Pedia Exam Set 1

1. A nurse in a clinic is assessing the weight of an infant.
Which infants weight indicates to the nurse that

the infants weight is normal for the infants age?
1. The babys weight has tripled in the first 6 months of life
2. The babys weight has doubled in the first year of life
3. The babys weight has doubled in the first 6 months of life and tripled in the first year
4. The babys weight has doubled in the first 6 months and doubled again in the next 6 months
ANSWER: 3
A babys weight should double in the first 4 to 6 months of life and triple by the end of the first year. The weight needs
to more than double the first year.
Test-taking Tip: As you read each option, take the normal weight of a newborn and apply the weight in the option before making
a selection.
2. A student explains to an instructor that the infant period is categorized as the oral phase according to
Freuds theory. Which statements by the student suggest an understanding of this phase? SELECT ALL
THAT APPLY.
1. An infant sucks for nourishment as well as pleasure
2. An infant does not find pleasure in sucking but does find enjoyment from the nourishment
3. An infant may have more pleasure in breastfeeding than bottle feeding because it expends more energy
4. An infant does not find pleasure in use of a pacifier
5. An infant explores the world through the mouth
6. An infant begins to explore the genital area to learn sexual identity
ANSWER: 1, 3, 5
An infant has the desire to suck, which may actually build the ego and self-esteem of an infant. There is more pleasure
in breastfeeding because it expends more energy and also provides other comforting mechanisms, such as warmth.
An infant explores the world through the mouth, especially the tongue. Freud believed the oral phase is important for both
nutrition and pleasure in the first year of life. An infant finds pleasure in sucking on a pacifier, according to Freud. A preschooler
learns sexual identity through awareness of the genital area.
Test-taking Tip: Look for key words in each option.
3. An 8-month-old baby girl, who is developing appropriately, is admitted to a pediatric unit for respiratory
syncytial virus (RSV). The baby is crying and being held by her mother. A nurse wants to provide
appropriate care based on Eriksons developmental stages. In which stage is this baby, according to
Eriksons theory?
1. Punishment versus obedience orientation
2. Oral stage
3. Initiative versus guilt
4. Trust versus mistrust
ANSWER: 4
Based on Eriksons stages of development, trust versus mistrust is appropriate for a child under a year old. The child
learns to love and be loved. Experiences that add to security include soft sounds, touch, and visual stimulation for an
active child. Punishment-versus-obedience orientation is not a developmental stage. Initiative versus guilt is a developmental task
in the preschool stage. The oral phase is based on Freud not Erikson.
Test-taking Tip: Use the process of elimination. Recall that
Eriksons developmental tasks include achievement of a task
versus nonachievement of a task.
4. A nurse is caring for a 3-month-old infant. Based on the developmental age of the child, which motor
skill should the nurse expect to see during an assessment?
1. Bangs objects held in hand
2. Begins to grab objects using a pincer grasp
3. Grabs objects using a palmar grasp
4. Looks and plays with own fingers
ANSWER: 4
Three-month-old babies can play with their own fingers. At 3 months, infants can reach for attractive objects in front
of them, but because their grasp is unpracticed, they usually miss them. A 2-month-old infant will hold an object for a few
minutes. A 10-month-old infant uses a pincer grasp. A 6-month-old infant uses a palmar grasp.
Test-taking Tip: Awareness of the developmental stages and age of a 3-month-old will assist with answering this question
correctly.
A nurse case manager is meeting with the parents of an 8-year-old client. The 8-year-old is scheduled for
surgery to repair a cleft palate. The parents ask the case manager when they should discuss and explain
the surgery to their child. Based on the childs developmental age, which is the best response by the
nurse?
1. Explain the surgery immediately before it is carried out.
2. Explain the surgery 1 to 2 hours before it is carried out.
3. Explain the surgery up to 1 week before it is carried out.
4. Explain the surgery several days before it is carried out.
ANSWER: 4
An 8-year-old can receive teaching several days before surgery. School-age children have concrete operational
thought and can remember events. A preschooler will remember explanations for only a couple of hours. A toddler has limited
attention span and limited ability to remember things. An adolescent can handle information for the longest period of time.
Test-taking Tip: Focus on the length of time in each of the options and how long an 8-year-old should be able to remember
events.
6. A 4-year-old child is hospitalized with a high fever. While the child is in bed, the child comforts himself by
sucking the thumb. The mother of the child becomes concerned because her child has not sucked his
thumb for 6 months. Which nursing response to the mothers concerns is most appropriate?
1. I dont know why he is sucking his thumb; maybe your child just needs more attention.
2. This is a form of developmental regression and can be a normal response for a child who is
hospitalized. Continue to love and support your child.
3. Is there anything else going on in your family right now that may be causing your child to feel
anxious?
4. Where is the childs father? Maybe the child wants his father?
ANSWER: 2
It is common for preschoolers to revert to a behavior they have outgrown in an effort to cope with difficult situations.
Sucking a thumb is a comfort measure for the child. Thumb-sucking does not indicate that the child is not getting enough
attention. Thumb-sucking does not mean there are other contributing factors. The hospitalization is enough stress in a childs life.
Having a father present may or may not be helpful to the child.
Test-taking Tip: Consider the developmental stages of the 4-year-old.
7. 1. A 1-day-old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assesses the morning
axillary temperature as 96.9F. Which of the following could explain

