s adjustment to extrauterine life, and the mother’s EDC is of no importance in determining gestational age.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   189

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing a 3-day-old, breast-fed newborn who weighed 7 pounds, 8 ounces at birth. The newborn’s mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most appropriate nursing intervention?
a. Recommend supplemental feedings of formula.
b. Explain that this weight loss is within normal limits.
c. Assess child further to determine cause of excessive weight loss.
d. Encourage mother to express breast milk for bottle feeding the newborn.

 

 

ANS:  B

The newborn normally loses about 10% of the birth weight by age 3 or 4 days. The birth weight is usually regained by the tenth day of life. Because this is an expected occurrence, no further action is needed. The mother should be taught about normal newborn feeding and growing patterns.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   192

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Why are rectal temperatures not recommended in the newborn?
a. They are inaccurate.
b. They do not reflect core body temperature.
c. They can cause perforation of rectal mucosa.
d. They take too long to obtain an accurate reading.

 

 

ANS:  C

Rectal temperatures are avoided in the newborn. If done incorrectly, the insertion of a thermometer into the rectum can perforate the mucosa. Rectal temperatures, if taken correctly, are considered an accurate reflection of core body temperature. The inherent risks and intrusive nature limit the use. The time it takes to determine body temperature is related to the equipment used, not the route only.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   192

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
a. 60 to 80 beats/min
b. 80 to 100 beats/min
c. 120 to 140 beats/min
d. 160 to 180 beats/min

 

 

ANS:  C

The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min; 60 to 100 beats/min is too slow for a neonate and 160 to 180 beats/min is too fast for a neonate.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   193

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is palpating a newborn’s fontanels. The nurse documents the anterior fontanel is which shape?
a. Circle
b. Triangle
c. Square
d. Diamond

 

 

ANS:  D

The anterior fontanel is diamond-shaped and measures from barely palpable to 4 to 5 cm. Neither of the fontanels is a circle or a square. The triangle is the shape of the posterior fontanel.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   196

TOP:   Integrated Process: Communication and Documentation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is the name of the suture separating the parietal bones at the top center of a newborn’s head?
a. Frontal
b. Coronal
c. Sagittal
d. Occipital

 

 

ANS:  C

The sagittal suture separates the parietal bones on top of the newborn’s head. The frontal suture separates the frontal bones. The coronal suture is said to “crown the head.” There is no occipital suture. The lambdoid suture is at the margin of the parietal and occipital bones.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   195

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. In a newborn’s eyes, strabismus is a normal finding because of:
a. congenital cataracts.
b. lack of binocularity.
c. absence of red reflex.
d. inability of pupil to react to light.

 

 

ANS:  B

Newborns are unable to focus their eyes on an object. Binocularity does not develop until ages 3 to 4 months. Congenital cataracts, absence of red reflex, and inability of pupil to react to light are not normal findings and need further evaluation.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   197

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse has determined that a newborn’s respiratory breathing is within a normal range. How should the nurse document this finding?
a. Irregular, abdominal, 30 to 60 breaths/min
b. Regular, abdominal, 25 to 35 breaths/min
c. Regular, noisy, 35 to 45 breaths/min
d. Irregular, quiet, 45 to 55 breaths/min

 

 

ANS:  A

The respirations of a normal newborn are irregular and abdominal, with a rate of 30 to 60 breaths/min. Newborn respirations are irregular. Pauses in respiration less than 20 seconds in duration are considered normal. The newborn is an abdominal breather with a wider range of respiratory rates.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   197

TOP:   Integrated Process: Communication and Documentation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. This should be interpreted as a(n):
a. normal finding.
b. hydrocele.
c. absence of testes.
d. inguinal hernia.

 

 

ANS:  A

A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. The presence or absence of testes would be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia. An inguinal hernia may be present at birth. It is more easily detected when the child is crying.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   199

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
a. Perez
b. Sucking
c. Rooting
d. Extrusion

 

 

ANS:  C

Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck is a description of the rooting reflex, which usually disappears by ages 3 to 4 months but may persist for up to 12 months. The Perez reflex involves stroking the newborn’s back when prone; the child flexes extremities, elevating head and pelvis. It disappears at ages 4 to 6 months. The newborn begins strong sucking movements in response to circumoral stimulation. The reflex persists throughout infancy, even without stimulation. Newborns force their tongues outward, when the tongue is touched or depressed. This reflex usually disappears by age 4 months.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   197-198

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which statement best represents the first stage of the first period of reactivity in the newborn?
a. It begins when the newborn awakes from a deep sleep.
b. It ends when the amount of respiratory mucus has decreased.
c. It is an excellent time to acquaint the parents with the newborn.
d. It is an excellent time for mother to sleep and recover.

