Maternity and Pediatrics
What does the nurse explain that a ventricular septal defect will allow?
Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
R: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
Withholding a dose if the apical heart rate is less than 100 beats/min
R: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.
What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants?
a. Using ear plugs during takeoff.
b. Omitting the meal just before takeoff.
c. Letting the infant nurse during descent.
d. Applying ear drops before takeoff.
Answer: c. Letting the infant nurse during descent.
Rationale: Encouraging an infant to swallow reduces the pressure in the ears during descent.
21. The nurse warns that exposure to HIV and hepatitis B is a major risk for persons who use:
A. Alcohol.
B. Opiates.
C. Cocaine.
D. Marijuana.
ANS: B
The use of opiates coupled with sharing needles put the user at risk for HIV and hepatitis B.
26. The school nurse cautions a group of parents about the prevalence of children who get high by inhaling hydrocarbons and fluorocarbons that are included in which product(s)? Select all that apply.
A. Glue
B. Chlorine
C. Cleaning fluid
D. Copy machine toner
E. Aerosol sprays
ANS: A, C, E
Although there are many products that could be inhaled, the most frequently used products are glue, cleaning fluid, aerosol sprays, Freon, shoe polish, and gasoline products.
Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
A loud, harsh murmur with a systolic thrill
R: A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.
A child develops carditis from rheumatic fever. Which areas of the heart are affected by carditis?
Heart muscle and the mitral valve
R: The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved.
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).
Answer: B, D, E
Rationale: Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.
22. The nurse recognizes the child of an alcoholic who tries to do everything perfectly has assumed the role of the:
A. Perfect child.
B. Super coper.
C. Flight.
D. Helper.
ANS: B
Of the four roles for the child of the alcoholic the super coper is one who tries to do everything perfectly and feels overly responsible. The perfect child is the child who tries to earn love by never causing any trouble.
27. The nurse takes into consideration in planning the care of an adolescent with anorexia nervosa that what characteristic(s) cause this disorder? Select all that apply.
A. Discomfort relative to emerging sexuality
B. Fear of intimacy
C. Pervasive low self-esteem
D. Egocentricity
E. Inability to meet developmental needs
ANS: A, B, C, D, E
All options listed are considered to be a cause of anorexia nervosa.
What finding would the nurse expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta?
Blood pressure lower in the legs than in the arms
R: 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 to the coarctation.
Which comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?
He tires out during feedings
R: Fatigue during feeding or activity is common to most infants with congenital cardiac problems.
What will the nurse include then documenting a grand mal seizure? (Select all that apply.)
a. Presence of incontinence.
b. Current dose of antispasmodic medication.
c. Activity level prior to and following seizure.
d. Level of consciousness following seizure.
e. length of seizure
Answer: A, C, D, E
Rationale: Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.
23. The nurse working with children from dysfunctional families must be prepared to address what associated problem(s)? Select all that apply.
A. Lack of trust
B. Acting out
C. Exaggerated self-confidence
D. Blaming others for problems
E. Depression
ANS: A, B, E
Children from dysfunctional families exhibit lack of trust, act out, and show signs of depression.
The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? On what understanding does the nurse base a response?
Clubbing occurs as a result of chronic hypoxia
R: Clubbing of the fingers develops in response to chronic hypoxia.
A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurses best response?
Squatting increases the return of venous blood back to the heart
R: The squatting position allows the child to breathe more easily because systemic venous return is increased.
The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How does Kawasaki disease affect my childs heart and blood vessels? On what understanding is the nurses response based?
Inflammation weakens blood vessels, leading to aneurysm
R: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.)
a. Encourage books with large type.
b. Words in books should be closely spaced.
c. Provide adequate lighting without glare.
d. Be sure desks and chairs are adequate height.
e. Instruct child to squint when reading
Answer: A, C, D
Rationale: 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.
24. The nurse counsels parents that the early school years create nervous tension in the child manifested by which 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 or thumb sucking that appear suddenly with no previous history are a clue to increased nervous tension in the young school-age child. Masturbation and food fads are normal behavioral phenomena is the early school-age child.
An 8-year-old near-drowning victim is rushed 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
Answer: B, C, D, E
Rationale: Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up.
An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). What does the nurse understand regarding why dyspnea occurs?
Blood is circulated through the lungs again, causing pulmonary circulatory congestion
R: When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.
The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest
R: In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.
The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow Coma Scale. What score will the nurse give if the child is babbling?
a. 1
b. 2
c. 3
d. 4
Answer: d. 4
Rationale: If babbling, the 10-month-old infant receives a score of 4 for responses.
25. The nurse states that the members 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 of the child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team.
The sign that suggests possible damage to the cortex of the brain is ____________ posturing.
Answer: decorticate
Rationale: Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet. This posture suggests injury to the brain cortex.