this assessment finding?
1. This is a normal temperature for a preterm neonate.
2. Axillary temperatures are not valid for preterm babies.
3. The supply of brown adipose tissue is incomplete.
4. Conduction heat loss is pronounced in the baby.
1. 1. The normal temperature of a premature
baby is the same as a full-term baby.
2. Axillary temperatures, when performed
correctly, provide accurate information.
3. Preterm babies are born with an insufficient
supply of brown adipose tissue
that is needed for thermogenesis,
or heat generation.
4. There is nothing in the question that
would explain conduction heat loss.
TEST-TAKING TIP: It is important for the
test taker not to read into questions.
Even though conduction can be a means
of heat loss in the neonate and, more
particularly, in the premature, there are
three other means by which neonates
lose heatradiation, convection, and
evaporation. Conduction could only be
singled out as a cause of the hypothermia
if it were clear from the question that
that were the cause of the problem
8. 5. A baby is grunting in the neonatal nursery. Which of the following actions by the
nurse is appropriate?
1. Place a pacifier in the babys mouth.
2. Check the babys diaper.
3. Have the mother feed the baby.
4. Assess the respiratory rate.
5. 1. Grunting is a sign of respiratory distress.
Offering a pacifier is an inappropriate intervention.
2. Diapering is an inappropriate intervention.
3. The baby is not hungry. Rather the baby
is in respiratory distress.
4. Grunting is often accompanied by
tachypnea, another sign of respiratory
distress.
TEST-TAKING TIP: If the test taker were to
attempt to grunt, he or she would feel
the respiratory effort that the baby is creating.
Essentially, the baby is producing
his or her own positive end-expiratory
pressure (PEEP) in order to maximize his
or her respiratory function.
6. A 6-month-old child developed kernicterus immediately after birth. Which of the
following tests should be done to determine whether or not this child has developed
any sequelae to the illness?
1. Blood urea nitrogen and serum creatinine.
2. Alkaline phosphotase and bilirubin.
3. Hearing and vision assessments.
4. Peak expiratory flow and blood gas assessments.
6. 1. Blood urea nitrogen and serum creatinine
tests are done to assess the renal system.
Kernicterus does not affect the renal system.
It results from an infiltration of
bilirubin into the central nervous system.
2. Although alkaline phosphotase and bilirubin
would be evaluated when a child is
jaundiced, they are not appropriate as assessment tests for the child who has developed
kernicterus.
3. Because the central nervous system
(CNS) may have been damaged by the
high bilirubin levels, testing of the
senses as well as motor and cognitive
assessments are appropriate.
4. The respiratory system is unaffected by
high bilirubin levels.