 

 

ANS:  C

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

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   201

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
a. Examine newborn’s eyes for ability to focus.
b. Assess for other attachment behaviors.
c. Recognize this as a common reaction in new mothers.
d. Ask mother why she won’t look at newborn.

 

 

ANS:  B

Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and the mother. The mother’s failure to make eye contact with her newborn may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Newborns do not have binocularity and cannot focus. It is uncommon for a mother to avoid making eye contact with her newborn and it is confrontational to ask why; this would put the mother in a defensive position.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   202

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. At the time of birth, what is the grayish white, cheeselike substance that normally covers the newborn’s skin called?
a. Miliaria
b. Meconium
c. Amniotic fluid
d. Vernix caseosa

 

 

ANS:  D

The grayish white, cheeselike substance that normally covers the newborn’s skin is the vernix caseosa. Miliaria are distended sweat glands that appear as minute vesicles. Meconium is the newborn’s first stool. Amniotic fluid is produced in utero.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   194

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What are distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period called?
a. Milia
b. Lanugo
c. Mongolian spots
d. Cutis marmorata

 

 

ANS:  A

Distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period are milia, which are common variations found in newborns. Lanugo is fine downy hair. Mongolian spots are irregular areas of deep blue pigmentation, usually in the sacral and gluteal areas. Cutis marmorata is transient mottling when the newborn is exposed to decreased body temperatures.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   203

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
a. Feet and hands
b. Bridge of nose
c. Circumoral area
d. Mucous membranes

 

 

ANS:  A

Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns. Cyanosis present at the bridge of the nose, the circumoral area, and the mucous membranes is a potential sign of distress or major abnormality.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   199

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent?
a. Acrocyanosis
b. Erythema toxicum
c. Mongolian spots
d. Harlequin color changes

 

 

ANS:  C

Irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent are Mongolian spots, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet that is a usual finding in newborns. Erythema toxicum is a pink papular with vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the newborn lies on one side, the lower half of the body becomes pink and the upper half is pale.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   203

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes flaring of nares in a newborn. This should be interpreted as:
a. nasal occlusion.
b. sign of respiratory distress.
c. common response to sneezing.
d. snuffles of congenital syphilis.

 

 

ANS:  B

Nasal flaring is an indication of respiratory distress. A nasal occlusion would prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this would require immediate referral. Sneezing and thin white mucus drainage are common in newborns and are not related to nasal flaring. Snuffles are indicated by a thick, bloody, nasal discharge without sneezing.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   207

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
a. Nystagmus
b. Profuse drooling
c. Dark green or black stools
d. Slight vaginal reddish discharge

 

 

ANS:  B

Profuse drooling or salivation is a potential sign of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. Pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   204

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is most important in the immediate care of the newborn?
a. Maintain patent airway.
b. Maintain stable body temperature.
c. Administer prophylactic eye care.
d. Establish identification of mother and baby.

 

 

ANS:  A

Maintaining a patent airway is the primary objective in the care of the newborn. The nurse uses a bulb syringe to clear the pharynx, followed by the nasal passages. Conserving the newborn’s body heat and maintaining a stable body temperature are important, but a patent airway must be established first. These are important functions, but physiologic stability is the first priority in the immediate care of the newborn.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   206

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The nurse is careful to place the incubator away from cold windows or air-conditioning units. This is to conserve the newborn’s body heat by preventing heat loss through:
a. radiation.
b. conduction.
c. convection.
d. evaporation.

 

 

ANS:  A

Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the incubator walls and subsequently the newborn’s body. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is the loss of heat similar to conduction but aided by air currents. Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   207

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
a. prevent bleeding.
b. enhance immune response.
c. prevent bacterial infection.
d. maintain nutritional status.

 

 

ANS:  A

Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is synthesized by the intestinal flora. Because the newborn’s intestine is sterile and breast milk is low in vitamin K, a supplemental source must be supplied. The purpose is not to enhance the immune response, prevent bacterial infection, or maintain nutritional status. The major function of vitamin K is to catalyze the liver synthesis of prothrombin, which is needed for blood clotting and coagulation.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   208

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. In the newborn, intramuscular phytonadione (vitamin K) is administered into which muscle?
a. Deltoid
b. Dorsogluteal
c. Vastus medialis
d. Vastus lateralis

 

 

ANS:  D

The vastus lateralis is the traditionally recommended injection site. The deltoid and dorsogluteal sites are not recommended for the vitamin K administration. The ventrogluteal may be used as an alternative site to the vastus lateralis. The vastus medialis is not used for intramuscular injections.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   208

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Recommendations for hepatitis B (HBV) vaccine include which statement?
a. First dose is given between birth and age 2 days.
b. First dose is given between ages 12 and 15 months.
c. It is not recommended for neonates who are at low risk for hepatitis B.
d. It is not recommended for neonates whose mothers are positive for HBV surface antigen.

