NCLEX OB Peds 2 of 3 - 947 Terms

10/6/21, 4:32 PM bstrandable NCLEX OB/Peds 2 of 3 Flashcards | Quizlet
bstrandable NCLEX OB/Peds 2 of 3

Terms in this set (947)
walks alone 15 M
builds 2 blocker tower 15 M
throws objects 15 M
grasps spoon 15 M
names commonplace objects 15 M
anterior fontanelle usually 18 M

closed
walks backward 18 M
climbs stairs 18 M
scribbles 18 M
builds 3 block tower 18 M
oral vocab 10 words 18 M
thumb sucking 18 M

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early efforts at jumping 24 M
builds 5 to 6 block tower 24 M
300 word vocab 24 M
obeys easy commands 24 M
walks on tiptoe 30 M
builds 7 to 8 block tower 30 M
stands on one foot 30 M
has sphincter control for toilet 30 M

training
what stage are toddlers in autonomy versus shame and doubt

according to Erikson
state first and last name 30M
In Abruptio Placenta, the Separates, prematurely

placenta _______________ from the
uterine wall ____________.
Abruptio Placenta usually Multi, 35 (HTN, trauma, cocaine)

occurs in (prima/multi) gravida
over the age of ____________.

How is the bleeding of pain and less voluminous in abruptio

Abruptio Placenta different
from that in placenta previa?
If you are the nurse starting the 18 (in preparation to give blood if necessary)
IV on the client with Abruptia
Placenta, what guage needle
should you use?
How often should you measure Q5-15 minutes for bleeding and maternal VS,
the vital signs, vaginal continuous fetal monitoring, deliver at earliest sign
bleeding, fetal heart rate of fetal distress
during Abruptio Placenta>?
How is an infant delivered Usually C-section

when Abruptio Placenta is
present?
Is there a higher or lower Highter

incidence of fetal death with
Abruptio Placenta compared
to Placenta Previa?
In what trimester does Third

Abruptio Placenta most
commonly occur?
At what age are accidental 2 years old

poisonings most common?
If a child swallows a potentially call medical help

poisonous substance, what
should be done first?
When taking a child to the ER the suspected poison

after accidental poisoning has
occurred what must
accompany the child to the
ER?
An elderly client is a (high/low) high - due to poor eyesight, high

risk for accidental poisoning?
What about a school age
child?
What types of chemicals cause Lye, caustic cleaners

burns to oral mucosa when
ingested?
Children at highest risk for drugs, insecticides

seizure activity after ingestion
are those who have swallowed
_____________ and ______________.
Can impaired skin integrity Yes, when lye or caustic agents have been ingested
ever be an appropriate nursing
diagnosis when poisoning has
occurred?
What is the causative organism P. acnes (propionibacterium acnes)

of acne?
What structures are involved in The sebaceous glands

acne vulgaris?
Name 3 drugs given for acne? Vitamin A, Antibiotics, Retinoids

Dietary indiscretions and NO

uncleanliness are causes of
acne?
What are the 3 causative Heredity, Bacterial, Hormonal

factors in acne vulgaris?
What is the most common Accutane

retinoid given to people with
acne?
Accutane is an analog of which Vitamin A

vitamin?
What is the most common side birth defects

effect of accutane and
Tetracycline?
What is the antibiotic most Tetracycline

commonly given to clients with
acne?
How long will it take for the 4 to 6 weeks

person to see results when
acne is being treated?
Does stress make acne worse? yes
How often should the client twice a day

with acne wash his face each
day?

What instructions do you give Take it on an empty stomach and avoid the sunlight
to a client taking tetracycline? (photosensitivity)
What are comedones? Blackheads and white heads
What virus causes AIDS? HIV - Human immunodeficiency virus
The AIDS virus invades helper T-lymphocytes (or CD4 cells)

____________.
AIDS is trasmissible through blood, sexual contact, breast feeding, across

what four routs? placenta in utero
HIV is present in all body Yes, but not transmitted by all, only blood, semen
fluids? and breast milk
Homosexual/bisexual men, IV drug users,

Name the 5 risk groups for
hemophiliacs, heterosexual partners of infected
AIDS
people, newborn children of infected women
What is the first test for HIV ELISA

antibodies?
What test confirms the ELISA? Western Blot
Which test is the best indicator CD4 count

of the progress of HIV
disease?
A CD4 count of under __________ 500

is associated with the onset of
AIDS-related symptoms.

A CD4 count of under _______ is 200

associated with the onset of
opportunistic infections.
Give 6 symptoms of HIV Anorexia, fatigue, weakness, night sweats, fever,

disease. diarrhea
Which 2 classes of drugs are NRTI's (nucleoside reverse transcriptease inhibitors)

given in combination for HIV and PI's (protease inhibitors)
sero-positivity?
an antiviral drug used against HIV (is incorporated

into the DNA of the virus and stops the building
NRTI (nucleoside reverse
process; results in incomplete DNA that cannot
transcriptease inhibitors)
create a new virus; often used in combination with
other drugs)
most potent of antiviral meds, inhibit cell protein

synthesis that interferes with viral replication, does
PI's (Protease inhibitors) not cure but slows progression of AIDS and
prolongs life, used prophylactically, used in AIDS to
decrease viral load and opportunistic infections
What do NRTI's and PI's do? They prevent viral replication
What does the physician hope A delayed onset of AIDS for as long as possible
to achieve with NRTI's and PI's (usually can delay onset for 10-15 years)
for HIV?
What is the most common AZT (zidovudine)

NRTI used?

What is the most challenging The number of pills that must be taken in 24 hours
aspect of combination of drug can be overwhelming. The frequency also makes it
therapy for HIV disease? hard to remember-an alarm wristwatch is used.
Clients with AIDS (gain/lose) lose

weight?
The typical pneumonia of AIDS Pneumocystic carinii

is caused by ___________ ____________.
What type of oral/esophageal Candida

infections do AIDS patients
get?
What is the #1 cancer that AIDS Kaposi's sarcoma

patients get?
Kaposi's sarcoma is a cancer of skin

the ___________.
T/F: AIDS patients get True

lymphomas?
What lab findings are present Decreased RBC's, WBC's and platelets
in AIDS?
If the AIDS patient has protective (reverse) isolation

leukopenia they will be on
_____________ ________________.
Define Leukopenia decrease in wbc, indicated viral infection

Without leukopenia the AIDS Standard precautions or blood and body fluid
patient will be on ____________ precautions
precautions.
When the AIDS patient has a bleeding precautions; No IM's, no rectal

low platelet count, what is temperatures, other bleeding precautions
indicated?
Does AIDS require a single Yes - if WBC counts are low

room?
When do you need a gown If you are going to get contaminated with
with AIDS? secretions
When do you need a mask with Not usually unless they have an infection caused by
AIDS? an airborne bug
When do you need goggles Suctioning, central line start, arterial procedures
with AIDS?
If an AIDS patient's blood 1:10 solution of bleach and water

contaminates a counter top,
with what di you clean?
Are all articles used by AIDS no - only those contaminated with secretions
patients double-bagged?
Can AIDS patients leave the Yes, unless WBC's are very low
floor?
Is dietary protein limited in Not usually, however if there is severe azotemia

AGN? then it may be restricted

nitrogenous wastes in the blood (increased

Define azotemia?
creatinine, BUN)
What is the best indicator of The serum creatinine

renal function?
Yes, the vast majority of all clients recover

Do people recover from AGN?
completely from it
By having all sore throats cultured for strep and

How can AGN be prevented?
treating any strep infections
What is the most important Bedrest - they can walk if hematuria, edema and
intervention in treating AGN? hypertension are gone.
What is the most common Moderate sodium restriction. Fluid restriction is #2 if

dietary restriction for AGN? edema is severe.
What are the urinaysis findings 2 to 3 weeks after initial infection

on AGN?
How do you assess fluid Daily weight

excess in the child with AGN?
What organism causes acute Group A beta hemolytic strep

glomerular nephritis?
It becomes clogged with antigen-antibody

What happens to the kidney in
complexes which then cause inflammation and loss
AGN?
of function.
How often are vital sign Q4 hours with blood pressure

measurements taken
bstrandable NCLEXin AGN?
OB/Peds 2 of 3
Will the client have hypo or Hypertension, because of fluid retention

hyper tension with AGN? Why?
What are the first signs of Puffiness of face, dark urine

AGN?
What are the three adult stages early adulthood, middle adulthood and later
of development called adulthood
What is the age range for early 19 to 35 years of age

adulthood?
What is the age range for 35 to 64 years of age

middle adulthood?
What is the age range for late 64 years of age to death

adulthood?
What is the developmental task Intimacy vs. Isolation

for early adulthood?
What is the developmental task Generativity vs. stagnation.

for middle adulthood?
Erikson's stage in which individuals form deeply

Intimacy vs. Isolation
personal relationships, marry, begin families
Erikson's stage of social development in which

middle-aged people begin to devote themselves
Generativity vs. Stagnation
more to fulfilling one's potential and doing public
service

What is the developmental task Ego Integrity vs. Despair

for later adulthood?
(Erikson) People in late adulthood either achieve a

sense of integrity of the self by accepting the lives
Ego Integrity vs. Despair
they have lived or yield to despair that their lives
cannot be relived
"Time is too short to start despair

another life, though I wish I
could," is an example of
___________.
"If I had to do it over again, I'd Ego Integrity

life my life just about the same,"
is an example of ____ ____________
What does AKA mean? Above the knee amputation
What does BKA mean? Below the knee amputation
If the patient had an AKA they prone (to prevent flexion contracture
should lie ____________ several
times per day.
The #1 contracture problem in flexion, hip

AKA is ____________ of the
_____________
What will prevent hip flexion Lying prone several times a day
contracture after AKA?

What is the #1 contracture Flexion of the knee

problem after BKA?
How do you prevent flexion Remide the patient to straighten their knee
contracture of the knee after constantly while standing
BKA?
To prevent post-op swelling, elevated

the stump should be __________.
How long should the stump be 12-24 hours

elevated to prevent post op
swelling?
How often should a stump be daily

washed?
When a stump is wrapped, the distally (far from the center), proximally (neareast to
bandage should be tightest the point)
_____________ and loosest
_____________.
If after a right BKA, the client phantom limb sensation (which is normal)
c/o pain in his right tow, he is
experiencing _____________.
When will phantom limb in a few months

sensation subside?
Name ways to toughen a push the stump against the wall, hitting it with a
stump so it will not breakdown pillow
due to the wear of the
prosthetic leg?
An aneurysim is an abnormal widening (it is also weakening)

_______________ of the wall of a(n)
artery.
What artery is widened in a the aorta

thoracic aneurysm?
An aneurysm can result from infection, syphilis

an _____________ and from ____________.
The most common symptom of a pulsating mass above the umbilicus

abdominal aneurysm is:
Which aneurysm is most likely the abdominal is most often "silent"

to have no symptoms?
Which vital signs are most The pulse and blood pressure
important to measure in clients
with aneurysm?
An aneurysm will most affect the pulse (many times the aneurysm will rupture and
which of the following, the much blood will be lost before the blood pressure
blood pressure or the pusle? starts to change.
What activity order is the client Bedrest. do not get these people up
with an aneurysm supposed to
have?
If the client with aneurysm is no, bedrest until the client is stable!
physically unstable, should you
encourage turning, coughing
and deep breathing?
What class of drugs is the Antihypertensives

client with an aneurysm most
likely to be on?
What is the BIG danger with Rupture, leads to shock and death
aneurysms of any type?
If an aneurysm is ruptured how decreased LOC (restlessness), tachycardia,

would you know it? hypotension - all signs of shock
If an aneurysm ruptures what is Get them to the operating room ASAP

the #1 priority?
Is there anything that can be Yes, if available you can get them into antishock
done for the client with a trousers but not if this causes a delay in getting
ruptured aneurysm before they them to the operating room
get to the operating room?
The post op thoracic aneurysm Chest tube, because the chest was opened
is most likely to have which
type of tube?
The post op abdominal NG tube for decompression of bowel

aneurysm repair client is most
likely to have which type of
tube?
If you care for a client who is check the distal extremity (far from center) for color,
post-op for a repair of a temperature, pain and PULSE, also document
femoral popliteal resection
what assessment must you
make every hour for the first 24
hours?
Decreased blood supply to myocardium, resulting

What causes angina pectoris?
in ischemia and pain
Describe the pain of angina crushing substernal chest pain that may radiate
pectoris
What drug treates angina Nitroglycerine

pectoris?
the pain of the two is similar, the way to tell the

How do you tell if a client has difference is if nitro and rest relieve the pain. For
angina or an MI? angina, nitro and rest relieve the pain, for MI, nitro
and rest do not relieve the pain
How many nitro tabs can you 3

take before you call the
doctor?
How many minutes should 5 minutes - take one nitro tab every 5 minutes 3
lapse between the nitro pills times, if no relief, call MD
you take?
By what route do you take sublingual

nitro?
dilates coronary arteries to increase blood supply

What is the action of nitro?
(O2 supply) and reduces preload.
What are the top 2 side effects headache and hypotension

of nitro?

What precaution must the wear gloves, nurse may get a dose of the med
nurse take when administering
topical nitro paste?
Everyone with angina needs False

bypass surgery? t/f
Anorexics are usually __________ females, 25

under the age of _____.
The diagnosis is made when 15 (weigh < 85% of normal body weight), hospitalize
there is a weight loss of _______% if 30% weight loss
or more of body weight.
A major mental/emotional Altered body image

nursing diagnosis seen in
anorexia nervosa is ___________.
The pulse rate of anorexics is Bradycardic

tachycardic or bradycardic?
List the most common amenorrhea

gynecologic symptom of
anorexia nervosa?
What is found over the body of lanugo

the client with anorexia
nervosa?
What is the top priority in the intake of enough food to keep them alive, have
care of the client with anorexia them gain weight
nervosa?

The best goal to evaluate the an adequate weight gain

progress of the client with
anorexia nervosa?
quick objective way to evaluate the vital functions of

What is the apgar scale?
the newborn
When is apgar scoring at one minute and again at 5 minutes after the birth
performed on infants?
Name the 5 criteria that are Cardiac status, respiratory effort, muscle tone,
recorded on an apgar scale neuromuscular irritability, and color
The total apgar score can 0 to 10

range from
The maximum score and infant 2

can receive on any one of the
criteria is
A 10 on the apgar means the in terrific health

baby is
A 0 on the apgar means the is stillborn

baby
On heart rate or cardiac status, 100

a 2 means that the HR is above
_______ BPM.

On the HR criteria an infant greater, less than

scores a "1" if their HR is _________
than 0 and ____________ 100
Temporary cyanotic condition, usually in newborns

resulting in a bluish color around the lips, hands and
Acrocyanosis
fingernails, feet and toenails. May last for a few
hours and disappear with warming.
Apendicitis is an _________ of the inflammation, obstruction

appendix due to __________.
Apendicitis occurs most in 15 to 35

what age group?
What is the most common Peritonitis

complication of appendicitis?
Peritonitis inflammation of the peritoneum
What is the first sign of right upper quadrant pain

appendicitis?
What follows the RUQ abd N/V

pain of appendicitis?
Where does the pain of RLQ

appendicitis finally end up?
What is the name of the RLQ McBirney's point

abd pain where appendicitis
pain finally localizes?

What is present when rebound Peritoneal inflammation

tenderness is present?
What is the hightes that the 102 F

temp will be in appendicitis?
What blood count is elevated WBC

in appendicitis?
What is the name for an Leukocytosis

elevated WBC?
What is the only treatment surgery - appendectomy

recommended for
appendicitis?
Before the client with pain meds, enemas, laxatives, food! NPO
suspected appendicitis sees
the physician what should be
avoided?
To lessen pain place the client fowlers (a sitting position) (also use post op)
in ___________ position.
Never apply __________ to the area heat (it causes rupture)

of the appendix.
After appendectomy, bowel sounds (peristalsis)

document in the nurses notes
the return of __________

1. The nurse needs to take the blood pressure of a

preschool boy for the first time. Which action would
be best in gaining his cooperation?
A. Taking his blood pressure when a parent is there

to comfort him
Correct Answer: D
B. Telling him that this procedure will help him get
Your Response: well faster.
C. Explaining to him how the blood flows through

the arm and why the blood pressure is important
D. Permitting him to handle equipment and see the

dial move before putting the cuff in place
2. It is time to give 3-year-old David his medication.

Which approach is most likely to receive a positive
response?
A. "It's time for your medication now, David. Would

Correct Answer: A
you like water or apple juice afterward?"
Your Response: B. "Wouldn't you like to take your medicine, David?"
C. "You must take your medicine, David, because

the doctor says it will make you better."
D. "See how nicely John took his medicine? Now

take yours."
3. When should clear liquids be stopped before

scheduled surgery?
Correct Answer: A
A. 2 hours before surgery
Your Response: B. 6 hours before surgery
C. The night before surgery, at 8 PM
D. The night before surgery, at midnight

4. The nurse is doing preoperative teaching with a

child and his parents. The parents say that he is
"dreading the shot" for premedication. The nurse's
response should be based on the knowledge that:
A. Preanesthetic medication can only be given

intramuscularly.
Correct Answer: D
B. In children the intramuscular route is safer than

Your Response:
the intravenous (IV) route.
C. The child will have no memory of the injection

because of amnesia.
D. Preanesthetic medication should be "atraumatic,"

using oral, existing intravenous, or rectal routes.
5. Maria, age 10, requires daily medications for a

chronic illness. Her mother tells the nurse that she is
always nagging her to take her medicine before
school. What is the most appropriate nursing action
to promote Maria's compliance?
A. Establishing a contract with her, including

Correct Answer: A
rewards
Your Response:
B. Suggesting time-outs when she forgets her
medicine
C. Discussing with her mother the damaging effects

of nagging
D. Asking Maria to bring her medicine containers to

each appointment so they can be counted

6. Allison, age 7 years, has a fever associated with a

viral illness. She is being cared for at home. The
nurse should recognize that the principal reason for
Correct Answer: A
treating fever in this child is:
Your Response: A. Relief of discomfort.
B. Reassurance that illness is temporary.
C. Prevention of secondary bacterial infection.
D. Prevention of life-threatening complications.
7. Standard Precautions for infection control

include:
A. Gloves are worn any time a patient is touched.
B. Needles are capped immediately after use and

Correct Answer: C
disposed of in a special container.
Your Response:
C. Gloves are worn to change diapers when there
are loose or explosive stools.
D. Masks are needed only when caring for patients

with airborne infections.
8. The nurse is preparing a plan to teach a mother

how to administer 1½ teaspoons of medicine to her
6-month-old child. The nurse should recommend
using:
Correct Answer: D
A. A household measuring spoon.
Your Response:
B. A regular silverware teaspoon.
C. A paper cup measure in 5-ml increments.
D. A plastic syringe (without needle) calibrated in

milliliters.

9. Several types of long-term central venous access

devices are used. A benefit of using an implanted
port (e.g., Port-a-cath) is that it:
A. Is easy to use for self-administered infusions.
B. Does not need to pierce the skin for access.
Correct Answer: C
C. Does not need to limit regular physical activity,

Your Response:
including swimming.
D. Cannot dislodge from the port, even if child

plays with port site.
10. The nurse observes erythema, pain, and edema

at a child's intravenous (IV) site with streaking along
the vein. What should the nurse do first?
Correct Answer: A
A. Immediately stop the infusion.
Your Response:
B. Check for a good blood return.
C. Ask another nurse to check the IV site.
D. Increase the IV drip for 1 minute and recheck.
11. The best explanation for why pulse oximetry is

used on young children is that it:
Correct Answer: A
A. Is noninvasive.
Your Response: B. Is better than capnography.
C. Is more accurate than arterial blood gases.
D. Provides intermittent measurements of O2.
12. When is bronchial (postural) drainage generally

performed?
Correct Answer: B
A. Immediately before all aerosol therapy
Your Response: B. Before meals and at bedtime
C. Immediately on arising and at bedtime
D. Thirty minutes after meals and at bedtime

13. The nurse is caring for an infant with a

tracheostomy when accidental decannulation
occurs. The nurse is unable to reinsert the tube.
What should be the next action by the nurse?
Correct Answer: D
A. Notifying the surgeon
Your Response:
B. Performing oral intubation
C. Trying to insert a larger-size tube
D. Trying to insert smaller-size tube
14. A neonate had corrective surgery 3 days ago for

esophageal atresia. The nurse notices that after the
child receives his gastrostomy feeding, there is
often a backup of formula feeding into the tube. As
a result, the nurse should:
A. Position the child in a supine position after

Correct Answer: C
feedings.
Your Response:
B. Position the child on his or her left side after
feedings.
C. Leave the gastrostomy tube open and

suspended after feedings.
D. Leave the gastrostomy tube clamped after

feedings.

ANS: C
15. What should the nurse consider when having
The informed consent must consent forms signed for surgery and procedures
include the nature of the on children?
procedure, benefits and risks, a. Only a parent or legal guardian can give consent.
and alternatives to the b. The person giving consent must be at least 18

procedure. In special years old.
circumstances such as c. The risks and benefits of a procedure are part of

emancipated minors, the the consent process.
consent can be given by d. A mental age of 7 years or older is required for a

someone younger than 18 consent to be considered "informed."
years without the parent or
legal guardian. A mental age of
7 years is too young for
consent to be informed.
ANS: B
16 The nurse is planning how to prepare a 4-year-
Illness and hospitalization may old child for some diagnostic procedures.
be viewed as punishment in Guidelines for preparing this preschooler should
preschoolers. Always state include to:
directly that procedures are a. Plan for a short teaching session of about 30
never a form of punishment. minutes.
Teaching sessions for this age b. Tell the child that procedures are never a form of
group should be 10 to 15 punishment.
minutes in length. Demonstrate c. Keep equipment out of the child's view.
the use of equipment and d. Use correct scientific and medical terminology in
allow the child to play with explanations.
miniature or actual equipment.
Explain the procedure in
simple terms and how it affects
the child.

17. Katie, 4 years old, is admitted to outpatient

surgery for removal of a cyst on her foot. Her
ANS: A
mother puts the hospital gown on her, but Katie is
It is appropriate for the child to crying because she wants to leave on her
leave her underpants on. This underpants. The most appropriate nursing action is
allows her some measure of to:
control during the foot surgery. a. Allow her to wear her underpants.
The mother should not be b. Discuss with her mother why this is important to
required to make the child Katie.
more upset. Katie is too young c. Ask her mother to explain to her why she cannot
to understand what hospital wear them.
policy means. d. Explain in a kind, matter-of-fact manner that this is

hospital policy.
ANS: B
18. Using knowledge of child development, the best
Prepare toddlers for approach when preparing a toddler for a procedure
procedures by using play. is to:
Demonstrate on a doll, but a. Avoid asking the child to make choices.
avoid the child's favorite doll b. Demonstrate the procedure on a doll.
because the toddler may think c. Plan for the teaching session to last about 20
the doll is really "feeling" the minutes.
procedure. In preparing a d. Show necessary equipment without allowing

toddler for a procedure, the child to handle it.
child is allowed to participate
in care and help whenever
possible. Teaching sessions for
toddlers should be about 5 to
10 minutes. Use a small replica
of the equipment and allow the
child to handle it.

ANS: A
19. The nurse is preparing a 12-year-old girl for a
The parents' preferences for bone marrow aspiration. She tells the nurse that she
assisting, observing, or waiting wants her mother with her "like before." The most
outside the room should be appropriate nursing action is to:
assessed, as well as the child's a. Grant her request.
preference for parental b. Explain why this is not possible.
presence. The child's choice c. Identify an appropriate substitute for her mother.
should be respected. If the d. Offer to provide support to her during the

mother and child are procedure.
agreeable, the mother is
welcome to stay. An
appropriate substitute for the
mother is necessary only if the
mother does not wish to stay.
Support is offered to the child
regardless of parental
presence.
ANS: C
20. The emergency department nurse is cleaning
The child should be allowed to multiple facial abrasions on 9-year-old Mike. His
express feelings of anger, mother is present. He is crying and screaming
anxiety, fear, frustration, or any loudly. The nurse should:
other emotion. The child needs a. Ask him to be quieter.

to know that it is all right to cry. b. Have his mother tell him to relax.
There is no reason for him to c. Tell him it is okay to cry and scream.
be quieter. He is too upset and d. Suggest that he talk to his mother instead of
needs to be able to express his crying.
feelings.

ANS: C
21. In some genetically susceptible children
Early signs of malignant anesthetic agents can trigger malignant
hyperthermia include hyperthermia. The nurse should be alert in
tachycardia, increasing blood observing that, in addition to an increased
pressure, tachypnea, mottled temperature, an early sign of this disorder is:
skin, and muscle rigidity. Apnea a. Apnea.
is not a sign of malignant b. Bradycardia.
hyperthermia. Tachycardia, not c. Muscle rigidity.
bradycardia, is an early sign of d. Decreased blood pressure.

malignant hyperthermia.
Increased, not decreased,
blood pressure is characteristic
of malignant hyperthermia.
ANS: C
22. The nurse is caring for an unconscious child. Skin
A draw sheet should be used care should include:
to move the child in the bed or a. Avoiding use of pressure reduction on the bed.
onto a gurney to reduce b. Massaging reddened bony prominences to

friction and shearing injuries. prevent deep tissue damage.
Do not drag the child from c. Using draw sheet to move child in bed to reduce
under the arms. Pressure- friction and shearing injuries.
reduction devices should be d. Avoiding rinsing skin after cleansing with mild
used to redistribute weight. antibacterial soap to provide a protective barrier.
Bony prominences should not
be massaged if reddened.
Deep tissue damage can occur.
Pressure-reduction devices
should be used instead. The
skin should be cleansed with
mild nonalkaline soap or soap-
free cleaning agents for
routine bathing.

ANS: D
23. An appropriate intervention to encourage food
Small, frequent meals and and fluid intake in a hospitalized child is to:
nutritious snacks should be a. Force child to eat and drink to combat caloric
provided for the child. Favorite losses.
foods such as peanut butter b. Discourage participation in noneating activities

and jelly sandwiches, fruit until caloric intake is sufficient.
yogurt, cheese, pizza, and c. Administer large quantities of flavored fluids at

macaroni and cheese should frequent intervals and during meals.
be available. Forcing a child to d. Give high-quality foods and snacks whenever

eat only meets with rebellion child expresses hunger.
and reinforces the behavior as
a control mechanism. Large
quantities of fluid may
decrease the child's hunger
and further inhibit food intake.
24. Kimberly, age 3 years, has a fever associated

ANS: A
with a viral illness. Her mother calls the nurse,

Most fevers are of brief
reporting a fever of 102° F even though she had
duration, have limited
acetaminophen 2 hours ago. The nurse's action
consequences, and are viral.
should be based on knowing that:
Little evidence supports the

a. Fevers such as this are common with viral
use of antipyretic drugs to
illnesses.
prevent febrile seizures.

b. Seizures are common in children when
Neither the increase in
antipyretics are ineffective.
temperature nor its response

c. Fever over 102° F indicates greater severity of
to antipyretics indicates the
illness.
severity or etiology of
d. Fever over 102° F indicates a probable bacterial
infection.
infection.

ANS: C
25. Tepid water or sponge baths are indicated for
Environmental measures such hyperthermia in children. The nurse should:
as sponge baths can be used a. Add isopropyl alcohol to the water.
to reduce temperature if b. Direct a fan on the child in the bath.
tolerated by the child and if c. Stop the bath if the child begins to chill.
they do not induce shivering. d. Continue the bath for 5 minutes.

Shivering is the body's way of
maintaining the elevated set
point. Compensatory shivering
increases metabolic
requirements above those
already caused by the fever.
Ice water and isopropyl
alcohol are inappropriate,
potentially dangerous
solutions. Fans should not be
used because of the risk of the
child developing
vasoconstriction, which defeats
the purpose of the cooling
measures. Little blood is
carried to the skin surface, and
the blood remains primarily in
the viscera to become heated.
The child is placed in a tub of
tepid water for 20 to 30
minutes.

ANS: D
26. The nurse approaches a group of school-age
The child must be correctly patients to administer medication to Sam Hart. To
identified before the identify the correct child, the nurse should:
administration of any a. Ask the group, "Who is Sam Hart?"
medication. Children are not b. Call out to the group, "Sam Hart?"
totally reliable in giving correct c. Ask each child, "What's your name?"
names on request; d. Check the patient's identification name band.

identification bracelets should
always be checked. Asking the
group to identify the child,
calling out the child's name,
and asking each child to give
their name are not acceptable
ways to identify a child. Older
children may exchange places,
give an erroneous name, or
choose not to respond to their
name as a form of a joke.
ANS: A
27. The nurse wore gloves during a dressing change.
When gloves are worn, the When the gloves are removed, the nurse should:
hands are washed thoroughly a. Wash hands thoroughly.
after removing the gloves b. Check the gloves for leaks.
because both latex and vinyl c. Rinse gloves in disinfectant solution.
gloves fail to provide complete d. Apply new gloves before touching the next
protection. Gloves should be patient.
disposed of after use and
hands should be thoroughly
washed again before new
gloves are applied.