TEST-TAKING TIP: The test taker must be
aware that kernicterus is the syndrome
that develops when a neonate is exposed
to high levels of bilirubin over time. The
bilirubin crosses the blood-brain barrier,
often leading to toxic changes in the CNS.
9.
A client asks about the difference between cows milk and the milk from her
breasts. The nurse should respond that cows milk differs from human milk in that
it contains:
1. Less protein, less calcium, and more carbohydrates
2. Less protein, more calcium, and more carbohydrates
3. More protein, less calcium, and fewer carbohydrates
4. More protein, more calcium, and fewer carbohydrates
Answer 4
Rationale 1. Cows milk contains more protein and more calcium.
Rationale 2. Cows milk contains more protein and fewer carbohydrates.
Rationale 3. Cows milk contains more calcium.
Rationale 4. Cows milk is more difficult to digest because it is meant to meet the
calls, not the infants, nutritional needs. It is not recommended until after the
infant is 1 year old.
Client Need: Health Promotion and Maintenance
Cognitive Level: Application
Integrated Process/Nursing Process: Teaching/Learning.
Planning/Implementation
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10.
The nurse should explain to a client that breastfeecling is always
contraindicated with:
1. Mastitis
2. Hepatitis C
3. Inverted nipples
4. Herpes genitalis
Answer 2
Rationale 1. Breastfeeding by a mother with mastitis is not always
contraindicated: the baby already has the organism in the mouth.
Rationale 2. Breastfeeding by a mother with hepatitis C is contraindicated to limit
the transmission of infection.

Rationale 3. Breastfeeding is not contraindicated with inverted nipples, because a
breast shield can provide mild suction to help evert a nipple.
Rationale 4. Breastfeeding is not always contraindicated with this disorder.
Client Need: Safety and Infection Control
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11.
At 10 hours of age an infant has a large amount of mucus and becomes
cyanotic.
What should the nurse do first?
1. Suction
2. Administer oxygen
3. Record the incident
4. Insert a nasogastric tube
Answer 1
Rationale 1. To maintain a patent airway and promote respiration and
gaseous
exchange. mucus must be removed.
Rationale 2. If the airway is obstructed. 2 will be of no use.
Rationale 3. Documentation is important, but secondary to clearing a
passageway
for air.
Rationale 4. This is for aspirating the stomach contents, not for airway
clearance.
Client Need: Physiological Adaptation
Integrated ProcessiNursing Process: Planningllmplementation

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12.
After the birth of a healthy neonate. the ductus arteriosus becomes the:
1. Venous ligament
2. Vesical ligament
3. Ligamentum teres
4. Ligamentum arteriosum
Answer 4
Rationale 1. This refers to the ductus venosus after it closes.
Rationale 2. There is no such ligament.
Rationale 3. This is a descriptive term meaning a long and round ligament.
Rationale 4. There is anatomic obliteration of the lumen by fibrous proliferation.
leading to the term ligamentum artenosum.
Chent Need: Health Promotion and Maintenance
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13.
When assessing a 9-lb neonate 2 hours after birth, the nurse identifies
jitteriness. irregular respirations, and temperature instability. The nurse knows

that these are indications that the neonate probably has:
1. Hyponatremia
2. Hypoglycemia
3.Acardiac defect
4.An immature CNS
Answer 2
Rationale 1. These are not signs of this problem.
Rationale 2. Hypoglycemia causes central nervous system and sympathetic
nervous symptom responses.
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14.
When caring for preterm infants with respiratory distress, the nurse
should keep:
1. Them prone to prevent aspiration
2. Them in a high-humidity environment
3. Their caloric intake low to decrease metabolic rate
4. Their oxygen concentration low to prevent eye damage
Answer 2
Rationale 1. They should be positioned side-lying rather than prone: the
prone position is associated with apnea and SIDS.
Rationale 2. The moisture provided by the humidity liquefies the tenacious
secretions. making gas exchange possible.
Rationale 3. Actually the caloric intake is increased: the amount. number.
and type of feedings are related to the metabolic rate.
Rationale 4. This is not a routine action: the concentration of oxygen that is
administered depends on the 2 concentration of the blood gases.
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15.
The client response that indicates understanding of teaching regarding breast
care for the mother who is breastfeeding is. I will:

1. Use a mild soap for washing
2. Remove my brassiere at night.
3.Air dry my nipples after feeding.
4. Line my breast pads with plastic
Answer 3
Rationale 1.Application of soap to breast tissue may result in drying and cracking
Rationale 2. Wearing a brassiere continuously, except for bathing. is
recommended for 2 to 3 weeks postpartum to provide support to breast tissue

structures.
Rationale 3. Air-drying nipples after feedings limits irritation and disruption of skin
integrity.
Rationale 4. Plastic liners trap moisture against tissue and may cause skin
breakdown.
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16.
When perlorming a newborn assessment, the nurse should measure the vital
signs
in which sequence?
1. Pulse. respirations, temperature
2. Temperature. pulse. respirations
3. Respirations. temperature. pulse
4. Respirations, pulse, temperature
Answer 4
Rationale 1. Measuring the respirations should precede heart rate measurement
because the vital signs will change when the baby is touched.
Rationale 2. Temperature should be measured last.
Rationale 3. Respirations should be measured first, but temperature should be
measured after the heart rate.
Rationale 4. This sequence is least disturbing. Touching with the stethoscope and
inserting the thermometer increase anxiety and elevate vital signs.
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17.
The nurse knows that neonates have difficulty maintaining their body
temperature. However, they have several mechanisms to help them maintain

it. Select all that apply.
1. Flexed fetal position
2. Hepatic insulin stores
3. Brown fat metabolism
4. Peripheral vasoconstnction
5. Parasympathetic nervous system
Answer 1,3,4
sympathetic nervous system: when the body becomes cool, the sympathetic
nervous system stimulates the breakdown of brown fat. which releases heat
as a byproduct.
4 Peripheral vasoconstnction helps conserve heat by keeping the central
core warm and not allowing heat to dissipate.
5 The sympathetic. not parasympathetic. nervous system is involved in
thermoregulation.
Rationale:
1 Full-term neonates have a flexed fetal position. which provides heat
conservation.
2 Insulin is not stored in the liver and is not involved with maintaining
neonatal
body temperature.
3 Brown fat starts being deposited at 28 weeks gestation and is innervated
by the
18.
An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has
Apgar scores of 7/9. on admission to the nursery, it is not necessary for the nurse
to:
1. Record vital signs
2. Administer oxygen
3. Evaluate the neonates health status
4. Support the neonates body temperature
Answer 2
Rationale 1. This is an important part of record keeping for all newborns.

Rationale 2. The babys Apgar score (7/9) does not indicate a need for 2
Rationale 3.All newborns are evaluated immediately.
Rationale 4. Poor thermoregulation necessitates keeping the baby warm to
stabilize body temperature.
Client Need: Reduction of Risk Potential
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19.
On a home visit the visiting nurse assesses that the 4-day-old infant who
was born at home has a purulent discharge from the eyes. The nurse
suspects that the infant hasp
1. Signs of Chiamydia tractiomatis infection
2. Acquired immunodefic iency syndrome (AIDS)
3. Retinopathy of prematurity (retrolental fibroplasia)
4.A reaction to the ophthalmic antibiotic instilled after birth
Answer I
Rationale I. This conjunctivitis occurs about 3 to 4 days after birth: if it is not
treated with an antibiotic, chronic follicular conjunctivitis with conjunctival
scarring will
occur.
Rationale 2. AIDS in the newborn does not manifest itself with conjunctivitis.
Rationale 3. High 2 concentrations given to severely compromised preterm
infants cause vasoconstriction of retinal capillaries, which can lead to
blindness: there are no data to indicate that this infant was preterm or
severely compromised
Rationale 4. This chemical conjunctivitis occurs within the first 48 hours and
is not purulent.
Cognitive Level: Analysis
Integrated Process/Nursing Process: Assess mentlAnalysis

20.
An infants intestines are sterile at birth, therefore lacking the bacteria
necessary
for the synthesis of:
1. Bilirubin
2. Bile salts
3. Prothrombin
4. Intrinsic factor
Answer 3
Rationale 1. This is an orange bile pigment produced by the breakdown of
hemoglobin.
Rationale 2. Bile salts are manufactured in the liver, not synthesized by bacteria.
Rationale 3. Bacteria. especially Eschericflia coil, produce substances
necessary to synthesize prothrombin.
Rationale 4. This is secreted by the gastric glands. not synthesized by bacteria.
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21.
At 12 weeks gestation. a client who is Rh-negative completely expels the
products of conception. After determining that she has not been previously
sensitized, the nurse should:
1.Administer Rh0GAM within 72 hours
2. Make certain the client receives Rh0GAM at her first clinic visit
3. Withhold the RhoGAM. because it is not used after the birth of a stillborn
4. Withhold administration of the RhoGAM. because the gestation lasted only 12
weeks
Answer 1
Rationale 1. RhoGAM must be given within 72 hours postpartum if the client has
not been sensitized previously, irrespective of the length of the gestation.