 

 

ANS:  A

To reduce the incidence of HBV in children and its serious consequences in adulthood, the first of three doses is recommended soon after birth and before hospital discharge. Between 12 and 15 months is too late. The recommendation is for the first dose to be given soon after birth. It is recommended for all newborns. Newborns born to mothers who are HBV surface antigen positive should be given the vaccine within 12 hours of birth. They also should be given hepatitis B immune globulin.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   209

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A newborn is being discharged at age 48 hours. The parents ask how the newborn should be bathed this first week home. The nurse’s best recommendation is to bathe the newborn:
a. daily with mild soap.
b. daily with an alkaline soap.
c. two or three times this week with plain water.
d. two or three times this week with mild soap.

 

 

ANS:  C

The newborn newborn’s skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the child no more than two or three times a week for the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the child’s skin, providing a medium for bacterial growth.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   209

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The stump of the umbilical cord usually separates in how many days?
a. 3
b. 10 to 14
c. 16 to 20
d. 28

 

 

ANS:  B

The average cord separates in 10 to 14 days; 3 days is too soon and 16 to 28 days is too late. The cord should be separated by these times.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   211

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this procedure. The nurse’s response should be based on the knowledge that newborns:
a. experience pain with circumcision.
b. do not experience pain with circumcision.
c. quickly forget about the pain of circumcision.
d. are too young for anesthesia or analgesia.

 

 

ANS:  A

Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that, when circumcision is performed, procedural analgesia be provided. Pain is associated with surgical procedures. The newborn experiences pain, which can be alleviated with analgesia. Topical and injected analgesia are available for this procedure.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   212

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Early this morning, a baby boy was circumcised by using the Plastibell method. The nurse should tell the mother that the baby can be discharged after:
a. the newborn voids.
b. receiving vitamin K.
c. yellow exudate forms over glans.
d. the Plastibell rim falls off.

 

 

ANS:  A

The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2 hours. After these observations and voiding, the newborn can be discharged. The newborn should have received vitamin K soon after delivery. This normal yellow exudate will usually form on the second day after the circumcision. Discharge can occur earlier. The Plastibell rim will separate and fall off within 5 to 8 days. The newborn should be discharged before this.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   212

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The American Academy of Pediatrics recommends that the best form of newborn nutrition is:
a. exclusive breastfeeding until age 2 months.
b. exclusive breastfeeding until at least age 1 year.
c. commercially prepared newborn formula for 1 year.
d. commercially prepared newborn formula until age 4 to 6 months.

 

 

ANS:  B

The American Academy of Pediatrics has reaffirmed its position that a newborn be breastfed exclusively for the first year of life. This group also supports programs that enable women to return to work and continue breastfeeding. Two months is too short of a period. The recommendation is for breastfeeding, not commercial formula. If the mother has stopped breastfeeding, then commercial formula, rather than whole milk, should be used until age 1 year.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   214-215

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Successful breastfeeding is most dependent on the:
a. mother’s socioeconomic level.
b. size of mother’s breasts.
c. mother’s desire to breastfeed.
d. birth weight of newborn.

 

 

ANS:  C

The factors that contribute to successful breastfeeding are the mother’s desire to breastfeed, satisfaction with breastfeeding, and available support systems. The mother’s socioeconomic level may affect the mother’s need to return to work and available support systems, but with support, the mother can be successful. The size of the mother’s breasts does not affect the success of breastfeeding. Very low–birth-weight newborns may be unable to breastfeed. The mother can express milk, and it can be used for the child.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   216

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nursing intervention to promote parent-newborn attachment should include:
a. delaying parent-newborn interactions until the second period of reactivity.
b. explaining individual differences among newborns to the parents.
c. alleviating stress for parents by decreasing their participation in the newborn’s care.
d. allowing a newborn to fuss for a period of time before soothing by holding.

 

 

ANS:  B

Nurses can positively influence the attachment of parent and child by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each newborn. The nurse should facilitate parent-newborn interaction during the first period of reactivity. Decreasing the parents’ participation in care will interfere with parent-newborn attachment. The parents should be encouraged to hold the newborn when he or she is fussy and learn how best to soothe their newborn.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   219-220

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A new mother wants to be discharged with her newborn as soon as possible. Before discharge, the nurse should make certain that:
a. newborn has voided at least once.
b. newborn does not spit up after feeding.
c. jaundice, if present, appeared before 24 hours.
d. appointment is made for home care or a primary care practitioner office visit within next 2 or 3 days.

 

 

ANS:  D

The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours of a short stay in either a primary practitioner’s office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is a normal occurrence in newborns. It would not delay discharge. Jaundice within the first 24 hours of life must be evaluated.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   222

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Nursing interventions to maintain a patent airway in a newborn should include:
a. sleeping in the prone (on abdomen) position.
b. wrapping neonate as snugly as possible.
c. positioning neonate supine while sleeping.
d. using bulb syringe to suction as needed, suctioning nose first, and then pharynx.