28. The nurse gives an injection in a patient's room.

ANS: A
What should the nurse do with the needle for
All needles (uncapped and disposal?
unbroken) are disposed of in a a. Dispose of syringe and needle in a rigid,

rigid, puncture-resistant puncture-resistant container in patient's room.
container located near the site b. Dispose of syringe and needle in a rigid,
of use. Consequently these puncture-resistant container in an area outside of
containers should be installed patient's room.
in the patient's room. The c. Cap needle immediately after giving injection and
uncapped needle should not dispose of in proper container.
be transported to an area d. Cap needle, break from syringe, and dispose of

distant from use. in proper container.
ANS: D
29. An 8-month-old infant is restrained to prevent
The nurse should remove the interference with the intravenous infusion. The nurse
restraints whenever possible. should:
When parents and/or staff are a. Remove the restraints once a day to allow
present, the restraints can be movement.
removed, and the intravenous b. Keep the restraints on constantly.

site protected. Restraints must c. Keep the restraints secure so infant remains
be checked and documented supine.
every 1 to 2 hours and should d. Remove restraints whenever possible.

be removed for range of
motion on a periodic basis. The
child should not be securely
restrained in the supine
position because of risks of
aspiration.

ANS: B
30. A venipuncture will be performed on a 7-year-
Both the mother's preference old girl. She wants her mother to hold her during
for assisting, observing, or the procedure. The nurse should recognize that this:
waiting outside the room and a. Is unsafe.
the child's preference for b. May help the child relax.
parental presence should be c. Is against hospital policy.
assessed. The child's choice d. Is unnecessary because of the child's age.

should be respected. This will
most likely help the child
through the procedure. If the
mother and child are
agreeable, the mother is
welcome to stay. Her familiarity
with the procedure should be
assessed, and potential safety
risks identified (mother may sit
in chair). Hospital policies
should be reviewed to ensure
that they incorporate family-
centered care

ANS: C
31. Frequent urine testing for specific gravity and
To obtain small amounts of glucose are required on a 6-month-old infant. The
urine, use a syringe without a most appropriate way to collect small amounts of
needle to aspirate urine urine for these tests is to:
directly from the diaper. If a. Apply a urine-collection bag to perineal area.
diapers with absorbent b. Tape a small medicine cup to the inside of the
material are used, place a small diaper.
gauze dressing or cotton balls c. Aspirate urine from cotton balls inside the diaper
inside the diaper to collect the with a syringe.
urine, and aspirate the urine d. Aspirate urine from a superabsorbent disposable
with a syringe. For frequent diaper with a syringe.
urine sampling, the collection
bag would be too irritating to
the child's skin. Taping a small
medicine cup to the inside of
the diaper is not feasible; the
urine will spill from the cup.
Diapers with superabsorbent
gels absorb the urine, so there
is nothing to aspirate.

ANS: B
32. An important nursing consideration when
The anxiety, fear, and performing a bladder catheterization on a young
discomfort experienced during boy is to:
catheterization can be a. Use clean technique, not Standard Precautions.
significantly decreased by b. Insert 2% lidocaine lubricant into the urethra.
preparing the child and c. Lubricate catheter with water-soluble lubricant

parents, selecting the correct such as K-Y Jelly.
catheter, and using appropriate d. Delay catheterization for 20 minutes while

insertion technique. Generous anesthetic lubricant is absorbed.
lubrication of the urethra
before catheterization and use
of lubricant containing 2%
lidocaine may reduce or
eliminate the burning and
discomfort associated with this
procedure.
Catheterization is a sterile
procedure, and Standard
Precautions for body-
substance protection should
be followed. Water-soluble
lubricants do not provide
appropriate local anesthesia.
Catheterization should be
delayed only 2 to 3 minutes.
This provides sufficient local
anesthesia for the procedure.
33. The Allen test is performed as a precautionary

ANS: C
measure before which procedure?
The Allen test assesses the

a. Heel stick
circulation of the radial, ulnar,

b. Venipuncture
or brachial arteries before

c. Arterial puncture
arterial puncture.
d. Lumbar puncture

ANS: C
34. A nurse must do a venipuncture on a 6-year-old
Restrain the child only as child. An important consideration in providing
needed to perform the atraumatic care is to:
procedure safely; use a. Use an 18-gauge needle if possible.
therapeutic hugging. Use the b. If not successful after four attempts, have another
smallest gauge needle that nurse try.
permits free flow of blood. A c. Restrain the child only as needed to perform
two-try-only policy is venipuncture safely.
desirable, in which two d. Show the child equipment to be used before

operators each have only two procedure.
attempts. If insertion is not
successful after four punctures,
alternative venous access
should be considered. Keep all
equipment out of sight until
used.
ANS: C
35. An appropriate method for administering oral
Mix the drug with a small medications that are bitter to an infant or small child
amount (about 1 teaspoon) of would be to mix them with:
sweet-tasting substance. This a. A bottle of formula or milk.
will make the medication more b. Any food the child is going to eat.
palatable to the child. If the c. A small amount (1 teaspoon) of a sweet-tasting

child does not finish substance such as jam or ice cream.
drinking/eating, it is difficult to d. Large amounts of water to dilute medication

determine how much sufficiently.
medication was consumed.
Medication should not be
mixed with essential foods and
milk. The child may associate
the altered taste with the food
and refuse to eat in future.

ANS: A
36. When liquid medication is given to a crying 10-
Administer the medication with month-old infant, which approach minimizes the
a syringe without needle possibility of aspiration?
placed alongside of the infant's a. Administering the medication with a syringe

tongue. The contents are (without needle) placed along the side of the
administered slowly in small infant's tongue
amounts, allowing the child to b. Administering the medication as rapidly as

swallow between deposits. possible with the infant securely restrained
Medications should be given c. Mixing the medication with the infant's regular
slowly to avoid aspiration. The formula or juice and administer by bottle
medication should be mixed d. Keeping the child upright with the nasal passages
with only a small amount of blocked for a minute after administration
food or liquid. If the child does
not finish drinking/eating, it is
difficult to determine how
much medication was
consumed. Essential foods also
should not be used. Holding
the child's nasal passages
increases the risk of aspiration.
ANS: B
37. Guidelines for intramuscular administration of
The needle should be inserted medication in school-age children include to:
quickly in a dartlike motion at a a. Inject medication as rapidly as possible.
90-degree angle unless b. Insert the needle quickly, using a dartlike motion.
contraindicated. Inject c. Penetrate the skin immediately after cleansing the

medications slowly. Allow skin site, before skin has dried.
preparation to dry completely d. Have the child stand, if possible, and if he or she
before skin is penetrated. Place is cooperative.
the child in a lying or sitting
position.

38. When teaching a mother how to administer eye

drops, where should the nurse tell her to place
ANS: A
them?
The lower lid is pulled down,

a. In the conjunctival sac that is formed when the
forming a small conjunctival
lower lid is pulled down
sac. The solution or ointment is

b. Carefully under the eye lid while it is gently
applied to this area. The
pulled upward
medication should not be

c. On the sclera while the child looks to the side
administered directly on the

d. Anywhere as long as drops contact the eye's
eyeball.
surface
ANS: B
39. A 2-year-old child comes to the emergency
In situations in which rapid department with dehydration and hypovolemic
establishment of systemic shock. What best explains why an intraosseous
access is vital and venous infusion is started?
access is hampered such as a. It is less painful for small children.
peripheral circulatory collapse b. Rapid venous access is not possible.
and hypovolemic shock, c. Antibiotics must be started immediately.
intraosseous infusion provides d. Long-term central venous access is not possible.

a rapid, safe lifesaving
alternative. The procedure is
painful, and local anesthesia
and systemic analgesia are
given. Antibiotics could be
given when vascular access is
obtained. Long-term central
venous access is time
consuming, and intraosseous
infusion is used in an
emergency situation.

ANS: D
40. When caring for a child with an intravenous
The nursing responsibility for infusion, the nurse should:
intravenous therapy is to a. Use a macrodropper to facilitate reaching the

calculate the amount to be prescribed flow rate.
infused in a given length of b. Avoid restraining the child to prevent undue

time, set the infusion rate, and emotional stress.
monitor the apparatus c. Change the insertion site every 24 hours.
frequently, at least every 1 to 2 d. Observe the insertion site frequently for signs of
hours, to make certain that the infiltration.
desired rate is maintained, the
integrity of the system remains
intact, the site remains intact
(free of redness, edema,
infiltration, or irritation), and the
infusion does not stop. A
minidropper (60 drops per
milliliter) is the recommended
intravenous tubing in
pediatrics. The intravenous site
should be protected. This may
require soft restraints on the
child. Insertion sites do not
need to be changed every 24
hours unless a problem is
found with the site. Frequent
change exposes the child to
significant trauma.

ANS: D
41. It is important to make certain that sensory
It is important to make certain connectors and oximeters are compatible since
that sensor connectors and wiring that is incompatible can cause:
oximeters are compatible. a. Hyperthermia.
Wiring that is incompatible can b. Electrocution.
generate considerable heat at c. Pressure necrosis.
the tip of the sensor, causing d. Burns under sensors.

second- and third-degree
burns under the sensor.
Incompatibility would cause a
local irritation or burn. A low
voltage is used, which should
not present risk of
electrocution. Pressure
necrosis can occur from the
sensor being attached too
tightly, but this is not a problem
of incompatibility.
ANS: A
42. The nurse is teaching a mother how to perform
For postural drainage and chest physiotherapy and postural drainage on her
percussion, the child should be 3-year-old child, who has cystic fibrosis. To perform
dressed in a light shirt to percussion the nurse should instruct her to:
protect the skin and placed in a. Cover the skin with a shirt or gown before
the appropriate postural percussing.
drainage positions. The chest b. Strike the chest wall with a flat-hand position.
wall is struck with a cupped- c. Percuss over the entire trunk anteriorly and
hand, not a flat-hand position. posteriorly.
The procedure should be done d. Percuss before positioning for postural drainage.
over the rib cage only.
Positioning precedes the
percussion.

ANS: C
43. The nurse must suction a child with a
Suctioning should require not tracheostomy. Interventions should include:
longer than 5 seconds per a. Encouraging the child to cough to raise the
pass. Otherwise the airway may secretions before suctioning.
be occluded for too long. If b. Selecting a catheter with a diameter three fourths
the child is able to cough up as large as the diameter of the tracheostomy tube.
secretions, suctioning may not c. Ensuring that each pass of the suction catheter
be indicated. The catheter take no longer than 5 seconds.
should have a diameter one- d. Allowing the child to rest after every five times
half the size of the the suction catheter is passed.
tracheostomy tube. If it is too
large, it might block the child's
airway. The child is allowed to
rest for 30 to 60 seconds after
each aspiration to allow
oxygen tension to return to
normal. Then the process is
repeated until the trachea is
clear.
ANS: B
44. A child is receiving total parenteral nutrition
The TPN infusion rate should (TPN; hyperalimentation). At the end of 8 hours the
not be increased or decreased nurse observes the solution and notes that 200 ml/8
without the practitioner being hr is being infused rather than the ordered amount
informed because alterations in of 300 ml/8 hr. The nurse should adjust the rate so
rate can cause hyperglycemia that how much will infuse during the next 8 hours?
or hypoglycemia. Any changes a. 200 ml
from the prescribed flow rate b. 300 ml
may lead to hyperglycemia or c. 350 ml
hypoglycemia. d. 400 ml

ANS: B
45. In preparing to give "enemas until clear" to a
Isotonic solutions should be young child, the nurse should select:
used in children. Saline is the a. Tap water.
solution of choice.
b. Normal saline.
Plain water is not used. This is a c. Oil retention.
hypotonic solution and can d. Fleet solution.

cause rapid fluid shift, resulting
in fluid overload. Oil-retention
enemas will not achieve the
"until clear" result. Fleet
enemas are not advised for
children because of the harsh
action of the ingredients. The
osmotic effects of the Fleet
enema can result in diarrhea,
which can lead to metabolic
acidosis.
ANS: A, B, E
46. The advantages of the ventrogluteal muscle as
Less painful, free of important an injection site in young children include (choose
nerves and vascular structures, all that apply):
and easily identifiable are a. Less painful than vastus lateralis
advantages of the b. Free of important nerves and vascular structures
ventrogluteal muscle. The c. Cannot be used when child reaches a weight of

major disadvantage is lack of 20 pounds
familiarity by health d. Increased subcutaneous fat, which increases drug

professionals and controversy absorption
over whether the site can be e. Easily identified by major landmarks

used before weight bearing.
Cannot be used when a child is
20 pounds or more and
increased subcutaneous fat are
not advantages of the
ventrogluteal muscle as an
bstrandable NCLEX
injection site in young OB/Peds 2 of 3
children.
47. MATCHING
The nurse is preparing to insert a nasogastric tube

into a 4-year-old child for intermittent suctioning
after abdominal surgery. Place in correct sequence
the steps for inserting a nasogastric tube.
a. Lubricate the nasogastric tube with water-soluble

lubricant.
b. Tape the nasogastric tube securely to the child's

face.
c. Check the placement of the tube by aspirating

stomach contents.
d. Place the child in the supine position with head

1. ANS: D
slightly hyperflexed.
2. ANS: F
e. Insert the nasogastric tube through the nares.
3. ANS: A
f. Measure the tube from the tip of the nose to the
4. ANS: E
ear lobe to midpoint between the xiphoid process
5. ANS: C
and the umbilicus.
6. ANS: B
1. Place the child in the supine position with head

slightly hyperflexed.
2. Measure the tube from the tip of the nose to the

ear lobe to midpoint between the xiphoid process
and the umbilicus.
3. Lubricate the nasogastric tube with water-soluble

lubricant.
4. Insert the nasogastric tube through the nares.
5. Check the placement of the tube by aspirating

stomach contents.
6. Tape the nasogastric tube securely to the child's

face.

48. Which behavior would most likely be manifested

in a young child experiencing the protest phase of
separation anxiety?
Correct Answer: B
A. Inactivity
Your Response:
B. Clings to parent
C. Depressed, sad
D. Regression to earlier behavior
49. The most consistent indicator of pain in infants is:
A. Increased respirations.
Correct Answer: D
B. Increased heart rate.

Your Response:
C. Squirming and jerking.
D. Facial expression of discomfort.
50. The psychosexual conflicts of preschool children

make them extremely vulnerable to:
Correct Answer: C
A. Separation anxiety.
Your Response: B. Loss of control.
C. Bodily injury and pain.
D. Loss of identity.
51. The nurse needs to start an intravenous (IV) line

on an 8-year-old child to begin administering
intravenous antibiotics. The child starts to cry and
tells the nurse, "Do it later, O.K.?" The nurse should:
A. Start the IV line because allowing the child to

manipulate the nurse is bad.
Correct Answer: B
B. Start the IV line because unlimited procrastination

Your Response:
results in heightened anxiety.
C. Postpone starting the IV line until the child is

ready so that the child experiences a sense of
control.
D. Postpone starting the IV line until the child is

ready so the child's anxiety is reduced.

52. A 4-year-old child will be having cardiac surgery

next week. The child's parents call the hospital,
asking about how to prepare her for this. The nurse's
reply should be based on knowledge that:
A. Preparation at this age will only increase the

child's stress.
Correct Answer: C
B. Preparation needs to be at least 2 to 3 weeks

Your Response:
before hospitalization.
C. Children who are prepared experience less fear

and stress during hospitalization.
D. Children who are prepared experience

overwhelming fear by the time hospitalization
occurs.
53. A mother tells the nurse that she will visit her 2-
year-old son tomorrow about noon. During the
child's bath, he asks for Mommy. The nurse's best
reply is:
Correct Answer: A
A. "Mommy will be here after lunch."
Your Response: B. "Mommy always comes back to see you."
C. "Your Mommy told me yesterday that she would

be here today about noon."
D. "Mommy had to go home for a while, but she will

be here today."
54. The nurse working in an outpatient surgery

center for children should understand that:
A. Children's anxiety is minimal in such a center.
B. Waiting is not stressful for parents in such a

Correct Answer: D
center.
Your Response:
C. Accurate and complete discharge teaching is the
responsibility of the surgeon.
D. Families need to be prepared for what to expect

after discharge.

ANS: A
55. What represents the major stressor of
The major stress for children hospitalization for children from middle infancy
from infancy through the throughout the preschool years?
preschool years is separation a. Separation anxiety
anxiety, also called anaclitic b. Loss of control
depression. This is a major c. Fear of bodily injury
stressor of hospitalization. Loss d. Fear of pain

of control, fear of bodily injury,
and fear of pain are all
stressors associated with
hospitalization. However,
separation from family is a
primary stressor in this age
group.
PTS: 1 DIF: Cognitive Level:

Comprehension REF: 1221
OBJ: Client Needs: Health

Promotion and Maintenance
TOP: Nursing Process:

Assessment

ANS: A
56. When a preschool child is hospitalized without
If a toddler is not prepared for adequate preparation, the nurse should recognize
hospitalization, a typical that the child may likely see hospitalization as:
preschooler fantasy is to a. Punishment.
attribute the hospitalization to b. Threat to child's self-image.
punishment for real or c. An opportunity for regression.
imagined misdeeds. Threat to d. Loss of companionship with friends.

child's self-image and loss of
companionship with friends are
reactions typical of school-age
children. Regression is a
response characteristic of
toddlers when threatened with
loss of control.
ANS: D
57. Because of their striving for independence and
When a child is hospitalized, productivity, which age group of children is
the altered family role, physical particularly vulnerable to events that may lessen
disability, loss of peer their feeling of control and power?
acceptance, lack of a. Infants
productivity, and inability to b. Toddlers
cope with stress usurps c. Preschoolers
individual power and identity. d. School-age children

This is especially detrimental to
school-age children, who are
striving for independence and
productivity and are now
experiencing events that lessen
their control and power.
Infants, toddlers, and
preschoolers, although
affected by loss of power, are
not as significantly affected as
are school-age children.

ANS: A
58. A 10-year-old girl needs to have another
This school-age child is intravenous (IV) line started. She keeps telling the
attempting to maintain control. nurse, "Wait a minute," and, "I'm not ready." The
The nurse should provide the nurse should recognize that:
girl with structured choices a. This is normal behavior for a school-age child.
about when the IV will be b. This behavior is usually not seen past the
inserted. This can be preschool years.
characteristic behavior when c. The child thinks the nurse is punishing her.
an individual needs to maintain d. The child has successfully manipulated the nurse
some control over a situation. in the past.
The child is trying to have
some control in the hospital
experience.
59. Amy, age 6 years, needs to be hospitalized again

because of a chronic illness. The clinic nurse
ANS: B
overhears her school-age siblings tell her, "We are
Siblings experience loneliness, sick of Mom always sitting with you in the hospital
fear, worry, anger, resentment, and playing with you. It isn't fair that you get
jealousy, and guilt. The siblings everything and we have to stay with the neighbors."
experience stress equal to that The nurse's best assessment of this situation is that:
of the hospitalized child. These a. The siblings are immature and probably spoiled.
are not uncommon responses b. Jealousy and resentment are common reactions
by normal siblings. There is no to the illness or hospitalization of a sibling.
evidence that the family has c. The family has ineffective coping mechanisms to
maladaptive coping. deal with chronic illness.
d. The siblings need to better understand their

sister's illness and needs.

ANS: B
60. An appropriate nursing intervention to minimize
A toddler experiences separation anxiety in a hospitalized toddler is to:
separation anxiety secondary a. Provide for privacy.
to being separated from the b. Encourage parents to room in.
parents. To avoid this, the c. Explain procedures and routines.
parents should be encouraged d. Encourage contact with children the same age.
to room in as much as possible.
Maintaining routines and
ensuring privacy are helpful
interventions, but they would
not substitute for the parents.
Contact with same-aged
children would not substitute
for having the parents present.
ANS: A
61. Four-year-old Brian appears to be upset by
Crying is an appropriate hospitalization. An appropriate intervention is to:
behavior for the upset a. Let him know that it is all right to cry.
preschooler. The nurse b. Give him time to gain control of himself.
provides support through c. Show him how other children are cooperating.
physical presence. Giving the d. Tell him what a big boy he is to be so quiet.
child time to gain control is
appropriate, but the child must
know that crying is acceptable.
The preschooler does not
engage in competitive
behaviors.

ANS: A
62. Natasha, age 8 years, is being admitted to the
School-age children need to hospital from the emergency department with an
have control of their injury from falling off her bicycle. What will help her
environment. The nurse should most in her adjustment to the hospital?
offer explanations or prepare a. Explain hospital schedules such as mealtimes.
the child for experiences that b. Use terms such as "honey" and "dear" to show a
are unavoidable. The nurse caring attitude.
should refer to the child by the c. Explain when parents can visit and why siblings
preferred name. Telling the cannot come to see her.
child about all of the limitations d. Orient her parents, because she is young, to her
of visiting does not help her room and hospital facility.
adjust to the hospital. At the
age of 8 years the child and
parent should be oriented to
the environment.
63. Samantha, age 5 years, tells the nurse that she

ANS: A
"needs a Band-Aid" where she had an injection. The

Children at this age group still
best nursing action is to:
fear that their insides may leak

a. Apply a Band-Aid.
out at the injection site. Provide

b. Ask her why she wants a Band-Aid.
the Band-Aid. No explanation

c. Explain why a Band-Aid is not needed.
should be required.
d. Show her that the bleeding has already stopped.

ANS: C
64. Kimberly, age 3 years, is being admitted for
Parents should bring favorite about 1 week of hospitalization. Her parents tell the
items from home to be with the nurse that they are going to buy her "a lot of new
child. Young children associate toys because she will be in the hospital." The nurse's
inanimate objects with reply should be based on an understanding that:
significant people; they gain a. New toys make hospitalization easier.
comfort and reassurance from b. New toys are usually better than older ones for
these items. New toys will not children of this age.
serve the purpose of familiar c. At this age children often need the comfort and
toys and objects from home. reassurance of familiar toys from home.
The parents may experience d. Buying new toys for a hospitalized child is a
some guilt as a response to the maladaptive way to cope with parental guilt.
hospitalization, but there is no
evidence that it is maladaptive.

ANS: A
65. Matthew, age 18 months, has just been admitted
Guilt is a common response of with croup. His parent is tearful and tells the nurse,
parents when a child is "This is all my fault. I should have taken him to the
hospitalized. They may blame doctor sooner so he wouldn't have to be here."
themselves for the child's What is appropriate in the care plan for this parent
illness or for not recognizing it who is experiencing guilt?
soon enough. The nurse should a. Clarify the misconception about the illness.
clarify the nature of the b. Explain to the parent that the illness is not serious.
problem and reassure parents c. Encourage the parent to maintain a sense of

that the child is being cared control.
for. Croup is a potentially very d. Assess further why the parent has excessive guilt
serious illness. The nurse feelings.
should not minimize the
parents' feelings. Encouraging
the parent to maintain a sense
of control would be difficult for
the parents while their child is
seriously ill. No further
assessment is indicated at this
time—guilt is a common
response for parents.

ANS: D
66. The nurse is doing a prehospitalization
This is a necessary part of orientation for Diana, age 7, who is scheduled for
preoperative preparation that cardiac surgery. As part of the preparation, the
will help reduce the anxiety nurse explains that she will not be able to talk
associated with surgery. If the because of an endotracheal tube but that she will
child wakes and is not be able to talk when it is removed. This explanation
prepared for the inability to is:
speak, she will be even more a. Unnecessary.
anxious. It is a joint b. The surgeon's responsibility.
responsibility of nursing, c. Too stressful for a young child.
medical staff, and child life d. An appropriate part of the child's preparation.
personnel. This is a necessary
component of preparation that
will help reduce the anxiety
associated with surgery.
ANS: C
67. The nurse is caring for an adolescent who had an
Loss of peer-group contact external fixator placed after suffering a fracture of
may pose a severe emotional the wrist during a bicycle accident. Which statement
threat to an adolescent by the adolescent would be expected about
because of loss of group separation anxiety?
status; friends visiting are an a. "I wish my parents could spend the night with me
important aspect of while I am in the hospital."
hospitalization for an b. "I think I would like for my siblings to visit me but
adolescent and would be very not my friends."
reassuring. Adolescents may c. "I hope my friends don't forget about visiting me."
welcome the opportunity to be d. "I will be embarrassed if my friends come to the

away from their parents. The hospital to visit."
separation from siblings may
produce reactions from
difficulty coping to a welcome
relief.

ANS: A, C, E
68. Ryan has just been unexpectedly admitted to
Intensive care units, especially the intensive care unit after abdominal surgery. The
when the family is unprepared nursing staff has completed the admission process,
for the admission, are a strange and Ryan's condition is beginning to stabilize. When
and unfamiliar place. There are speaking with the parents, the nurses should expect
many pieces of unfamiliar which stressors to be evident? Choose all that
equipment, and the sights and apply.
sounds are much different from a. Unfamiliar environment
a general hospital unit. Also, b. Usual day-night routine
with the child's condition being c. Strange smells
more precarious, it may be d. Provision of privacy
difficult to keep the parents e. Inadequate knowledge of condition and routine

updated and knowledgeable
about what is happening.
Lights are usually on around
the clock, seriously disrupting
the diurnal rhythm. There is
usually little privacy available
for families in intensive care
units.
69. The nurse is using the C.R.I.E.S. pain assessment

tool on a preterm infant in the neonatal intensive
care unit. A component of this tool is:
Correct Answer: C
A. Color.
Your Response:
B. Reflex.
C. Oxygen saturation.
D. Posture of arms and legs.

70. A child who is terminally ill with bone cancer is in

severe pain. Nursing interventions should be based
on knowledge that:
A. Children tend to be overmedicated for pain.
Correct Answer: D
B. Giving large doses of opioids causes euthanasia.
Your Response: C. Narcotic addiction is common in terminally ill

children.
D. Large doses of opioids are justified when there

are no other treatment options.
71. The most consistent indicator of pain in infants is:
A. Increased respirations.
Correct Answer: D
B. Increased heart rate.

Your Response:
C. Clenching the teeth and lips.
D. Facial expression of discomfort.
72. The nurse is starting an intravenous (IV) line on a

school-age child with cancer. The child says, "I have
had a million IVs. They hurt." The nurse's response
should be based on the knowledge that:
A. Children tolerate pain better than adults.
Correct Answer: D
B. Children become accustomed to painful

Your Response:
procedures.
C. Children often lie about experiencing pain.
D. Children often demonstrate increased behavioral

signs of discomfort with repeated painful
procedures.

73. An important consideration when using the

FACES Pain Rating Scale with children is:
A. Children color the face with the color they

choose to best describe their pain.
B. The scale can be used with most children as

Correct Answer: B
young as 3 years of age.
Your Response:
C. The scale is not appropriate for use with
adolescents.
D. The scale is useful in pain assessment but is not as

accurate when assessing physiologic responses.
74. Nonpharmacologic strategies for pain

management:
A. May reduce pain perception.
Correct Answer: A
B. Make pharmacologic strategies unnecessary.
Your Response:
C. Usually take too long to implement.
D. Trick children into believing that they do not have

pain.
75. The nurses caring for a child are concerned

about the child's frequent requests for pain
medication. During a team conference a nurse
suggests that they consider administering a placebo
instead of the usual pain medication. This decision
should be based on knowledge that:
Correct Answer: A
A. This practice is unjustified and unethical.
Your Response:
B. This practice is effective in determining whether a
child's pain is real.
C. The absence of a response to a placebo means

the child's pain has an organic basis.
D. A positive response to a placebo will not occur if

the child's pain has an organic basis.

76. A child who has been receiving morphine

intravenously will now start receiving it orally. The
nurse should anticipate that, to achieve
equianalgesia (equal analgesic effect), the oral dose
Correct Answer: B
will be:
Your Response:
A. The same as the intravenous (IV) dose.
B. Greater than the IV dose.
C. One half of the IV dose.
D. One fourth of the IV dose.
77. Transdermal fentanyl (Duragesic) is being used

for an adolescent with cancer who is in hospice
care. The adolescent has been comfortable for
several hours but now complains of severe pain. The
most appropriate nursing action is to:
Correct Answer: B
A. Administer meperidine (Demerol) intramuscularly

Your Response:
(IM).
B. Administer morphine sulfate immediate release

(MSIR) intravenously (IV).
C. Use a nonpharmacologic strategy.
D. Place another fentanyl patch on the adolescent.
78. The nurse is caring postoperatively for an 8-

year-old child with multiple fractures and other
trauma resulting from a motor vehicle injury. The
child is experiencing severe pain. An important
consideration in managing the child's pain is to:
Correct Answer: C
A. Give only an opioid analgesic at this time.
Your Response: B. Increase the dosage of analgesic until the child is

adequately sedated.
C. Plan a preventive schedule of pain medication

around the clock.
D. Give the child a clock and explain when he or she

can have pain medications.

