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Question 5476)

Which factor would most likely be a cause of epiglottitis? 

A. Acquiring the child’s first puppy the day before the onset of symptoms 

B. Exposure to the parainfluenza virus 

C. Exposure to Haemophilus influenzae, type B 

D. Frequent upper respiratory infections as an infant 

Answer: C 

Explanation: H. influenzae is the usual causative agent of epiglottitis. A puppy would be more apt to cause asthma than epiglottitis. 

Question 5477) 

The nurse is caring for a child who has epiglottitis. What position would the child be most likely to assume? 

A. Squatting 

B. Sitting upright and leaning forward, supporting self with hands 

C. Crouching on hands and knees and rocking back and forth 

D. Knee-chest position 

Answer: B 

Explanation: Sitting upright and leaning forward, supporting self with hands, is the position typically assumed by children with epiglottitis. It helps to promote the airway and drainage of secretions. Squatting is more typically seen in children who have cyanotic heart defects. 

Question 5478) 

The nurse is assessing a child who has epiglottitis and is having respiratory difficulty. Which of the following is the nurse most likely to assess in the child? 

A. Flaring of the nares; cyanosis; lethargy 

B. Diminished breath sounds bilaterally; easily agitated 

C. Scattered rales throughout lung fields; anxious and frightened 

D. Mouth open with a protruding tongue; inspiratory stridor 

Answer: D 

Explanation: The child with an edematous glottis will keep his mouth open with his tongue protruding to increase free movement in the pharynx. In the presence of potential laryngeal obstruction, laryngeal stridor can be heard, especially during inspiration. Rales and diminished breath sounds are more typical of croup. Cyanosis is typical of late-stage, extremely critical respiratory distress. 

Question 5479) 

Which of the following is the most important goal of nursing care in the management of a child with epiglottitis? 

A. Preventing the spread of infection from the epiglottis throughout the respiratory tract 

B. Reduction of high fever and prevention of hyperthermia 

C. Maintaining a patent airway 

D. Maintaining the child in an atmosphere of high humidity with oxygen 

Answer: C 

Explanation: In a child with epiglottitis, the first signs of difficulty in breathing can progress to severe inspiratory distress or complete airway obstruction in a matter of minutes or hours. The child usually has a high fever, but the airway takes precedence. High humidity may also be appropriate, but the highest priority is maintaining an airway. 

Question 5480) 

Which of the following is the most important nursing action when caring for a child with epiglottitis? 

A. Cardiac monitoring 

B. Blood pressure monitoring 

C. Temperature monitoring 

D. Monitoring intravenous infusion Answer: A Explanation: Regular monitoring of cardiac rate is essential because a rapidly rising heart rate is an initial indication of hypoxia and impending obstruction of the airway. The blood pressure and temperature may well be monitored, but they are not the most important. An IV will be monitored, if present, but is not the highest priority. 

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Question 5471) 

The nurse notes that a child who has had a serious heart condition since birth does not do the expected activities for that age. The child’s mother says, “I worry constantly about my child. I don’t let the older children or the neighborhood kids play with my child very much. I try to make things as easy for my child as I can.” What is the best interpretation of these data? 

A. The child is physically incapable due to his cardiac defect 

B. The child’s mother is overprotective and allows the child few challenges to develop skills.

C. The child is probably mentally retarded from the effects of continual hypoxia. 

D. The child has regressed due to the effects of hospitalization. 

Answer: B 

Explanation: The child’s mother does not let the child play with others and appears to do everything for the child. She seems to be overprotective. Most children with heart defects are capable of doing most age-appropriate activities. There is no evidence to support that the child is mentally retarded. There are no data to support that the child has regressed. 

Question 5472) 

Ten days after cardiac surgery, an 18-month-old child is recovering well. The child is alert and fairly active and is playing well with the parents. Discharge is planned soon. The nurse notes that the parents are still very reluctant to allow the child to do anything without help. What is the best initial action for the nurse to take? 

A. Reemphasize the need for autonomy in toddlers 

B. Provide opportunities for autonomy when the parents are not present 

C. Reassess the parent’s needs and concerns 

D. Discuss the success of the surgery and how well the child is doing 

Answer: C 

Explanation: Before the nurse can teach the parents, it will be necessary to reassess their needs and concerns. The question asks for the best initial action. Initially, the nurse should assess. Later, the nurse may emphasize the toddler’s need for autonomy. The nurse may provide the child with opportunities to develop autonomy, although it would be better to teach the parents. The nurse may also discuss the success of the surgery and how well the child is doing, but this is not the initial action. 

Question 5473) 

Sodium salicylate is prescribed for a child with rheumatic fever. What should the nurse assess the child for because the child is on this medication? 

A. Tinnitus and nausea 

B. Dermatitis and blurred vision 

C. Unconsciousness and acetone odor of breath 

D. Chills and elevation of temperature 

Answer: A 

Explanation: Tinnitus and nausea are signs of toxicity to salicylate drugs 

Question 5474) 

The nurse makes an initial assessment of a 4-year old child admitted with possible epiglottitis. Which observation is most suggestive of epiglottitis? 

A. Low-grade fever 

B. Retching 

C. Excessive drooling 

D. Substernal retractions 

Answer: C 

Explanation: Excessive drooling is a sign of epiglottitis. A child with epiglottitis is apt to have a high fever. Retching is not typical. Retractions could occur if respiratory distress was great enough, but drooling is the hallmark of epiglottitis. 

Question 5475) 

Which Nursing Action could be life threatening for a child with epiglottitis? 

A. Examining the child’s throat with a tongue blade 

B. Placing the child in a semi-sitting position 

C. Maintaining high humidity 

D. Obtaining a nasopharyngeal culture 

Answer: A 

Explanation: Examining the child’s throat with a tongue blade may cause the epiglottis to become so irritated that it will close off completely and obstruct the airway. The child should be placed in a semi-sitting to upright position. Humidity is not a problem. A nasopharyngeal culture would not cause problems. The nurse should get a throat culture, however.

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Question 5461) 

A 6-year-old child with tetralogy of Fallot is being admitted for surgery. What is most important to teach the child during the preoperative period? 

A. Strict hand washing technique 

B. How to cough and deep breathe 

C. The importance of drinking plenty of fluids 

D. Positions of comfort 

Answer: B 

Explanation: The child will have to learn to cough and deep breathe postoperatively. Studies demonstrate that preoperative teaching makes it easier for the client to perform coughing and deep breathing exercises in the postoperative period. The nurses will do strict hand washing, not the client. Fluids will likely be restricted postoperatively. It is important to teach the client about positions of comfort, but it is more important to teach the child how to deep breathe and cough. 

Question 5462) 

A 6-year-old with tetralogy of Fallot has open heart surgery. The septal defect was closed, and the pulmonic valve was replaced. When the child returns to the unit, he has oxygen, IVs, and closed chest drainage. How should the nurse position the chest drainage system? 

A. Above the level of the bed 

B. At the level of the heart 

C. Below the level of the bed 

D. Alternating above and below the bed every two hours 

Answer: C 

Explanation: Chest bottles are always positioned below bed level to prevent the reflux of material into the chest cavity. 

Question 5463) 

A parent brings a 3-week-old infant to the clinic. The parent states that the baby does not eat very well. She takes 45 cc of formula in 45 minutes and gets “tired and sweaty” when eating. The nurse observes the baby sleeping in the parent’s arms. Her color is pink, and the child is breathing without difficulty. What is the best response for the nurse to make? 

A. “It’s normal for an infant to get tired while feeding. That will go away as the child gets older.” 

B. “It’s normal for an infant to get tired while feeding. You could try feeding the baby smaller amounts of formula more frequently.” 