 

 

ANS:  C

Supine is the position recommended by the American Academy of Pediatrics to prevent sudden infant death syndrome. Sleeping in the prone position is not advised because of the possible link between sleeping in the prone position and sudden infant death syndrome. The child can be wrapped snugly, but should be placed on side or back. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   206

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is assessing the presence of expected reflexes in a newborn. Which figure depicts the elicitation of the tonic neck reflex?
a. c.
b. d.

 

 

ANS:  B

The tonic neck reflex is elicited when the newborn’s head is turned to one side; the arm and leg extend on that side, and opposite arm and leg flex (fencing position). The Moro reflex is elicited by sudden jarring or change in equilibrium. The newborn has extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape followed by flexion and adduction of extremities; legs may weakly flex. The dancing reflex is elicited when the newborn is held so that the sole of the foot touches a hard surface; there is a reciprocal flexion and extension of the leg, simulating walking. The crawl reflex is elicited when the newborn is placed on the abdomen; the newborn makes crawling movements with arms and legs.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   198

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications for breastfeeding? (Select all that apply.)
a. Human immunodeficiency virus (HIV) in mother
b. Mastitis
c. Inverted nipples
d. Maternal cancer therapy
e. Twin births

 

 

ANS:  A, D

HIV in the mother and maternal cancer therapy place the newborn at risk. HIV can be transmitted through breast milk, as can be the metabolites of chemotherapy. Mastitis, inverted nipples, and twin births are not contraindications.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   215

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is conducting discharge teaching for parents of a newborn. The nurse instructs the parents on which method of care for the umbilical cord? (Select all that apply.)
a. Covering the cord with the diaper
b. Cleansing the cord with water daily
c. Keeping the cord area free of urine and stool
d. Monitoring for signs of infection
e. Applying bacitracin ointment to the cord daily

 

 

ANS:  B, C, D

Parents are taught to keep the cord area free of urine and stool, cleanse daily with water if needed, and observe for any signs of infection. The diaper should not cover the cord. The diaper is folded in front below the cord to avoid irritation and wetness on the site. Bacitracin ointment should not be applied because the cord area should be kept dry, not moist.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   211

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
a. Limiting the feeding to 15 minutes
b. Propping the bottle for night feedings is acceptable
c. Proper technique for cleansing the bottles and nipples
d. Feeding infant on alternate sides of the lap
e. Use of bottled water without fluoride should be avoided to mix powdered formula.

 

 

ANS:  C, D, E

Parents preparing infant formula must wash their hands well and then wash all of the equipment used to prepare the formula (including the cans of formula) with soap and water. Sterilizing bottles and nipples 5 minutes in boiling water may be required when a hot-water dishwasher is not available. Similar to breastfed infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli. Bottled water should not be considered sterile unless otherwise indicated; bottled water without fluoride should be avoided for mixing infant formula. Propping the bottle during infant feedings at night time could cause the infant to aspirate. The feeding should not be hurried. Even though they may suck vigorously for the first 5 minutes and seem to be satisfied, infants should be allowed to continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provide for oral gratification.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   217-218

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is “term” if which findings are assessed? (Select all that apply.)
a. Posture with fully flexed arms and legs
b. Arm recoil brisk
c. Square window at 90 degrees
d. Scarf sign of elbow crossing over the midline
e. Popliteal angle less than 90 degrees

 

 

ANS:  A, B, E

A term newborn will have a posture that is fully flexed (arms and legs) and a brisk arm recoil. The popliteal angle in a term infant is less than 90 degrees. The square window should show no angle, the hand should lie flat on the ventral surface of the arm in the term newborn. In a term newborn, the elbow should not cross the midline during assessment of the scarf sign.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   190

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

SHORT ANSWER

 

  1. A nurse is performing a 1-minute Apgar on a newborn. The nurse assesses that the newborn has a heart rate over 100, a good strong cry, some flexion of extremities, sneezes, and has a pink body with blue extremities. The nurse records what number as the Apgar? Record your answer in a whole number.

 

ANS:

8

  0 1 2
Heart rate Absent Slow, <100 beats/min >100 beats/min
Respiratory effort Absent Irregular, slow, weak cry Good, strong cry
Muscle tone Limp Some flexion of extremities Well flexed
Reflex irritability No response Grimace Cry, sneeze
Color Blue, pale Body pink, extremities blue Completely pink

The newborn gets 2 for heart rate, 2 for respiratory effort, 1 for muscle tone, 2 for reflex irritability and 1 for color = 8

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   189

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is preparing to administer a prescribed phytonadione (vitamin K) injection 0.5 mg intramuscularly to a newborn. The phytonadione (vitamin K) ampule is labeled 1 mg equals 0.5 ml. How many milliliters will the nurse administer? Record your answer using two decimal places.