ANS: D
79. Kyle, age 6 months, is brought to the clinic. His
The child is displaying a local parent says, "I think he hurts. He cries and rolls his
sign of pain. Rolling the head head from side to side a lot." This most likely
from side to side and pulling at suggests which feature of pain?
ears indicate pain in the ear. a. Type
The child's behavior indicates b. Severity
the location of the pain. The c. Duration
behavior does not provide d. Location

information about the type,
severity, or duration.
ANS: D
80. Physiologic measurements in children's pain
Physiologic manifestations of assessment are:
pain may vary considerably, not a. The best indicator of pain in children of all ages.
providing a consistent measure b. Essential to determine whether a child is telling

of pain. Heart rate may the truth about pain.
increase or decrease. The same c. Of most value when children also report having
signs that may suggest fear, pain.
anxiety, or anger also indicate d. Of limited value as sole indicator of pain.

pain. In chronic pain the body
adapts, and these signs
decrease or stabilize. These are
of limited value and must be
viewed in the context of a
pain-rating scale, behavioral
assessment, and parental
report. When the child states
that pain exists, it does. That is
the truth.

ANS: A
81. Nonpharmacologic strategies for pain
Nonpharmacologic techniques management:
provide coping strategies that a. May reduce pain perception.
may help reduce pain b. Make pharmacologic strategies unnecessary.
perception, make the pain c. Usually take too long to implement.
more tolerable, decrease d. Trick children into believing they do not have
anxiety, and enhance the pain.
effectiveness of analgesics.
Nonpharmacologic techniques
should be learned before the
pain occurs. With severe pain it
is best to use both
pharmacologic and
nonpharmacologic measures
for pain control. The
nonpharmacologic strategy
should be matched with the
child's pain severity and taught
to the child before the onset of
the painful experience. Some
of the techniques may facilitate
the child's experience with mild
pain, but the child will still
know that discomfort is
present.

ANS: B
82. Which drug is usually the best choice for
The most commonly patient-controlled analgesia (PCA) for a child in the
prescribed medications for immediate postoperative period?
PCA are morphine, a. Codeine
hydromorphone, and fentanyl. b. Morphine
Parenteral use of codeine is c. Methadone
not recommended. Methadone d. Meperidine

is not available in parenteral
form in the United States.
Meperidine is not used for
continuous and extended pain
relief.
ANS: C
83. A lumbar puncture is needed on a school-age
EMLA is an effective analgesic child. The most appropriate action to provide
agent when applied to the skin analgesia during this procedure is to apply:
60 minutes before a a. Tetracaine-adrenaline-cocaine (TAC) 15 minutes

procedure. It eliminates or before procedure.
reduces the pain from most b. Transdermal fentanyl (Duragesic) patch

procedures involving skin immediately before procedure.
puncture. TAC provides skin c. Eutectic mixture of local anesthetics (EMLA) 1

anesthesia about 15 minutes hour before procedure.
after application to nonintact d. EMLA 30 minutes before procedure.

skin. The gel can be placed on
the wound for suturing.
Transdermal fentanyl patches
are useful for continuous pain
control, not rapid pain control.
For maximal effectiveness
EMLA must be applied
approximately 60 minutes in
advance.

ANS: A
84. The nurse is caring for a child receiving
The management of opioid- intravenous (IV) morphine for severe postoperative
induced respiratory depression pain. The nurse observes a slower respiratory rate,
includes lowering the rate of and the child cannot be aroused. The most
infusion and stimulating the appropriate management of this child is for the
child. If the respiratory rate is nurse to:
depressed and the child a. Administer naloxone (Narcan).
cannot be aroused, IV b. Discontinue IV infusion.
naloxone should be c. Discontinue morphine until child is fully awake.
administered. The child will be d. Stimulate child by calling name, shaking gently,
in pain because of the reversal and asking to breathe deeply.
of the morphine. The morphine
should be discontinued, but
naloxone is indicated if the
child is unresponsive.
ANS:
85. Skin-to-skin holding of infants dressed only in
Kangaroo
diapers next to their mother's or father's chest is
Infants who spent 1 to 3 hours commonly known as _________________ care.
in kangaroo care showed
increased frequency in quiet
sleep, longer duration of quiet
sleep and decreased crying in
the neonatal intensive care
unit. Significant differences
were found in pain responses
during heel lancing between
infants who were kangaroo
held and those that were not.

86. Which statement is true concerning the

increased use of telephone triage by nurses?
A. Telephone triage has led to an increase in health

care costs.
B. Emergency department visits are not
Correct Answer: C
recommended by nurses and thus are not a
Your Response: component of telephone triage.
C. Access to high-quality health care services has
increased through telephone triage.
D. Home care is often recommended when it is not

appropriate.
87. The nurse is interviewing the mother of Adam,

age 9 years. As the nurse begins to assess Adam's
school performance, the most appropriate question
to ask is:
Correct Answer: C
A. "Did Adam go to preschool?"
Your Response:
B. "Does Adam have problems at school?"
C. "How is Adam doing in school?"
D. "How well does Adam seem to be doing in

school?"
88. Guidelines for a nurse using an interpreter in

developing a care plan for an 8-year-old admitted
to rule out epilepsy include:
A. Explaining to the interpreter what information is

necessary to obtain from the patient and family.
Correct Answer: A
B. Encouraging the interpreter to ask several
Your Response: questions at a time to make the best use of time.
C. Not giving the interpreter too much information

so the interview evolves.
D. Discouraging the interpreter and client from

discussing topics that are deemed irrelevant to the
original intent of the interview.
89. What assessment tool would help the nurse

assess a family member's satisfaction with the
family's functional state?
Correct Answer: D
A. Genogram
Your Response: B. Sociogram

C. Family ECOMAP
D. Family Apgar
90. Which statement explains why it can be difficult

to assess a child's dietary intake?
A. No systematic assessment tool has been

developed for this purpose.
Correct Answer: D
B. Biochemical analysis for assessing nutrition is
Your Response: expensive.
C. Families usually do not understand much about

nutrition.
D. Recall of children's food consumption is

frequently unreliable.
91. The nurse is ready to begin a physical

examination on an 8-month-old infant. The child is
sitting contentedly on his mother's lap, chewing on
Correct Answer: B
a toy. What should the nurse do first?
Your Response: A. Elicit reflexes
B. Auscultate heart and lungs
C. Examine eyes, ears, and mouth
D. Examine head, systematically moving toward feet

92. The most accurate method of determining the

length of a child less than 12 months of age is:
A. Standing height.
B. Estimation of length to the nearest centimeter or

½ inch.
Correct Answer: D
C. Recumbent length measured in the prone

Your Response:
position.
D. Recumbent length measured in the supine

position.
93. The nurse needs to take the blood pressure of a

small child. Of the cuffs available, one is too large,
and one is too small. The best nursing action is to:
Correct Answer: D
A. Use the small cuff.
Your Response: B. Use the large cuff.
C. Use either cuff, using palpation method.
D. Locate the proper-size cuff before taking the

blood pressure.
94. The nurse is assessing skin turgor in a child. The

nurse grasps the skin on the abdomen between the
thumb and index finger, pulls it taut, and quickly
releases it. The tissue remains suspended, or tented,
for a few seconds, then slowly falls back on the
Correct Answer: D
abdomen. Which evaluation can the nurse correctly

Your Response:
assume?
A. The tissue shows normal elasticity.
B. The child is properly hydrated.
C. The assessment is done incorrectly.
D. The child has poor skin turgor.

95. What explains the importance of detecting

strabismus in young children?
A. Color vision deficit may result.
Correct Answer: B
B. Amblyopia, a type of blindness, may result.
Your Response:
C. Epicanthal folds may develop in affected eye.
D. Ptosis may develop secondarily.
96. During an otoscopic examination on an infant, in

which direction is the pinna pulled?
Correct Answer: A
A. Down and back
Your Response: B. Down and forward
C. Up and forward
D. Up and back
97. Which method should the nurse use to view the

tonsils and oropharynx of a cooperative 6-year-old
child?
A. Ask child to open mouth wide & say "aah"
Correct Answer: A
B. Ask child to open mouth wide and then place the
Your Response: tongue blade in the center back area of the tongue
C. Examine the mouth when the child is crying to

avoid use of tongue blade
D. Pinch nostrils closed until the child opens his or

her mouth and then insert tongue blade
98. When assessing a preschooler's chest, the nurse

would expect:
A. Respiratory movements to be chiefly thoracic.
Correct Answer: D
B. Anteroposterior diameter to be equal to the
Your Response: transverse diameter.
C. Intercostal retractions on respiratory movement.
D. Movement of the chest wall to be symmetric

bilaterally and coordinated with breathing.

99. Superficial palpation of the abdomen is often

perceived by the child as tickling. Which measure by
the nurse is most likely to minimize this sensation
and promote relaxation?
A. Palpating another area simultaneously
Correct Answer: D
B. Asking the child not to laugh or move if it tickles
Your Response:
C. Beginning with deeper palpation and gradually
progressing to superficial palpation
D. Having the child "help" with palpation by placing

his or her hand over the palpating hand
100. The nurse needs to give an injection in the

deltoid to a 4-year-old child. The best approach to
use is to:
A. Smile while giving the injection to help child

relax.
Correct Answer: D
B. Tell the child that you will be so quick that the

Your Response:
injection won't even hurt.
C. Explain that the child will experience "a little stick

in the arm."
D. Explain with concrete terms such as "putting

medicine under the skin."

ANS: A
101. The nurse is seeing an adolescent boy and his
The first thing that nurses must parents in the clinic for the first time. What should
do is to introduce themselves the nurse do first?
to the patient and family. a. Introduce self.
Parents and other adults c. Explain the purpose of the interview.
should be addressed with b. Make the family comfortable.
appropriate titles unless they d. Give an assurance of privacy.

specify a preferred name.
During the initial part of the
interview the nurse should
include general conversation
to help make the family feel at
ease. Next the purpose of the
interview and the nurse's role
should be clarified. The
interview should take place in
an environment as free of
distraction as possible. In
addition, the nurse should
clarify which information will
be shared with other members
of the health care team and
any limits to the confidentiality.

ANS: C
102. What action is most likely to encourage parents
Closed-ended questions to talk about their feelings related to their child's
should be avoided when illness?
attempting to elicit parents' a. Be sympathetic.

feelings. Open-ended b. Use direct questions.
questions require the parent to c. Use open-ended questions.
respond with more than a brief d. Avoid periods of silence.

answer. Sympathy is having
feelings or emotions in
common with another person
rather than understanding
those feelings (empathy).
Sympathy is not therapeutic in
the helping relationship. Direct
questions may obtain limited
information. In addition, the
parent may consider them
threatening. Silence can be an
effective interviewing tool. It
allows sharing of feelings in
which two or more people
absorb the emotion in depth.
Silence permits the interviewee
to sort out thoughts and
feelings and search for
responses to questions.

ANS: C
103. What is the single most important factor to
The nurse must be aware of the consider when communicating with children?
child's developmental stage to a. The child's physical condition
engage in effective b. The presence or absence of the child's parent
communication. The use of c. The child's developmental level
both verbal and nonverbal d. The child's nonverbal behaviors

communication should be
appropriate to the
developmental level. Although
the child's physical condition is
a consideration, developmental
level is much more important.
The parents' presence is
important when
communicating with young
children, but it may be
detrimental when speaking
with adolescents. Nonverbal
behaviors vary in importance
based on the child's
developmental level.

ANS: B
104. What is an important consideration for the
Using a transition object allows nurse who is communicating with a very young
the young child an opportunity child?
to evaluate an unfamiliar a. Speak loudly, clearly, and directly.
person (the nurse). This b. Use transition objects such as a doll.
facilitates communication with c. Disguise own feelings, attitudes, and anxiety.
this age child.

d. Initiate contact with child when parent is not
Speaking loudly, clearly, and present.
directly tends to increase
anxiety in very young children.
The nurse must be honest with
the child. Attempts at
deception lead to a lack of
trust. Whenever possible, the
parent should be present for
interactions with young
children.

ANS: A
105. When introducing hospital equipment to a
Young children attribute human preschooler who seems afraid, the nurse's approach
characteristics to inanimate should be based on which principle?
objects. They often fear that a. The child may think the equipment is alive.
the objects may jump, bite, cut, b. The child is too young to understand what the
or pinch all by themselves equipment does.
without human direction. c. Explaining the equipment will only increase the
Equipment should be kept out child's fear.
of sight until needed. The child d. One brief explanation is enough to reduce the
should be given simple child's fear.
concrete explanations about
what the equipment does and
how it will feel to the child.
Simple, concrete explanations
help alleviate the child's fear.
The preschooler will need
repeated explanations as
reassurance.
ANS: C
106. Which age group is most concerned with body
School-age children have a integrity?
heightened concern about a. Toddler
body integrity. They place b. Preschooler
importance and value on their c. School-age child
bodies and are overly sensitive d. Adolescent

to anything that constitutes a
threat or suggestion of injury.
Body integrity is not as
important a concern to
children in the toddler,
preschooler, and adolescent
age groups.

ANS: C
107. An 8-year-old girl asks the nurse how the blood
School-age children require pressure apparatus works. The most appropriate
explanations and reasons for nursing action is to:
everything. They are interested a. Ask her why she wants to know.
in the functional aspect of all b. Determine why she is so anxious.
procedures, objects, and c. Explain in simple terms how it works.
activities. It is appropriate for d. Tell her she will see how it works as it is used.
the nurse to explain how
equipment works and what will
happen to the child. A nurse
should respond positively for
requests for information about
procedures and health
information. By not responding
the nurse may be limiting
communication with the child.
The child is not exhibiting
anxiety, just requesting
clarification of what will be
occurring. The nurse must
explain how the blood
pressure cuff works so the
child can then observe during
the procedure.

ANS: B
108. When the nurse interviews an adolescent, it is
Adolescents, like all children, especially important to:
need an opportunity to a. Focus the discussion on the peer group.
express their feelings. Often b. Allow an opportunity to express feelings.
they will interject feelings into c. Emphasize that confidentiality will always be
their words. The nurse must be maintained.
alert to the words and feelings d. Use the same type of language as the
expressed. Although the peer adolescent.
group is important to this age
group, the focus of the
interview should be on the
adolescent. The nurse should
clarify which information will
be shared with other members
of the health care team and
any limits to confidentiality. The
nurse should maintain a
professional relationship with
adolescents. To avoid
misinterpretation of words and
phrases that the adolescent
may use, the nurse should
clarify terms frequently.

ANS: D
109. The nurse is having difficulty communicating
Drawing is one of the most with a hospitalized 6-year-old child. What technique
valuable forms of might be most helpful?
communication. Children's a. Suggest that the child keep a diary.
drawings tell a great deal b. Suggest that the parent read fairy tales to the
about them because they are child.
projections of the child's inner c. Ask the parent if the child is always
self. It would be difficult for a uncommunicative.
6-year-old child to keep a d. Ask the child to draw a picture.

diary, since the child is most
likely learning to read. Reading
fairy tales to the child is a
passive activity involving the
parent and child. It would not
facilitate communication with
the nurse. The child is in a
stressful situation and is
probably uncomfortable with
strangers, not necessarily
uncommunicative.

ANS: B
110. The nurse is taking a health history on an
The chief complaint is the adolescent. What best describes how the chief
specific reason for the child's complaint should be determined?
visit to the clinic, office, or a. Ask for detailed listing of symptoms.
hospital. Because the b. Ask adolescent, "Why did you come here today?"
adolescent is the focus of the c. Use what adolescent says to determine, in correct
history, this is an appropriate medical terminology, what the problem is.
way to determine the chief d. Interview parent away from adolescent to

complaint. A listing of determine chief complaint.
symptoms will make it difficult
to determine the chief
complaint. The adolescent
should be prompted to tell
which symptom caused him to
seek help at this time. The chief
complaint is usually written in
the words that the parent or
adolescent uses to describe
the reason for seeking help.
The parent and adolescent
may be interviewed separately,
but the nurse should determine
the reason the adolescent is
seeking attention at this time.

ANS: C
111. Where in the health history should the nurse
The history of the present describe all details related to the chief complaint?
illness is a narrative of the chief a. Past history
complaint from its earliest b. Chief complaint
onset through its progression c. Present illness
to the present. The focus of the d. Review of systems

present illness is on all factors
relevant to the main problem,
even if they have disappeared
or changed during the onset,
interval, and present. Past
history refers to information
that relates to previous aspects
of the child's health, not to the
current problem. The chief
complaint is the specific reason
for the child's visit to the clinic,
office, or hospital. It does not
contain the narrative portion
describing the onset and
progression. The review of
systems is a specific review of
each body system.

ANS: A
112. The nurse is interviewing the mother of an infant.
The birth history refers to She reports, "I had a difficult delivery, and my baby
information that relates to was born prematurely." This information should be
previous aspects of the child's recorded under which heading?
health, not to the current a. Birth history
problem. The mother's difficult b. Present illness
delivery and prematurity are c. Chief complaint
important parts of the past d. Review of systems

history of an infant. The history
of the present illness is a
narrative of the chief complaint
from its earliest onset through
its progression to the present.
Unless chief complaint is
directly related to the
prematurity, this information is
not included in the history of
present illness. The chief
complaint is the specific reason
for the child's visit to the clinic,
office, or hospital. It would not
include the birth information.
The review of systems is a
specific review of each body
system. It does not include the
premature birth. Sequelae such
as pulmonary dysfunction
would be included.

ANS: C
113. When interviewing the mother of a 3-year-old
Information about the child, the nurse asks about developmental
attainment of developmental milestones such as the age of walking without
milestones is important to assistance. This should be considered because
obtain. It provides data about these milestones are:
the child's growth and a. Unnecessary information because the child is age
development that should be 3 years.
included in the history. b. An important part of the family history.
Developmental milestones c. An important part of the child's past growth and

provide important information development.
about the child's physical, d. An important part of the child's review of systems.
social, and neurologic health.
The developmental milestones
are specific to this child. If
pertinent, attainment of
milestones by siblings would
be included in the family
history. The review of systems
does not include the
developmental milestones.

ANS: B
114. The nurse is taking a sexual history on an
Asking the adolescent girl if adolescent girl. The best way to determine whether
she is having sex with anyone is she is sexually active is to:
a direct question that is well a. Ask her, "Are you sexually active?"
understood. The phrase b. Ask her, "Are you having sex with anyone?"
sexually active is broadly c. Ask her, "Are you having sex with a boyfriend?"
defined and may not provide d. Ask both the girl and her parent if she is sexually
specific information to the active.
nurse to provide necessary
care. The word anyone is
preferred to using gender-
specific terms such as
boyfriend or girlfriend.
Because homosexual
experimentation may occur, it
is preferable to use gender-
neutral terms. Questioning
about sexual activity should
occur when the adolescent is
alone.

ANS: C
115. When doing a nutritional assessment on an
The diet that contains Hispanic family, the nurse learns that their diet
vegetable, legumes, and consists mainly of vegetables, legumes, and
starches may provide sufficient starches. The nurse should recognize that this diet:
essential amino acids, even a. Indicates that they live in poverty.
though the actual amount of b. Is lacking in protein.
meat or dairy protein is low. c. May provide sufficient amino acids.
Many cultures use diets that d. Should be enriched with meat and milk.
contain this combination of
foods. It does not indicate
poverty. Combinations of
foods contain the essential
amino acids necessary for
growth. A dietary assessment
should be done, but many
vegetarian diets are sufficient
for growth.
ANS: D
116. Which parameter correlates best with
Upper arm circumference is measurements of the body's total protein stores?
correlated with measurements a. Height
of total muscle mass. Muscle b. Weight
serves as the body's major c. Skin-fold thickness
protein reserve and is d. Upper arm circumference

considered an index of the
body's protein stores. Height is
reflective of past nutritional
status. Weight is indicative of
current nutritional status. Skin-
fold thickness is a
measurement of the body's fat
content.

ANS: C
117. An appropriate approach to performing a
Parents can remove clothing, physical assessment on a toddler is to:
and the child can remain on a. Always proceed in a head-to-toe direction.
the parent's lap. The nurse b. Perform traumatic procedures first.
should use minimal physical c. Use minimal physical contact initially.
contact initially to gain the d. Demonstrate use of equipment.

child's cooperation. The head-
to-toe assessment can be
done in older children but
usually must be adapted in
younger children. Traumatic
procedures should always be
performed last. These will most
likely upset the child and inhibit
cooperation. The nurse should
introduce the equipment
slowly. The child can inspect
the equipment, but
demonstrations are usually too
complex for this age group.
ANS: C
118. With the National Center for Health Statistics
Children who have BMI-for- (NCHS) criteria, which body mass index (BMI)-for-
age greater than or equal to age percentile indicates a risk for being
the 85th percentile and less overweight?
than the 95th percentile are at a. 10th percentile
risk for being overweight. b. 9th percentile
Children in the 9th and 10th c. 85th percentile
percentiles are within normal d. 95th percentile

limits. Children who are greater
than or equal to the 95th
percentile are considered
overweight.

ANS: D
119. The nurse is using the NCHS growth chart for an
The NCHS growth charts can African-American child. The nurse should consider
serve as reference guides for that:
all racial or ethnic groups. U.S. a. This growth chart should not be used.
African American-children b. Growth patterns of African-American children are

were included in the sample the same as for all other ethnic groups.
population. The growth chart c. A correction factor is necessary when the NCHS
can be used with the growth chart is used for non-Caucasian ethnic
perspective that different groups.
groups of children have d. The NCHS charts are accurate for U.S. African-
varying normal distributions on American children.
the growth curves. No
correction factor exists.
ANS: B
120. Which tool measures body fat most accurately?
Calipers are used to measure a. Stadiometer
skin-fold thickness, which is an b. Calipers
indicator of body fat content. c. Cloth tape measure
Stadiometers are used to d. Paper or metal tape measure

measure height. Cloth tape
measures should not be used
because they can stretch.
Paper or metal tape measures
can be used for recumbent
lengths and other body
measurements that must be
made.

ANS: C
121. By what age do the head and chest
Head circumference begins circumferences generally become equal?
larger than chest a. 1 month
circumference. Between ages 1 b. 6 to 9 months
and 2 years, they become c. 1 to 2 years
approximately equal. Head d. 2.5 to 3 years

circumference is larger than
chest circumference at ages 1
month and 6 to 9 months.
Chest circumference is larger
than head circumference at
age 2.5 to 3 years.
ANS: B
122. The earliest age at which a satisfactory radial
Satisfactory radial pulses can pulse can be taken in children is:
be used in children older than a. 1 year
2 years. In infants and young b. 2 years
children the apical pulse is c. 3 years

more reliable. The radial pulse d. 6 years
can be used for assessment at
ages 3 and 6 years.
ANS: C
123. Where is the best place to observe for the
Petechiae, small distinct presence of petechiae in dark-skinned individuals?
pinpoint hemorrhages, are a. Face
difficult to see in dark skin b. Buttocks
unless they are in the mouth or c. Oral mucosa
conjunctiva. d. Palms and soles

ANS: D
124. When palpating the child's cervical lymph
Small nontender nodes are nodes, the nurse notes that they are tender,
normal. Tender, enlarged, and enlarged, and warm. The best explanation for this is:
warm lymph nodes may a. Some form of cancer.
indicate infection or b. Local scalp infection common in children.
inflammation close to their c. Infection or inflammation distal to the site.
location. Tender lymph nodes d. Infection or inflammation close to the site.

do not usually indicate cancer.
A scalp infection usually does
not cause inflamed lymph
nodes. The lymph nodes close
to the site of inflammation or
infection would be inflamed.
125. The nurse has just started assessing a young

child 1who is febrile and appears very ill. There is
ANS: A
hyperextension of the child's head (opisthotonos)

These symptoms indicate
with pain on flexion. The most appropriate action is
meningeal irritation and needs
to:
immediate evaluation.
a. Refer for immediate medical evaluation.
Continuing the assessment is

b. Continue assessment to determine cause of neck
not necessary. No indication of
pain.
injury is present. This is not

c. Ask parent when neck was injured.
descriptive of head lag.

d. Record "head lag" on assessment record and
continue assessment of child.
ANS: D
126. The nurse should expect the anterior fontanel
Ages 2 through 8 months are to close at age:
too early. The expected a. 2 months
closure of the anterior fontanel b. 2 to 4 months
occurs between ages 12 and 18 c. 6 to 8 months
months; if it closes at these d. 12 to 18 months

earlier ages, the child should
be referred for further
bstrandable
evaluation. NCLEX OB/Peds 2 of 3
127. During a funduscopic examination of a school-

age child, the nurse notes a brilliant, uniform red
ANS: A
reflex in both eyes. The nurse should recognize that
A brilliant, uniform red reflex is this is:
an important normal and a. A normal finding.
expected finding. It rules out b. An abnormal finding; child needs referral to

many serious defects of the ophthalmologist.
cornea, aqueous chamber, c. A sign of possible visual defect; child needs vision
lens, and vitreous chamber. screening.
d. A sign of small hemorrhages, which usually

resolve spontaneously.
ANS: B
128. Binocularity, the ability to fixate on one visual
Binocularity is usually achieved field with both eyes simultaneously, is normally
by ages 3 to 4 months. Age 1 present by what age?
month is too young for a. 1 month
binocularity. If binocularity is b. 3 to 4 months
not achieved by 6 months, the c. 6 to 8 months
child must be observed for d. 12 months

strabismus.
ANS: D
129. The most frequently used test for measuring
The Snellen letter chart, which visual acuity is the:
consists of lines of letters of a. Denver Eye Screening test.
decreasing size, is the most b. Allen picture card test.
frequently used test for visual c. Ishihara vision test.
acuity. Single cards (Denver— d. Snellen letter chart.

letter E; Allen—pictures) are
used for children age 2 years
and older who are unable to
use the Snellen letter chart. The
Ishihara vision test is used for
color vision.

ANS: C
130. The nurse is testing an infant's visual acuity. By
Visual fixation and following a what age should the infant be able to fix on and
target should be present by follow a target?
ages 3 to 4 months. Ages 1 to 2 a. 1 month
months are is too young for this b. 1 to 2 months
developmental milestone. If c. 3 to 4 months
the infant is not able to fix and d. 6 months

follow by 6 months of age,
further ophthalmologic
evaluation is needed.
ANS: B
131. The appropriate placement of a tongue blade
The side of the tongue is the for assessment of the mouth and throat is the:
correct position. It avoids the a. Center back area of tongue.
gag reflex yet allows b. Side of the tongue.
visualization. Placement on the c. Against the soft palate.
center back area of the tongue d. On the lower jaw.

elicits the gag reflex. Against
the soft palate and on the
lower jaw are not appropriate
places for the tongue blade.

ANS: A
132. What type of breath sound is normally heard
Vesicular breath sounds are over the entire surface of the lungs except for the
heard over the entire surface upper intrascapular area and the area beneath the
of lungs, with the exception of manubrium?
the upper intrascapular area a. Vesicular
and the area beneath the b. Bronchial
manubrium. Bronchial breath c. Adventitious
sounds are heard only over the d. Bronchovesicular

trachea near the suprasternal
notch. Adventitious breath
sounds are not usually heard
over the chest. These sounds
occur in addition to normal or
abnormal breath sounds.
Bronchovesicular breath
sounds are heard over the
manubrium and in the upper
intrascapular regions where
trachea and bronchi bifurcate.

ANS: C
133. What term is used to describe breath sounds
Wheezes are produced as air that are produced as air passes through narrowed
passes through narrowed passageways?
passageways. The sound is a. Rubs
similar when the narrowing is b. Rattles
caused by exudates, c. Wheezes
inflammation, spasm, or tumor. d. Crackles

Rubs are the sound created by
the friction of one surface
rubbing over another. Pleural
friction rub is caused by
inflammation of the pleural
space. Rattles is the term
formerly used for crackles.
Crackles are the sounds made
when air passes through fluid
or moisture.
ANS: D
134. The nurse must assess a child's capillary filling
Capillary filling time is assessed time. This can be accomplished by:
by pressing lightly on the skin a. Inspecting the chest.
to produce blanching and then b. Auscultating the heart.
noting the amount of time it c. Palpating the apical pulse.
takes for the blanched area to d. Palpating the skin to produce a slight blanching.
refill. Inspecting the chest,
auscultating the heart, and
palpating the apical pulse will
not provide an assessment of
capillary filling time.

ANS: C
135. What heart sound is produced by vibrations
Murmurs are the sounds that within the heart chambers or in the major arteries
are produced in the heart from the back-and-forth flow of blood?
chambers or major arteries a. S1, S2
from the back-and-forth flow b. S3, S4
of blood. S1 is the closure of c. Murmur
the tricuspid and mitral valves, d. Physiologic splitting

and S2 is the closure of the
pulmonic and aortic valves,
and both are considered
normal heart sounds. S3 is a
normal heart sound sometimes
heard in children. S4 is rarely
heard as a normal heart sound.
If heard, medical evaluation is
required. Physiologic splitting
is the distinction of the two
sounds in S2, which widens on
inspiration. It is a significant
normal finding.
ANS: D
136. Examination of the abdomen is performed
The correct order of correctly by the nurse in this order:
abdominal examination is a. Inspection, palpation, and auscultation
inspection, auscultation, and b. Palpation, inspection, and auscultation
palpation. Palpation is always c. Palpation, auscultation, and inspection
performed last because it may d. Inspection, auscultation, and palpation

distort the normal abdominal
sounds.