C. “This could be a sign of a health problem. Does your baby’s skin color change while eating?” 

D. “This could be a sign of a health problem. How does your baby’s behavior compare with your other children when they were that age?” 

Answer: C 

Explanation: Activity intolerance related to feeding is often a key sign of a serious cardiac problem in an infant. Taking only 45 cc of formula in 45 minutes at 3 weeks of age probably indicates difficulty sucking. This is definitely not normal. The fact that the infant’s color is pink at rest does not tell you what happens during exertion, such as with eating. Asking about skin color during feeding is a good first question to ask. Answers 1 and 2 are incorrect because they interpret the infant’s behavior as normal, which it is not. Answer 4 is not correct. It does identify the behavior as abnormal but suggests comparing it to the child’s siblings. This is not the appropriate question to ask to get the most information. 

Question 5464) 

The nurse is explaining cardiac catheterization to the parents of a child. The nurse explains to the parents that information about which of the following can be obtained during cardiac catheterization? 

A. Oxygen levels in the chambers of the heart 

B. Pulmonary vascularization 

C. Presence of abdominal aortic aneurysm 

D. Activity tolerance 

Answer: A 

Explanation: The catheter is passed into the chambers of the heart, and oxygen levels can be measured. The cardiac catheter does not assess pulmonary vascularization. Coronary arteries can be visualized, however. An abdominal aortic aneurysm is diagnosed with an arteriogram, not a cardiac catheterization. A cardiac catheterization gives information about the heart structures but does not give information about activity tolerance. 

Question 5465) 

The nurse is caring for a toddler who is six hours post cardiac catheterization. The nurse is administering antibiotics. The child’s mother asks why the child needs to have antibiotics. The nurse’s response should indicate that antibiotics are given to the client to prevent which type of infection? 

A. Urinary tract infection 

B. Pneumonia 

C. Otitis media 

D. Endocarditis 

Answer: D 

Explanation: During a cardiac catheterization, a catheter is inserted into the heart; therefore, the infection that the client is most at risk for is endocarditis. Urinary tract infection, pneumonia, and otitis media are not related to a client undergoing a cardiac catheterization. 

Question 5466) 

The nurse is caring for a toddler with a cardiac defect who has had several episodes of congestive heart failure in the past few months. Which data would be the most useful to the nurse in assessing the child’s current congestive heart failure? 

A. The degree of clubbing of the child’s fingers and toes 

B. Amount of fluid and food intake 

C. Recent fluctuations in weight 

D. The degree of sacral edema 

Answer: C 

Explanation: Weight is the best indicator of fluid balance. Congestive heart failure causes fluid retention. Sacral edema is positionally dependent. Weight will give a better indication of the child’s status. Clubbing of the fingers and toes is an indication of chronic hypoxemia, not the status of his current congestive heart failure. Fluid and food intake is a general indicator of his status and is not particularly related to his current congestive heart failure. 

Question 5467) 

A child with a cyanotic heart defect has an elevated hematocrit. What is the most likely cause of the elevated hematocrit? 

A. Chronic infection 

B. Recent dehydration 

C. Increased cardiac output 

D. Chronic oxygen deficiency 

Answer: D 

Explanation: The body tries to compensate for chronic oxygen deficiency by making additional red cells to transport oxygen. The additional red cells increase the hematocrit, which is the percentage of blood that is red blood cells. Chronic infection can cause anaemia. Recent dehydration will cause an elevated hematocrit because there is less fluid in the blood. However, there is no indication that the child is dehydrated, and we are told that he has a cyanotic heart defect, which makes him chronically hypoxic. Therefore, answer 4 is better than answer 2. Answer 3, increased cardiac output, is also incorrect. Increased cardiac output does not cause an elevated hematocrit. 

Question 5468) 

The nurse is administering the daily digoxin dose of 0.035 mg to a 10-month-old child. Before administering the dose, the nurse takes the child’s apical pulse, and it is 85. Which of the following interpretations of these data is most accurate? 

A. The child has just awakened, and the heart action is slowest in the morning.

B. This is a normal rate for a 10-month-old child. 

C. The child may be going into heart block due to digoxin toxicity 

D. The child’s potassium level needs to be evaluated. 

Answer: C 

Explanation: A pulse below 100 in a 10-month-old child who is taking digoxin most likely indicates digoxin toxicity. The nurse should withhold the medication and notify the physician. The normal pulse for this age is about 120 or a little more at rest. The pulse rate does not tell us that the child needs to have his/her potassium level checked. If the child is also taking Lasix or another potassium-depleting diuretic, then the potassium should be checked. 

Question 5469) 

The nurse is discussing dietary needs of a child with a serious heart defect. The child is being treated with digoxin and hydrochlorothiazide (Hydrodiuril). The nurse should stress the importance of giving the child which of the following foods? 

A. Cheese and ice cream 

B. Finger foods such as hot dogs 

C. Apricots and bananas 

D. Four glasses of whole milk per day 

Answer: C 

Explanation: The child should be on a sodium-restricted diet with high-potassium foods because he is taking Hydrodiuril, a potassium-depleting diuretic. Apricots and bananas are low in sodium and high in potassium. Cheese and ice cream are high in sodium. Hot dogs are high in sodium. Whole milk is high in sodium. Not only is potassium needed, but excessive sodium should also be avoided because those with severe heart defects are prone to fluid retention. 

Question 5470) 

A child with a cyanotic heart defect has a hypoxic episode. What should the nurse do for the child at this time? 

A. Administer PRN oxygen and position the child in the squat position 

B. Position the child side-lying and give the ordered morphine 

C. Ask the parents to leave and start oxygen 

D. Give oxygen and notify the physician 

Answer: A 

Explanation: The knee-chest or squat position increases intra-abdominal pressure and increases blood flow to the lungs. Oxygen is also indicated because the child is hypoxic. Positioning on the side is not appropriate because it will not improve the blood flow to the lungs. There is no need to ask the parents to leave. In fact, they need to know how to handle these episodes if they are not yet comfortable doing so. Children with cyanotic heart defects have hypoxic episodes fairly regularly. Positioning in the squat position is more important at this time than notifying the physician. 

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Question 5451) 

An 8-year-old child is terminally ill. Considering the child’s age, which statement would you most expect the child to make? 

A. “After I’m dead, will you come visit me?” 

B. “Who will take care of me when I am dead?” 

C. “Will it hurt me when I die?” 

D. “Can you help me do a videotape about dying from leukemia?” 

Answer: C 

Explanation: An 8-year-old is concerned about pain and mutilation. An 8-year-old has an understanding that death is the end of life as we know it and would be unlikely to respond with answers 1 or 2. Answers 1 and 2 are typical of a preschooler. Answer 4 is typical of an adolescent who wants to leave a legacy. 

Question 5452) 

A father has bought his 4 month old daughter to the well-baby clinic. Which statement that he makes is the greatest cause for concern to the nurse? 

A. “She cannot sit up by herself.” 

B. “She does not hold the rattle as well as she did at first.” 

C. “She does not follow objects with her eyes.” 

D. “She spits up after a feeding.” 

Answer: C 

Explanation: A 4-month-old should follow objects with her eyes. A 4-month-old is not likely to be able to sit up by herself. This behavior is seen at 6 months of age. Not being able to hold the rattle as well as she did at first is typical of the time after the loss of the grasp reflex and before pincer movement is established. Most newborn reflexes are gone by about 4 months of age. Spitting up after a feeding is normal 4-month-old behavior. 

Question 5453) 

A 3-year-old child has all of the following abilities. Which did he acquire most recently? 