 

ANS:

0.25

Formula:

 

Desired

Available ´ Volume =

 

0.5 mg

1 mg ´ 0.5 mL = 0.25 mL

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   208

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

Chapter 12: Health Promotion of the Toddler and Family

 

MULTIPLE CHOICE

 

  1. Which factor is most important in predisposing toddlers to frequent infections?
a. Respirations are abdominal.
b. Pulse and respiratory rates are slower than those in infancy.
c. Defense mechanisms are less efficient than those during infancy.
d. Toddlers have a short, straight internal ear canal and large lymph tissue.

 

 

ANS:  D

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

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   379

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The psychosocial developmental tasks of toddlerhood include which characteristic?
a. Development of a conscience
b. Recognition of sex differences
c. Ability to get along with age-mates
d. Ability to delay gratification

 

 

ANS:  D

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

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   380

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The child of 15 to 30 months is likely to be struggling with which developmental task?
a. Trust
b. Initiative
c. Autonomy
d. Intimacy

 

 

ANS:  C

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

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   380

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A parent of an 18-month-old boy tells the nurse that he says “no” to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse’s best interpretation of this behavior is included in which statement?
a. This is normal behavior for his age.
b. This is unusual behavior for his age.
c. He is not effectively coping with stress.
d. He is showing he needs more attention.

 

 

ANS:  A

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

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   379

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is planning care for a 17-month-old child. According to Piaget, which stage should the nurse expect the child to be in cognitively?
a. Trust
b. Preoperational
c. Secondary circular reaction
d. Tertiary circular reaction

 

 

ANS:  D

The 17-month-old child is in the fifth stage of the sensorimotor phase, tertiary circular reactions. The child uses active experimentation to achieve previously unattainable goals. Trust is Erikson’s first stage. Preoperational is the stage of cognitive development usually present in older toddlers and preschoolers. Secondary circular reactions last from about ages 4 to 8 months.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   380

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is descriptive of a toddler’s cognitive development at age 20 months?
a. Searches for an object only if he or she sees it being hidden
b. Realizes that “out of sight” is not out of reach
c. Puts objects into a container but cannot take them out
d. Understands the passage of time, such as “just a minute” and “in an hour”

 

 

ANS:  B

At this age, the child is in the final sensorimotor stage. Children will now search for an object in several potential places, even though they saw only the original hiding place. Children have a more developed sense of objective permanence. They will search for objects even if they have not seen them hidden. When a child puts objects into a container but cannot take them out, this is indicative of tertiary circular reactions. An embryonic sense of time exists, although the children may behave appropriately to time-oriented phrases; their sense of timing is exaggerated.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   381

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Although a 14-month-old girl received a shock from an electric outlet recently, her parent finds her about to place a paper clip in another outlet. Which is the best interpretation of this behavior?
a. Her cognitive development is delayed.
b. This is typical behavior because toddlers are not very developed.
c. This is typical behavior because of the inability to transfer knowledge to new situations.
d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.

 

 

ANS:  C

During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The slot of an outlet is for putting things into. Her cognitive development is appropriate for her age. Trying to put things into an outlet is typical behavior for a toddler. Only some awareness exists of a causal relation between events.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   381

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. Which is the best interpretation of this behavior?
a. This is typical behavior because toddlers are aggressive.
b. This is typical behavior because toddlers are egocentric.
c. Toddlers should know that sharing toys is expected of them.
d. Toddlers should have the cognitive ability to know right from wrong.

 

 

ANS:  B

Play develops from the solitary play of infancy to the parallel play of toddlers. The toddler plays alongside other children, not with them. This typical behavior of the toddler is not intentionally aggressive. Shared play is not within their cognitive development. Toddlers do not conceptualize shared play. Because the toddler cannot view the situation from the perspective of the other child, it is okay to take the toy. Therefore, no right or wrong is associated with taking a toy.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   385

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Steven, 16 months old, falls down a few stairs. He gets up and “scolds” the stairs as if they caused him to fall. This is an example of which of the following?
a. Animism
b. Ritualism
c. Irreversibility
d. Delayed cognitive development

 

 

ANS:  A

Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain the sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the inability to reverse or undo actions initiated physically. Steven is acting in an age-appropriate manner.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   382

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which should the nurse expect for a toddler’s language development at age 18 months?
a. Vocabulary of 25 words
b. Increasing level of comprehension
c. Use of holophrases
d. Approximately one third of speech understandable

 

 

ANS:  B

During the second year of life, level of comprehension and understanding of speech increases and is far greater than the child’s vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. The 18-month-old child has a vocabulary of 10 or more words. At this age, the child does not use the one-word sentences that are characteristic of the 1-year-old child. The child has a limited vocabulary of single words that are comprehensible.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   384

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which statement is correct about toilet training?
a. Bladder training is usually accomplished before bowel training.
b. Wanting to please the parent helps motivate the child to use the toilet.
c. Watching older siblings use the toilet confuses the child.
d. Children must be forced to sit on the toilet when first learning.