ANS: A
137. The nurse has a 2-year-old boy sit in "tailor"
The tailor position stretches the position during palpation for the testes. The
muscle responsible for the rationale for this position is that:
cremasteric reflex. This a. It prevents cremasteric reflex.
prevents its contraction, which b. Undescended testes can be palpated.
pulls the testes into the pelvic c. This tests the child for an inguinal hernia.
cavity. Undescended testes d. The child does not yet have a need for privacy.
cannot be predictably
palpated. Inguinal hernias are
not detected by this method.
This position is used for
inhibiting the cremasteric
reflex. Privacy should always
be provided for children.
ANS: D
138. During examination of a toddler's extremities,
Lateral bowing of the tibia the nurse notes that the child is bowlegged. The
(bowlegged) is common in nurse should recognize that this finding is:
toddlers when they begin to a. Abnormal and requires further investigation.
walk, not an abnormal finding. b. Abnormal unless it occurs in conjunction with

It usually persists until all of knock-knee.
their lower back and leg c. Normal if the condition is unilateral or

muscles are well developed. asymmetric.
Further evaluation is needed if d. Normal because the lower back and leg muscles
it persists beyond ages 2 to 3 are not yet well developed.
years, especially in African-
American children.

ANS: B
139. Kimberly is having a checkup before starting
The finger-to-nose-test is an kindergarten. The nurse asks her to do the "finger-
indication of cerebellar to-nose" test. The nurse is testing for:
function. This test checks a. Deep tendon reflexes.
balance and coordination. b. Cerebellar function.
Each deep tendon reflex is c. Sensory discrimination.
tested separately. Each sense is d. Ability to follow directions.

tested separately. Although this
test enables the nurse to
evaluate the child's ability to
follow directions, it is used
primarily for cerebellar
function.
ANS: B, C
140. The nurse must check vital signs on a 2-year-old
Research has demonstrated boy who is brought to the clinic for his 24-month
that cuff selection with a checkup. Which criteria should the nurse use in
bladder width that is 40% of determining the appropriate-size blood pressure
the arm circumference will cuff? Choose all that apply.
usually have a bladder length a. The cuff is labeled "toddler."
that is 80% to 100% of the b. The cuff bladder width is approximately 40% of
upper arm circumference. This the circumference of the upper arm.
size cuff will most accurately c. The cuff bladder length covers 80% to 100% of
reflect measured radial artery the circumference of the upper arm.
pressure. The name of the cuff d. The cuff bladder covers 50% to 66% of the length
is a representative size that of the upper arm.
may not be suitable for any
individual child. Choosing a
cuff by limb circumference
more accurately reflects
arterial pressure than choosing
a cuff by length.

ANS: A, C, E, F
141. Which data would be included in a health
The review of systems, sexual history? Choose all that apply.
history, nutritional assessment, a. Review of systems
and family medical history are b. Physical assessment
part of the health history. c. Sexual history
Physical assessment and d. Growth measurements
growth measurements are e. Nutritional assessment
components of the physical f. Family medical history

examination.
ANS: C
142. Which family theory explains how families react
Family stress theory explains to stressful events and suggests factors that
the reaction of families to promote adaptation to these events?
stressful events. In addition, a. Family systems theory
crisis intervention strategies c. Family stress theory
are used to help family b. Developmental theory
members cope with the d. Family assessment

challenging event. In the family
systems theory, the focus is on
the interaction of family
members within the larger
environment. In the
developmental theory the
nurse provides anticipatory
guidance to help family
members cope with the
challenging event. Family
assessment is not a theory. An
assessment is necessary to
discover the family's dynamics,
strengths and weaknesses.

ANS: A
143. What type of family is one in which all members
A consanguineous family is one are related by blood?
of the most common types and a. Consanguineous
consists of members who have c. Family of origin
a blood relationship. The affinal b. Affinal
family is one made up of d. Household

marital relationships. Although
the parents are married, they
may each bring children from a
previous relationship. The
family of origin is the family unit
that a person is born into.
Considerable controversy has
been generated about the
newer concepts of families (i.e.,
communal, single-parent or
homosexual families). To
accommodate these other
varieties of family styles, the
descriptive term household is
frequently used.
ANS: B
144. Studies about the ordinal position of children
Firstborn children, like only suggest that firstborn children tend to:
children, tend to be more a. Be praised less often.
achievement oriented. Later- b. Be more achievement oriented.
born children are praised less c. Be more popular with the peer group.
often, are more popular with d. Identify with peer group more than parents.
their peer group, and identify
with their peer group more
than with their parents.

ANS: B
145. Birth position of children affects their
Later-born children are personalities. What is considered to be a
obliged to interact with older characteristic of children who are the youngest in
siblings from birth and seem to their family?
be more outgoing and make a. More dependent than firstborn children.
friends more easily than b. More outgoing than firstborn children.
firstborns. Characteristics of c. Identify more with parents than with peers.
firstborn children and only d. Are subject to greater parental expectations.

children include only children
are more dependent than
firstborn children, both types
of children identify more with
their parents than with their
peers, and both types of
children are subject to greater
parental expectations.
ANS: D
146. What applies to the rate of frequency of
Monozygotic twins occur with monozygotic (identical) twins being born?
the same frequency uniformly a. The rate is affected by heredity.
in all populations. The c. It varies among races.
tendency toward monozygotic b. The rate is affected by maternal age.
twins is unaffected by heredity. d. It occurs uniformly in all populations.

Monozygotic twins are not
affected by maternal age, but
higher-order births are. The
frequency is uniform among
races.

ANS: A
147. Nicole and Kelly, age 5 years, are identical
Twins work out a relationship twins. Their parents tell the nurse that the girls
that is reasonably satisfactory always want to be together. The nurse's suggestions
to both. They develop a should be based on knowing that:
remarkable capacity for a. Some twins thrive best when they are constantly
cooperative play and together.
considerable loyalty and b. Individuation cannot occur if twins are together

generosity toward each other. too much.
Parents should foster individual c. Separating twins at an early age helps them
differences and allow the develop mentally.
children to follow their natural d. When twins are constantly together, pathologic
inclinations. Individuation does bonding occurs.
occur. In twinship one member
of the pair is more dominant,
outgoing, and assertive than
the other. Early separation may
produce unnecessary stresses
for the children. There is no
evidence that pathologic
bonding occurs.

ANS: A
148. The nurse is teaching a group of new parents
If parents are supportive of about the experience of role transition. Which
each other, they can serve as statement by a parent indicates a correct
positive influences on understanding of the teaching?
establishing satisfying parental a. "My marital relationship can have a positive or

roles. When marital tensions negative effect on the role transition."
alter caregiving routines and b. "If an infant has special care needs, the parents'
interfere with the enjoyment of sense of confidence in their new role is
the infant, the marital strengthened."
relationship has a negative c. "Young parents can adjust to the new role easier
effect. Infants with special care than older parents."
needs can be a significant d. "A parent's previous experience with children

source of added stress. Older makes the role transition more difficult."
parents are usually more able
to cope with the greater
financial responsibilities,
changes in sleeping habits, and
reduced time for each other
and other children. Parents
who have previous experience
with parenting appear more
relaxed, have less conflict in
disciplinary relationships, and
are more aware of normal
growth and development.

ANS: A
149. When assessing a family, the nurse determines
Permissive parents avoid that the parents exert little or no control over their
imposing their own standards children. This style of parenting is called:
of conduct and allow their a. Permissive.
children to regulate their own c. Democratic.
activity as much as possible. b. Dictatorial.
The parents exert little or no d. Authoritarian.

control over their children's
actions. Dictatorial or
authoritarian parents attempt
to control their children's
behavior and attitudes through
unquestioned mandates. They
establish rules and regulations
or standards of conduct that
they expect to be followed
rigidly and unquestioningly.
Democratic parents combine
permissive and dictatorial
styles. They direct their
children's behavior and
attitudes by emphasizing the
reasons for rules and
negatively reinforcing
deviations. They respect the
child's individual nature.

ANS: D
150. What is most characteristic of the physical
Through the use of physical punishment of children, such as spanking?
punishment, children learn a. Psychologic impact is usually minimal.
what they should not do. When b. Children rarely become accustomed to spanking.
parents are not around, it is c. Children's development of reasoning increases.
more likely that children will d. Misbehavior is likely to occur when parents are
misbehave because they have not present.
not learned to behave well for
their own sake but rather out of
fear of punishment. Spanking
can cause severe physical and
psychologic injury and
interfere with effective parent-
child interaction. Children do
become accustomed to
spanking, requiring more
severe corporal punishment
each time. The use of corporal
punishment may interfere with
the child's development of
moral reasoning.

ANS: A
151. A 3-year-old girl was adopted immediately after
It is important for the parents birth. The parents have just asked the nurse how
not to withhold information they should tell the child that she is adopted. Which
about the adoption from the guideline concerning adoption should the nurse
child. It is an essential use in planning her response?
component of the child's a. Telling the child is an important aspect of their

identity. There is no parental responsibilities.
recommended best time to tell b. The best time to tell the child is between ages 7
children. It is believed that and 10 years.
children should be told young c. It is not necessary to tell the child who was
enough so they do not adopted so young.
remember a time when they d. It is best to wait until the child asks about it.
did not know. It should be
done before the children enter
school to keep third parties
from telling the children before
the parents have had the
opportunity.
ANS: B
152. A parent of a school-age child tells the school
Parental divorce affects nurse that the parent is going through a divorce. The
school-age children in many child has not been doing well in school and
ways. In addition to difficulties sometimes has trouble sleeping. The nurse should
in school, they often have recognize this as:
profound sadness, depression, a. Indicative of maladjustment.
fear, insecurity, frequent crying, b. Common reaction to divorce.
loss of appetite, and sleep c. Suggestive of lack of adequate parenting.
disorders. Uncommon d. Unusual response that indicates need for referral.

responses to parental divorce
include indications of
maladjustment, the suggestion
of lack of adequate parenting,
and the need for referral.

ANS: D
153. A mother brings 6-month-old Eric to the clinic
"Let's talk about the child-care for a well-baby checkup. She comments, "I want to
options that will be best for go back to work, but I don't want Eric to suffer
Eric" is an open-ended because I'll have less time with him." The nurse's
statement that will assist the most appropriate answer is:
mother in exploring her a. "I'm sure he'll be fine if you get a good
concerns about what is best babysitter."
for both her and Eric. "I'm sure b. "You will need to stay home until Eric starts
he'll be fine if you get a good school."
babysitter," "You will need to c. "You should go back to work so Eric will get used
stay home until Eric starts to being with others."
school," and "You should go d. "Let's talk about the child-care options that will be
back to work so Eric will get best for Eric."
used to being with others" are
directive statements and do
not address the effect of her
working on Eric.
ANS: A, D
154. A young couple who has just delivered their
Internal resources include both first child adapts to the stress of new parenthood by
adaptability and integration. using two types of family resources. These include
Adaptation is learning to be (choose all that apply):
patient, becoming better a. Internal resources.
organized and more flexible. b. Adaptation.
Integration refers to the c. Integration.
couples attempt to continue d. Coping strategies.
some activities they engaged e. Community resources.

in before they became parents.
The second resource for
dealing with stress is the use of
coping strategies. These
include the use of social
support systems such as
friends, family and neighbors
and community resources.
155. What is descriptive of the family system theory?
A. Family is viewed as the sum of individual

members.
B. Change in one family member cannot create a

change in other members.
Correct Answer: D
C. Individual family members are readily identified
as the source of a problem.
D. When the family system is disrupted, change can

occur at any point in the system.
156. Studies of families with only one child indicate

that only children:
A. Tend to be selfish.
Correct Answer: B
B. Are similar to firstborn children.
C. Are less stimulated toward achievement.
D. Grow up lonely and dependent on other adults.
157. The parents of a young child ask the nurse for

suggestions on how to discipline. When discussing
the use of "time-outs," the nurse should include:
A. Sending the child to his or her room if the child

has one.
Correct Answer: C B. Trying another approach if child cries, refuses, or

is more disruptive.
C. Selecting an area that is safe and nonstimulating

such as a hallway.
D. Teaching that the general rule for length of time is

1 hour per year of age.

158. What is appropriate advice for parents who are

preparing to tell their children about their decision
to divorce?
A. Avoid crying in front of children.
B. Avoid discussing the reason for the divorce.
Correct Answer: C
C. Give reassurance that the divorce is not the
children's fault.
D. Give reassurance that the divorce will not affect

most aspects of the children's lives.
159. Which term refers to a shared cultural, social,

and linguistic heritage?
A. Beliefs
Correct Answer: C
B. Culture
C. Ethnicity
D. Socialization
160. The most overwhelming adverse influence on

health is:
A. Race.
Correct Answer: C
B. Customs.
C. Socioeconomic status.
D. Genetic constitution.
161. Which statement is true concerning folk

remedies?
A. They may be used to reinforce the treatment

plan.
B. They are incompatible with modern medical

Correct Answer: A
regimens.
C. They are a leading cause of death in some

cultural groups.
D. They are not a part of the culture in large,

developed countries.
162. The nurse is caring for a dying boy whose

religion is Islam (Muslim/Moslem). An important
nursing consideration related to his impending
death and religion is that:
A. There are no special rites.
Correct Answer: B B. There are specific practices to be followed.
C. The family is expected to "wait" away from the

dying person.
D. Baptism should be performed if it has not been

done previously.
163. The nurse is planning care for a patient with an

ethnic background different from that of the nurse.
An appropriate goal is to:
A. Strive to keep ethnic background from

influencing health needs.
Correct Answer:D B. Encourage continuation of ethnic practices in the

hospital setting.
C. Attempt in a nonjudgmental way to change

ethnic beliefs.
D. Adapt as necessary ethnic practices to health

needs.
164. A group of people with shared characteristics

who interact with each other is known as:
A. Culture.
Correct Answer: B
B. Community.
C. Target population.
D. Individual countries and states.

165. The nurse is setting up a community safety

program about car seats. What level of prevention is
this?
Correct Answer: A A. Primary
B. Tertiary
C. Secondary
D. Environmental
ANS: B
166. Which term best describes the identification of
Epidemiology is the science of the distribution and causes of disease, injury, or
population health applied to illness?
the detection of morbidity and a. Nursing process
mortality in a population. It c. Community-based statistics
identifies the distribution and b. Epidemiologic process
causes of diseases across a d. Mortality and morbidity statistics

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.
ANS: C
167. One of the community nurses at the health
Incidence will provide the department is trying to identify how many new
number of cases of a particular cases of acquired immunodeficiency syndrome
disease process. Mortality have occurred in her city this past year. The term
statistics specify the number of that best describes this measurement is:
deaths from a given cause. a. mortality
Morbidity statistics specify the c. incidence
prevalence of specific illnesses b. morbidity
in a population at a particular d. prevalence

time.

ANS: C
168. The nurse is collecting subjective and objective
The nursing process stages are information about the target population to diagnose
similar, whether the client is problems based on community needs. Which step in
one child or a population of the community nursing process is this?
children. The assessment phase a. Planning
of the nursing processes c. Assessment
focuses on collecting b. Diagnosis
subjective and objective data. d. Establishing objectives

Planning is the development of
community-centered goals and
objectives. Diagnosis is the
identification of problems
specific to the community.
ANS: A
169. A number of children in the same neighborhood
An agent is responsible for have developed illness related to an exposure to
causing a disease or infectious lead paint. Which of the three factors that form the
illness. Lead paint is a physical epidemiologic triangle is responsible for this
agent. Host factors are those condition?
specific to an individual or a. Agent
group. These can be either c. Environmental factor
genetic or lifestyle factors. b. Host factor
Environmental factors provide d. Lifestyle factor

a setting for the host and
include climatic conditions
related to home and school. A
lifestyle factor consists of food
selections or exercise patterns.
Lifestyle is a component of the
host factor.

ANS: C
170. Demography is the study of population
Males are at a much greater characteristics. Which demographic characteristic
risk of having hemophilia A and would be associated with an increased risk for
B. Although age is one of the hemophilia?
most important factors, it does a. Age
not increase the risk for this c. Gender
disease. Race has long been b. Race and ethnicity
associated with a number of d. Socioeconomic status

other diseases and disabilities.
Low socioeconomic status
predisposes children to a
variety of health problems.
ANS: F
True or False
This is an example of a 171. A local community has recently experienced

secondary intervention. severe flooding with loss of homes and injuries.
Secondary prevention includes Counseling has been provided to assist families in
tuberculosis and lead coping with the sequelae of this natural disaster. This
screening as well as mental is an example of primary prevention.
health counseling for stressful
events. Primary prevention
focuses on health promotion
and disease prevention (i.e.,
well-baby clinics and
immunizations).
172. What has had the greatest impact on reducing

infant mortality in the United States?
Correct Answer: A
A. Improvements in perinatal care
Your Response:
B. Decreased incidence of congenital abnormalities
C. Better maternal nutrition
D. Improved funding for health care

173. The role of the pediatric nurse is influenced by

trends in health care. The greatest trend in health
care is:
A. Primary focus on treatment of disease or

Points Earned: 0/1
disability.
Correct Answer: D
B. National health care planning on a distributive or
Your Response: episodic basis.
C. Accountability to professional codes and

international standards.
D. Shift of focus to prevention of illness and

maintenance of health.
174. Evidence-based practice, a current health care

trend, is best described as:
A. Gathering evidence of mortality and morbidity in

children.
Points Earned: 0/1
B. Meeting physical and psychosocial needs of the

Correct Answer: D
child and family in all areas of practice.
Your Response:
C. Using a professional code of ethics as a means
for professional self-regulation.
D. Questioning why something is effective and

whether there is a better approach.
175. The etiology component of the nursing

diagnosis describes:
A. Projected changes in an individual's health status,

clinical conditions, or behavior.
B. An individual's response to health pattern deficits

Points Earned: 0/1
in the child, family, or community.
Correct Answer: D
C. A cluster of cues and/or defining characteristics

Your Response:
that are derived from patient assessment and
indicate actual health problems.
D. Physiologic, situational, and maturational factors

that cause the problem or influence its
development.
176. When the nurse uses a standard nursing care

plan as a guide in planning care for a hospitalized
Points Earned: 0/1
child, what should be eliminated?
Correct Answer: C
A. Expected outcome/goal
Your Response: B. Dependent nursing functions
C. Problems not pertinent to the child or family
D. Potential health problems of the child or family
ANS: D
177. Information about morbidity and mortality gives
Analysis of these data provides the nurse data to identify:
the nurse with information a. Lifespan statistics.
about which groups of b. Effectiveness of treatment.
individuals are at risk for which c. Cost-effective treatment for general population.
health problems. Lifespan d. High risk age groups for certain disorders or
statistics are part of the hazards.
mortality data. Treatment
modalities and cost are not
included in these data.
ANS: A
178. From a worldwide perspective, infant mortality
Although the death rate has in the United States:
decreased, the United States
still ranks last among nations a. Is the highest of the other developed nations.
with the lowest infant death b. Lags behind five other developed nations.
rates. The United States has the c. Is the lowest infant death rate of developed
highest infant death rate of nations.
developed nations. d. Lags behind 20 other developed nations.

ANS: A
179. The leading cause of death in infants younger
Congenital anomalies account than 1 year is/are:
for 20.6% of deaths in infants
younger than 1 year. Sudden a. Congenital anomalies.
infant death syndrome b. Sudden infant death syndrome.
accounts for 7.7% of deaths in c. Respiratory distress syndrome.
this age group, while d. Infections specific to the perinatal period.

respiratory distress syndrome
accounts for 3.6% of deaths in
this age group. Infections
specific to the perinatal period
account for 2.9% of deaths in
this age group.
ANS: C
180. The major cause of death for children older
Unintentional injuries than 1 year is:
(accidents) are the leading
cause of death after age 1 year a. Cancer.
through adolescence. Cancer c. Unintentional injuries.

is the leading cause of death in b. Infection.
those younger than 1 year and d. Congenital abnormalities.

is less significant in this age
group. There have been major
declines in deaths attributed
infection and congenital
abnormalities because of
improved therapies.

ANS: B
181. In addition to injuries, the leading causes of
In this age group, homicide death in adolescents ages 15 to 19 years are:
and suicide account for 22.6%
of deaths, suicide and cancer a. Suicide, cancer.
account for 14.4%, homicide c. Homicide, heart disease.
and heart disease account for b. Suicide, homicide.
14.5%, and drowning and d. Drowning, cancer.

cancer account for 2.8%.
ANS: C
182. The leading cause of death from unintentional
Motor vehicle-related fatalities injuries in children is:
is the leading cause of death in
children, as either passengers a. Poisoning.
or pedestrians. Poisoning is the c. Motor vehicle-related fatalities.
ninth leading cause of death. b. Drowning.
Drowning is the second d. Fire- and burn-related fatalities.

leading cause of death. Fire-
and burn-related fatalities are
the third leading cause of
death.
183. Which of the following is descriptive of deaths

ANS: A
caused by unintentional injuries?
Most deaths from unintentional

injuries occur in males. The

a. More deaths occur in males.
pattern of death caused by

b. More deaths occur in females.
unintentional injuries is
c. Pattern of deaths varies widely in Western
consistent in Western societies.
societies.
Causes of unintentional deaths

d. Pattern of deaths does not vary according to age
vary with age and gender.
and sex.

ANS: B
184. The type of injury a child is especially
The child's developmental susceptible to at a specific age is most closely
stage determines the type of related to:
injury that is likely to occur. The
child's physical health may a. Physical health of the child.
facilitate his or her recovery b. Developmental level of the child.
from an injury. Educational c. Educational level of the child.
level is related to d. Number of responsible adults in the home.

developmental level, but it is
not as important as the child's
developmental level in
determining the type of injury.
The number of responsible
adults in the home may affect
the number of unintentional
injuries, but the type of injury
will be related to the child's
developmental stage.
ANS: B
185. Morbidity statistics describe:
The prevalence of a specific a. The number of individuals who have died over a
illness in the population at a specific period.
particular time is the definition b. The prevalence of a specific illness in the

of morbidity statistics. The population at a particular time.
number of individuals who c. Disease occurring in greater than the expected

have died over a specific number of cases in a community.
period refers to mortality d. Disease occurring regularly within a geographic

statistics. Data regarding location.
diseases occurring in greater
than the expected number of
cases in a community and
occurring regularly within a
geographic location may be
extrapolated from analysis of
the morbidity statistics.
ANS: B
186. What is descriptive of morbidity in childhood?
Morbidity is not distributed a. Morbidity does not vary with age.
randomly in children. Increased b. Morbidity is not distributed randomly.
morbidity is associated with c. Little can be done to improve morbidity.
certain groups of children, d. Unintentional injuries do not have an effect on

including children living in morbidity.
poverty and those who were
low birth weight. Morbidity
does vary with age. The types
of illnesses in children are
different for each age group.
Morbidity can be decreased
with interventions focused on
groups with high morbidity and
on decreasing unintentional
injuries, which also affect
morbidity.

ANS: C
187. What is most descriptive of family-centered
The key components of family- care?
centered care are for the nurse a. Reduces effect of cultural diversity on the family
to support, respect, encourage b. Encourages family dependence on health care

and embrace the family's system
strength by developing a c. Recognizes that the family is the constant in a

partnership with the child's child's life
parents. Family-centered care d. Avoids expecting families to be part of the

recognizes the family as the decision-making process
constant in the child's life. The
nurse should support the
cultural diversity of the family,
not reduce its effect. The family
should be enabled and
empowered to work with the
health care system, and to be
part of the decision-making
process.

ANS: B
188. The nurse is preparing staff in-service
Preparing the child for any education about atraumatic care for pediatric
unfamiliar treatments, patients. Which intervention should the nurse
controlling pain, allowing include?
privacy, providing play a. Prepare the child for separation from parents
activities for expression of fear during hospitalization by reviewing a video.
and aggression, providing b. Prepare the child before any unfamiliar treatment
choices, and respecting or procedure by demonstrating on a stuffed animal.
cultural differences are c. Help the child accept the loss of control
components of atraumatic associated with hospitalization.
care. In providing atraumatic d. Help the child accept pain that is connected with
care, the separation of child a treatment or procedure.
from parents during
hospitalization is minimized.
The nurse should promote a
sense of control for the child.
Preventing and minimizing
bodily injury and pain are major
components of atraumatic
care.

ANS: A
189. What most suggests that a nurse has a
Many of the nurse's actions nontherapeutic relationship with a patient and
may serve the needs of the family?
nurse rather than those of the a. The boundaries between staff and patients are
child and the family. It would blurred.
be therapeutic for the patient b. Staff assignments allow the nurse to care for
and family to have the same same patient and family over an extended time.
nurse provide care over an c. Nurse is able to withdraw emotionally when

extended period of time. By emotional overload occurs but still remains
withdrawing somewhat, nurses committed.
can protect themselves while d. Nurse uses teaching skills to instruct patient and
providing therapeutic care. The family rather than doing everything for them.
nurse's role is to transition the
child and family to self-care.
ANS: B
190. What is most descriptive of critical thinking?
Critical thinking is a complex, a. A simple developmental process
developmental process based b. Purposeful and goal directed
on rational and deliberate c. Based on deliberate and irrational thought
thought. When thinking is clear, d. Assists individuals in guessing what is most

precise, accurate, relevant, appropriate
consistent, and fair, a logical
connection develops between
the elements of thought and
the problem at hand.