A. Walking 

B. Throwing a large ball 

C. Riding a tricycle 

D. Stating his name 

Answer: C 

Explanation: Riding a tricycle is 3-year-old behavior. Remember, “three years, three wheels.” Children start to walk at about 1 year of age. Throwing a large ball and stating his name are 2-year-old behaviors. Remember to use developmental trends when determining the most recently acquired behavior—head to tail and simple to complex. Look for a complex lower body behavior. 

Question 5454) 

The mother of a 2-year-old child calls the doctor’s office because her child swallowed “the rest of the bottle of adult aspirin” about a half hour ago. The nurse determines that there were about 15 tablets left in the bottle. What initial assessment findings are consistent with aspirin ingestion? 

A. Bradypnea and pallor 

B. Hyperventilation and hyperpyrexia 

C. Subnormal temperature and bleeding 

D. Melena and bradycardia 

Answer: B 

Explanation: The child will have an elevated body temperature. Contrary to what you might expect, metabolism is increased following aspirin overdose. The child will be hot and flushed. Hyperpyrexia means high temperature. The child will be in metabolic acidosis from the acid load of the aspirin. Compensation for metabolic acidosis is rapid, deep breathing. The first choice is incorrect; the child will be hyperventilating and will be flushed, not pale. The third choice is not correct; the temperature will be high, not low. Bleeding may occur following aspirin ingestion, but not initially. The fourth choice is not correct. Melena is hidden blood in the stool. It will take some time for a gastrointestinal bleed to develop and pass through the stool. Bradycardia will not be present. The child will have tachycardia. 

Question 5455) 

A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care? 

A. Administration of syrup of ipecac 

B. Cardiopulmonary resuscitation 

C. Ventilatory support D. Gastric lavage 

Answer: D 

Explanation: Since the child is breathing, there is no need for cardiopulmonary resuscitation (CPR) or ventilatory support. Gastric lavage is usually used rather than inducing emesis. In any event, the child is difficult to arouse, so it would not be safe to induce vomiting. 

Question 5456) 

A 6-month-old child is being seen for a well-baby visit. The child has received all immunizations as recommended so far. What immunizations does the nurse expect to give at this visit? 

A. DTP, MMR, IPV 

B. DTP, hepatitis B, HIB 

C. HIB, IPV, varicella D. MMR, hepatitis B, HIB 

Answer: B 

Explanation: At 6 months of age, the nurse would expect to administer the third DTP, the third hepatitis B, and the third Haemophilus influenzae type B (HIB) immunizations. MMR (measles, mumps, and rubella) is not given until 15 months of age. IPV is given at 2 months and 4 months and then again at 18 months and preschool. Varicella vaccine is given between the ages of 1 year and 12 years. 

Question 5457) 

The mother of a 6-year-old child who has chickenpox asks the nurse when the child can go back to school. What information should be included in the nurse’s response? The child is contagious: 

A. until all signs of the disease are gone 

B. as long as the child has scabs 

C. as long as there are fluid-filled vesicles. 

D. until the rash and fever are gone. 

Answer: C 

Explanation: Chickenpox is contagious as long as there are fluid-filled vesicles. Scabs are not contagious. The child will have scabs for a while. The fever may be down, but if there are fluid-filled vesicles, the child is contagious. 

Question 5458) 

A 2-year-old child is in for an annual examination. Which comment by the mother alerts the nurse to a risk for lead poisoning? 

A. “Why does he eat paint off the window sills?” 

B. “Will his temper tantrums ever stop?” 

C. “I haven’t been able to toilet train him yet.” 

D. “He is such a messy eater.” 

Answer: A 

Explanation: Eating paint is one of the major risk factors for lead poisoning. Temper tantrums are normal in a 2- year-old. Most 2-year-olds are not toilet trained. Most 2-year-olds are messy eaters. 

Question 5459) 

A 6-year-old boy has tetralogy of Fallot. He is being admitted for surgery. The nurse knows that which problem is not associated with tetralogy of Fallot? 

A. Severe atrial septal defect 

B. Pulmonary stenosis 

C. Right ventricular hypertrophy 

D. Overriding aorta 

Answer: A 

Explanation: Atrial septal defect is not associated with tetralogy of Fallot. The four defects are pulmonary stenosis, which causes right ventricular hypertrophy, ventricular septal defect, and overriding aorta. 

Question 5460) 

A 6-year-old child with tetralogy of Fallot is being admitted for surgery. While the nurse is orienting the child to the unit, the child suddenly squats with the arms thrown over the knees and knees drawn up to the chest. What is the best immediate nursing action? 

A. Observe and assist if needed 

B. Place the child in a lying position 

C. Call for help and return the child to the room 

D. Assist the child to a standing position 

Answer: A 

Explanation: The squatting position will help the child with tetralogy of Fallot to have better hemodynamics. It increases intra-abdominal pressure and increases pulmonary blood flow. Placing the child in a lying or standing position will increase his symptoms and be counterproductive. It is not necessary to call for help because this is not an emergency situation. 

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Question 5441) 

A 6-year-old child is admitted for a tonsillectomy. Considering the child’s age, which of the following would be the most important to include in a preoperative physical assessment? 

A. Characteristics of tongue, gum, or lip sores 

B. Any sign of tonsillar inflammation 

C. The number and location of any loose teeth 

D. The location and presence of tenderness in any swollen lymph nodes 

Answer: C 

Explanation: A 6-year-old is apt to be loosing baby teeth. This is an important consideration when anesthesia is to be administered and the child will be intubated. The nurse should assess for loose teeth in any school-age child who is admitted for surgery or other procedures requiring intubation of any kind. 

Question 5442) 

A 6-year-old child is in the terminal stage of leukemia. The child appears helpless and afraid. How can the nurse best help the child? 

A. Allow the child to make the major decisions for her care 

B. Make all decisions for the child 

C. Discuss with the child the fears that dying children usually have 

D. Discuss with the child the reasons for her fears 

Answer: D 

Explanation: by discussing with child the reasons for the child’s fears, the child will feel less afraid and less abnormal. Discussion of fears should be individualized. The child is not old enough to make care decisions. The child should, however, be given some input into the care plan. The child might decide which site the nurse will use for an injection but not whether or not the medication will be given. The parents will make those decisions. 

Question 5443) 

The nurse is preparing a 6-year-old child for cardiac surgery. Which preoperative teaching technique is most appropriate? 

A. Have the child practice procedures that will be performed postoperatively, such as coughing and deep breathing 

B. Arrange for the child to tour the operating room and surgical intensive care unit 

C. Encourage the child to draw pictures illustrating the operation. 

D. Arrange for the child to discuss heart surgery and postoperative events with a group of children who have undergone heart surgery. 

Answer: A 

Explanation: A 6-year-old learns best by doing. A 6-year-old cannot conceptualize what he or she cannot see. Touring the operating room and surgical intensive care unit can be very frightening for a 6-yearold. Drawing pictures of the procedure would be more appropriate postoperatively, when the nurse may want to help him in understanding what happened to him. Drawing pictures is a good way to express feelings that a 6-year-old cannot put into words. Group discussion is more appropriate for an adolescent. A 6-year-old does not have the verbal skills to participate in and learn from a discussion group. 

Question 5444) 

A 10-year-old girl is being treated for rheumatic fever. Which would be an appropriate activity while she is on bed rest? 

A. Stringing large wooden beads 

B. Engaging in a pillow fight 

C. Making craft items from felt 

D. Watching television 

Answer: C 

Explanation: Craft work allows her to accomplish something while meeting her needs for rest. Industry is the developmental task for school-age children. The joint pains with rheumatic fever tend to be in the large joints, not the small ones, so craft work using finger activity would probably not be painful. Stringing large wooden beads is appropriate for younger children. Pillow fighting requires too much energy for a child on bed rest and is not appropriate for a hospital environment. Watching television is a solitary activity with no sense of accomplishment. 