 

 

ANS:  B

Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   385

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which characteristic best describes the gross motor skills of a 24-month-old child?
a. Skips and can hop in place on one foot
b. Rides tricycle and broad jumps
c. Jumps with both feet and stands on one foot momentarily
d. Walks up and down stairs and runs with a wide stance

 

 

ANS:  D

The 24-month-old child can go up and down stairs alone with two feet on each step and runs with a wide stance. Skipping and hopping on one foot are achieved by 4-year-old children. Jumping with both feet and standing on one foot momentarily are achieved by 30-month-old children. Tricycle riding and broad jumping are achieved at age 3.

 

PTS:   1                    DIF:    Cognitive Level: Remember           REF:   379

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. The nurse should recognize in this situation that:
a. blocks at this age are used primarily for throwing.
b. toddlers are too young to imitate the behavior of others.
c. toddlers are capable of building a tower of blocks.
d. toddlers are too young to build a tower of blocks.

 

 

ANS:  C

Building with blocks is a good parent-child interaction. The 18-month-old child is capable of building a tower of three or four blocks. The ability to build towers of blocks usually begins at age 15 months. With ongoing development, the child is able to build taller towers. The 18-month-old child imitates others around him or her.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   380

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. At what age should the nurse expect a child to give both first and last names when asked?
a. 15 months
b. 18 months
c. 24 months
d. 30 months

 

 

ANS:  D

At 30 months, the child is able to give both first and last names and refer to self with an appropriate pronoun. At 15 and 18 months, the child is too young to give his or her own name. At 24 months, the child is able to give first name and refer to self by that name.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   384 | 387

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The parents of a newborn say that their toddler “hates the baby; he suggested that we put him in the trash can so the trash truck could take him away.” Which is the nurse’s best reply?
a. “Let’s see if we can figure out why he hates the new baby.”
b. “That’s a strong statement to come from such a small boy.”
c. “Let’s refer him to counseling to work this hatred out. It’s not a normal response.”
d. “That is a normal response to the birth of a sibling. Let’s look at ways to deal with this.”

 

 

ANS:  D

The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers have their entire schedule and routines disrupted because of the new family member. The nurse should work with parents on ways to involve the toddler in the newborn’s care and to help focus attention on the toddler. The toddler does not hate the infant. This is an expected response to the changes in routines and attention that affect the toddler. The toddler can be provided with a doll to tend to the doll’s needs at the same time the parent is performing similar care for the newborn.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   389

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A toddler’s parent asks the nurse for suggestions on dealing with temper tantrums. Which is the most appropriate recommendation?
a. Punish the child.
b. Leave the child alone until the tantrum is over.
c. Remain close by the child but without eye contact.
d. Explain to child that this is wrong.

 

 

ANS:  C

The parent should be told that the best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common in toddlers as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The parent’s presence is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   389-390

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A parent asks the nurse about negativism in toddlers. Which is the most appropriate recommendation?
a. Punish the child.
b. Provide more attention.
c. Ask child not always to say “no.”
d. Reduce the opportunities for a “no” answer.

 

 

ANS:  D

The nurse should suggest to the parent that questions be phrased with realistic choices rather than yes or no answers. This provides the toddler with a sense of control and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to be asked to not always say “no.”

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   390

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which technique is best for dealing with the negativism of the toddler?
a. Offer the child choices.
b. Remain serious and intent.
c. Provide few or no choices for child.
d. Quietly and calmly ask the child to comply.

 

 

ANS:  A

The child should have few opportunities to respond in a negative manner. Questions and requests should provide choices. This allows the child to be in control and reduces opportunities for negativism. The child will continue trying to assert control. The toddler is too young for verbal explanations. The negativism is the child testing limits. These should be clearly defined by structured choices.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   390

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use “baby talk” since the arrival of their new baby. The nurse should recommend which intervention?
a. Ignore the “baby talk.”
b. Explain to the toddler that “baby talk” is for babies.
c. Tell the toddler frequently, “You are a big kid now.”
d. Encourage the toddler to practice more advanced patterns of speech.

 

 

ANS:  A

The baby talk is a sign of regression in the toddler. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is children’s way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   389-390

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table with the family briefly, and wants snacks “all the time.” Which intervention should the nurse recommend?
a. Give her nutritious snacks.
b. Offer rewards for eating at mealtimes.
c. Avoid snacks so she is hungry at mealtimes.
d. Explain to her in a firm manner what is expected of her.