Rationale 2. It would be useless at this time because antibodies have been
produced already.
Rationale 3. Rh0GAM is always indicated at the termination of a pregnancy, even
with fetal demise.
Rationale 4. Rh0GAM is always indicated at the termination of a pregnancy. even
with a short-term pregnancy.
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22.
The nurse is aware that a healthy newborns respirations are:
1. Irregular. thoracic, 30 to 60/mm. deep

2. Regular. abdominal, 40 to 50/mm, deep
3. Regular. thoracic. 40 to 60/mm. shallow
4. Irregular. abdominal. 30 to 60/mm. shallow
Answer 4
Rationale 1. Newborns respirations are abdominal.
Rationale 2. Newborns respirations usually are irregular.
Rationale 3. Newborns respirations are irregular and abdominal in origin.
Rationale 4. The healthy newborns breathing is abdominal and irregular in
rhythm and depth (alternates between shallow and deep) the rate ranges from 30
to 60 breaths/mm.
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23. A
new mother is breastfeeding her 2-day-old infant and tells the home health
nurse that she cannot believe her newborn wants to breastfeed again, since she
just fed him 2112 hours ago. The nurse should plan to teach the client that a
newborn usually should be nursed:

1. Every hour
2. On demand
3. Every 4 hours
4.At 5-hour intervals
Answer 2
Rationale 1. A newborn may want to nurse hourly if irritable, but this is not a
usual
feeding pattern.
Rabonale 2. Breast milk is digested faster than formula: therefore breastfed
newborns
become hungry sooner.
Rationale 3. A breastfed newborn must be fed more often than this.
Rabonale 4. All newborns must be fed more often than this.
Client Need: Basic Care and Comfort
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24. A
low Apgar score at 5 minutes after bwth correlates with the occurrence of:
1. Cerebral palsy
2. Genetic defects
3. Mental retardation
4. Neonatal morbidity
Answer 4
Rationale 1. The diagnosis of cerebral palsy is not related to the Apgar score.
Rationale 2. Genetic defects may or may not be apparent at this time. They are
not
related to the Apgar score.
Rationale 3. This has not been proven, although research continues in this area
Rationale 4. This is related to neonatal morbidity and mortality: by 5 minutes the
healthy neonate is relatively stable and requires routine care.
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25.
A preterm neonate admitted to the neonatal intensive care nursery has muscle
twitching. seizures, cyanosis. abnormal respirations. and a short, shrill cry. The
nurse suspects that this infant may have:
1. Tetany
2. Spina bitida
3. Hyperkalemia
4. Intracranial hemorrhage
Answer 4
Rationale 1. This is caused by hypocalcemia: it is manifested by exaggerated
muscular twitching.
Rationale 2. This is an obvious defect of the spinal column: it is easily
recognized.
Rationale 3. Elevated potassium level causes cardiac irregulanties.
Rationale 4. Intracranial bleeding may occur in the subdural, subarachnoid. or
intraventricular spaces of the brain, causing pressure on vital centers: clinical
signs are related to the area and degree of cerebral involvement.
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26. The
nurse in the newborn nursery observes a yellowish skin color of an infant
whose mother had a cesarean birth. The immediate nursing action should be to:
1. Notify the practitioner
2. Ascertain the age of the neonate
3. Take a heel blood sample and send it to the laboratory
4. Cover the eyes and place the infant under the ultraviolet light
Answer 2
Rationale 1. Unless the jaundice was pathologic (occurring in the first 24 hours of
life), this is not necessary.
Rationale 2. The infants age is critical because the development of jaundice
before 24 to 48 hours after birth may indicate a blood dyscrasia requiring
immediate investigation. Jaundice occurring between 48 and 72 hours after birth
(physiologic jaundice) is a consequence of the expected breakdown of fetal red
cells and immaturity of the liver.
Rationale 3. First. the age of the infant must be ascertained to determine if this is
physiologic or pathologic jaundice. then, the nurse should perform a heelstick to
determine the amount of bilirubin in the blood
Rationale 4. Bilirubin studies would be done first to determine whether the
amount of bilirubin present warranted phototherapy
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27. The
nurse should know that an asymmetric Moro reflex is frequently
associated
with:
1. Down syndrome
2. Cranial nerve damage
3. Cerebral or cerebellar injuries
4. Brachial plexus. clavicular. or humeral injuries
Answer 4
Rationale 1. Children with Down syndrome exhibit a normal Moro reflex.
Rationale 2. This frequently is not associated: however, if the cochlea were
undeveloped or the eighth cranial (vestibulocochlear) nerve were injured, it would
affect equilibrium and response to the test.
Rationale 3. These injuries usually cause a symmetric loss of the Moro reflex.
Rationale 4. Injury to the brachial plexus. clavicle, or humerus prevents abduction
and adduction movements of an upper extremity.