Question 5445) 

A 10-year-old boy who is immobilized in a cast following an accident has been squirting other children and the staff with a syringe filled with water. The nurse wants to provide other activities to help him express his aggression. Which activity would be most appropriate?
A. Cranking a wind-up toy 

B. Pounding clay 

C. Putting charts together 

D. Writing a story 

Answer: B 

Explanation: Pounding movements allow for the expression of aggression. The other activities would not allow for an expression of aggression. The scenario describes a child who is expressing aggression in a very physical manner. This child is not likely to respond well to writing a story. Writing a story could be used to help a child express aggression, but pounding clay is more appropriate given the child’s aggressive behavior. 

Question 5446) 

An 11-year-old boy is admitted to the pediatric unit in traction with a fractured femur sustained in a motorcycle accident. His uncle, who was driving the cycle when the accident occurred, received only minor injuries. The child tells the nurse that his uncle was not to blame for the accident. He is “the best motorcycle rider in the world.” The nurse interprets this to mean that the child is exhibiting which defense mechanism? 

A. Denial 

B. Repression 

C. Hero worship 

D. Fantasy

Answer: C 

Explanation: Hero worship is very common among school age children. Denial would be manifested by saying that his leg really is not broken. Repression is putting an upsetting or guilt-laden experience deep in the unconscious mind. This behavior does not suggest repression. Fantasy is living in a make-believe world. This boy shows no evidence of living in a make-believe world. 

Question 5447) 

The nurse is planning care for an 11-year-old child who has a fractured femur and is in traction. Which activity would be most appropriate? 

A. Dramatizing with puppets 

B. Building with popsicle sticks 

C. Watching television 

D. Coloring with crayons or colored pencils 

Answer: B 

Explanation: Building with popsicle sticks will foster his sense of industry and can be done while he is in bed in traction. Puppets and coloring would be more appropriate for younger children. Watching television will not promote his development, although it can be used as diversion occasionally. 

Question 5448) 

A 2-year-old child is hospitalized for a fractured femur. During his first two days in the hospital, he lies quietly, sucks his thumb, and does not cry. Which is the best interpretation of his behavior? 

A. He has made a good adjustment to being in the hospital. 

B. He is comfortable with the nurses caring for him. 

C. He is experiencing anxiety 

D. He does not have a good relationship with his parents. 

Answer: C 

Explanation: The child’s behavior is typical of the despair phase of toddler responses to anxiety. The child should cry. Lying quietly, sucking his thumb, and saying nothing are suggestive of severe anxiety, a bad adjustment to the hospital, and no comfort with the nurses. This anxiety response does not suggest a poor relationship with his parents. In fact, his severe separation anxiety may be because he is so close to his parents. 

Question 5449) 

A hospitalized 2.5-year-old child has a temper tantrum while her mother is bathing her. Her mother asks the nurse how she should handle this behavior. Which information should be included in the nurse’s reply? 

A. Temper tantrums in a hospitalized child indicate regression. 

B. Tantrums suggest a poorly developed sense of trust. 

C. Discipline is necessary when a child has a temper tantrum 

D. This behavior is a normal response to limit setting in a child of this age. 

Answer: D 

Explanation: Temper tantrums are a normal response to limit setting in a 2-year-old child. Answer 1 might be correct if the child were older. However, temper tantrums in a 2-year-old child do not indicate regression; rather, they are normal for this age. Tantrums are not suggestive of a poorly developed sense of trust; they are normal. Ignoring the tantrum is preferable to discipline when a 2-yearold has a tantrum. 

Question 5450) 

A 3-year-old child resists going to bed at night. Her mother asks the nurse what she should say to her. Which response should the nurse suggest to the mother as most appropriate? 

A. “I don’t love you anymore because you don’t know how to listen.” 

B. “All good children go to bed on time.” 

C. “If you go to sleep now, I’ll take you to the zoo tomorrow.” 

D. “Here is your blanket. It’s time to go to sleep.” 

Answer: D 

Explanation: The best response is to simply state that it is time for sleep and to give the child her security blanket or toy. Answer 1, telling the child that she isn’t loved because she won’t listen, is not therapeutic. Answer 2 implies that if you don’t go to bed on time, you are not a good child. This is not a good suggestion to implant in a child. Answer 3 is bribery and is not appropriate

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Question 5431) 

Which toys would be best for a 5-month-old infant who has infantile eczema? 

A. Soft, washable toys 

B. Stuffed toys 

C. Puzzles and games 

D. Toy cars 

Answer: A 

Explanation: Soft, washable toys of smooth, nonallergenic material should be used. Stuffed toys are contraindicated. Puzzles and games are not age appropriate. Toy cars could be used for scratching and should be avoided. Toy cars are also not age appropriate 

Question 5432) 

Which diversion would be appropriate for the nurse to plan to use with an 8- month-old infant? 

A. A colorful mobile 

B. Large blocks to stack 

C. A colorful rattle 

D. A game of peek-a-boo 

Answer: D 

Explanation: Peek-a-boo is appropriate for an 8-month-old. Peek-a-boo helps the infant with the concept of object permanence; things that are out of sight do exist. An 8-month-old can sit up; once an infant can sit up, the mobiles should be removed because they can strangle an infant who might try to stand up. An 8-month-old infant cannot stack large blocks yet. A colorful rattle is more appropriate for a younger infant. 

Question 5433)

Which activity would best occupy a 12-month-old child while the nurse is interviewing the parents? 

A. String of large snap beads and a large plastic bowl 

B. Riding toy 

C. Several small puzzles 

D. Paste, paper, and scissors 

Answer: A 

Explanation: Stringing large beads is appropriate for 12 months. Note that the beads are large and therefore not subject to being swallowed. A riding toy and small puzzles would be more appropriate for a toddler. Paste, paper, and scissors are appropriate for a preschooler when used with supervision. 

Question 5434) 

An 18-month-old child is admitted for a repeat cardiac catheterization. The parents are continuously present and do everything for the child—dress him, feed him, and even play for him. The nurse wants to prepare the child and the parents for the procedure. Which of the following should be included in the care plan? 

A. Give the child simple explanations 

B. Talk with the parents to assess their knowledge and how they can help with the child’s care. 

C. No specific action will be necessary because the child and family have been through a cardiac catheterization previously. 

D. Ask the parents to stay away as much as possible because they upset the child. 

Answer: B 

Explanation: An 18-month-old child cannot understand explanations. The nurse needs to assess the clients’ knowledge and base teaching on that assessment. The nurse should not assume that no teaching is needed just because the child has had the procedure before. There are no data to indicate that the parents upset the child. They do appear to be smothering the child, but at this time, the child would probably be more miserable without the parents. The nurse may want to teach parents about growth and development needs of the toddler. 

Question 5435) 

In planning care for an 18-month-old child, the nurse would expect him to be able to do which of the following? 

A. Button his shirt and tie his shoes 

B. Feed himself and drink from a cup 

C. Cut with scissors 

D. Walk up and down stairs 

Answer: B 

Explanation: An 18-month-old should be able to feed himself and drink from a cup. He may be messy. A 5- or 6- year-old can usually button a shirt and tie shoes. Cutting with scissors is appropriate for a preschool child. A 2- year-old child can go up and down stairs with both feet on the same step, and a 3-year-old child can go up and down stairs by alternating feet. 

Question 5436) 

The mother of a 2-year-old child asks the nurse how to cope with the child’s frequent temper tantrums when he does not get what he wants immediately. What information should the nurse include when responding? 