 

 

ANS:  A

Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated with the slower growth rate. Parents should help the child develop healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should be not be used as positive or negative reinforcement for behavior. The child may develop habits of overeating or eat nonnutritious foods in response.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   390

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is:
a. a sign the child is spoiled.
b. a way to exert unhealthy control.
c. regression, common at this age.
d. ritualism, common at this age.

 

 

ANS:  D

The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. Ritualism is not indicative of a child who has unreasonable expectations, but rather normal development. Toddlers use ritualistic behaviors to maintain necessary structure in their lives. This is not regression, which is a retreat from a present pattern of functioning.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   391

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Developmentally, most children at age 12 months:
a. use a spoon adeptly.
b. relinquish the bottle voluntarily.
c. eat the same food as the rest of the family.
d. reject all solid food in preference to the bottle.

 

 

ANS:  C

By age 12 months, most children are eating the same food that is prepared for the rest of the family. Using a spoon usually is not mastered until age 18 months. The parents should be engaged in weaning a child from a bottle if that is the source of liquid. Toddlers should be encouraged to drink from a cup at the first birthday and be weaned from the bottle totally by 14 months. The child should be weaned from a milk- or formula-based diet to a balanced diet that includes iron-rich sources of food.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   391

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The most effective way to clean a toddler’s teeth is for the:
a. child to brush regularly with a toothpaste of his or her choice.
b. parent to stabilize the chin with one hand and brush with the other.
c. parent to brush the mandibular occlusive surfaces, leaving the rest for the child.
d. parent to brush the front labial surfaces, leaving the rest for the child.

 

 

ANS:  B

For young children, the most effective cleaning of teeth is by the parents. Different positions can be used if the child’s back is to the adult. The adult should use one hand to stabilize the chin and the other to brush the child’s teeth. The child can participate in brushing, but for a thorough cleaning, adult intervention is necessary.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   394

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is an appropriate recommendation for preventing tooth decay in young children?
a. Substitute raisins for candy.
b. Substitute sugarless gum for regular gum.
c. Use honey or molasses instead of refined sugar.
d. When sweets are to be eaten, select a time not during meals.

 

 

ANS:  B

Regular gum has high sugar content. When the child chews gum, the sugar is in prolonged contact with the teeth. Sugarless gum is less cariogenic than regular gum. Raisins, honey, and molasses are highly cariogenic and should be avoided. Sweets should be consumed with meals so that the teeth can be cleaned afterward. This decreases the amount of time that the sugar is in contact with the teeth.

 

PTS:   1                    DIF:    Cognitive Level: Analyze               REF:   395

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is the leading cause of death during the toddler period?
a. Injuries
b. Infectious diseases
c. Congenital disorders
d. Childhood diseases

 

 

ANS:  A

Injuries are the single most common cause of death in children ages 1 through 4 years. This represents the highest rate of death from injuries of any childhood age group except adolescence. Infectious diseases and childhood diseases are less common causes of deaths in this age group. Congenital disorders are the second leading cause of death in this age group.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   396

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. Kimberly’s parents have been using a rearward-facing, convertible car seat since she was born. Most car seats can be safely switched to the forward-facing position when the child reaches which age?
a. 1
b. 2
c. 3
d. 4

 

 

ANS:  B

It is now recommended that all infants and toddlers ride in rear-facing car safety seats until they reach the age of 2 years or height recommended by the car seat manufacturer. Children 2 years old and older who have outgrown the rear-facing height or weight limit for their car safety seat should use a forward-facing car safety seat with a harness up to the maximum height or weight recommended by the manufacturer. One year is too young to switch to a forward-facing position.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   396 | 398

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. The nurse recommends to parents that peanuts are not a good snack food for toddlers. The nurse’s rationale for this action is that they:
a. are low in nutritive value.
b. are high in sodium.
c. cannot be entirely digested.
d. can be easily aspirated.

 

 

ANS:  D

Foreign-body aspiration is common during the second year of life. Although they chew well, this age child may have difficulty with large pieces of food, such as meat and whole hot dogs, and with hard foods, such as nuts or dried beans. Peanuts have many beneficial nutrients, but should be avoided because of the risk of aspiration in this age group. The sodium level may be a concern, but the risk of aspiration is more important. Many foods pass through the gastrointestinal tract incompletely undigested. This is not necessarily detrimental to the child.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   391

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. The parent of a 16-month-old toddler asks, “What is the best way to keep our son from getting into our medicines at home?” The nurse’s best advice is:
a. “All medicines should be locked securely away.”
b. “The medicines should be placed in high cabinets.”
c. “The child just needs to be taught not to touch medicines.”
d. “Medicines should not be kept in the homes of small children.”