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28.
After bwth. when inspecting her newborn girl, the mother notices a
discharge from the nipples of both of her infants breasts. The nurse should
explain that this is evidence of:
1. Monilia contracted during birth
2.An infection contracted in utero
3. Congenital hormonal imbalance
4.An effect from maternal hormones
Answer 4
Rationale 1. This usually is manifested in the oral mucosa as thrush (white.
adherent
patches).
Rationale 2. Evidence of infection would not appear so rapidly after birth.
Rationale 3. This is uncommon and usually undetectable in the newborn
period.
Rationale 4. Some maternal oxytocin crosses the placenta and induces the
secretion of fluids that have accumulated in the fetal breasts (sometimes
called witchs milKs).
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29. The
nurse understands that one of the factors influencing the availability of
milk in
the lactating woman is the:
1. Distribution of erectile tissue in nipples
2.Age of the woman at the time of the birth
3. Viewpoint of the womans family toward breastfeeding

4. Amount of milk products consumed during the pregnancy
Answer 3
Rationale 1.This has no influence on lactation.
Rationale 2. This has no influence on lactation.
Rationale 3. If the woman perceives a negative viewpoint about breastfeeding
from significant others, she may be tense and the let-down may not occur; a
positive attitude from significant others toward breastfeeding promotes relaxation
and the let-down reflex.
Rationale 4. Milk or milk product intake during pregnancy has little influence on
lactation.
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30. Which
assessment, observed immediately after birth, will probably necessitate
prolonged follow-up care of a newborn?

1.Apgar score of 5
2. Weight of 3500 g
3. Umbilical cord that contains 2 blood vessels
4. Aspiration of 20 mL of milky-colored gastric fluid
Answer 3
Rationale 1. If the Apgar score 5 minutes later showed marked improvement,
there
would be no need for placing the infant in the ICU.
Rationale 2. This is the average weight for a full-term newborn.
Rationale 3. The congenital absence of a blood vessel in the umbilical cord is
often associated with life-threatening congenital anomalies
Rationale 4. The fetus may have swallowed some amniotic fluid: this is not
unusual or dangerous.

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31. A
peripheral central venous catheter has just been inserted in the arm of a 7-
year- old child on the pediatric unit. A peripheral IV line is still in place. An
antibiotic is to be administered immediately. Which intravenous access line
should the nurse use for the antibiotic infusion and why?
1. Central venous catheter, because this will help determine its patency
2. Peripheral line, because the central venous catheter is reserved for fluids
3. Peripheral line, because the central venous catheter placement has not been
confirmed by radiography
4. Central venous catheter, because the antibiotic must be given systemically as
quickly as possible
Answer 3
Rationale 1. The central line should not be used until placement is confirmed.
Rationale 2. Drugs and fluids can be administered through central venous lines
most devices have multiple ports.
Rationale 3. The peripheral line must be used until the placement of the central
venous line is confirmed by radiography or fluoroscopy this prevents fluid from
entering the lung or interstitial space if the catheter is misplaced.
Rationale 4. The central line should not be used until placement is confirmed.
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32. A
nurse. planning an initial home care visit to a mother who gave birth to a
highrisk infant, understands that the visit will be more productive if scheduled when
the:
1. Husband is out of the home
2. Mother is feeding the infant
3. Time is convenient for the family