ANS: A, B, C, E, F
191. The nursing process is a method of problem
The accepted model is identification and problem solving that describes
assessment, diagnosis, what the nurse actually does. The five steps include
planning, implementation and (choose all that apply):
evaluation. The diagnosis phase a. Assessment
is separated into two steps: b. Diagnosis
nursing diagnosis and outcome c. Planning
identification. Although d. Identification
important, identification is not e. Implementation
a stand-alone step in the f. Evaluation

nursing process.
ANS: Evidence-Based Practice

192. EBP, __________________ _____________ _______________, is the
Evidence-based nursing collection, interpretation and integration of valid,
practice combines knowledge important and applicable patient-reported, nurse-
with clinical experience and observed and research-derived information.
intuition. It provides a rational
approach to decision making.
Babies weight
doubles by 6 months
-two triples by 12 months
plays peak-a-boo by 6 months
Babies ability
Sits upright w/o support by 8 months
-three Fine pincer grasp by 10-12 months (pick up

Cheerios)
Toddler age range 1-3
Throw ball overhand at 18 months
Toddler ability
2-3 word sentences at 2rs
-three
Toilet training 2 yrs old

No concept of time
Toddler behavior/concepts
Frequent Tantrums
Preschool age range 3-5
Preschool ability rides tricycle at 3
Preschool favorite word why?
Preschool speech 5-8 words
School age range 6-12
gains 4-6lbs per year
School age growth

grows 2 inches
School age ability

able to tell time
-important? socialization with peers important
Adolescence growth rapid growth second only to the first year of life
Which vaccines would the d-tap, HepB

nurse expect to be prescribed HIB
for a 2-month-old during well IPV
checkup? PCV
HIB haemophilus Influenza B for glottitis and meningitis
IPV inactivated poliovirus vaccine
PCV pneumococcal conjugate vaccine

MMR and allergies? Expect to hold for Egg/neomycin Allergy
Syndrome which is an acute encephalopathy

(inflammation of the brain). Usually follows a viral
illness & linked to intake of aspirin. Use
Reye's Syndrome
acetaminophen (not aspirin) to reduce fever with
child with a communicable disease (virus) to prevent
this.
Bacterial Epiglottitis Symptom Excessive drooling due to painful swallowing
Tonsilectomy warning sign swallowing repeatedly can signify bleeding
Tonsilectomy risk for bleeding First 24 hrs
times 5-10 days post-op (scabs fall off)
fever
Otitis Media S/S pulling at ear
discharge from ear
Newborn Vital signs

Resp. 40-60.
-Resp
HR 110-160.
-HR
BP 65-85/45-55
-BP
RSV Respiratory Synctial Virus
Respiratory Synctial Virus common respiratory virus that affects children.
Isolation (contact)
RSV Tx
Antiviral agent (ribavirin aerosols)

severe, life threatening infection of the epiglottis

and supraglottic stuructures that occurs most
Epiglottitis commonly in children between 2 and 12 years of

age.
-excessive drooling is the universal sign
-in addition, the child will have a sudden onset of

dysphagia or difficulty swallowing, stridor, and high-
Epiglottitis S/S
grade fever.
-the child may also be in the TRIPOD POSITION

upon arrival
Tripod Position
Cystic Fibrosis, the most common congenital

disease
CF the child's lungs and intestines and pancreas

become clogged with thick mucus; caused by
defect in a single gene; there is no cure
Pilocarpine sweat test -> normal = 10, severe variant

CF diagnosis
>60, mild=40-60 -> genetic diagnosis

a common congenital heart defect
an abnormal opening in the septum dividing the

ventricles allows blood to pass directly from the left
to the right ventricle; large openings may cause
Ventricular Septal defect congestive heart failure
an abnormal opening between the left and right

atria of the heart
Atrial Septal Defect
Failure of the ductus arteriosus to close after birth,

allowing blood to flow from the aorta into the
pulmonary (lung) artery
Patent Ductus Arteriosus
narrowing of the descending portion of the aorta,

Coarctation of the aorta resulting in a limited flow of blood to the lower part
of the body
a severe disease chiefly of children and

Rheumatic Fever characterized by painful inflammation of the joints
and frequently damage to the heart valves

Chorea muscle twitch
Rheumatic Fever S/S carditis chest pain SOB
sub q nodles
sudden, rapid, jerky, purposeless movement

Chorea
involving limbs, trunk, or face
Seizures
Generalized tonic/clonic
-two Petit mal
also called tonic-clonic seizures; characterized by a

sudden loss consciousness, falling down, and
involuntary muscle contractions. Often preceded by
Grand mal seizure
an aura, a peculiar sensation such as visual
disturbance, numbness, or dizziness, which appears
just before more definite symptoms
A state of muscle contraction in which there is

Tonic phase
excessive muscle tone; rigid & stiff
the phase of a grand mal seizure in which the

Clonic Phase
patient shows rhythmic jerking movements
period following the cessation of seizure activity;

Postictal phase
patient is confused, needs close monitoring
"Absence Seizure"
Petit mal Momentary LOC, appears like daydreaming
-lasts 5-10 seconds
inflammation of the protective membranes covering

Bacterial Meningitis the brain and spinal cord caused by various types of
bacteria
Neck Stiffness!!!
Bacterial Meningitis S/S Kernig sign + Brudzinski sign
inability to fully extend the knees with hips flexed.
Kernig sign
A positive sign of meningitis, in which there is an

involuntary flexion of the arm, hip, and knee when
the patient's neck is passively flexed.
Brudzinski sign
often, BUT NOT ALWAYS associated with ASA use
Reye's Syndrome
-Rapidly progressing encephalopathy
Lethargy progressing to coma
Reye's S/S vomiting
hypoglycemia
Reye's Tx Mannitol for ICP control
any of several hereditary diseases of the muscular

Muscular Dystrophy system characterized by weakness and wasting of
skeletal muscles
MD -onset age? Onset between ages 2-6

Duchenne MD most common type of MS affecting only males
MD Dx Muscle biopsy
Serum creatine phosphokinase (CK) levels are

MD Lab extremely high in the first 2 years of life before
onset
Delayed Walking
Frequent Falls
MD S/S
Easily tires when walking
Trouble climbing stairs
Result of valvular malfunction and backflow of urine

Vesicoureteral Reflex into the ureters (and higher) from the bladder
(severe cases are associated with hydronephrosis
Acute Glomerulonephritis
This is a sudden inflammation of the Glomerulus,

inflamed because of an antigen, antibody reaction
AGN
to STREP, that damages the glomerulus. Causes the
Glomerulus membrane to thicken so it doesn't filter.
Will show high protein and RBC's in the urine.
Oliguria
Hematuria
AGN S/S
Proteinuria
Edema/HTN
Daily Weights/ Strict I & O
restriction of salt,
AGN Tx maintenance of fluid and electrolyte balance,
antipyretics(fever)
diuretics(edema)
a syndrome characterized by edema and large

Nephrotic Syndrome amounts of protein in the urine and usually
increased blood cholesterol
Frothy urine
Massive proteinuria
Nephrotic Syndrome Dx
Edema
Anorexia
FeSO4 drops administration

Use Straw to prevent teeth staining
-with what drink Give with Orange Juice... not Milk
Cleft Lip fx age/weight infant weighs 10 lbs
Cleft Palate age ~1 year
Pyloric Stenosis feature Projectile vomit around 14 days after birth
Telescoping of one part of intestine
Intussesception
A human genetic disease of red blood cells caused

by the substitution of a single amino acid in the
Sickle Cell Anemia
hemoglobin protein; it is the most common
inherited disease among African Americans.
Chronic fatigue,
dyspnea,
Sickle Cell Anemia Symptoms

joint pain,
swelling chest pain

Hydration, Oxygenation, Pain management
Sickle Cell Tx (morphine, ect..), blood transfusions, bone marrow

transplant- life threatening, eg. strokes
genetic disorder in which the body cannot

PKU
metabolize their amino acid phenylalanine
Done at birth (after breast feeding or formula to

PKU Screening
allow body to fail at processing)
-When is best
Also done at 3 weeks
Avoid meat, milk, dairy, eegs
PKU Diet
Eat fruits, juices, cereal, bread, starches
Used for fractures of the FEMUR, HIP, or KNEE

contractures. How is by pulling the hip and femur
into extension.
Buck's traction
-part of body
uses a knee sling to provide support of the affected

leg. It is commonly used to treat fractures of the
end of the tibia in the leg.
Russell's traction
-part of body

temporary skin traction used for Fx of the upper arm

and for shoulder dislocations.
Dunlop's Traction
-part of body
boot cast and pins surgically through distal part of

90/90 traction
femur
-part of body
and hip and knee
for small children with fracture of the femur
uses the weight of the child's lower body to pull the

bone fragments of the fractured leg into alignment.
To accomplish this, the child's buttocks should just
Bryant's traction
clear the mattress and the legs should be at a 90-

-age
degree angle to the trunk.

-part of body
Positive Ortolani sign
Unequal fold of skin on buttock
Limited abduction of hip

Congenital Dislocated hip

abducting the thighs and applying gentle pressure

Ortolani sign forward over the greater trochanter produces a
'clunk"
movement away from the body
Abduction
movement of a limb toward the body
Adduction
keep femur in acetabulum (4-5mon)
wear 24 hrs a day
adjust every 2 weeks because of rapid growth

Pavlik Harness

A 52-year-old client states, "My ANS: B
husband is upset because I The nurse should assess the client's last menstrual
don't enjoy sex as much as I cycle to determine if the client is experiencing the
used to." Which priority client onset of menopause. Menopause usually occurs
data should a nurse initially around the age of 50. The decrease in estrogen can
collect?
result in multiple symptoms including a decrease in
biological drives and sexual activity.
A. History of hysterectomy
B. Date of last menstrual cycle
C. Use of birth control

methods
D. History of thought disorder
In the course of an assessment ANS: A
interview, a female client The nurse should initially self-assess personal

reveals a history of bisexual attitudes toward homosexuality. The nurse must be
orientation. Which action able to recognize the potential for negative feelings
should the nurse initially compromising client care. Unconditional
implement when working with acceptance of each individual is an essential
this client?
component of compassionate nursing.
A. Self-assess personal
attitudes toward
homosexuality.
B. Review client's possible

childhood sexual abuse history.
C. Encourage discussion of
aversion to heterosexual
relationships.
D. Explore client's family history

of homosexuality.

A recently widowed client ANS: B
reports a fear of intimacy due Based on the client's symptoms, the nurse should
to an inability to achieve and prioritize the nursing diagnosis of sexual
sustain an erection. He has dysfunction R/T dysfunctional grieving AEB inability
become isolative, has difficulty to experience orgasm. The nurse should assess the
sleeping, and has recently lost client's mood and level of energy because
weight. Which correctly written depression and fatigue can decrease desire for
nursing diagnosis should be participation in sexual activity.
prioritized for this client?
A. Risk for situational low self-

esteem AEB inability to achieve
an erection
B. Sexual dysfunction R/T

dysfunctional grieving AEB
inability to experience orgasm
C. Social isolation R/T low self-

esteem AEB refusing to
engage in dating activities
D. Disturbed body image R/T

penile flaccidity AEB client
statements

A nurse is assessing a client ANS: B
diagnosed with pedophilia. The nurse should identify that pedophilia is a sexual
What would differentiate this disorder in which individuals partake in
sexual disorder from a sexual inappropriate sexual behaviors. Sexual dysfunction
dysfunction?
involves impairment in normal sexual response.
Pedophilia involves having sexual urges, behaviors,
A. Symptoms of sexual or sexually arousing fantasies involving sexual
dysfunction include activity with a prepubescent child.
inappropriate sexual behaviors,
whereas symptoms of a sexual
disorder include impairment in
normal sexual response.
B. Symptoms of a sexual
disorder include inappropriate
sexual behaviors, whereas
symptoms of sexual
dysfunction include impairment
in normal sexual response.
C. Sexual dysfunction can be

caused by increased levels of
circulating androgens, whereas
levels of circulating androgens
do not affect sexual disorders.
D. Sexual disorders can be

caused by decreased levels of
circulating androgens, whereas
levels of circulating androgens
do not affect sexual
dysfunction.

A female client on an inpatient ANS: C
unit enters the day area for The most appropriate intervention by the nurse is to
visiting hours dressed in a see- lead the client back to her room and assist her to
through blouse and wearing choose appropriate clothing. The client could be
no undergarments. Which exhibiting signs of exhibitionism which is
intervention should be a nurse's characterized by urges to expose oneself to
first priority?
unsuspecting strangers.
A. Discuss with the client the

inappropriateness of her attire.
B. Avoid addressing her

attention-seeking behavior.
C. Lead the client back to her

room and assist her to choose
appropriate clothing.
D. Restrict client to room until

visiting hours are over.

A nurse is working with a client ANS: C
diagnosed with pedophilia. During the first week of hospitalization, identifying

Which client outcome is triggers that lead to inappropriate behaviors is an
appropriate for the nurse to appropriate outcome for a client diagnosed with
expect during the first week of pedophilia. Pedophilia involves intense sexual
hospitalization?
urges, behaviors, or fantasies involving sexual
activity with a prepubescent child.
A. The client will verbalize an
understanding of the
importance of follow-up care.
B. The client will implement

several relapse-prevention
strategies.
C. The client will identify

triggers that lead to
inappropriate behaviors.
D. The client will attend

aversion therapy groups.
When planning care for a client ANS: D
diagnosed with female sexual The expected outcome of senate focus exercises is
arousal disorder, what should a to reduce goal-oriented demands of intercourse.
nurse document as an Senate focus exercises consist of touching and
expected outcome of senate being touched by another with attention focused on
focus exercises?
the physical sensations encountered. Erotic contact
is gradually increased, leading to the possibility of
A. To initiate immediate orgasm
sexual intercourse. The reduction in demands
B. To reduce anxiety by reduces performance pressures and anxiety
eliminating physical touch
associated with possible failure.
C. To focus on touching breasts
and genitals
D. To reduce goal-oriented
demands of intercourse

A newly married woman comes ANS: A
to a gynecology clinic The nurse should expect the physician to implement

reporting anorexia, insomnia, a thorough physical to include a gynecological
and extreme dyspareunia that examination to assess for any physiological causes
have affected her intimate of the client's symptoms. Dyspareunia is recurrent or
relationship. What initial persistent genital pain associated with sexual
intervention should the nurse intercourse.
expect a physician to
implement?
A. A thorough physical to
include gynecological
examination
B. Referral to a sex therapist
C. Assessment of sexual history

and previous satisfaction with
sexual relationships
D. Referral to the recreational

therapist for relaxation therapy

A client is diagnosed with ANS: A
sexual aversion disorder. Which The nurse should recognize that this sexual aversion
symptom of this disorder disorder is characterized by an avoidance of genital
should the nurse correctly pair sexual contact. Sexual aversion implies anxiety, fear,
with an appropriate or disgust in sexual situations. Sexual aversion can
therapeutic intervention?
be treated by systematic desensitization.
A. Avoidance of all genital

sexual contact treated by
systematic desensitization
B. Avoidance of all genital

sexual contact treated by
medicating with tadalafil
(Cialis)
C. Anorgasmia treated by
vardenafil (Levitra)
D. Anorgasmia treated by
sensate focus exercises

A psychiatric nursing instructor ANS: D
is teaching about the The instructor should identify the need for further
psychological effects of the instruction if a student states that antibiotics can
diagnosis of a sexually cure all STDs. STDs refer to infections that are
transmitted disease (STD). contracted primarily through sexual activities or
Which student statement intimate contact. An example of an incurable STD is
indicates that further HIV. STDs are at epidemic levels in the United
instruction is needed?
States.
A. "STDs carry strong

connotations of illicit sex and
considerable social stigma."
B. "STDs can cause insanity."
C. "The diagnosis of HIV can

generate hopelessness and
helplessness."
D. "Antibiotics administered in
the early stages can cure all
STDs."
A client is diagnosed with ANS: C
female sexual aversion The nurse should identify that medication therapy of
disorder. In addition to amoxapine could complement systematic
systematic desensitization desensitization techniques. Amoxapine is a
techniques, which medication heterocyclic antidepressant that can assist in
therapy could accompany this reduction of anxiety.
intervention?
A. Quetiapine (Seroquel)
B. Phenelzine (Nardil)
C. Amoxapine (Asendin)
D. Carbamazepine (Tegretol)

A nurse is counseling a client ANS: B
diagnosed with The nurse should identify that clients diagnosed

transgenderism. Which with transgenderism are dissatisfied with their
characteristic would gender, whereas clients diagnosed with transvestic
differentiate this disorder from fetishism are not. Both clients diagnosed with
transvestic fetishism? transgenderism and transvestic fetishism may
participate in cross-dressing.
A. Clients diagnosed with
transvestic fetishism are
dissatisfied with their gender,
whereas clients diagnosed with
transgenderism are not.
B. Clients diagnosed with

transgenderism are dissatisfied
with their gender, whereas
clients diagnosed with
transvestic fetishism are not.
C. Clients diagnosed with

transgenderism never engage
in cross-dressing, whereas
clients diagnosed with
transvestic fetishism do.
D. Clients diagnosed with

transvestic fetishism never
engage in cross-dressing,
whereas clients diagnosed with
transgenderism do.

Which of the following ANS: A, B, E
characteristics should a nurse The nurse should identify that experimenting with
identify as "normal" in the masturbation and homosexual play and not wanting
development of human to undress in front of others are characteristics that
sexuality for an 11-year-old are normal in the development of human sexuality
child? (Select all that apply.)
in an 11-year-old child. Interest in the opposite sex
usually increases during this age, and children often
A. The child experiments with become self-conscious about their bodies.
masturbation.
B. The child may experience

homosexual play.
C. The child shows little interest

in the opposite sex.
D. The child shows little

concern about physical
attractiveness.
E. The child is unlikely to want

to undress in front of others.

A nursing instructor is teaching ANS: B, C, E
about the various categories of Categories of paraphilia include voyeurism

paraphilia. Which of the (observing unsuspecting people who are naked,
following categories are dressing, or engaged in sexual activity), frotteurism
correctly matched with (touching or rubbing against a nonconsenting
expected behaviors? (Select person), fetishism (using nonliving objects in sexual
all that apply.)
ways), and pedophilia (recurrent sexual urges
involving sexual activity with a prepubescent child).
A. Exhibitionism: Mary models Exhibitionism is a paraphilia but involves the urge to
lingerie for a company that show one's genitals to unsuspecting strangers.
specializes in home parties.
B. Voyeurism: John is arrested

for peering in a neighbor's
bathroom window.
C. Frotteurism: Peter enjoys

subway rush-hour female
contact that results in arousal.
D. Pedophilia: George can

experience an orgasm by
holding and feeling shoes.
E. Fetishism: Henry masturbates

into his wife's silk panties.
1.A nurse is caring for a client in 1.4. The second stage of labor begins when the
labor. The nurse determines cervix is dilated completely and ends with the birth
that the client is beginning in of the neonate.
the 2nd stage of labor when
which of the following
assessments is noted?
A.The client begins to expel
clear vaginal fluid
B.The contractions are regular
C.The membranes have

ruptured
D.The cervix is dilated

bstrandable
completely NCLEX OB/Peds 2 of 3
A nurse in the labor room is 3. Late decelerations are due to uteroplacental

caring for a client in the active insufficiency as the result of decreased blood flow
phases of labor. The nurse is and oxygen to the fetus during the uterine
assessing the fetal patterns and contractions. This causes hypoxemia; therefore
notes a late deceleration on oxygen is necessary. The supine position is avoided
the monitor strip. The most because it decreases uterine blood flow to the
appropriate nursing action is fetus. The client should be turned to her side to
to:
displace pressure of the gravid uterus on the
inferior vena cava. An intravenous pitocin infusion is
1.Place the mother in the discontinued when a late deceleration is noted.
supine position
2.Document the findings and

continue to monitor the fetal
patterns
3.Administer oxygen via face

mask
4.Increase the rate of pitocin IV

infusion
A nurse is performing an 1. A normal fetal heart rate is 120-160 beats per

assessment of a client who is minute. A count of 180 beats per minute could
scheduled for a cesarean indicate fetal distress and would warrant physician
delivery. Which assessment notification. By full term, a normal maternal
finding would indicate a need hemoglobin range is 11-13 g/dL as a result of the
to contact the physician?
hemodilution caused by an increase in plasma
volume during pregnancy.
1.Fetal heart rate of 180 beats
per minute
2.White blood cell count of

12,000
3.Maternal pulse rate of 85

beats per minute
4.Hemoglobin of 11.0 g/dL

A client in labor is transported 4. Vena cava and descending aorta compression by

to the delivery room and is the pregnant uterus impedes blood return from the
prepared for a cesarean lower trunk and extremities. This leads to decreasing
delivery. The client is cardiac return, cardiac output, and blood flow to
transferred to the delivery the uterus and the fetus. The best position to
room table, and the nurse prevent this would be side-lying with the uterus
places the client in the:
displaced off of abdominal vessels. Positioning for
abdominal surgery necessitates a supine position;
1.Trendelenburg's position with however, a wedge placed under the right hip
the legs in stirrups
provides displacement of the uterus.
2.Semi-Fowler position with a
pillow under the knees
3.Prone position with the legs

separated and elevated
4.Supine position with a wedge

under the right hip

. A nurse is caring for a client in 4. The nurse simultaneously should palpate the
labor and prepares to maternal radial or carotid pulse and auscultate the
auscultate the fetal heart rate fetal heart rate to differentiate the two. If the fetal
by using a Doppler ultrasound and maternal heart rates are similar, the nurse may
device. The nurse most mistake the maternal heart rate for the fetal heart
accurately determines that the rate. Leopold's maneuvers may help the examiner
fetal heart sounds are heard locate the position of the fetus but will not ensure a
by:
distinction between the two rates.
1.Noting if the heart rate is

greater than 140 BPM
2.Placing the diaphragm of the

Doppler on the mother
abdomen
3.Performing Leopold's
maneuvers first to determine
the location of the fetal heart
4.Palpating the maternal radial

pulse while listening to the
fetal heart rate

A nurse is caring for a client in 2. A normal fetal heart rate is 120-160 BPM.
labor who is receiving Pitocin Bradycardia or late or variable decelerations
by IV infusion to stimulate indicate fetal distress and the need to discontinue to
uterine contractions. Which pitocin. The goal of labor augmentation is to
assessment finding would achieve three good-quality contractions in a 10-
indicate to the nurse that the minute period.
infusion needs to be
discontinued?
1.Three contractions occurring

within a 10-minute period
2.A fetal heart rate of 90 beats

per minute
3.Adequate resting tone of the

uterus palpated between
contractions
4.Increased urinary output
A nurse is beginning to care for 2. Continuous electronic fetal monitoring should be

a client in labor. The physician implemented during an IV infusion of Pitocin.
has prescribed an IV infusion
of Pitocin. The nurse ensures
that which of the following is
implemented before initiating
the infusion?
1.Placing the client on

complete bed rest
2.Continuous electronic fetal

monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the

client's bedside

A nurse is monitoring a client in 4. A normal fetal heart rate is 120-160 beats per
active labor and notes that the minute. Fetal bradycardia between contractions may
client is having contractions indicate the need for immediate medical
every 3 minutes that last 45 management, and the physician or nurse mid-wife
seconds. The nurse notes that needs to be notified.
the fetal heart rate between
contractions is 100 BPM. Which
of the following nursing actions
is most appropriate?
1.Encourage the client's coach

to continue to encourage
breathing exercises
2.Encourage the client to

continue pushing with each
contraction
3.Continue monitoring the fetal

heart rate
4.Notify the physician or nurse

mid-wife

A nurse is caring for a client in 1. Accelerations are transient increases in the fetal
labor and is monitoring the heart rate that often accompany contractions or are
fetal heart rate patterns. The caused by fetal movement. Episodic accelerations
nurse notes the presence of are thought to be a sign of fetal-well being and
episodic accelerations on the adequate oxygen reserve.
electronic fetal monitor tracing.
Which of the following actions
is most appropriate?
1.Document the findings and

tell the mother that the monitor
indicates fetal well-being
2.Take the mothers vital signs

and tell the mother that bed
rest is required to conserve
oxygen.
3.Notify the physician or nurse

mid-wife of the findings.
4.Reposition the mother and
check the monitor for changes
in the fetal tracing

A nurse is admitting a pregnant 2. Assessing the baseline fetal heart rate is

client to the labor room and important so that abnormal variations of the
attaches an external electronic baseline rate will be identified if they occur.
fetal monitor to the client's
abdomen. After attachment of Options 1 and 3 are important to assess, but not as
the monitor, the initial nursing the first priority.
assessment is which of the
following?
1.Identifying the types of

accelerations
2.Assessing the baseline fetal

heart rate
3.Determining the frequency of

the contractions
4.Determining the intensity of

the contractions
A nurse is reviewing the record 1. Station is the relationship of the presenting part to
of a client in the labor room an imaginary line drawn between the ischial spines,
and notes that the nurse is measured in centimeters, and is noted as a
midwife has documented that negative number above the line and a positive
the fetus is at -1 station. The number below the line. At -1 station, the fetal
nurse determines that the fetal presenting part is 1 cm above the ischial spines.
presenting part is:
1.1 cm above the ischial spine
2.1 fingerbreadth below the

symphysis pubis
3.1 inch below the coccyx
4.1 inch below the iliac crest

A pregnant client is admitted to 4. Anemic women have a greater likelihood of

the labor room. An assessment cardiac decompensation during labor, postpartum
is performed, and the nurse infection, and poor wound healing. Anemia does
notes that the client's not specifically present a risk for hemorrhage.
hemoglobin and hematocrit Having a loud mouth is only related to the person
levels are low, indicating typing up this test.
anemia. The nurse determines
that the client is at risk for
which of the following?
1.A loud mouth
2.Low self-esteem
3.Hemorrhage
4.Postpartum infections
A nurse assists in the vaginal 4. As the placenta separates, it settles downward

delivery of a newborn infant. into the lower uterine segment. The umbilical cord
After the delivery, the nurse lengthens, and a sudden trickle or spurt of blood
observes the umbilical cord appears.
lengthen and a spurt of blood
from the vagina. The nurse
documents these observations
as signs of:
1.Hematoma
2.Placenta previa
3.Uterine atony
4.Placental separation

A client arrives at a birthing 2. Amniotomy can be used to induce labor when the
center in active labor. Her condition of the cervix is favorable (ripe) or to
membranes are still intact, and augment labor if the process begins to slow.
the nurse-midwife prepares to Rupturing of membranes allows the fetal head to
perform an amniotomy. A nurse contact the cervix more directly and may increase
who is assisting the nurse- the efficiency of contractions.
midwife explains to the client
that after this procedure, she
will most likely have:
1.Less pressure on her cervix
2.Increased efficiency of
contractions
3.Decreased number of
contractions
4.The need for increased

maternal blood pressure
monitoring
A nurse is monitoring a client in 2. Variable decelerations occur if the umbilical cord

labor. The nurse suspects becomes compressed, thus reducing blood flow
umbilical cord compression if between the placenta and the fetus. Early
which of the following is noted decelerations result from pressure on the fetal head
on the external monitor tracing during a contraction. Late decelerations are an
during a contraction?
ominous pattern in labor because it suggests
uteroplacental insufficiency during a contraction.
1.Early decelerations
Short-term variability refers to the beat-to-beat
2.Variable decelerations
range in the fetal heart rate.
3.Late decelerations
4.Short-term variability

A nurse explains the purpose 2. Effleurage is a specific type of cutaneous

of effleurage to a client in early stimulation involving light stroking of the abdomen
labor. The nurse tells the client and is used before transition to promote relaxation
that effleurage is:
and relieve mild to moderate pain. Effleurage
provides tactile stimulation to the fetus.
1.A form of biofeedback to
enhance bearing down efforts
during delivery
2.Light stroking of the

abdomen to facilitate
relaxation during labor and
provide tactile stimulation to
the fetus
3.The application of pressure to

the sacrum to relieve a
backache
4.Performed to stimulate
uterine activity by contracting a
specific muscle group while
other parts of the body rest
A nurse is caring for a client in 2. Pains, helplessness, panicking, and fear of losing
the second stage of labor. The control are possible behaviors in the 2nd stage of
client is experiencing uterine labor.
contractions every 2 minutes
and cries out in pain with each
contraction. The nurse
recognizes this behavior as:
1.Exhaustion
2.Fear of losing control
3.Involuntary grunting
4.Valsalva's maneuver

A nurse is monitoring a client in 1, 4, 2. 5, 3.
labor who is receiving Pitocin
and notes that the client is If uterine hypertonicity occurs, the nurse
experiencing hypertonic immediately would intervene to reduce uterine
uterine contractions. List in activity and increase fetal oxygenation. The nurse
order of priority the actions would stop the Pitocin infusion and increase the
that the nurse takes.
rate of the nonadditive solution, check maternal BP
for hyper or hypotension, position the woman in a
1.Stop of Pitocin infusion
side-lying position, and administer oxygen by snug
2.Perform a vaginal face mask at 8-10 L/min. The nurse then would
examination
attempt to determine the cause of the uterine
3.Reposition the client
hypertonicity and perform a vaginal exam to check
4.Check the client's blood for prolapsed cord
pressure and heart rate
5.Administer oxygen by face

mask at 8 to 10 L/min
A nurse is assigned to care for 3. Therapeutic management for hypotonic uterine

a client with hypotonic uterine dysfunction includes oxytocin augmentation and
dysfunction and signs of a amniotomy to stimulate a labor that slows.
slowing labor. The nurse is
reviewing the physician's
orders and would expect to
note which of the following
prescribed treatments for this
condition?
1.Medication that will provide

sedation
2.Increased hydration
3.Oxytocin (Pitocin) infusion
4.Administration of a tocolytic
medication

A nurse in the labor room is 2. Management of hypertonic labor depends on the

preparing to care for a client cause. Relief of pain is the primary intervention to
with hypertonic uterine promote a normal labor pattern.
dysfunction. The nurse is told
that the client is experiencing
uncoordinated contractions
that are erratic in their
frequency, duration, and
intensity. The priority nursing
intervention would be to:
1.Monitor the Pitocin infusion

closely
2.Provide pain relief measures
3.Prepare the client for an

amniotomy
4.Promote ambulation every 30

minutes
A nurse is developing a plan of 3. The priority is to monitor the fetal heart rate.
care for a client experiencing
dystocia and includes several
nursing interventions in the
plan of care. The nurse
prioritizes the plan of care and
selects which of the following
nursing interventions as the
highest priority?
1.Keeping the significant other

informed of the progress of the
labor
2.Providing comfort measures
3.Monitoring fetal heart rate
4.Changing the client's position

bstrandable
frequently NCLEX OB/Peds 2 of 3
A maternity nurse is preparing 3. In a client with a multi-fetal pregnancy, each fetal

to care for a pregnant client in heart rate is monitored separately.
labor who will be delivering
twins. The nurse monitors the
fetal heart rates by placing the
external fetal monitor:
1.Over the fetus that is most

anterior to the mothers
abdomen
2.Over the fetus that is most

posterior to the mothers
abdomen
3.So that each fetal heart rate is

monitored separately
4.So that one fetus is

monitored for a 15-minute
period followed by a 15 minute
fetal monitoring period for the
second fetus