A. As long as the child is safe, ignore him during the tantrum. 

B. If the child’s demands are reasonable, give him part of what he wants. 

C. Spank the child if the tantrum continues for more than five minutes. 

D. Explain to the child why he cannot have what he wants and promise him a reward when he stops crying. 

Answer: A 

Explanation: Temper tantrums are common and normal in a 2-year-old because he is developing autonomy. As long as the child is safe, he should be ignored. Giving in to the child’s demands is likely to reinforce the negative behavior and create a longterm pattern of behavior. The nurse should not recommend to the parents that they spank a child. Promising a reward to stop crying is bribing the child and should not be recommended. A 2-yearold who is having a temper tantrum is not likely to listen to explanations. 

Question 5437) 

A 3-year-old child is admitted to the pediatric unit for diagnostic tests. His mother is discussing the child’s hospitalization with the nurse. She is concerned about staying with this child and caring for her other two children at home. Which suggestion to the mother will most help the child adjust to being in the hospital? 

A. Do not visit the child until discharge so that your child won’t cry when you leave. 

B. Spend the night in the hospital with your child 

C. Bring your child’s favorite teddy bear and security blanket to the hospital. 

D. Buy your child a gift to let the child know you care deeply. 

Answer: C 

Explanation: The child’s teddy bear and security blanket will help to give the child a sense of security. Spending the night would be ideal, but it may not be possible for this mother with two children at home. It is part of the normal separation reaction for a 3-year-old to be upset when the mother leaves. The parents should visit even if the child cries when they leave. Buying a gift will provide less security than bringing the child’s favorite comfort items to the hospital. 

Question 5438) 

The parents of a 3-year-old child are leaving for the evening. Which behavior would the nurse expect the child to exhibit? 

A. Wave goodbye to the parents 

B. Cry when the parents leave 

C. Hide his/her head under the covers 

D. Ask to go to the playroom 

Answer: B 

Explanation: It is normal for a 3-year-old to cry when the parents leave. The child will probably not wave goodbye even though he/she is able to. The child is not likely to hide under the covers. The child will likely be too upset to ask to go to the playroom. 

Question 5439) 

When planning outdoor play activities for a normal 4-year-old child, which activity is most appropriate? 

A. Two-wheeled bike 

B. Sandbox 

C. Climbing trees 

D. Push toy lawn mower 

Answer: B 

Explanation: A sandbox is appropriate for outdoor play. A 4-year-old is too young for a two-wheeled bike or for climbing a tree without strict supervision. He is probably past the age of pushing a toy lawn mower, which is more appropriate for a toddler. 

Question 5440) 

A 5-year-old child had major surgery several days ago and is allowed to be up. When planning diversional activity, which action by the nurse is most appropriate? 

A. Give the child a book to read 

B. Play a board game with the child 

C. Encourage the child to play house with other children. 

D. Turn on the television so the child can watch cartoons. 

Answer: C 

Explanation: Five-year-old children like cooperative play, such as playing house. The other activities are solitary activities. Note that the child is several days postsurgery. Most 5-year-olds are not able to read a book by themselves. Playing a board game with a child is not wrong, but it is a solitary activity. Most 5-year-olds would prefer to play with other children. There is almost always a better alternative than turning on the television. This child is several days postsurgery and is able to be up and play with others. 

104 - Nursing Exams Questions & Answers - Svastham Exemplar

 Question 5421) 

A baby boy was born at 2:45 A.M. after a 35-week gestation. He weighed 1170 g. Upon admission to the premature nursery, he had slight respiratory distress, nasal flaring, grunting, intercostal retractions, and slight cyanosis. Apgar score at one minute was 4, and at five minutes, it was 6. Apical pulse is 164, respirations are 44, and axillary temperature is 96°F. What was the most likely cause of the baby’s cyanosis? 

A. Increased serum concentration of bilirubin B. Inadequate oxygenation of arterial blood 

C. Excessive number of red blood cells 

D. Lack of subcutaneous fatty tissue 

Answer: B 

Explanation: Cyanosis is indicative of inadequate oxygenation. Increased bilirubin would be evidenced by jaundice. It is normal for newborns to have excessive red blood cells. This does not cause cyanosis. Lack of subcutaneous fatty tissue is common in premature infants and causes poor temperature regulation. 

Question 5422)

When assessing a newborn’s need for oxygen, which of the following should the nurse assess because it is the best indicator? 

A. Respiratory rate 

B. Skin color 

C. Pulse rate 

D. Arterial pO2 

Answer: D 

Explanation: Arterial pO2 is the best indicator of oxygen levels. Respiratory rate, skin color, and pulse rate can be affected by factors other than oxygenation. They are indicators but are not the most reliable. 

Question 5423) 

On the evening of the second day after birth, the nurse notes that an infant appears icteric. What is the most likely cause? 

A. Rupture of a great number of fragile red cells in a short period of time 

B. Inflammatory obstruction of hepatic bile ducts and resorption of pigments 

C. Extravasation of blood from ruptured capillaries into subcutaneous tissue 

D. Faulty melanin metabolism due to absence of enzymes for normal protein synthesis 

Answer: A 

Explanation: Red blood cells of premature infants are fragile and break down rapidly, causing an increase in bilirubin, which causes icterus or jaundice. The timing is key. Jaundice occurring after 49 hours is usually physiological jaundice. Jaundice presenting at birth or within the first 24 hours is usually pathological in nature. Obstruction of hepatic bile ducts would be a pathological cause of jaundice and would occur earlier. Answer 3 is not realistic. This might cause a bruising appearance but not jaundice. Answer 4 makes no sense. 

Question 5424) 

On the evening of the second day after birth, an infant was observed to be icteric, so he was exposed to blue light. What is the purpose of the blue light? 

A. To stimulate increased formation of vitamin K in the skin 

B. To enhance pigment breakdown by increasing body temperature 

C. To convert indirect bilirubin to a less toxic compound 

D. To increase brain electrical activity by stimulating the optic nerve 

Answer: C 

Explanation: The bili light or blue light enhances the breakdown of indirect bilirubin to a less toxic compound. Vitamin K is not made in the skin; it is made in the intestines. Vitamin D is absorbed by the skin. Increasing temperature does not enhance pigment breakdown. The eyes are covered when the blue light is used to protect the eyes against damage. 

Question 5425) 

A young woman delivered her first baby this morning. She asks the nurse why the top of the baby’s head is so soft and does not seem to have any bone. What should the nurse include when responding to the mother? 

A. This soft spot is called a fontanel and is normal; it makes delivery easier. 

B. It is a condition that occurs in some babies and will disappear within a few days. 

C. The physician is monitoring the infant for any problems that might occur with this common defect. 

D. It is called caput succedaneum and is caused by bleeding under the scalp during birth. 

Answer: A 

Explanation: The mother appears to be describing the anterior fontanel, or soft spot, which occurs in all babies. The skull bones are not completely fused, allowing molding of the head during the birth process. This should close between 12 and 18 months. It is a normal condition occurring in all babies and is not a defect. Caput succedaneum is a swelling that may occur on the head following delivery. It crosses suture lines and is due to swelling under the scalp during birth. It is normal and disappears in a few days. This is not what is described in the question. 

Question 5426) 

Which finding, if present, would suggest to the nurse that the infant was not at term when born? 

A. The scrotum has rugae 

B. Testicles are not descended. 

C. Scanty vernix 

D. Sparse lanugo 

Answer: B 

Explanation: Testicles normally descend into the scrotum at eight months gestation. An infant born prior at that time will have undescended testicles. A term infant will have rugae on the scrotum. Vernix and lanugo are less with a term infant than with a premature infant. 

Question 5427) 

The nurse is preparing a 3-day-old infant for discharge from the hospital. When checking the record for completeness, the nurse checks to see that the infant has had which of the following? 