 

 

ANS:  A

The major reason for poisoning in the home is improper storage. Toddlers can climb, unlatch cabinets, and obtain access to high-security places. For medications, only a locked cabinet is safe. Toddlers can climb by using furniture. High places are not a deterrent to an exploring toddler. Toddlers are not able to generalize as dangerous all the different forms of medications that may be available in the home. It is not feasible to not keep medicines in the homes of small children. Many parents require medications for chronic illnesses. Parents must be taught safe storage for their home and when they visit other homes.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   402

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. The most fatal type of burn in the toddler age group is:
a. flame burn from playing with matches.
b. scald burn from high-temperature tap water.
c. hot object burn from cigarettes or irons.
d. electric burn from electric outlets.

 

 

ANS:  A

Flame burns from matches and lighters represent one of the most fatal types of burns in the toddler age group. High-temperature tap water, hot objects, and electrical outlets are all significant causes of burn injury. The child should be protected from these causes by reducing the temperature on the hot water in the home, keeping objects such as cigarettes and irons away from children, and placing protective guards over electric outlets when not in use.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   401

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. Which play item should the nurse bring from the playroom to a hospitalized toddler in isolation?
a. Small plastic Lego
b. Set of large plastic building blocks
c. Brightly colored balloon
d. Coloring book and crayons

 

 

ANS:  B

Play objects for toddlers must still be chosen with an awareness of danger from small parts. Large, sturdy toys without sharp edges or removable parts are safest. Large plastic blocks are appropriate for a toddler in isolation. Small plastic toys such as Lego can cause choking or can be aspirated. Balloons can cause significant harm if swallowed or aspirated. Coloring book and crayons would be too advanced for a toddler.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   403

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. A nurse places some x-ray contrast the toddler is to drink in a small cup instead of a large cup. Which concept of a toddler’s preoperational thinking is the nurse using?
a. Inability to conserve
b. Magical thinking
c. Centration
d. Irreversibility

 

 

ANS:  A

The nurse is using the toddler’s inability to conserve. This is when the toddler is unable to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass. Instead, toddlers judge what they see by the immediate perceptual clues given to them. A small glass means less amount of contrast. Magical thinking is believing that thoughts are all-powerful and can cause events. Centration is focusing on one aspect rather than considering all possible alternatives. Irreversibility is the inability to undo or reverse the actions initiated, such as being unable to stop doing an action when told.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   382

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents need further teaching about the use of car safety seats if they make which statement?
a. “Even if our toddler helps buckle the straps, we will double-check the fastenings.”
b. “We won’t start the car until everyone is properly restrained.”
c. “We won’t need to use the car seat on short trips to the store.”
d. “We will anchor the car seat to the car’s anchoring system.”

 

 

ANS:  C

Parents need to be taught to always use the restraint even for short trips. Further teaching is needed if they make this statement. Parents have understood the teaching if they encourage the child to help attach buckles, straps, and shields but always double-check fastenings; do not start the car until everyone is properly restrained; and anchor the car safety seat securely to the car’s anchoring system and apply the harness snugly to the child.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   400

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which are characteristic of physical development of a 30-month-old child? (Select all that apply.)
a. Birth weight has doubled.
b. Primary dentition is complete.
c. Sphincter control is achieved.
d. Anterior fontanel is open.
e. Length from birth is doubled.
f. Left or right handedness is established.

 

 

ANS:  B, C

Usually by age 30 months, the primary dentition of 20 teeth is completed, and the child has sphincter control in preparation for bowel and bladder control. Birth weight doubles at approximately ages 5 to 6 months. The anterior fontanel closes at age 12 to 18 months. Birth length is doubled around age 4. Left or right handedness is not established until about age 5.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   387

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which should the nurse teach to parents of toddlers about accidental poison prevention? (Select all that apply.)
a. Keep toxic substances in the garage.
b. Discard empty poison containers.
c. Know the number of the nearest poison control center.
d. Remove colorful labels from containers of toxic substances.
e. Caution child against eating nonedible items, such as plants.

 

 

ANS:  B, C, E

To prevent accidental poisoning, parents should be taught to promptly discard empty poison containers, know the number of the nearest poison control center and to caution the child against eating nonedible items, such as plants. Parents should place all potentially toxic agents, including cosmetics, personal care items, cleaning products, pesticides, and medications in a locked cabinet, not in the garage. Parents should be taught to never remove labels from containers of toxic substances.

 

PTS:   1                    DIF:    Cognitive Level: Apply                  REF:   397

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which gross motor milestones should the nurse assess in an 18-month-old child? (Select all that apply.)
a. Jumps in place with both feet
b. Takes a few steps on tiptoe
c. Throws ball overhand without falling
d. Pulls and pushes toys
e. Stands on one foot momentarily

 

 

ANS:  A, C, D

An 18-month-old child can jump in place with both feet, throw a ball overhand without falling, and pull and push toys. Taking a few steps on tiptoe and standing on one foot momentarily is not acquired until 30 months of age.

 

PTS:   1                    DIF:    Cognitive Level: Understand          REF:   386

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

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