A nurse in the postpartum unit 4. Because the placenta is implanted in the lower
is caring for a client who has uterine segment, which does not contain the same
just delivered a newborn infant intertwining musculature as the fundus of the uterus,
following a pregnancy with this site is more prone to bleeding.
placenta previa. The nurse
reviews the plan of care and
prepares to monitor the client
for which of the following risks
associated with placenta
previa?
1.Disseminated intravascular
coagulation
2.Chronic hypertension
3.Infection
4.Hemorrhage
A nurse in the delivery room is 4. Signs of placental separation include lengthening

assisting with the delivery of a of the umbilical cord, a sudden gush of dark blood
newborn infant. After the from the introitus (vagina), a firmly contracted
delivery of the newborn, the uterus, and the uterus changing from a discoid (like
nurse assists in delivering the a disk) to a globular (like a globe) shape. The client
placenta. Which observation may experience vaginal fullness, but not severe
would indicate that the uterine cramping. I am going to look more into this
placenta has separated from answer. According to our book on page 584, this is
the uterine wall and is ready not one of our options.
for delivery?
1.The umbilical cord shortens in

length and changes in color
2.A soft and boggy uterus
3.Maternal complaints of
severe uterine cramping
4.Changes in the shape of the

uterus
A nurse in the labor room is 1. When cord prolapse occurs, prompt actions are
performing a vaginal taken to relieve cord compression and increase
assessment on a pregnant fetal oxygenation. The mother should be positioned
client in labor. The nurse notes with the hips higher than the head to shift the fetal
the presence of the umbilical presenting part toward the diaphragm. The nurse
cord protruding from the should push the call light to summon help, and
vagina. Which of the following other staff members should call the physician and
would be the initial nursing notify the delivery room. No attempt should be
action?
made to replace the cord. The examiner, however,
may place a gloved hand into the vagina and hold
1.Place the client in the presenting part off of the umbilical cord.
Trendelenburg's position
Oxygen at 8 to 10 L/min by face mask is delivered to
2.Call the delivery room to the mother to increase fetal oxygenation.
notify the staff that the client
will be transported
immediately
3.Gently push the cord into the

vagina
4.Find the closest telephone

and stat page the physician

A maternity nurse is caring for 1. DIC is a state of diffuse clotting in which clotting
a client with abruptio placenta factors are consumed, leading to widespread
and is monitoring the client for bleeding. Platelets are decreased because they are
disseminated intravascular consumed by the process; coagulation studies
coagulopathy. Which show no clot formation (and are thus normal to
assessment finding is least prolonged); and fibrin plugs may clog the
likely to be associated with microvasculature diffusely, rather than in an isolated
disseminated intravascular area. The presence of petechiae, oozing from
coagulation?
injection sites, and hematuria are signs associated
with DIC. Swelling and pain in the calf of one leg
1.Swelling of the calf in one leg
are more likely to be associated with
2.Prolonged clotting times
thrombophebitis.
3.Decreased platelet count
4.Petechiae, oozing from

injection sites, and hematuria
A nurse is assessing a pregnant 3. In abruptio placentae, acute abdominal pain is

client in the 2nd trimester of present. Uterine tenderness and pain accompanies
pregnancy who was admitted placental abruption, especially with a central
to the maternity unit with a abruption and trapped blood behind the placenta.
suspected diagnosis of The abdomen will feel hard and boardlike on
abruptio placentae. Which of palpation as the blood penetrates the myometrium
the following assessment and causes uterine irritability. Observation of the
findings would the nurse fetal monitoring often reveals increased uterine
expect to note if this condition resting tone, caused by failure of the uterus to relax
is present?
in attempt to constrict blood vessels and control
bleeding.
1.Absence of abdominal pain
2.A soft abdomen
3.Uterine tenderness/pain
4.Painless, bright red vaginal

bleeding

A maternity nurse is preparing 3. Manual pelvic examinations are contraindicated

for the admission of a client in when vaginal bleeding is apparent in the 3rd
the 3rd trimester of pregnancy trimester until a diagnosis is made and placental
that is experiencing vaginal previa is ruled out. Digital examination of the cervix
bleeding and has a suspected can lead to maternal and fetal hemorrhage. A
diagnosis of placenta previa. diagnosis of placenta previa is made by ultrasound.
The nurse reviews the The H/H levels are monitored, and external
physician's orders and would electronic fetal heart rate monitoring is initiated.
question which order?
External fetal monitoring is crucial in evaluating the
fetus that is at risk for severe hypoxia
1.Prepare the client for an
ultrasound
2.Obtain equipment for

external electronic fetal heart
monitoring
3.Obtain equipment for a

manual pelvic examination
4.Prepare to draw a Hgb and

Hct blood sample

An ultrasound is performed on 2. The goal of management in abruptio placentae is

a client at term gestation that is to control the hemorrhage and deliver the fetus as
experiencing moderate vaginal soon as possible. Delivery is the treatment of choice
bleeding. The results of the if the fetus is at term gestation or if the bleeding is
ultrasound indicate that an moderate to severe and the mother or fetus is in
abruptio placenta is present. jeopardy.
Based on these findings, the
nurse would prepare the client
for:
1.Complete bed rest for the

remainder of the pregnancy
2.Delivery of the fetus
3.Strict monitoring of intake

and output
4.The need for weekly

monitoring of coagulation
studies until the time of
delivery
A nurse in a labor room is 2. Excessive fundal pressure, forceps delivery,

assisting with the vaginal violent bearing down efforts, tumultuous labor, and
delivery of a newborn infant. shoulder dystocia can place a woman at risk for
The nurse would monitor the traumatic uterine rupture. Hypotonic contractions
client closely for the risk of and weak bearing down efforts do not alone add to
uterine rupture if which of the the risk of rupture because they do not add to the
following occurred?
stress on the uterine wall.
1.Hypotonic contractions
2.Forceps delivery
3.Schultz delivery
4.Weak bearing down efforts

A client is admitted to the 1. Determining the fetal well-being supersedes all

birthing suite in early active other measures. If the FHR is absent or persistently
labor. The priority nursing decelerating, immediate intervention is required.
intervention on admission of
this client would be:
1.Auscultating the fetal heart
2.Taking an obstetric history
3.Asking the client when she

last ate
4.Ascertaining whether the

membranes were ruptured
A client who is gravida 1, para 0 3. A station of +1 indicates that the fetal head is 1 cm
is admitted in labor. Her cervix below the ischial spines.
is 100% effaced, and she is
dilated to 3 cm. Her fetus is at
+1 station. The nurse is aware
that the fetus' head is:
1.Not yet engaged
2.Entering the pelvic inlet
3.Below the ischial spines
4.Visible at the vaginal opening

After doing Leopold's 3. Fetal heart tones are best auscultated through the
maneuvers, the nurse fetal back; because the position is ROP (right
determines that the fetus is in occiput presenting), the back would be below the
the ROP position. To best umbilicus and on the right side.
auscultate the fetal heart tones,
the Doppler is placed:
1.Above the umbilicus at the

midline
2.Above the umbilicus on the

left side
3.Below the umbilicus on the

right side
4.Below the umbilicus near the

left groin
The physician asks the nurse 3. This is the way to determine the frequency of the
the frequency of a laboring contractions
client's contractions. The nurse
assesses the client's
contractions by timing from the
beginning of one contraction:
1.Until the time it is completely

over
2.To the end of a second

contraction
3.To the beginning of the next

contraction
4.Until the time that the uterus

becomes very firm

The nurse observes the client's 3. by 36 weeks' gestation, normal amniotic fluid is
amniotic fluid and decides that colorless with small particles of vernix caseosa
it appears normal, because it present.
is:
1.Clear and dark amber in color
2.Milky, greenish yellow,

containing shreds of mucus
3.Clear, almost colorless, and

containing little white specks
4.Cloudy, greenish-yellow, and

containing little white specks
At 38 weeks' gestation, a client 4. Adjusting the catheter would be indicated.

is having late decelerations. Normal fetal pulse oximetry should be between
The fetal pulse oximeter shows 30% and 70%. 75% to 85% would indicate maternal
75% to 85%. The nurse should:
readings.
1.Discontinue the catheter, if

the reading is not above 80%
2.Discontinue the catheter, if

the reading does not go below
30%
3.Advance the catheter until

the reading is above 90% and
continue monitoring
4.Reposition the catheter,

recheck the reading, and if it is
55%, keep monitoring

When examining the fetal 2. Variable decelerations usually are seen as a result
monitor strip after rupture of of cord compression; a change of position will
the membranes in a laboring relieve pressure on the cord.
client, the nurse notes variable
decelerations in the fetal heart
rate. The nurse should:
1.Stop the oxytocin infusion
2.Change the client's position
3.Prepare for immediate

delivery
4.Take the client's blood

pressure
When monitoring the fetal 1. An acceleration is an abrupt elevation above the

heart rate of a client in labor, baseline of 15 beats per minute for 15 seconds; if the
the nurse identifies an acceleration persists for more than 10 minutes it is
elevation of 15 beats above the considered a change in baseline rate. A tachycardic
baseline rate of 135 beats per FHR is above 160 beats per minute
minute lasting for 15 seconds.
This should be documented as:
1.An acceleration
2.An early elevation
3.A sonographic motion
4.A tachycardic heart rate

A laboring client complains of 4. A persistent occiput-posterior position causes

low back pain. The nurse intense back pain because of fetal compression of
replies that this pain occurs the sacral nerves. Occiput anterior is the most
most when the position of the common fetal position and does not cause back
fetus is:
pain.
1.Breech
2.Transverse
3.Occiput anterior
4.Occiput posterior
The breathing technique that 1. Blowing forcefully through the mouth controls the
the mother should be strong urge to push and allows for a more
instructed to use as the fetus' controlled birth of the head.
head is crowning is:
1.Blowing
2.Slow chest
3.Shallow
4.Accelerated-decelerated
During the period of induction 2. Uterine tetany could result from the use of
of labor, a client should be oxytocin to induce labor. Because oxytocin
observed carefully for signs of:
promotes powerful uterine contractions, uterine
tetany may occur. The oxytocin infusion must be
1.Severe pain
stopped to prevent uterine rupture and fetal
2.Uterine tetany
compromise.
3.Hypoglycemia
4.Umbilical cord prolapse
What are normal hematocrit 32%-42%

values at 28-32 weeks
gestation?

What is the normal fetal heart 110-160 bpm

rate?
What would the fundal height At the umbilicus

be at 20 weeks?
What should the total weight 25-35 lbs.

gain be in a "normal" weight
woman during pregnancy?
At what point is fetal heart rate 10-12 weeks.

able to be auscultated during
pregnancy?
Every 4 weeks until week 28. Every two weeks from

What is the pattern of check-
28 to 36 weeks. Every week from week 36 to
ups in a low-risk pregnancy?
delivery.
When is chorionic villus Between 8 and 12 weeks' gestation.

sampling done?
When is amniocentesis done? As early as 14-16 weeks
How do you calculate the From the beginning of one contraction to the
frequency of contractions? beginning of the next
What is measured in The intensity of contractions, measured by the

intraunterine monitoring that increased IUP in mmHg (30-70 mmHg)
cannot be measured
externally?
The heart rate between contractions, monitored

What is the baseline FHR?
over a 10-minute period.
What is variability? The normal irregularity of the cardiac rhythm.
An increase in FHR in response to stimulus

What are FHR accelerations?
(contractions, etc.). Indicates a healthy fetus.
A decrease in FHR that can be early or late when

What are FHR decelerations?
compared to uterine contractions.
Decelerations that begin with the beginning of

contractions or with contractions that symbolize a
What are early decelerations?
benign pattern caused by head compression.
Slowly decelerates and returns to baseline.
Common pattern with rapid decelerations that is

What are variable
variable in duration, depth, and fall, and timing
decelerations?
relative to the contraction cycle.
Change position, stimulate fetus if indicated, d/c

What are the nursing actions
oxytocin, give O2 at 10L by tight face mask, SVE for
associated with variable
cord prolapse, and the report findings to physician
decelerations?
and document.
An ominous and potentially disastrous non-

reassuring sign. Indicates uteroplacental
insufficiency. Uniform shape of deceleration that
What are late decelerations?
occurs toward the end of contractions and recovery
occurs after end of contraction. Decel's don't go
past 100 bpm

Turn client to left side, d/c oxytocin, give O2 10L by

tight face mask, assist with fetal blood sampling if
indicated, maintain IV, elevate legs to increase
What are nursing actions for
venous return (if possible), correct any hypotension
late decelerations?
by increasing IV or with meds, assess FHR variability,
notify MD, and document pattern and response to
each nursing action.
How is fetal bradycardia A FHR below 110 bpm for 10 minutes.

defined?
fetal hypoxia (late manifestation), medications,

What are causes of fetal
maternal hypotension, fetal heart block, prolonged
bradycardia?
umbilical cord compression.
How is fetal tachycardia Baseline of greater than 160 bpm for 10 minutes.
defined?
Early sign of fetal hypoxia, fetal anemia,

What are the causes of fetal dehydration, maternal infection/fever, maternal
tachycardia? hyperthyroid disease, and medication-induced
tachycardia.
FHR below 70 bpm lasing longer than 30 seconds,

What are severe variable
with a slow return to baseline and decreasing or
decelerations?
absent variablity.
Turn client to left side, d/c oxytocin, give O2 10L by

tight face mask, assist with fetal blood sampling if
What are the nursing actions indicated, maintain IV, elevate legs to increase
for severe variable venous return (if possible), correct any hypotension
decelerations? by increasing IV or with meds, assess FHR variability,
notify MD, and document pattern and response to
each nursing action.
Position mother to relieve pressure on the cord

How should cord prolapse be (knee-chest) or push presenting part off of cord
managed? until delivery is accomplished.
What conditions might cause Preeclampsia, DM, cardiac disease, and placentae
uteroplacental insufficiency abruptio.
and late decelerations?
How is IUGR diagnosed? With serial ultrasounds
Name two nursing Have client fill bladder and lie supine with uterine
interventions to be done prior wedge.
to a first trimester ultrasound.
It can be done earlier (8-12 weeks gestation) with

What is an advantage CVS has
results back within a week, allowing for a first
over amniocentesis?
trimester termination, if warranted.
What do high or low AFP levels High could:NTD (neural tube defect) low: could be
mean? trisomy 21.
What is the most important FHR variability

indicator of fetal autonomic
nervous system integrity and
health?
A normal result indicating good fetal health where

What is a reactive fetal the fetus responds to its own movements with an
nonstress test? acceleration of 15 bpm lasting for 15 seconds after
the movement, twice within a 20 minute period.

First stage: From beginning of regular contractions

What is the first stage of labor? or rupture of membranes to 10 cm dilation with 100%
effacement
Latent - from beginning to 3-4 cm; Active - from 4-7

What are the three phases of
cm cervical dilation; Transition - from 8-10 cm
the first stage of labor?
dilation
What is the second stage of 10 cm to delivery

labor?
What is the third stage of Deliver of the fetus to delivery of the placenta
labor?
What is the fourth stage? About two hours after the delivery of the placenta
The part of the fetus that is presenting int the inlet.

What is fetal presentation?
Usually, the vertex, acromion, or breech.
The relationship of the point of reference on the

What is fetal position? fetal presenting part to the mother's pelvis. LOA is
left occiput anterior. Left is the mother's left pelvis.
The relationship of the spine of the mother to the

What is the fetal lie? spine of the fetus. It can be longitudinal, transverse
(perpendicular), or oblique.
The relationship of the fetal parts to one another.

What is the fetal attitude?
The fetal attitude can be flexion or extension.
Name three uterine stimulants Oxytocin, methergine, and hemabate.

given for uterine atony.

What should be assessed Blood pressure - withhold if over 140/90 and notify
before giving methergine? physician. Use with caution in pts with preeclampsia
Who should not get Patients with asthma

hemabate?
Full bladder - if patient has soft fundus displaced to

What is the most common
the right of the umbilicus, massage uterus and then
cause of uterine atony?
have patient empty bladder.
1st degree - epidermis
2nd degree - dermis, muscle and fascia
What tissue to tears extend to?

3rd degree - extends into anal sphincter
4th degree - extends into rectal mucosa
What five things does APGAR Appearance, Pulse, Grimace, Activity, Respiration
assess?
How should an IV bolus be Slowly, beginning at the start of a contraction, so

administered during labor? that less gets to the fetus.
Name two tests that show the Nitrazine paper turns dark blue or black; ferning
membranes have ruptured. under microscope
Name two reasons that Given too early can retard labor; given too late can
anesthesia and analgesia cause fetal distress
should be given in the
midactive phase of stage I
labor.
What blood gas issues can be Respiratory alkalosis.

caused by hyperventiliaton?

Where is the fetal heart rate Through the fetal back in vertex, OA positions
best heard?
What is considered normal <100 bpm

maternal pulse during labor?
Name three signs of placental Gush of blood, lengthening of cord and globular
separation. shape of uterus.
What is considered a "good" 7-10

APGAR score?
What immediate intervention Arrange for immediate ET observation.

should occur if meconium
passage occurred in utero?
What is one of the first signs of Nausea

hypotension occurring
immediately after
administration of regional
block?
What occurs to the maternal Pulse may decrease to 50 bpm; normal puerperal
pulse after delivery? bradycardia
When does normal cardiac Within 2 to 3 weeks postpartum

output return?
What is considered normal 12,000 to 25,000

WBC level after labor?
What is the normal 12,000 to 15,000

leukocytosis of pregnancy?
What is the most common Retained placental fragments

cause of uterine atony after the
first postpartum day?
How soon after delivery should Within four hours of delivery.

the client void?
What should the fundal height 3 finger-breadths below the umbilicus

be three days after a vaginal
delivery?
What is the normal range for 30-60 breaths/min

newborn respirations?
What is the normal newborn 110-160; 100-180 if sleeping or crying

heart rate?
What is the normal newborn 97.7-99.4

temperature?
What is the normal newborn 80/50, but not usually measured.

blood pressure?
How should suctioning be Mouth first and then nose (to prevent aspiration in
done in the newborn? the mouth)
Edema under the scalp that crosses suture lines and

What is caput succedaneum?
is usually present at birth.
Bruising under the periosteum that does not cross

What is cephalhematoma? suture lines and usually manifests a few hours after
birth. Can cause hyperbilirubinemia.
What vessels should be found One vein and two arteries

in the umbilical cord?
What complications can occur Depletion of glucose and the use of brown fat --
from hypothermia? ketoacidosis.
What precautions should be Avoid the plantar artery in the middle of the heel
done when performing heel and wipe away the first drop with sterile gauze.
stick?
What muscle should be used in The vastus lateralis muscle of the thigh.
newborn injections?
How is pathologic jaundice It occurs before 24 hours of age or persists for

different from physiologic longer than 7 days.
jaundice?
It begins 2-3 days after birth because the newborn

What causes physiologic
liver can't keep up with the RBC destruction and to
jaundice of the newborn?
bind bilirubin. Unconjugated bilirubin is the culprit.
How do you calculate 1 mL of Each gram of weight of the urine is calculated as 1

urine when weighting diaper? mL of urine.
What respiratory rate in the 60 breaths/min or more

newborn indicates that the
newborn should not be fed?
How many calories/day does About 50 calories/lb or 108 calories/kg of body

an infant need for the first six weight.
months?

What is considered the The first 6-8 hours.

newborn transitional period of
life?
What three risk factors can Cesarean delivery, mag given to mother in labor,
lead to respiratory depression and/or ashyxia or fetal distress during labor
(depression) in the newborn?
Is the newborn's head smaller No, it should be 2cm larger unless severe molding
than its chest? has occurred.
Should a newborn have a A positive unti 12-18 months of age

positive or negative Babinski?
How are SGA and LGA Below the 10th percentile or above the 90th
defined? percentile.
What is normal blood glucose 40-80

in the term neonate?
When is PKU testing done At 2-3 days of life

usually?
What should patients be taught Lethargy, temp > 100, vomiting, green stools, or
are signs that the doctor refusal of two feeds in a row.
should be called after
discharge?
When do most miscarriages Between 8 and 13 weeks.

occur?

Start IV of at least 18 gauge, give RhoGAM if

What interventions should be
indicated, and teach client to notify nurse with temp
done in patient having
> 100.4, foul-smelling discharge, or bright-red
miscarriage?
bleeding with tissue larger than a dime.
Because hCG levels that do not diminish can lead to

Why is hCG taken for a year
choriocarcinoma. Pregnancy must also be avoided
after hydatidiform mole?
for a year.
How is placentae abruptio Dark red vaginal bleeding, rigid uterus, and severe
different from previa? pain.
Notify MD! Do not manipulate abdomen or vagina,

give O2 by facemask, monitor for DIC signs, type
started with placentae
and cross-match, side-lying position, and prepare
abruptio?
for emergency C-section.
How is previa different from Painless, bright red bleeding, soft uterus, with FHR
abruption? usually normal.
Side-lying position, bed rest, bp and pulse every 15

minutes, start IV, type and screen, monitor blood
started with previa?
loss, prepare for u/s and possible c/s.
First trimester: Hgb < 11; Hct < 37%
How is anemia defined through

Second: Hgb < 10.5; Hct < 35%
the pregnancy?
Third: Hgb < 10 ; Hct < 32%
How is chlamydia treated in Erythromycin and treat for gonorrhea, too (penicillin
pregnancy? and/or erythromycin and ceftriaxone)
How is gonorrhea treated in Penicillin and/or erythromycin and ceftriaxone and

pregnancy? treat for chlamydia (erythromycin)
What HPV drug is Podophyllin is contraindicated; The one with the

contraindicated in pregnancy initials is still used (TCC/BCA, idk, lol)
and what drug is
recommended?
How is toxoplasmosis treated Sulfa drugs; maybe therapeutic abortion if

during pregnancy? discovered before 20 weeks.
How is Flagyl used during Its use is contraindicated in the first trimester and its
pregnancy? use in the second trimester is contraversial.
What are nursing implications Maternal pulse should not exceed 140 bpm, fetal
with Yutopar (Ritodrine) and heart rate should not exceed 180 bpm, and keep
terbutaline? antidote (beta-blocking agent) available.
What are nursing implications Hold if respirations are < 12/min or urine output is <
with Mag sulfate? 100 mL/4hrs; keep calcium gluconate handy
Check bp for hypotension immediately before

What are nursing implications
given, do not use with Mag, and dangle before
with Procardia (nifedipine)?
rising.
What are nursing implications Only give for 48 hours or less, do not use for
with indomethacin? women with bleeding potential, and give with food.
Respirations < 12/min, urine output < 100 mL/4 hr,

What are signs of mag toxicity
absent DTRs, Mag serum levels > 8mg/dL; Hold
and what should be done?
dose and notify provider.
What are symptoms of uterine Sharp pains accompanied by abrupt cessation of

rupture? contractions.

What is the main drug given for Mag sulfate

preeclampsia in the hospital?
When are antihypertensives If the diastolic is greater than 110 mm Hg, and then
given to the preeclamptic hydralazine is given.
patient?
When is the risk of seizures 48 hours after birth

usually gone in the
preeclamptic patient?
What drugs should cardiac Terbutaline or Yutopar (ritodrine HCl) because of

patients NOT get for preterm the risk of myocardial ischemia.
labor?
What can cause problems Normal postpartum diuresis can increase CO.
postpartum in the cardiac
patient?
What anticoagulant can be Heparin

used in pregnancy?
Can oral hypoglycemics be Nope.

taken during pregnancy?
What insulin should be used Regular insulin

during labor?
Transient tachypnea of the newborn; commonly

What is TTN?
seen in c/s babies

What instructions should be Bedrest for 24-48 hours, no sex for 2 weeks.
given to the woman with a
threatened abortion?
When cervix is < 4cm dilated, <50% effacement, and

When can preterm labor be
membranes are intact and not bulging out of the
arrested?
cervical os.
What is considered a > 14 hours

prolonged latent phase in a
multipara?
What is considered a > 20 hours

prolonged latent phase in a
nullipara?
Name three conditions that DM Preeclampsia, hydramnios, and infection

patients are likely to develop in
pregnancy.
Can insulin be used in Yes

breastfeeding?
What is the euglycemia goal 70-90 mg/dL

for the diabetic patient in
labor?
What type of contraceptive They should avoid estrogen. They should also avoid
should diabetics use? IUDs due to the increased risk for infection.
What interventions are used Semi- or high- Fowler position, prevent valsalva,
during the labor of a cardiac side-lying position for regional anesthesia, and
patient? avoid stirrups.
What immediate nursing Massage fundus, notify HCP if fundus doesn't get
interventions should be taken firm with massage, count pads, assess vital signs,
when a postpartum increase IV fluids, and administer oxytocin as
hemorrhage is detected? prescribed.
Subinvolution, lochia returning to rubra with

What are signs of
possible foul smell, temper of 100.4 or higher, and
endometritis?
unusual fundal tenderness.
Only if pus present or antibiotics are

When should breastfeeding be contraindicated for neonate. However, the mother
discontinued in the patient with may throw away expressed milk to help condition
mastitis? and resume breastfeeding after the infection has
cleared.
What two diseases can cause Hypoglycemia and hypocalcemia

jitteriness in the newborn?
What is the Silverman- A measure of respiratory distress where 10 is severe

Anderson Index? and 1 is okay.
What complications can result Retinopathy of prematurity and bronchopulmonary

from O2 toxicity? dysplasia.
What are complications with NEC, PDA, or intraventricular hemorrhage.

neonatal hypoxia?
Blanche forehead with thumb. If jaundiced, skin will

How do you assess for turn yellow before normal skin color reappears. In
jaundice in the infant? dark-skinned infants, observe conjunctival sac and
oral mucosa.

What is the dangerous bilirubin The unconjugated, indirect type.

type?
When should compressions be HR < 60 bpm; do 90 compressions and 30 breaths.

done in a newborn?
When administering digoxin pulse rate is below 100 beats/min

(Lanoxin) to an infant, the
medication should be withheld
and the physician notified if
the:
1.) pulse rate is below 60

beats/min
2.) infant is dyspneic
3.) pulse rate is below 100

beats/min
4.) respiratory rate is above 40

breaths/min
An infant with tetralogy of Knee-chest

Fallot is experiencing a tet
attack involving cyanosis and
dyspnea. Which position
should the infant be placed in?
1.) Fowler's
2.) Knee-chest
3.) Trendelenburg's
4.) Prone

Prevention of rheumatic fever having sore throats cultured as soon as possible

can best be accomplished by:
1.) keeping children with fever

home
2.) sending children with sore

throats home from school
3.) having sore throats cultured

as soon as possible
4.) treating all colds with

antibiotics
The nurse is assessing a child peeling skin on fingers

admitted with possible
Kawasaki's disease. A
characteristic sign or symptom
that the nurse should observe
and document would be:
1.) cardiac dysrhythmia
2.) decreased urine output
3.) peeling skin on fingers
4.) decreased level of

consciousness

A child who has had heart keep the drainage bottle below the chest level at all
surgery returns to the pediatric times
unit with a chest tube and
drainage bottles in place. What
is a priority nursing
responsiblity when caring for a
child with chest tubes?
1.) empty the chest tube

drainage bottles each shift
2.) clamp the chest tubes when

turning the patient
3.) place the drainage bottles

ont he bed when moving the
bed
4.) keep the drainage bottle

below the chest level at all
times
When the patient experiences stops the transfusion, allows normal saline solutions
apprehension and urticaria to run slowly, and notifies the charge nurse
while receiving a blood
transfusion, the nurse:
1.) slows the transfusion and

takes the patient's vital signs
2.) observes the child for

further transfusion reactions
3.) stops the transfusion, allows

normal saline solution to run
slowly, and notifies the charge
nurse
4.) stops what he or she is

doing and obtains the patient's
history

Thalassemia major (Cooley's multiple blood transfusions

anemia) is treated primarily
with:
1.) a diet high in iron
2.) multiple blood transfusions
3.) bed rest until the

sedimentation rate is normal
4.) oxygen therapy
A child who is in a may induce seziures

vasoocclusive crisis caused by
sickle cell anemia is
experiencing acute pain. The
nurse understands that
Demerol (Meperidine) is not an
appropriate pain medication to
administer to this child because
it:
1.) is very addictive
2.) is not strong enough
3.) may induce seizures
4.) cannot be given by mouth

Which principle should the administer between meals

nurse teach the parent
concerning administering
liquid iron preparations to the
child with iron-deficiency
anemia?
1.) allow the preparation to mix

with saliva and bathe the teeth
before swallowing
2.) warm the medication before

administering
3) administer between meals
4.) administer in the bottle of

formula
What is a characteristic enlarged lymph nodes

manifestation of Hodgkin's
Disease?
1.) petechiae
2.) erythematous rash
3.) enlarged lymph nodes
4.) pallor
The pathologic disturbance of hypertrophy of the pyloric muscle

pyloric stenosis results from:
1.) edema of the pyloric muscle
2.) ischemia of the pyloric

muscle
3.) hypertrophy of the pyloric

muscle
4.) neoplastic obstruction

Which menu selections are corn tortilla and fresh fruit

best for a child diagnosed with
celiac disease?
1.) pizza and chocolate cake
2.) spaghetti and blueberry

muffin
3.) chicken sandwich on whole-

wheat bread
4.) corn tortilla and fresh fruit
After surgery for pyloric Be fed clear liquids within 6 hours

stenosis, the nurse could
anticipate that the infant will:
1.) have nasogastric suction for

24 hours
2.) be fed clear liquids within 6

hours
3.) remain NPO for 24 to 48

hours
4.) be fed formula within 4

hours
How are pinworms diagnosed?