A. DTP and polio immunizations 

B. MMR immunization and tuberculin test 

C. Pneumococcal vaccine and HIV test 

D. Hepatitis B vaccine and PKU test 

Answer: D

Explanation: Hepatitis B vaccine is given within the first 12 hours after birth. A PKU test is done when the infant has had milk feedings for 24 hours. DTP and polio immunizations are usually started at two months of age. MMR is given at 15 months. A tuberculin test is usually done at one year. Pneumococcal vaccine is given to infants starting at two months. Newborns are not routinely tested for HIV. 

Question 5428) 

The physician has told the parents that their child probably has phenylketonuria. The parents ask the nurse what special needs the child will have. What should the nurse include in the response? 

A. The baby will most likely not develop normally for longer than six months and will die in a few years. 

B. The baby will have a special formula and cannot eat protein foods during childhood. 

C. Special feeding techniques are necessary until the child has surgery. 

D. The baby will not be able to void normally and will need to be catheterized frequently. 

Answer: B 

Explanation: Phenylketonuria is a disorder of purine metabolism in which phenylalanine is not metabolized properly and builds up in the blood and brain and causes severe mental retardation if not treated promptly. The treatment is to avoid foods containing phenylalanine. The child will have a special formula (Lofenalac) and cannot eat protein-containing foods. If diagnosed early and if the proper diet is followed, the child should do well. Answer 1 is more typical of Tay-Sachs disease. Answer 3 is typical of cleft lip or palate. 

Question 5429) 

A 3-month-old infant is admitted. Upon admission, the nurse assesses her developmental status as appropriate for age. Which of the following is the child least likely to be able to do? 

A. Smile in response to mother’s face 

B. Reach for shiny objects but miss them 

C. Hold head erect and steady D. Sit with slight support 

Answer: D 

Explanation: Sitting with slight support would be expected in a child of 5 months. All of the other tasks are appropriate for this age. 

Question 5430) 

A 3-month-old infant is doing well after the repair of a cleft lip. The nurse wants to provide the client with appropriate stimulation. What is the best toy for the nurse to provide? 

A. Colorful rattle 

B. String of large beads 

C. Mobile with a music box 

D. Teddy bear with button eyes 

Answer: C 

Explanation: Anything that can be put in the mouth is inappropriate for a child with cleft lip repair. A rattle and beads can go in the mouth. Button eyes are a hazard for any infant because the infant may swallow them. A mobile with a music box is appropriate for a 3-month-old who lays in a crib, and this item cannot be put in the mouth. Note that a colorful rattle is also age appropriate but not condition appropriate.

103 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5411) 

Parents of a newborn note petechiae on the newborn’s face and neck. The nurse should tell them that this is a result of which of the following? 

A. Increased intravascular pressure during delivery 

B. Decreased vitamin K level in the newborn infant 

C. A rash called erythema toxicum 

D. Excessive superficial capillaries 

Answer: A 

Explanation: Increased intravascular pressure during delivery can cause petechiae. These will quickly disappear. Decreased vitamin K level in the infant might predispose the infant to bleeding from the umbilical cord but does not cause petechiae on the face and neck. Erythema toxicum is a generalized rash sometimes seen in newborns. It is not limited to the face and neck. Petechiae are not a result of excessive superficial capillaries. 

Question 5412) 

A newborn has a total body response to noise or movement that is distressing to her parents. What should the nurse tell the parents about this response? 

A. It is a reflexive response that indicates normal development. 

B. It is a voluntary response that indicates insecurity in a new environment. 

C. t is an automatic response that may indicate that the baby is hungry 

D. It is an involuntary response that will remain for the first year of life. 

Answer: A 

Explanation: The response described is the startle reflex and is normal in newborns. It lasts only a few months. 

Question 5413) 

When changing her newborn infant, a mother notices a reddened area on the infant’s buttocks. How should the nurse respond? 

A. Have staff nurses instead of the mother change the infant 

B. Use both lotion and powder to protect the area 

C. Encourage the mother to cleanse and change the infant more frequently 

D. Notify the physician and request an order for a topical ointment 

Answer: C 

Explanation: More frequent changing and cleaning of the area should help to prevent diaper rash. The mother should learn how to care for her baby and should be encouraged to change the infant. Using both lotion and powder would create a caked mess. The description in the question suggests a diaper rash. There is no need to contact the physician. The nurse will, of course, record the observation on the client’s record. 

Question 5414) 

A woman, at 32 weeks gestation, delivers a 3-lb, 8-oz baby boy two hours after arriving at the hospital. What is the baby at risk for because of his gestational age? 

A. Mental retardation and seizures 

B. Hypothermia and respiratory distress 

C. Acrocyanosis and decreased lanugo 

D. Patent ductus arteriosus and pneumonia 

Answer: B 

Explanation: A premature infant lacks fat cells and is not able to alter body temperature. He has decreased surfactant and is apt to develop respiratory distress. Mental retardation and seizures are possible later complications of prematurity. Acrocyanosis is normal. Decreased lanugo is seen at term; a premature infant has more lanugo. Patent ductus arteriosus is not specifically related to prematurity. Pneumonia is not specifically related to prematurity. 

Question 5415) 

Orders for a premature infant are for nipple feedings or gavage. What assessment findings are necessary before nipple feedings are given?

A. The baby must have a respiratory rate of 20 to 30 and heart rate of 110 to 130 

B. The baby must be alert and rooting. 

C. Sucking and gag reflexes must be present. 

D. Weight and temperature must be stable. 

Answer: C 

Explanation: Before an infant can be given nipple feedings, he/she must have sucking and gag reflexes to prevent aspiration. The respiratory rate and heart rate given in answer 1 are below those of term infants and are totally unrealistic. A baby who is alert and rooting but does not have sucking and gag reflexes should not be given nipple feedings. Stable weight and temperature are not requirements for nipple feeding. 

Question 5416) 

The mother of a 3-lb preterm infant has expressed a desire to breastfeed her baby. Because of his prematurity, she expresses fear that she can’t. What is the best response for the nurse to make? 

A. “The baby won’t be able to nurse for several weeks, but you can try at that time.” 

B. “Breast milk does not have enough calories for premature babies.” 

C. “You must be very disappointed that he is so small. Special formula is necessary. Perhaps you can nurse your next baby.” 

D. “Breast milk is very good for premature babies. Even if he is not strong enough to nurse now, we will help you pump your breasts and give him the milk.” 

Answer: D 

Explanation: This response helps to reinforce the mother’s positive feelings as well as gives correct information. Answer 1 denies the mother’s feelings and does not give correct information. Answers 2 and 3 are not correct. Breast milk is the best food for premature babies. 

Question 5417) 

The mother of a term newborn born two hours ago asks the nurse why the baby’s hands and feet are blue. What information should the nurse include when responding? 

A. Blue hands and feet can indicate possible heart defects. 

B. This is normal in newborns for the first 24 hours. 

C. This pattern of coloration is more common in infants who will eventually have darker skin color. 

D. Once the baby’s temperature is stabilized, the hands and feet will warm up and be less blue. 

Answer: B 

Explanation: Acrocyanosis or blue hands and feet is normal for the first 24 hours of life and is thought to be related to the establishment of circulation after delivery. Acrocyanosis in the first 24 hours does not suggest heart defects. Continuing acrocyanosis might. Bluish discolorations over the lower back and buttocks are called Mongolian spots and are typical in infants with more pigment in their skin. Acrocyanosis is not related to the regulation of temperature as much as it is related to the establishment of nonfetal circulatory patterns. 

Question 5418) 

A newborn is thought to have toxoplasmosis. The nurse explains to the family that toxoplasmosis is most likely to have been transmitted to the infant in which manner? 