A "Scotch tape test" in the early morning
1.) seeing the worm in the stool
2.) a blood antigen level
3.) A "Scotch tape test" in the

early morning
4.) a stool laboratory

examination obtained at the
hour of sleep

Priority teaching for a parent of slicing each stool passed to observe for the foreign
a child who ingested a foreign body
body includes:
1.) encouraging the use of a

mild laxative every night
2.) slicing each stool passed to

observe for the foreign body
3.) encouraging a daily enema

until the foreign body is passed
4.) keeping the child NPO until

the foreign body is passed
The nurse understands that strategies that preserve the child's body image
genitourinary surgery affects
growth and development.
When caring for a 4-year-old
child postoperatively, a priority
nursing responsibility would
include:
1.) strategies that preserve the

child's body image
2.) assurances that appearance

and sexual function will not be
affected
3.) providing age-appropriate

toys such as tricycles
4.) preventing embarrassment

by limiting visitation of family
and frients

The administration of increased risk of infection

prednisone to children with
nephrosis creates the problem
of:
1.) intolerance of foods
2.) increased risk of infection
3.) increased periorbital edema
4.) weight loss
Daily weights are obtained in changes in the amount of edema

children with nephrosis to
monitor:
1.) weight loss from a low-

protein diet
2.) accuracy of fluid balance

sheets
3.) changes in the amount of

edema
4.) percentile on the growth

grid
A priority nursing responsibility omit abdominal palpation during daily assessments

in the care of a child with
Wilms' tumor is to:
1.) maintain accurate intake and

output records
2.) omit abdominal palpation

during daily assessments
3.) maintain strict bed rest
4.) assess neurological function

The nurse is caring for a child massive proteinuria
diagnosed with nephrosis. edema

Symptoms that are
characteristic of nephrosis
include (select all that apply)
1.) massive proteinuria
2.) edema
3.) a positive antistreptolysin

titer
4.) bacteriuria
What is an important aspect of the routine administration of growth hormone

a teaching plan for the parent should be carried out at bedtime
of a child with hypopituitarism?
1.) the child should be enrolled

in a special education program
at school
2.) the routine administration of

growth hormone should be
carried out at bedtime
3.) all family members should

have an endocrine workup
4.) the routine medication

should be administered before
the school day starts

A child who has diabetes insulin is destroyed by digestive enzymes

mellitus asks why he cannot
take insulin orally instead of by
subcutaneous injection. The
best response of the nurse
would be that:
1.)pills are only for adults
2.) insulin is destroyed by

digestive enzymes
3.) insulin can cause a stomach

ulcer
4.) insulin interacts with food in

the stomach
What may indicate a need for red lips and fruity odor to the breath
insulin in a diabetic child?
1.) diaphoresis and tremors

2.) red lips and fruity odor to
the breath
3.) confusion and lethargy
4.) headache and pallor
The nurse teaches the diabetic prevent lipoatrophy of subcutaneous fat

child to rotate sites of insulin
injection in order to:
1.) prevent subcutaneous

deposit of the drug
2.) prevent lipoatrophy of

subcutaneous fat
3.) decrease the pain of the

injection
4.) increase absorption of

insulin

Kussmaul's respirations are ketoacidosis

seen in diabetic children with:
1.) neuropathy
2.) ketoacidosis
3.) hypoglycemia
4.) retinopathy
The adolescent with anorexia feeling "fat" even when appearing thin
nervosa has a body self-image
characteristically expressed by:
1.) wearing tight clothing to

emphasize thinness
2.) increasing elation as weight

is lost
3.) feeling "fat" even when

appearing thin
4.) efforts to achieve specific

figure measurements
A priority goal in the approach correct malnutrition

to a child with anorexia
nervosa is to"
1.) encourage weight gain
2.) prevent depression
3.) limit exercise
4.) correct malnutrition
A child with suspected bulimia erosion of tooth enamel

should be assesed for:
1.) abnormal weight gain
2.) abnormal weight loss
3.) erosion of tooth enamel
4.) amenorrhea

An important approach to the a structured one-on-one environment

care for a 7-year-old child
diagnosed with attention
deficit hyperactivity disorder is
to encourage:
1.) a diet high in processed

foods
2.) regular use of sedatives
3.) strict discipline
4.) a structured, one-on-one

environment
When assessing an 8-year-old ritualistic behavior

child with obsessive
compulsive disorder, the nurse
would expect to find:
1.) an intelligence deficit
2.) ritualistic behavior
3.) antisocial behavior
4.) combative behavior
self centered, show off rude 6Y
extreme sensitivity to criticism 6Y
begins losing temporary teeth 6Y
appearance of first permanent 6Y

teeth
tie knots 6Y
temporal perception
bstrandable NCLEX improving 7Y 3
OB/Peds 2 of
increased self reliance for 7Y

basic activities
team games/ sports/ 7Y

organizations
friends sought out actively 8Y
eye development generally 8Y

complete
movements more graceful 8Y
writing replaces printing 8Y
skillful manual work possible 9Y
conflicts between adult 9Y

authorities and peer groups
better behaved 9Y
conflict between needs for 9Y

independence and
dependence
likes school 9Y
remainder of teeth 10-12Y
uses telephone 10-12Y

capable of helping 10-12Y
increasingly responsible 10-12Y
more selective when choosing 10-12Y

friends
develops beginning of interest 10-12Y

in opposite
loves conversation 10-12Y
raises pets 10-12Y
what stage are school age in industry v. inferiority

head sags 1M
early crawling movements 1M
closing of posterior fontanelle 2M
diminished tonic neck 2M
diminished moro reflex 2M
able to turn from side to back 2M
eyes begin to follow a moving 2M

object

Social smile first appears 2M
can bring objects to mouth at 3M

will
head held erect, steady 3M
binocular vision 3M
smiles in mother's presence 3M
laughs audibly 3M
appearance of thumb 4M
apposition
absent tonic neck reflex 4M
evidence of pleasure in social 4M

contact
drooling 4M
moro reflex absent after 3-4 M 4M
Birth weight usually doubled 5M
takes objects presented to 5M

him/her
average weight gain of 4 oz 6M

per week
teething may begin 6M
lower central incisors come in 6M
can turn from back to stomach 6M
early ability to distinguish and 6M

recognize strangers
sits for short periods using 7M

hands for support
grasps toy with hand 7M
fear of strangers begins to 7M

appear
lability of mood (abrupt mood 7M

shifts)
anxiety with strangers 8M
elevates self to sitting position 9M
rudimentary imitative 9M
expression
responds to parental anger 9M
expressions like dada may be 9M

heard

crawls well 10 M
pulls self to standing position 10 M

with support
brings hands together 10 M
vocalizes one or two words 10 M
erect standing posture with 11 M

support
birth weight usually trippled 12 M
needs help while walking 12 M
sits from standing position 12 M

without assistance
eats with fingers 12 M
usually says two words in 12 M

addition to mama and dada
doll's reflex disappears 2-3M
drooling begins 4M
responds to their own name 6-8M
takes deliberate steps when 9-10M

standing
pick up bite size pieces of 11M

ceral
1. Agent: Paramyxovirus (viral)
Rubeola (Measles)
2. Incubation period: 10-20 days
3. Communicable period: from 4 days before to 5

1. Agent?
days after rash appears.
2. Incubation period?
4. Source: Respiratory tract secretions, blood, or

3. Communicable period?
urine
4. Source?
5. Transmission: Airborne particles or direct contact

5. Transmission?
with infectious droplets; transplacental
1. Fever
2. Malaise
3. The three "C's" - coryza, cough, conjunctivitis
4. Red, erythematous maculopapular eruption

starting on face and spreading down towards feet;
Rubeola (Measles)
blanches with pressure and gradually turns

brownish color (1 week)
5 Signs and symptoms

5. Koplik's spots: small red spots with a bluish white
center and red base, located on buccal mucosa
Remember: Three "Cs" & Koplik's spots are the key

for identifying measles.
Roseola (Exanthema Subitum)

1. Agent: Human herpesvirus type 6 (viral)

1. Agent?
3. Communicable period: unknown, but thought to
be from febrile stage to time rash appears
4. Source: unknown
4. Source?
5. Transmission: unknown
5. Transmission?

1. Sudden high (>38.8 C / >102 F) fever of 3 to 5 day's

duration in a child that appears well, followed by a
rash (rose-pink macules that blanch with pressure.
Roseola (Exanthema Subitum)
2. Rash appears several hours to 2 days after fever

subsides and lasts 1 to 2 days.
2 Signs and symptoms?

Disease is self-limiting and treatment is supportive.

Remember: fever first, then rash.
Mumps
1. Agent: Paramyxovirus (viral)

1. Agent?
3. Communicable period: Immediately before and
after parotid gland swelling begins.
4. Source: Saliva of infected persons.
4. Source?
5. Transmission: Direct contact or droplet spread
5. Transmission?
1. Fever
2. Headache and malaise
3. Anorexia
Mumps
4. Jaw or ear pain aggravated by chewing, followed

by parotid gland swelling.
5 signs and symptoms

5. Orchitis (inflamed testes) may occur
Remember: Key is parotid gland swelling.
1. Agent: Bordetella pertussis (Gram negative

Pertussis (Whooping Cough)
bacteria)
2. Incubation period: 5-21 days (usually 10)
1. Agent?
3. Communicable period: greatest during the

catarrhal stage
4. Source: Discharge from resp. tract of infected

4. Source?
person
5. Transmission?
5. Transmission: Direct contact or droplet spread

1. Symptoms of respiratory infection followed by

increased severity of cough, with a loud, whooping
INSPIRATION.
2. May experience cyanosis, resp. distress, and

Pertussis (Whooping Cough)
tongue protrusion.
3. Listlessness, irritability, anorexia.

Remember: Key is whooping inspirations. Child will

be receiving antimicrobials. Institute airborne
precautions and isolate child.
1. Agent: Group A beta-hemolytic streprococci

(Gram positive bacteria)
Scarlet Fever
2. Incubation period: 1 to 7 days

3. Communicable period: About 10 days during the
1. Agent?
incubation period and clinical illness; during the first
2 weeks of the carrier stage, although may persist
for months.
4. Source?
4. Source: Nasophayngeal secretions of infected
5. Transmission? person and carriers.
5. Transmission: Direct contact or droplet spread;

indirectly by contact with contaminated articles.

1. Abrupt high fever, flushed cheeks, vomiting,

headache, enlarged lymph nodes in neck, malaise,
ab. pain
2. Red, fine, sandpaper-like rash develops in the
axilla, groin, and neck that spreads to cover the
entire body except face.
3. Rash blanches with pressure, except in areas of

deep creases and folds of joints.
Scarlet Fever
4. Desquamanation of skin on palms and soles

appears by weeks 1-3
7 signs and symptoms 5. Tongue is initially coated by white, furry covering

with red papillae; by fifth day, white coat sloughs off
leaving red, swollen tongue (White strawberry
tongue -> Red strawberry tongue)
6. Tonsils are reddened and covered with exudate.
7. Pharynx is edematous and beefy red
Remember: Key is the strawberry tongue
Erythema Infectiosum (Fifth 1. Agent: Human Parvovirus B19 (viral)
Disease)
2. Incubation period: 4 - 14 days, may be 20 days
3. Communicable period: Uncertain, but before

1. Agent?
onset of symptoms in most children.
4. Source: Infected persons
5. Transmission: Unknown mode of transmission,
4. Source?
possibly resp. secretions and blood.
5. Transmission?

Fifth Disease is marked by a rash that appears in

three stages. Just prior to the rash appearance the
child may experience mild fever, malaise, headache
or runny nose.
Stage 1: Erythema on face, chiefly on cheeks.

"Slapped cheek" appearance. Disappears by 1 - 4
days.
Stage 2: About 1 day after rash appears on face,

Erythema Infectiosum (Fifth
maculopapular red spots appear, symmetrically
Disease)
distributed on the extremities; the rash progresses

from proximal to distal surfaces and may last a week
Signs and symptoms
or more.
Stage 3: The rash subsides, but may reappear if skin

becomes irritated by sun, heat, cold, exercise, or
friction.
REMEMBER: Pregnant women need to avoid

infected persons. Key to identification is "slapped
cheek" appearance. Child is not usually hospitalized
as disease is self-limiting.
Infectious Mononucleosis
1. Agent: Epstein-Barr virus (viral)

2. Incubation period: 4 to 6 weeks
1. Agent?
3. Communicable period: Unknown
4. Source: Oral secretions
5. Transmission: Direct intimate contact
4. Source?
5. Transmission?

1. Fever, malaise, headache, fatigue, nausea,

abdominal pain, sore throat, enlarged red tonsils.
2. Lymphadenopathy and hepatosplenomegaly
Infectious Mononucleosis
3. Discrete macular rash most prominent over the

trunk may occur.
3 signs and symptoms and 1

important complication to
TEACH PARENTS TO MONITOR FOR SPLENIC
teach parents to monitor for.
RUPTURE: Marked by abdominal pain, left upper
quadrant pain, referred left-shoulder pain.
1. Agent: Varicella-zoster virus (viral)
3. Communicable period: From 1 to 2 days before

Chickenpox (Varicella)
the onset of rash to 6 days after the first crop of

vesicles, when crusts have formed.
1. Agent?
4. Source: Respiratory tract secretions of infected

persons; skin lesions.
5. Transmission: Direct contact, droplet,

4. Source?
contaminated objects
5. Transmission?

REMEMBER: Child is no longer contagious once

lesions have dried and crusts have formed.
1. Slight fever, malaise, and anorexia are followed by

a macular rash that first appears on the trunk and
Chickenpox (Varicella)
scalp and move to the face and extremities.

2. Lesions become pustules, begin to dry, and
3 signs and symptoms develop a crust.
3. Lesions may appear on mucous membranes of

mouth, genital area, or rectum.

1. Agent: Rubella virus (viral)
Rubella (German Measles)
3. Communicable period: From 7 days before to

about 5 days after rash appears.
1. Agent?
4. Source: Nasopharyngeal secretions; virus is also

present in blood, stool, urine.
5. Transmission: Airborne or direct contact

4. Source?
w/infectious droplets. Indirectly via articles freshly

5. Transmission?
contaminated. Also transplacental.
1. low-grade fever
2. Malaise
3. Pinkish red maculopapular rash the begins on

face and spreads to the entire body within 1 to 3
Rubella (German Measles)
days.
4. Petechial, red, pinpoint spots may appear on the

4 signs and symptoms and 1 soft palate.
very important intervention to
remember Key for identification is rash covering entire body

and spots on soft palate.
REMEMBER: ISOLATE CHILD FROM PREGNANT

WOMEN.
1. Agent: Corynebacterium diptheriae

Diphtheria
3. Communicable period: Variable. Until virulent

bacteria are no longer present (three consecutively

1. Agent?
negative cultures of pharyngeal secretions); usually

2 weeks, can be 4 weeks.
4. Source: Discharge from mucous membranes of

4. Source?
nose and nasopharynx, skin and other lesions.
5. Transmission?
5. Transmission: Direct contact with infected person,
carrier, or contaminated articles
1. low-grade fever, malaise, sore throat
2. Foul-smelling, mucoprurulent nasal discharge
3. Dense pseudomembrane formation of the throat

that may interfere with eating, drinking and
Diphtheria
breathing.
4. Lymphadenitis, neck edema, "bull neck"
4 signs and symptoms and 2

important interventions
Interventions: Strict isolation for hospitalized child.
Administer diphtheria antitoxin only AFTER a skin or
conjunctival test rules out sensitivity to horse serum.
Rocky Mountain Spotted Fever

1. Agent: Rickettsia rickettsii (Gram negative

bacteria)
1. Agent?
3. Communicable period: NOT CONTAGIOUS
4. Source: Tick bite from mammal, usually wild
4. Source?
rodents and dogs.
5. Transmission? 5. Transmission: Tick bite
1. Fever, malaise, anorexia, vomiting, headache,

myalgia
2. Maculopapular OR petechial rash primarily on the

extremities (ankles and wrists), but may spread to
Rocky Mountain Spotted Fever
other areas, characteristically on the palms and

soles.

Key: Rash on ankles, wrists, palms and soles.

Remember it is not communicable. Provide parents
teaching about preventing tick bites.
H1N1 Vaccine: When are 6 months. Children younger than six months are not
children old enough to receive old enough, but family members and caregivers
it? should be vaccinated.

HPV vaccine is administered in three injections over

six months. First dose, then the second dose 2
Human Papillomavirus Vaccine
months later, followed by the final dose 6 months
after the first.
How many injections comprise
the full course of vaccination Girls can receive it around age 11 to 12.
and at what age should girls Boys can receive it from age 9 to 18.
receive it? What age should
boys receive it? Guards against cervical cancer and genital warts in
females and genital warts in males.
1. Individuals with a reaction to a previous injection.
Contraindications for HPV

2. PREGNANT WOMEN should not receive HPV
vaccine?
vaccine.
copies a circle 3Y
builds bridge w/ 3 cubes 3Y
less negativistic than toddler, 3Y

decreased tantrums
learns from experience 3Y
rides tricycle 3Y
walks backward and 3Y

downstairs without assistance
undressed without help 3Y
900 word vocab 3Y

uses sentences 3Y
may invent imaginary friend 3Y
climbs and jumps well 4Y
laces shoes 4Y
brushes teeth 4Y
1500 word vocab 4Y
skips and hops on one foot 4Y
throws overhead 4Y
runs well 5Y
jumps rope 5Y
dresses without help 5Y
2100 word vocab 5Y
tolerates increasing periods of 5Y

separation from parents
beginnings of cooperative play 5Y
gender specific behavior 5Y

skips on alternate feet 5Y
ties shoes 5Y
what stage are preschoolers in initiative versus guilt

1. As part of the postpartum A. Presence of soft, nontender colostrum.
assessment, the nurse
examines the breasts of a Breasts are essentially unchanged for the first 2 to 3
primiparous breastfeeding days after birth. Colostrum is present and may leak
woman who is 1 day from the nipples.
postpartum. An expected Leakage of milk occurs around day 2 or 3.
finding would be:

Engorgement occurs at day 2 or 3 postpartum.
A. Presence of soft, nontender A few blisters and a bruise indicate problems with
colostrum.
the breastfeeding techniques being used.
B. Leakage of milk at let-down
C. Swollen, warm, and tender

on palpation.
D. A few blisters and a bruise

on each areola.

2. A woman gave birth to a 7- B. Excessive uterine bleeding.
pound, 3-ounce infant boy 2
hours ago. The nurse A urinary tract infection may result from
determines that the woman's overdistention of the bladder, but it is not the most
bladder is distended because serious consequence.
her fundus is now 3 cm above Excessive bleeding can occur immediately after
the umbilicus and to the right birth if the bladder becomes distended because it
of the midline. In the immediate pushes the uterus up and to the side and prevents it
postpartum period, the most from contracting firmly.
serious consequence likely to A ruptured bladder may result from a severely

occur from bladder distention overdistended bladder. However, vaginal bleeding
is:
most likely would occur before the bladder reaches
A. Urinary tract infection.
this level of overdistention.
B. Excessive uterine bleeding.

Bladder distention may result from bladder wall
C. A ruptured bladder.
atony. The most serious concern associated with
D. Bladder wall atony. bladder distention is excessive uterine bleeding.

3. Which statement by a newly B. "My first menstrual cycle will be heavier than
delivered woman indicates that normal, and my period will return to my
she knows what to expect prepregnant volume within three or four cycles."
about her menstrual activity
after childbirth?
She can expect her first menstrual cycle to be
A. "My first menstrual cycle will heavier than normal, and the volume of her
be lighter than normal and subsequent cycles to return to prepregnant levels
then will get heavier every within three or four cycles.
month thereafter."
Saying the first menstrual cycle will be heavier than
B. "My first menstrual cycle will normal and the subsequent three or four cycles will
be heavier than normal, and return to prepregnant volume is an accurate
my period will return to my statement and indicates her understanding of her
prepregnant volume within expected menstrual activity.
three or four cycles."

Most women experience a heavier than normal flow
C. "I will not have a menstrual during the first menstrual cycle, which occurs by 3
cycle for 6 months after months after childbirth.
childbirth."
She can expect her first menstrual cycle to be
D. "My first menstrual cycle will heavier than normal, and the volume of her
be heavier than normal and subsequent cycles to return to prepregnant levels
then will be light for several within three or four cycles.
months after."

4. Which description of B. The vagina gradually returns to prepregnancy size

postpartum restoration or by 6 to 10 weeks after childbirth.
healing times is accurate?

A. The cervix shortens, The cervix regains its form within days; the cervical
becomes firm, and returns to os may take longer to return to form.
form within a month The vagina returns to prepregnancy size by 6 to 10

postpartum.
weeks; however, lubrication may take longer to
B. The vagina gradually returns return to prepregnancy level.
to prepregnancy size by 6 to 10 Most episiotomies take 2 to 3 weeks to heal.
weeks after childbirth.

Hemorrhoids can take 6 weeks to decrease in size.
C. Most episiotomies heal
within a week.
D. Hemorrhoids usually
decrease in size within 2 weeks
of childbirth.
5. The breasts of a bottle- A. Wear a snug, supportive bra.
feeding woman are engorged.
The nurse should tell her to:

A snug, supportive bra limits milk production and
A. Wear a snug, supportive bra. reduces discomfort by supporting the tender
B. Allow warm water to soothe breasts and limiting their movement.
the breasts during a shower.
Cold packs reduce tenderness, whereas warmth
C. Express milk from breasts would increase circulation, thereby increasing
occasionally to relieve discomfort.
discomfort.
Expressing milk results in continued milk production.
D. Place absorbent pads with Plastic liners keep the nipples and areola moist,
plastic liners into her bra to leading to excoriation and cracking.
absorb leakage.

C. More noticeable in births in which the uterus was

6. With regard to afterbirth overdistended.
pains, nurses should be aware
that these pains are:

The cramping that causes afterbirth pains arises
A. Caused by mild, continuous from periodic, vigorous contractions and
contractions for the duration of relaxations, which persist throughout the first part of
the postpartum period.
the postpartum period.
B. More common in first-time Afterbirth pains are more common in multiparous

mothers.
women because first-time mothers have better
C. More noticeable in births in uterine tone.
which the uterus was A large baby or multiple babies overdistend the
overdistended.
uterus and this accounts for afterbirth pains.
D. Alleviated somewhat when Breastfeeding intensifies afterbirth pain because it

the mother breastfeeds. stimulates contractions.
7. Postbirth uterine/vaginal D. Should smell like normal menstrual flow unless an

discharge, called lochia:
infection is present.
A. Is similar to a light menstrual
period for the first 6 to 12 Lochia flow should approximate a heavy menstrual
hours.
period for the first 2 hours and then steadily
B. Is usually greater after decrease.
cesarean births.
Less lochia usually is seen after cesarean births.
C. Will usually decrease with Lochia usually increases with ambulation and
ambulation and breastfeeding.
breastfeeding.
D. Should smell like normal An offensive odor usually indicates an infection.

menstrual flow unless an
infection is present.

8. Although all other joints A. True
return to their normal
prepregnancy state, those in This is an accurate statement.

the parous woman's feet do
not. The new mother may
notice a permanent increase in
her shoe size.
A. True
B. False
9. Changes in the maternal B. False
immune system during the
postpartum period account for No significant changes in the maternal immune

the profuse diaphoresis that system occur during the postpartum period.
new mothers experience.
A. True
B. False
10. When palpating the fundus C. Assist the woman to empty her bladder
of a woman 18 hours after birth,
the nurse notes that it is firm, 2 A firm fundus should not be massaged because
fingerbreadths above the massage could overstimulate the fundus and cause
umbilicus, and deviated to the it to relax.
left of midline. The nurse Methergine is not indicated in this case because it is
should:
an oxytocic and the fundus is already firm.
A. Massage the fundus.

The findings indicate a full bladder, which pushes
B. Administer Methergine, 0.2 the uterus up and to the right or left of midline. The
mg PO, that has been ordered recommended action would be to empty the
prn.
bladder. If the bladder remains distended, uterine
C. Assist the woman to empty atony could occur, resulting in a profuse flow.
her bladder
A Firm fundus that is 2 fingerbreadths above the
D. Recognize this as an umbilicus and deviated to the left of midline is not a
expected finding during the normal finding, and an action is required.
first 24 hours following birth

D. Pain in left calf with dorsiflexion of left foot
11. Which finding would be a

Postural hypotension is an expected finding related
source of concern if noted
to circulatory changes after birth.
during the assessment of a

A temperature of 100.4° F in the first 24 hours most
woman who is 12 hours'
likely indicates dehydration, which is easily
postpartum?
corrected by increasing oral fluid intake.
A. Postural hypotension
A heart rate of 55 beats/min is an expected finding

B. Temperature of 100.4° F
in the initial postpartum period.
C. Bradycardia—pulse rate of
Findings of pain in the left calf with dorsiflexion of
55 beats/min
the left foot indicate a positive Homan's sign and

D. Pain in left calf with
are suggestive of thrombophlebitis and should be
dorsiflexion of left foot
investigated.
12. The nurse examines a B. Massage her fundus.
woman 1 hour after birth. The
woman's fundus is boggy, There is no indication of a distended bladder; thus

midline, and 1 cm below the having the woman urinate will not alleviate the
umbilicus. Her lochial flow is problem.
profuse, with two plum-sized A boggy or soft fundus indicates that uterine atony
clots. The nurse's initial action is present. This is confirmed by the profuse lochia
would be to:
and passage of clots. The first action would be to
A. Place her on a bedpan to massage the fundus until firm.
empty her bladder.

The physician can be called after massaging the
B. Massage her fundus.
fundus, especially if the fundus does not become or
C. Call the physician.
remain firm with massage.
D. Administer Methergine, 0.2 Methergine can be administered after massaging

mg IM, which has been the fundus, especially if the fundus does not
ordered prn. become or remain firm with massage.

13. Perineal care is an D. Uses the peribottle to rinse upward into her
important infection control vagina.
measure. When evaluating a
postpartum woman's perineal Washing the vulva and perineum with soap and
care technique, the nurse water is an appropriate measure.
would recognize the need for Washing from symphysis pubis back toward
further instruction if the episiotomy is an appropriate measure.
woman:
Changing the perineal pad every 2 to 3 hours in an
A. Uses soap and warm water appropriate measure.
to wash the vulva and The peribottle should be used in a backward

perineum.
direction over the perineum. The flow should never
B. Washes from symphysis be directed upward into the vagina because debris
pubis back to episiotomy.
would be forced upward into the uterus through the
C. Changes her perineal pad still-open cervix.
every 2 to 3 hours.
D. Uses the peribottle to rinse

upward into her vagina.
14. Which measure would be C. Massage the fundus every hour for the first 24
least effective in preventing hours following birth.
postpartum hemorrhage?

A. Administer Methergine, 0.2 Administration of Methergine can help prevent

mg every 6 hours for four postpartum hemorrhage.
doses, as ordered.
Voiding frequently can help the uterus contract,
B. Encourage the woman to thus preventing postpartum hemorrhage.
void every 2 hours.

The fundus should be massaged only when boggy
C. Massage the fundus every or soft. Massaging a firm fundus could cause it to
hour for the first 24 hours relax.
following birth.
Rest and nutrition are helpful for enhancing healing
D. Teach the woman the and preventing hemorrhage.
importance of rest and
nutrition to enhance healing.

A. Health maintenance organizations (HMOs) and

private insurers.
15. While admitting the

pregnant woman, the nurse

The trend for shortened hospital stays is based
should be aware that
largely on efforts to reduce health care costs.
postpartum hospital stays that

Secondarily consumers have demanded less
are becoming shorter are
medical intervention and more family-centered
primarily the result of the
experiences.
influence of:
Hospitals are obligated to follow standards of care

A. Health maintenance
and federal statutes regarding discharge policies.
organizations (HMOs) and

The Newborns' and Mothers' Health Protection Act
private insurers.
provided minimum federal standards for health plan

B. Consumer demand.
coverage for mothers and their newborns. Under

C. Hospitals.
this act, couples were allowed to stay in the hospital

D. The federal government.
for longer periods.
16. Discharge instruction, or A. At the time of admission to the nurse's unit.
teaching the woman what she
needs to know to care for Discharge planning, the teaching of maternal and
herself and her newborn, newborn care, begins on the woman's admission to
officially begins:
the unit, continues throughout her stay, and actually
A. At the time of admission to never ends as long as she has contact with medical
the nurse's unit.
personnel.
B. When the infant is presented
to the mother at birth.
C. During the first visit with the

physician in the unit.
D. When the take-home

information packet is given to
the couple.
17. The _________________________ test is The correct response is "Kleihauer-Betke"

used to detect the amount of
fetal blood in the maternal
bstrandable
circulation. NCLEX OB/Peds 2 of 3
18. When making a visit to the C. Vacillate between the desire to have her own
home of a postpartum woman nurturing needs met and the need to take charge of
1 week after birth, the nurse her own care and that of her newborn.
should recognize that the
woman would Expressing a strong need to review events is

characteristically:
characteristic of the taking-in stage, which lasts for
A. Express a strong need to the first few days after birth.
review events and her behavior Exhibiting a reduced attention span is characteristic
during the process of labor of the taking-in stage, which lasts for the first few
and birth.
days after birth.
B. Exhibit a reduced attention One week after birth, the woman should exhibit
span, limiting readiness to behaviors characteristic of the taking-hold stage.
learn.
This stage lasts for as long as 4 to 5 weeks after
C. Vacillate between the desire birth.
to have her own nurturing Reestablishing her role as spouse/partner reflects

needs met and the need to the letting-go stage, which indicates that
take charge of her own care psychosocial recovery is complete.
and that of her newborn.
D. Have reestablished her role

as a spouse/partner.

19. Parents can facilitate the A. Having the children choose or make a gift to give
adjustment of their other to the new baby on its arrival home.
children to a new baby by:

A. Having the children choose Having the sibling make or choose a gift for the new
or make a gift to give to the baby helps to make the child feel a part of the
new baby on its arrival home.
process.
B. Emphasizing activities that Special time should be set aside just for the other
keep the new baby and other children, time without interruption from the
children together.
newborn.
C. Having the mother carry the Someone other than the mother should carry the
new baby into the home so she baby into the home so she can give full attention to
can show him or her to the greeting her other children.
other children.
Children should be actively involved in the care of
D. Reducing stress on other the baby according to their ability but without
children by limiting their overwhelming them.
involvement in the care of the
new baby.