A. Through a blood transfusion given to the mother 

B. Through breast milk during breastfeeding 

C. By contact with the maternal genitals during birth 

D. It crosses the placenta during pregnancy. 

Answer: D 

Explanation: Toxoplasmosis is transmitted from the mother to the baby through the placenta. The mother most likely acquired it from cat feces or eating raw meat. The mother could contract HIV or hepatitis from a blood transfusion. HIV could then affect the fetus. HIV can probably be transmitted through breast milk. Gonorrhea, chlamydia, and herpes can all be picked up by the infant during the birth process. 

Question 5419) 

A newborn infant is with his mother, who is a diabetic. He appeared pink and alert and his temperature was stable when he left the nursery 15 minutes ago. His mother calls the nurse and says, “Look at his legs.” The nurse observes spontaneous jerky movements. What is the best INITIAL action for the nurse to take? 

A. Tell his mother that this is normal behavior for a newborn 

B. Tell the mother to feed him his glucose water now 

C. Do a Dextrostix test on the infant 

D. Take the baby back to the nursery and observe him for other behaviors and neurological symptoms 

Answer: C 

Explanation: The nurse needs more data on which to make an assessment. Dextrostix will test for blood sugar. The baby of a diabetic mother is apt to develop hypoglycemia. If the blood sugar is 35 mg/dL or less, he will be given glucose water, and the physician will be notified. Jerky movements of the extremities are not normal and suggest hypoglycemia. 

Question 5420) 

The nurse is caring for a premature infant. Immediately after arrival in the nursery, which nursing action is essential? 

A. Take the rectal temperature 

B. Examine for anomalies 

C. Check the airway for patency 

D. Cleanse the skin of vernix 

Answer: C 

Explanation: The airway should be checked for patency immediately. Removing vernix is not a high priority. The temperature will be monitored, but this is not the highest priority. The nurse will check for anomalies, but this is not the highest priority. When the infant is stable, he/she will be bathed, and bloody material will be removed. Vernix is good for the skin. 

102 - Nursing Exams Questions & Answers - Svastham Exemplar

 Question 5401) 

The nurse is caring for several immediate postpartum women. Which client should the nurse attend to first? 

A. A woman who had a cesarean delivery asks for a drink of water. 

B. A woman who had a natural child birth says she needs to urinate. 

C. A woman whose baby is nursing says her uterus hurts. 

D. A woman says her bed suddenly feels wet beneath her bottom. 

Answer: D 

Explanation: The woman who reports her bed suddenly feeling wet beneath her bottom may be hemorrhaging. This needs to be checked out first. The other situations are all probably normal events. The woman who had the cesarean delivery has been NPO for several hours and is probably thirsty. The woman who had the natural childbirth may well need to urinate. The baby nursing stimulates oxytocin and uterine contractions. 

Question 5402) 

The nurse is observing a new mother for good maternal–infant attachment. Which observation would be a sign of inappropriate attachment? 

A. Calling the baby “little bit.” 

B. Holding the baby in “en face” position. 

C. Telling the baby, “You look just like your daddy.” 

D. Continually saying, “I’m too tired to hold the baby.” 

Answer: D 

Explanation: This may mean she is rejecting the baby. Nicknames, holding the baby in “en face” position (so the mother can look at the baby’s face), and seeing family resemblance are positive signs of attachment. 

Question 5403) 

A woman who had a cesarean section tells the nurse, “I guess I flunked natural childbirth because I had to have a cesarean.” This statement is most indicative of which phase of postpartum adjustment? 

A. Taking in 

B. Working through 

C. Taking hold D. Letting go 

Answer: A 

Explanation: By discussing her experience, she is bringing it into reality. This is characteristic of the taking in phase. The taking hold phase is when the mother tries to reassert her control of the family, and letting go is when the baby is integrated into the family. Working through is not one of the phases of postpartum adjustment. 

Question 5404) 

Six hours after delivery, the nurse notes that a woman’s fundus is two finger breadths above the umbilicus and deviated to the right of the midline. What is the most likely cause of this finding? 

A. Retained placental fragments 

B. Bladder distention 

C. Normal involution 

D. Second-degree uterine atony 

Answer: B 

Explanation: Bladder distention causes uterine displacement, which interferes with involution and may lead to postpartum hemorrhage. With normal involution, the fundus would be at or slightly above the umbilicus and in the midline. Retained placental fragments and uterine atony would cause excessive bleeding. 

Question 5405) 

Which area of health teaching will a new mother be most responsive to during the taking in phase of the postpartum period? 

A. Family planning 

B. Newborn care 

C. Community support groups 

D. Perineal care 

Answer: D 

Explanation: During the taking in phase, the mother is more self-centered. She will be most responsive to perineal care. She will be most responsive to family planning and newborn care during the taking hold phase. Awareness of community support groups would be in the taking hold or letting go phases. 

Question 5406) 

On the first day after a cesarean section, the client is ambulating. She is uncomfortable and asks the nurse, “Why am I being made to walk so soon after surgery?” What is the nurse’s best response? 

A. “You can get to hold your baby more quickly if you walk around.” 

B. “Early walking keeps the blood from pooling in your legs and prevents blood clots.” 

C. “Walking early will prevent your wound from opening.” 

D. “Early walking helps lower the incidence of wound infection.” Answer: B Explanation: Early walking helps to prevent thrombophlebitis. She does not have to walk in order to hold her baby. Walking does not prevent dehiscence or wound infection. 

Question 5407) 

A pregnant woman tells the nurse that she is planning to breastfeed because “You don’t have to take contraceptives until you wean the baby.” What is the best response for the nurse? 

A. “Lactation does suppress ovulation, so you are not likely to get pregnant.” 

B. “You will not get pregnant until you start to menstruate again.” 

C. “When a woman is breastfeeding, she may not menstruate, although she may ovulate. It is best to use some type of birth control.” 

D. “You will find that you won’t be interested in resuming sexual activity until after you wean the baby.” 

Answer: C 

Explanation: The bottle-feeding mother’s ovulation and menstrual cycle has been noted to occur as early as 36 days; the breastfeeding mother’s cycle can occur as early as 39 days. Lactation sometimes, but not always, suppresses ovulation. A nursing mother may ovulate and not menstruate, so another method of contraception is recommended. Lactation does not have an effect on sexual desire. Breastfeeding is not a reliable method of contraception. 

Question 5408) 

A new mother who has been breastfeeding her infant for six weeks calls the nurse at the doctor’s office and says her right nipple is cracked and sore; she has a temperature and feels as though she had the flu. How should the nurse respond to the woman? 

A. “Try putting warm compresses over your right breast.” 

B. “Immediately stop nursing and apply cold compresses to your breasts.” 

C. “Come to see the physician. You may need medication to help.” 

D. “Reduce the time the baby nurses on your right breast, and call again if the breast is not better in two days.” 

Answer: C 

Explanation: The data suggest that the mother has mastitis. Antibiotics may be a part of the treatment. She should be seen by the physician. Warm compresses might be helpful, but the woman needs to be seen by the physician. Cold compresses are not indicated for infection. She will probably not need to stop nursing or reduce feeding on that breast. 

Question 5409) 

At 3 hours of age, a term newborn seems jittery and has a weak and high-pitched cry and irregular respirations. The nurse suspects that the infant may have which of the following? 

A. Hypoglycemia 

B. Hypercalcemia 

C. Hypervolemia 

D. Hypothyroidism 

Answer: A 

Explanation: Being jittery and having a weak and highpitched cry and irregular respirations are classic symptoms of hypoglycemia. 

Question 5410) 

The mother of a newborn is breastfeeding her infant on the delivery table. How can the nurse best assist her? 

A. Touch the infant’s cheek adjacent to the nipple to elicit the rooting reflex 

B. Leave the mother and baby alone and allow the infant to nurse as long as desired 

C. Position of the Infant to gasp th nipple so as to express milk 

D. Give the infant a bottle first to evaluate the baby’s ability to suck 

Answer: A 

Explanation: The rooting reflex is stimulated when the cheek next to the breast is gently stroked. Answer 2 is not correct. The nurse should not leave the mother and baby alone until the nurse is confident that mother and baby are doing well. The infant should not nurse long enough to cause sore nipples. Answer 3 is not correct. The infant should grasp the areola, not the nipple. Answer 4 is not correct. Giving a bottle first would serve no purpose and might interfere with nursing.

101 - Nursing Exams Questions & Answers - Svastham Exemplar

 

Question 5391) 

The day after delivery, a new mother asks why her milk is so creamy and yellow. What is the best response for the nurse to make? 

A. “I wouldn’t worry about it.” 

B. “This is normal. It will soon turn to real milk.” 

C. “You’re coming along fine.” 

D. “You haven’t gotten your milk in yet.” 

Answer: B 

Explanation: The client is describing colostrum. Milk comes in about 72 hours after delivery. Answers 1 and 3 do not address the question asked by the mother. Answer 4 is technically accurate but does not give as much information and reassurance as answer 2. 

Question 5392) 

A new mother is in the first period of adjustment following birth called the takingin phase. What type of maternal behavior would the nurse expect her to exhibit? 

A. Passivity and dependence 

B. Preoccupation with baby’s needs 

C. Independence 

D. Resuming control of life 

Answer: B 

Explanation: The taking in period is characterized by passivity and dependence. The mother relives her labor and integrates it into her being. Preoccupation with the baby’s needs and reasserting independence are characteristic of the taking hold phase, which follows the taking in phase. Resuming control of life is characteristic of the letting go phase. 

Question 5393) 

A new mother has decided not to breastfeed her baby. Which statement indicates the best understanding of the management of engorgement? 

A. “I will stand with my back to the shower.” 

B. “I will take a sitz bath every day.” 

C. “I will apply a warm compress to my breasts three times a day.” 

D. “I will drink a lot of liquids for the next few days.” 

Answer: A 

Explanation: Standing with her back to the shower will keep the warm water from stimulating milk production. Cool compresses will help with engorgement; warm compresses stimulate milk flow. A sitz bath is indicated for an episiotomy. It is not related to the care of the breasts. Consumption of excess fluids will encourage milk production. Some additional fluids are necessary during the diaphoresis/diuresis phase after delivery. 

Question 5394) 

A new mother is about to be discharged from the hospital. Which statement made by a new mother indicates a need for more instruction? 

A. “I will use my old diaphragm for contraception.” 

B. “I have an appointment for my six-week checkup.” 

C. “My mother will be helping me with the children for the next two weeks.” 

D. “I plan to go back to my job as a secretary in six weeks.” 

Answer: A 

Explanation: A woman should be resized for a diaphragm after the birth of a baby. The old one may no longer be the correct size. The resizing will occur after involution is completed, usually at her sixweek checkup. If sexual activity is resumed before that time, another means of contraception (such as the condom) should be used if she does not wish to get pregnant. All of the other responses indicate understanding of postpartum care. 

Question 5395) 

A woman who delivered today by cesarean delivery asks the nurse, “How come my baby has such a round head? My other baby’s head was not so round, and she was more red.” What is the best response for the nurse to make?

A. “Each baby is different. It is not a good idea to compare your children.” 

B. “Were forceps used when your older child was delivered?” 

C. “Babies born by cesarean have rounder heads because they do not go through the birth canal.” 

D. “A round head is a sign the baby is very intelligent. Your child should do very well in school.” 

Answer: C 

Explanation: Babies born by cesarean delivery do not have molded heads because they have not passed through the pelvis and the birth canal. The other responses are not helpful. Answer 1 does not address the question. Forceps can cause distinctive marks on the head. A round head is not a sign of intelligence. 

Question 5396) 

The nurse is caring for a woman who delivered a healthy infant via cesarean delivery 30 minutes ago. The mother says to the nurse, “Please don’t touch my belly. I had an operation.” What is the nurse’s best response? 

A. “Alright I won’t. Be sure to let me know if you have any pain or bleeding.” 

B. “I do need to look at your abdomen to check your incision.” 

C. “I must touch your abdomen to check you uterus, but I won’t touch your incision.” 

D. “I can wait two more hours before I will need to check your uterus.” 

Answer: C 

Explanation: A woman who had a cesarean delivery still needs to have the uterine fundus checked for firmness and massaged if it is not firm. This is usually done every 15 minutes for the first two hours after delivery. The uterine fundus is well above the incision site, so it is not necessary to touch the incision. The nurse should inspect the dressing for bleeding. 

Question 5397) 

A woman is admitted to the postpartum unit two hours after delivery of a baby. What action is especially important because the membranes were ruptured for 28 hours before delivery? 

A. Monitor her temperature every two hours 

B. Provide perineal care with Zephiran every four hours 

C. Maintain a strict perineal pad count 

D. Have the mother take a sitz bath four times a day 

Answer: A 

Explanation: Temperature over 100.4°F after the second day usually indicates infection. Infection is the most frequent maternal complication after prolonged rupture of the membranes. Zephiran perineal care is not a current practice and is not related to prolonged rupture of the membranes. A strict perineal pad count is not necessary. Sitz baths are a comfort measure for a sore perineum and are not related to prolonged rupture of the membranes. 

Question 5398) 

The nurse is caring for a woman who delivered a baby three hours ago. The woman pulls the emergency call light and says she is bleeding all over the bed. The nurse enters the room and sees the blood-soaked bed. What is the best initial action for the nurse to take? 

A. Assess and massage the fundus if soft 

B. Take vital signs 

C. Place the client in sharp Trendelenburg position 

D. Notify the physician immediately 

Answer: A 

Explanation: The most common cause of postpartum hemorrhage is uterine atony. Always assess the fundus first and massage it if it is not firm. Taking vital signs and notifying the physician will be done after the nurse assesses and massages the fundus if necessary. The client will not be placed in the Trendelenburg position. 

Question 5399) 

Methergine 5 mg qid is ordered for a postpartum client. An hour after taking the drug, the woman complains of uterine cramping. What is the best explanation for the nurse to give her? 

A. “This is an unfortunate side effect, but you need the medicine.” 

B. “The cramping is uncomfortable, but it is a sign that the drug is keeping your uterus contracted so you won’t bleed too much.” 

C. “Since you are experiencing cramps, I’ll ask the doctor to discontinue the drug.” 

D. “The cramping should decrease soon. If it does not, let me know. I’ll see if the doctor will decrease the dosage.” 

Answer: B 

Explanation: This response explains the drug’s action to the client. Methergine is an oxytocic drug that helps the uterus to contract and prevents postpartum bleeding. Answer 1 is not correct because it does not give the mother the information she needs to understand why she is cramping. Answers 3 and 4 are not accurate. 

Question 5400) 

The nurse is caring for a woman who had a postpartum hemorrhage. Which of the following facts about her delivery most likely contributed to her hemorrhage? 

A. The baby weighed 10 lb 6 oz. 

B. She received Pitocin after delivery of the placenta. 

C. She delivered 10 days after her due date 

D. Her second stage of labor lasted an hour Answer: A Explanation: An overstretched uterus is subject to hemorrhage. A large baby causes additional stretching of the uterus. Answer 2 is not correct. Pitocin contracts the uterus and decreases hemorrhage. It is also standard procedure following delivery. Answer 3 is not correct. Delivering after the due date itself does not increase postpartum hemorrhage. However, the large baby does. Answer 4 is not correct. It is normal for the second stage of labor to last an hour.