20. Many first-time parents do B. "Grandparents can help you with parenting skills
not plan on their parents' help and also help preserve family traditions."
immediately after the newborn
arrives. What statement by the Intergenerational help may be perceived as

nurse is the most appropriate interference, but a statement of this sort is not
when counseling new parents therapeutic to the adaptation of the family.
about the involvement of Stating that grandparents can help with parenting
grandparents?
skills and also help preserve family traditions is the
A. "You should tell your parents most appropriate response.
to leave you alone."

Stating that grandparent involvement can be
B. "Grandparents can help you disruptive is invalid; it also is not an appropriate
with parenting skills and also nursing response.
help preserve family traditions." Regardless of age, grandparents can help with
C. "Grandparent involvement parenting skills and can preserve family traditions.
can be very disruptive to the Stating that the grandparents are old is not the most
family."
appropriate statement, and it does not demonstrate
D. "They are getting old. You sensitivity on the part of the nurse.
should let them be involved
while they can."

21. The nurse observes that a B. Show the mother how the infant initiates
15-year-old mother seems to interaction and pays attention to her.
ignore her newborn. A strategy
that the nurse can use to Telling the mother she has to pay attention to the
facilitate mother-infant baby may be perceived as derogatory and is not
attachment in this mother is to:
appropriate.
A. Tell the mother she must pay Pointing out the responsiveness of the infant is a
attention to her infant.
positive strategy for facilitating parent-infant
B. Show the mother how the attachment.
infant initiates interaction and Educating the young mother in infant care is
pays attention to her.
important, but pointing out the responsiveness of
C. Demonstrate for the mother her baby is a better tool for facilitating mother-
different positions for holding infant attachment.
her infant while feeding.

Videos are an educational tool that can
D. Arrange for the mother to demonstrate parent-infant attachment, but
watch a video on parent-infant encouraging the mother to recognize the infant's
interaction. responsiveness is more appropriate.
A. Mutuality.

Mutuality extends the concept of attachment to

include this shared set of behaviors.
22. When the infant's behaviors Bonding is the process over time of parents forming
and characteristics call forth a an emotional attachment to their infant. Mutuality
corresponding set of maternal refers to a shared set of behaviors that is a part of
behaviors and characteristics, the bonding process.
this is called:
Claiming is the process by which parents identify
A. Mutuality.
their new baby in terms of likeness to other family
B. Bonding.
members and their differences and uniqueness.
C. Claiming.
Mutuality refers to a shared set of behaviors that is
D. Acquaintance. part of the bonding process.
Like mutuality, acquaintance is part of attachment. It

describes how parents get to know their baby
during the immediate postpartum period through
eye contact, touching, and talking.
23. A primiparous woman is in B. Provide time for the mother to reflect on the
the taking-in stage of events of and her behavior during childbirth.
psychosocial recovery and
adjustment following birth. Once the mother's needs are met, she would be
Recognizing the needs of more able to take an active role, not only in her own
women during this stage, the care but also the care of her newborn.
nurse should:
Women express a need to review their childbirth
A. Foster an active role in the experience and evaluate their performance.
baby's care.
Short teaching sessions, using written materials to
B. Provide time for the mother reinforce the content presented, are a more
to reflect on the events of and effective approach.
her behavior during childbirth.

The focus of the taking-in stage is nurturing the new
C. Recognize the woman's mother by meeting her dependency needs for rest,
limited attention span by giving comfort, hygiene, and nutrition.
her written materials to read
when she gets home rather
than doing a teaching session
now.
D. Promote maternal
independence by encouraging
her to meet her own hygiene
and comfort needs.

D. An environment that fosters as much privacy as

possible should be created.
24. Nursing activities that

promote parent-infant
Once the baby has demonstrated adjustment to
attachment are many and
extrauterine life (either in the mother's room or the
varied. One activity that should
transitional nursery), all care should be provided in
not be overlooked is the
one location. This important principle of family-
management of the
centered maternity care fosters attachment by
environment. While providing
giving parents the opportunity to learn about their
routine mother-baby care, the
infant 24 hours a day. One nurse should provide
nurse should ensure that:
care to both mother and baby in this couplet care

A. The baby is able to return to
or rooming-in model. It is not necessary for the
the nursery at night so that the
baby to return to the nursery at night. In fact, the
new mother can sleep.
mother will sleep better with the infant close by.
B. Routine times for care are

Care should be individualized to meet the parents'
established to reassure the
needs, not the routines of the staff. Teaching goals
parents.
should be developed in collaboration with the

C. The father should be
parents.
encouraged to go home at
The father or other significant other should be
night to prepare for mother-
permitted to sleep in the room with the mother. The
baby discharge.
maternity unit should develop policies that allow for

D. An environment that fosters
the presence of significant others as much as the
as much privacy as possible
new mother desires.
should be created.
Care providers need to knock before gaining entry.
Nursing care activities should be grouped.

25. During a phone follow-up C. Postpartum (PP) blues.
conversation with a woman
who is 4 days' postpartum, the The taking-in phase is the period after birth when
woman tells the nurse, "I don't the mother focuses on her own psychologic needs.
know what's wrong. I love my Typically this period lasts 24 hours.
son, but I feel so let down. I PPD is an intense, pervasive sadness marked by
seem to cry for no reason!" The severe, labile mood swings; it is more serious and
nurse would recognize that the persistent than the PP blues.
woman is experiencing:
During the PP blues, women are emotionally labile,
A. Taking-in.
often crying easily and for no apparent reason. This
B. Postpartum depression lability seems to peak around the fifth PP day.
(PPD).
Crying is not a maladaptive attachment response; it
C. Postpartum (PP) blues.
indicates PP blues.
D. Attachment difficulty.
26. What concerns about A. Infant safety
parenthood are often B. Transportation
expressed by visually impaired D. Missing out visually
mothers? Choose all that E. Needing extra time for parenting activities to
apply.
accommodate the visual limitations
A. Infant safety
B. Transportation
C. The ability to care for the

infant
D. Missing out visually
E. Needing extra time for

parenting activities to
accommodate the visual
limitations

A: bisexual
B: transsexual
C: homosexual
D: transvestite
A patient reports for a
preoperative appointment in
preparation for surgery that will B: transsexual
change his body from a female rationale:
to male. The patient has A transsexual is a person of certain biological

expressed to the nurse and gender who has the feelings of the opposite sex,
physician that he should been and the person is trapped within the body of the
born a man. What sexual wrong sex. For many transsexuals, the solution is to
orientation is the patient change their bodies. A homosexual is one who
demonstrating? experiences sexual fulfillment with a person of the
same gender. A bisexual is a person who finds
pleasure with both the opposite sex and same-sex
partners. A transvestite is an individual who desires
to take on the role or where the clothes of the
opposite sex.

A: excitement phase
B: resolution phase
C: orgasm
A female patient informs the

D: plateau phase
nurse that her husband is

concerned about her sexual

response. The patient reports

that during stimulation her

husband has noticed her

D: plateau phase
clitoris disappears, and he

rationale
wonders if she is enjoying the

during the plateau phase, the intensity of
experience despite her
excitement increases but not enough to cause
positive responses to his
orgasm. The female clitoris reacts and disappears
stimulation. The nurse explains
under the clitoral hood. This phase may last for 15 to
that building excitement and
20 minutes. The excitement phase is initiated by
retraction of the clitoris are
erotic stimulation and arousal, and physiologic
normal characteristics of which
changes begin. Orgasm defines the climax and
stage of the sexual response
sexual explosion of the tension that has been
cycle?
building during the preceding phases. The
resolution phase is the return to normal body
function.

A: condoms are recommended for anal intercourse.
B: anal intercourse and be avoided
C: lubricants should be avoided during anal

intercourse
During a routine physical exam, D: the rectal mucosa is thick and Withstand vigorous
a male patient forms the activity.
nursethat he frequently
participates in anal intercourse
with his new girlfriend. The
nurse discusses this practice A: condoms are recommended for anal intercourse.
with the patient by informing Rationale
the patient that: Condoms are recommended for anal and vaginal
intercourse to prevent sexually transmitted diseases.
Care should be used to avoid injury to the delicate
rectal mucosa, and lubrication is necessary for
comfort.
AA: "this is a strong sign that he is ready for toilet

training"
B: "you should just discourage this behavior now

before it worsens as he gets older"
A mother expressed concern C: "this this normal behavior for a child of his age"
because her three-year-old D: "we should obtain a urine sample to assess for an
son is fondling his penis. The infection"
mother does not know the best
approach for the child's
behavior. What is the nurses
response to the mother? C: "this is normal behavior for a child of the age"
rationale
children ages 1 to 3 enjoyed fondling their genitals.

Punishment for genital fondling may lead to guilt
and shame regarding sexual behavior later in life.

A: STI's are more prevalent among teenagers and

young adults
B: STI disproportionately affect people with a lower

social economic status and education.
C: the incidence of STI is decreasing due to limited

sex partners
D: the signs and symptoms of STI are obvious.
A school nurse is providing a

class on sexually-transmitted

infections (STIs). Which

A:STI's are more prevalent among teenagers and
statement is correct regarding
adults.
STI's?
Rationale
STIs are more prevalent among teenagers and

young adults, and nearly 2/3 of all STIs occur
people younger than 25 years age. The incident of
STI is increasing due to multiple sex partners and
sexual activity at a younger age. STI affect men and
women of all backgrounds and economic levels.

A: impotence
B: erectile failure
C: retarded ejaculation
D: premature ejaculation
A male patient informs the
urology nurse that he is
embarrassed because his wife
rarely has time to reach sexual Premature ejaculation
satisfaction because the rationale
experiences an orgasm as premature ejaculation is a condition in which a man

soon as he enters the vagina . reaches ejaculation or orgasm before or soon after
What is the condition best entering the vagina. Erectile failure, also known as
known as? impotence, is the inability of a man to maintain an
erection to the extent that he cannot have
satisfactory intercourse. Retarded ejaculation refers
to a man's inability to ejaculate into the vagina or
delayed intravaginal ejaculation.
A; Spermicides
B: Condoms
C: A cervical cap
D: A diaphragm
The nurse should inform a
young female client that the
barrier method providing the
best protection against STIs is: B: condoms
rationale
condoms provide effective (though imperfect)

protection against STIs. Spermicides, diaphragms,
and cervical cap donot provide effective protection
against STIs.

A: antibiotic
B: antihypertensives
C: nonsteroidal anti-drugs
D: bronchodilators
The nurse is justified in

assessing for sexual

dysfunction in patients who are

B: antihypertensives
receiving:
rationale
antihypertensives are among the drug implicated in

sexual dysfunction. Antibiotics, bronchodilators, and
NSAIDs do not typically have this effect.
A: a cervical cap
B: a diaphragm
C: a condom
D: the vaginal sponge
After receiving information on
various forms of birth control, a
young couple decides to use a
barrier methods because they B: a diaphragm
would like to try and conceive rationale
in a year or two. Which barrier a diaphragm in the dome shaped device made from
method uses a rubber barrier latex rubber that mechanically prevents semen from
to hold spermicide against the coming in contact with the cervix, and it holds a
cervix? spermicidal jelly in place against the cervix. A kind
of rolls over an erect penis collects the semen after
ejaculation. A cervical cap is placed over the cervix
and may be left in place for up to three days. A
vaginal sponge contains spermicide and of a
reservoir to hold the semen.

AA: environmental harassment
B: fetishism
C: quid pro quo harassment
D: hostile environment harassment
During hospitalization for a

suicide attempt, the patient

informs the nurse that she does

not want to return to work

C: quid pro quo harassment
because her boss expects

rationale
sexual favors each week

quid pro quo means that something is given or
before he gives her a
withheld in exchange for something else. It
paycheck. The patient finorms
generally occurs with a person in a position of
the nurse that she needs job
authority offers either direct or indirect reward or
but is embarrassed that she
punishment based on the granting of sexual favors.
performs these favors. The
Environmental harassment and hostile environment
nurse informs the patient that is
harassment are the situation and occur when
his illegal behavior and is
workplace behaviors of a sexual nature create a
called:
hostile, intimidating environment that interferes with
a person's work performance. Fetishism is sexual
arousal with the aid of an inanimate object not
generally associated with sexual activity.

A: sex is chromosomally determined, while gender

is a psychosocial construct.
B: Biologics sex and gender identity are considered

synonymous in nursing practice
C: Biologics facts and gender identity are both

modifiable by surgery and medical interventions.
D: Biologic sex is genetically determined but

gender identity is chosen during adolescence.
Which of the following
statements best describes the
relationship between biologic A: sex is chromosomally determined, while gender

sex and gender identity? is a psychosocial construct.
Rationale
biologic sex is the term used to denote

chromosomal sexual development. Gender identity
is the inner sense a person has of being male or
female. As such, Biologic sex is amenable to
medical intervention, but surgery and hormone
therapy will not change individuals inner sense of
being male or female. Gender identity is not
commonly thought to be chosen or objectively
selecting during adolescence.

A: Cervix
B: Fallopian tubes
C: Clitoris
D: ovaries
What are the uterus and vagina
connected by?
A: Cervix
rationale
the cervix is the structure at the lower portion of the

uterus that connects the uterus and vagina.
A: Increased blood flow to the penis
B: feelings of relaxation and fulfillment
C: the ability to begin the excitement phase again
D: intense physical pleasure
What is associated with the
resolution phase of the male B: Feelings of relaxation and fulfillment
sexual response cycle? rationale:
The resolution phase of the sexual response cycle is

associated with feelings of relaxation, fatigue, and
fulfillment. The most intense pleasure of a physical
nature takes place during orgasm and the male
experiences a refactory period during which he is
incapable sexual response. Blood flow to the penis
returns to normal levels during the resolution phase.

A: resource as shown the nature of sexual activity

changes with age but that it actually becomes more
frequent.
B: that's true, but it's important for us to give them

the teaching they need in order to resume this part
An elderly couple who have
of their relationship.
just relocated to a long-term

C: it's true that they probably stopped having sexual
care facility have been unable
activity, but it's important for them to have
to obtain a shared room. A staff
companionship.
member at the facility states
D: actually it's not ture that older people always
that this should not be a
stop having sexual activity when they get older.
concern and implies that

sexual activity between the

couple likely ceased many

years ago. How should the

D: actually it is not ture that older people always
nurse to best respond to this
stop having sexual activity when they get older.
individual's assertion?
Rationale
Sexual activity need not be hindered by age. There's

no evidence, however, that it becomes increasingly
frequent and late adulthood.

A 49-year-old woman has A: Dyspareunia
sought care from her primary B: a sexually transmitted infection (STI)
care provider because of C: Vaginismus
"intimacy problems". Upon D: Vulvodynia
questioning, I the woman
reveals that she is experiencing
sexual desire, but the
intercourse causes her A: Dyspareunia
significant pain. In the absence rationale
of sexual activity, the woman Dyspareunia is painful intercourse. Vaginismus is

states that she does not have characterized by difficult penetration rather than
any significant vaginal acute pain during intercourse, vulvodynia is
discomfort. What should the associated with pain that is not limited to
clinician recognize that this intercourse. And STI may or may not be contributing
patient is most likely to the woman's problem, though most cases of
experiencing? dyspareunia are related to infections.
A: Retarded ejaculation
B: Premature ejaculation
C: Erectile dysfunction
D; Sexually-transmitted infections
A 50-year-old man has a long

history of type I diabetes,

C; Erectile dysfunction
which poorly controlled. What

rationale
does diabetes greatly increase

diabetes mellitus is significant risk factor for erectile
the man's risk of experiencing?
dysfunction. Retarded or premature ejaculation is
less likely, since these problems do not have
vascular etiology. Diabetes does not behave an
appreciably increased risk of developing STIs,
though persons with diabetes do have an increased
susceptibility to infections of all kinds.

A: you ever had any sexually-transmitted diseases in

the past?
B: how do you feel about yourself as a woman?
C: do you find that your health allows you to enjoy a

meaningful sex life?
D: are you satisfied with the quality of your

relationships right now?

assessment questions is most

likely to yield clinically

B: how do you feel about yourself as a woman?
meaningful data about a

Rationale
female patients sexual identity?

Sexual identity is a broad concept that includes, but
supersedes, sexual functioning. However, it is more
specific than simply asking about the quality of
relationships. Asking an open-ended question about
how the patient feels about herself as a woman is
likely to elicit important insights. Assessing the
patient's history of STIs does not directly address
her sexual identity.

A: disturbed body image
B: sexual dysfunction: Dyspareunia
C: alteration in comfort: Pain
A female patient experienced a D: altered sexuality patterns: change in sexual

pelvic fracture in a motor expression
vehicle accident several
months earlier and her
recovery has been slow.
Among the challenges
presented by event is the fact C: alteration in comfort: pain
that sexual activity causes a rationale
dull ache in her pelvis.What The patient's change in sexual behavior is directly
diagnosis is most important for attributable to the pain of her injury.
this patient? There is no evidence of alterations and her sexual

expression or a disturbed body image. Dyspareunia
involves genital, rather than skeletal, pain.
A: on day one of a new cycle
B: on day 14
C: from days 15 to 28
D; when sperm is present
During the menstrual cycle,
when does ovulation typically
take place? B: on day 14
rationale
ovulation generally occurs on day 14 when the

mature ova ruptures from the follicle and the
surface of the ovary and is swept into the fallopian
tube. Monday 15 to day 28, the phase and ovaries is
called the luteal phase.

A: condoms
B: Intrauterine devices (IUD)
C: Coitus interruptus.
D: oral contraceptives
A nurse is conducting a healthy

living workshop with a group

of female college students.


methods of contraception

should the nurse recommend

A: condoms
as a means of preventing
rationale
pregnancy and sexually

Coitus interruptus, oral contraceptives, and IUD
transmitted infections?
provide no protection against STIs, while condoms
provide significant (but imperfect) protection
against both pregnancy and STIs.
Temp Birth-1 year 97.7-98.9
Temp 1-12 years 98.1-99.9
Temp 12 + 97.8-98.0
Pulse birth-1 week 100-160
Pulse 1 week-3 months 100-220
Pulse 3 months-2 years 80-150
Pulse 2-12 years 70-110
Pulse 12 + 50-90

Resp Newborn 30-60 w some apnea (<15s)
Resp newborn-1 year 30
Resp 1-2 years 25-30
Resp 12+ 16-18
BP Girls 1 year 97-107/53-60
BP Boys 1 year 94-106/50-59
BP Girls 3 years 100-110/61-65
BP Boys 3 years 100-113/59-67
BP Girls 6 years 104-114/67-75
BP Boys 6 years 105-117/67-76
BP Girls 10 years 112-122/73-80
BP Boys 10 years 110-123/73-82
BP Girls 16 years 122-132/79-86
BP Boys 16 years 125-138/79-87

Where do you hear S1? Where S1- Apex, S2- Base

do you hear S2?
Describe height changes in Increases 50% in the first year

first year
Weight changes in first year? Doubles within first 6 months, triples in one year
When does the posterior 2-3 months

fontanelle close?
When does the anterior 10-12 months (before 18 months)

fontanelle close?
1 month old Motor skills Head lag with grasp reflex
2 months old motor skills head lift with hands held open
head and shoulders lift with no more grasp reflex

3 months old motor skills
and hands held open
4 months old motor skills rolls back to side, puts objects in mouth
5 months old motor skills rolls front to back, has palmar grasp
6 months old motor skills rolls back to front, can hold a bottle
Able to fully bear weight, can move objects

between hands
8 months old motor skills sits unsupported, has pincer grasp

pulls to a standing position, has a crude pincer

9 months old motor skills grasp
goes from prone to sitting by themselves, grasps a

rattle
walks while holding onto something; can put

objects in a container
sits from standing; attempts to create a 2 block

tower but fails.
When is trust vs. mistrust infant-first year of life
When is the sensorimotor Birth-24 months of age; separation, object

stage? What are the 3 permanence, and mental representation
components that make it up? (recognition of symbols)
How much should toddlers Four times their birth weight

weight at 30 months?
walks without help, creeps up and down stairs,

Motor skills 15 months
builds block towers
assumes standing position; manages a spoon, turns

Motor skills at 18 months
pages of book
walks up and down stairs; builds block tower of 6-7

2 years motor skills
blocks

jumps in place with both feet, stands on one foot

2.5 years motor skills momentarily; draws circles, has good hand-finger
coordination
Toddlers, Includes object permanence, have

When is the preoperational
memories, domestic mimicry, imitation but not
stage?
understanding of viewpoints, egocentric
What is Erikson's psychosocial autonomy vs. shame and doubt

stage for a toddler (1-3 years)
How much do toddlers grow 3 inches

each year?
What type of play do toddlers Gender appropriate, parallel play

engage in?
When can a rear-facing car Until the toddler weights 20lbs

seat be used until?
Until what age should toddlers 4 years

remain in a car seat?
How much weight should 3-6 4.5-6.5 lbs annually.

year olds gain per year?
How much should 3-6 years 2.5-3 inches per year

olds grow per year?
rides a tricycle, jumps off of bottom step, stands on

Motor skills 3 years old
one foot for a while
Motor skills
bstrandable 4 years OB/Peds 2 of
NCLEX skips
3 and hops on one foot, throws a ball overhead
jumps rope, walks backward with heel to toe, moves

Motor skills 5 years old
up and down stairs easily
Still in preoperational. Misconceptions occur:

artificialism (everything comes from humans),
animism (inanimate objects are alive), Imminent
Piaget stage of development
justice (universal code exists that determines law
for 3-6 years old?
and order), intuitive thought (awareness of cause
Misconceptions occurring at
and effect relationships), Time (begin to understand
this age?
the concept of time), Language (enjoy talking, can
identify colors and speak in sentences. Vocab
jumps)
Initiative vs. guilt. May feel remorse when cannot

Erikson's stage for 3-6 years?
complete an assigned task
Associative play- playing ball, puzzles, playing

What play stage is associated
pretend/dress-up, role-play, painting, seweing cards
with Preschool aged children?
and beads, reading books
How much weight should a 4.4-8lbs annually

school aged child gain per
year? (6-12 yr)
Height for school age per 2 inches per year

year?
Order of pubescent changes breasts bud, pubic hair appears, onset of menarche
for girls
enlargement of testicles with looseness of scrotum,

Order of pubescent changes in appearance of pubic hair, growth of genitalia,
boys growth of axillary hair, downy hair on upper lip,
bstrandable NCLEX OB/Peds 2 of 3 in voice
change
What psychosocial stage for 6- industry vs. inferiority

12 years?
Appropriate play for school competitive and cooperative play. Peers of same
aged children? gender.
Concrete operations- weight/vol unchanging,

What stage of Piaget in school understands analogies, understands time, classifies
aged children? more complex info, understands various emotions,
self-motivated, able to solve problems
Formal operations: capable of thinking at adult

Piaget stage for adolescents? level, abstract thinking, imaginative/idealistic,
deductive reasoning
Identity vs. role confusion. Sense of personality

Erikson's stage for adolescents developed that is influenced by expectations of
parents
Acyanotic congenital defect
vascular channel between the left main pulmonary

artery and the descending aorta as a result of failure
of the fetal ductus arteriosis to close.
shunt of oxygenated blood from aorta into pulm
Patent ductus arteriosis
artery. increased LV output and work load. Usually
asymptomatic but may hear a machinery murmur
and witness a widening pulse pressure.
Administer indocin or undergo ligation of patent

ductus

Acyanotic defect
Shunt of oxygenated blood from L to R ventricle,

leads to R ventricular hypertrophy, needs surgical
repair, and bidirectional shunting may occur.
May be asymptomatic, heart murmur heard in first

Ventricular septal defect
week of life, growth failure, feeding problems, FTT,
respiratory infections
Some may close spontaneously, others require

open heart surgery
Acyanotic
Malfunctioning foramen ovale causes shunting of

oxygenated blood from L to R atrium, increased RV
output and work load, may develop pulm
hypertension in adulthood
Atrial Septal defect

May be asymptomatic or may hear soft blowing,
systolic murmur, have frequent episodes of pulm
inflammatory diseases, poor exercise intolerance
May require open heart surg with direct closure or

suturing with plastic prosthesis.
Acyanotic
preductal constriction of aorta between subclavian

artery and ductus arteriosis. Postductal constriction
of aorta directly beyond ductus. Leads to
obstructions of blood flow through the constricted
Coarction of aorta segments, weak or absent pulsations in lower
extremities, heart failure, may notice fatigue,
headaches, leg cramps, epistaxis.
Surgical resection of coarctate area with direct

anastamosis or use of a graft. Must be done within 2
years of age to prevent hypertension

Cyanotic
Combo of four defects: pulm stenosis, VSD,

overriding aorta, hypertrophy of RV.
Obstruction of outflow of blood from the RV into

the pulmonary circuit and increased pressure in the
right ventricle leads to R-L shunting of oxygenated
blood through the VSD directly into the aorta
Tetralogy of Fallot Severity of defect depends on degree of pulm

stenosis and size of vsd. Results in acute cyanosis @
birth, cyanosis increases with activity, clubbing of
fingers and toes, systolic murmur, acute episodes of
cyanosis, squatting, growth retardation.
Surgical tx: blalock-taussing procedures, or repair

of openings.
Cyanotic
Aorta originates from the RV and the pulmonary

artery from the LV.
two separate circulations without mixture of
oxygenated/unoxygenated blood.
Transposition of great vessels Usually deep cyanosis shortly after birth or closing
of ductus, clubbed fingers/toes, poor growth and
development, heart failure.
TX with prostaglandins to keep ductus arteriosis

open until surgery, then repair by switching the
great vessels.
Hep B Birth, 1-2 months, 6-18 months
2 months, 4 months, 6 months, 15-18 months, 4-6

DTap
years
Rotavirus 2, 4, 6 months

Hib 2, 4, 6, 12-15 months
Pneumococcal 2, 4, 6, 12-15 months
Inactivated polio 2, 4, 6 months, 4-6 years
Influenza 6 months initiate, annually
MMR 12-15 months, 4-6 years
Varicella 12-15 months, 4-6 years
Hep A 2 doses between 12-23 months

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What developmental milestones are discussed for infants and toddlers?

What developmental milestones are discussed for infants and toddlers?

What conditions are discussed related to pregnancy complications?

What conditions are discussed related to pregnancy complications?

10/6/21, 4:32 PM bstrandable NCLEX OB/Peds 2 of 3 Flashcards | Quizlet

bstrandable NCLEX OB/Peds 2 of 3

builds 2 blocker tower 15 M

names commonplace objects 15 M

anterior fontanelle usually 18 M

builds 3 block tower 18 M

oral vocab 10 words 18 M

bstrandable NCLEX OB/Peds 2 of 3

early efforts at jumping 24 M

builds 5 to 6 block tower 24 M

300 word vocab 24 M

obeys easy commands 24 M

builds 7 to 8 block tower 30 M

stands on one foot 30 M

has sphincter control for toilet 30 M

what stage are toddlers in autonomy versus shame and doubt

state first and last name 30M

In Abruptio Placenta, the Separates, prematurely

Abruptio Placenta usually Multi, 35 (HTN, trauma, cocaine)

bstrandable NCLEX OB/Peds 2 of 3

How is the bleeding of pain and less voluminous in abruptio

How is an infant delivered Usually C-section

Is there a higher or lower Highter

In what trimester does Third

At what age are accidental 2 years old

If a child swallows a potentially call medical help

When taking a child to the ER the suspected poison

An elderly client is a (high/low) high - due to poor eyesight, high

What types of chemicals cause Lye, caustic cleaners

Children at highest risk for drugs, insecticides

What is the causative organism P. acnes (propionibacterium acnes)

What structures are involved in The sebaceous glands

Name 3 drugs given for acne? Vitamin A, Antibiotics, Retinoids

bstrandable NCLEX OB/Peds 2 of 3

Dietary indiscretions and NO

What are the 3 causative Heredity, Bacterial, Hormonal

What is the most common Accutane

Accutane is an analog of which Vitamin A

What is the most common side birth defects

What is the antibiotic most Tetracycline

How long will it take for the 4 to 6 weeks

Does stress make acne worse? yes

How often should the client twice a day

bstrandable NCLEX OB/Peds 2 of 3

What are comedones? Blackheads and white heads

What virus causes AIDS? HIV - Human immunodeficiency virus

The AIDS virus invades helper T-lymphocytes (or CD4 cells)

AIDS is trasmissible through blood, sexual contact, breast feeding, across

Homosexual/bisexual men, IV drug users,

What is the first test for HIV ELISA

What test confirms the ELISA? Western Blot

Which test is the best indicator CD4 count

A CD4 count of under __________ 500

bstrandable NCLEX OB/Peds 2 of 3

A CD4 count of under _______ is 200

Give 6 symptoms of HIV Anorexia, fatigue, weakness, night sweats, fever,