4. Nurse has time to spend with the family
Answer 3
Rationale 1. The father should be included in the visit if at all possible.
Rationale 2. This may be an inconvenient time for the mother and interfere with
productivity.
Rationale 3. The family members are more inclined to share problems with the
nurse if they are not feeling pressured: in addition, it aids in the development of a
productive relationship.
Rationale 4. This may be at a time that is inconvenient for the family and thus
interfere with productive interaction.
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33. A
1-week-old infant has been in the pediatric unit for 18 hours following
placement of a spica cast. The nurse notes that the respiratory rate is less
than 24 breaths/mm. No other changes are observed, and because the
infant is apparently well, there is no report or documentation of the slow
respiratory rate. Several hours later, the infant experiences severe
respiratory distress and emergency care is necessary. Legal responsibility in
this instance should take into consideration that:
1. Most infants respirations are slow when they are uncomfortable
2. The respirations of young infants are irregular so a drop in rate is
unimportant
3. Vital signs that are outside the expected parameters are significant and
should be documented
4. The respiratory tract of young infants is underdeveloped and their
respiratory rate is not significant
Answer: 3
Rationale 1. Respirations Will accelerate when there is discomfort.
Rationale 2.Any significant change should be reported immediately.

Rationale 3.A respiratory rate below 30 breathslmin in the young infant is not
within the expected range of 30 to 60 breaths/mm: a drop below 30/mm is a
significant change and should be documented.
Rationale 4. The respiratory tract is fully developed at birth, and the
respiratory rate is a cardinal sign of the infants well-being.
Client Need: Management of Care
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Evaluation/Outcomes
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34. The
nurse teaches a 5-year-old girl with cystic fibrosis how to use an inhaler.
What
is the most appropriate way to evaluate her understanding?
1. Showing the nurse how to use the inhaler
2. Asking questions about using the inhaler
3. Explaining how the inhaler will be used at home
4. Telling the nurse about the things that have been learned
Answer 1
Rabonale 1. The nurse can best evaluate teaching by asking the learner for a
demonstration. Behavior, rather than words, more readily shows what a child has
learned.
Rabonale 2. The child may be too young to know if there are any questions.
Rabonale 3. A demonstration rather than an explanation can be evaluated more
readily.
Rationale 4. This would be difficult for 5 year olds their vocabularies are still
growing.
Integrated Process/Nursing Process: Teaching/Learning.. Evaluation/Outcomes
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35.
The nurse plans specific care for infants based on the knowledge that infants
are at greater risk for a fluid volume deficit and hyperosmolar imbalance than
adults because
1. Their metabolic processes are slower
2. They have a slower glomerular filtration rate
3. Their body fluid loss is proportionately greater per kilogram of weight
4. They have not yet developed a generalized response to insensible fluid loss
Answer 3
Rationale 1. Their metabolic rate is more rapid.
Rationale 2. Infants have a rapid glomerular filtration rate: a decreased rate is
common in the older adult.
Rationale 3. Infants are not protected from water loss because they ingest and
excrete a relatively greater daily water volume than adults, therefore the
proportion of total body water is higher.
Rationale 4. Infants and children have a rapid generalized response to insensible
fluid loss.
Chent Need: Basic Care and Comfort
Integrated Process/Nursing Process: Planning/Implementation
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36. A
7-year-old girl develops a urinary tract infection. The practitioner orders a
sulfonamide preparation. What is a major nursing responsibility when

administering this drug?
1. Weigh the child daily.
2. Give milk with the medication.
3. Monitor the childs temperature frequently.
4. Administer the drug at the prescribed times.
Answer 4
Rationale 1. Weighing is important with drugs that affect fluid balance.
Rationale 2. Giving medication with milk or meals is important with drugs that
cause GI
distress.
Rabonale 3. Monitoring temperature would be important with antipyretic drugs.

Rabonale 4. To maintain the desired blood level, the drug must be given in the
exact amount at the times directed. It the blood level of the drug falls, the
organisms have an opportunity to build resistance to the drug.
Client Need: Phaimacological and Parenteral Therapies
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37. When
picked up by the mother or the nurse. an 8-month-old infant screams
and seems to be in pain. The nurse notes the behavior and talks to the mother
about. 1.Accidents and the importance of their prevention
2. Limiting play time with other children in the family
3.Any other behaviors that the mother may have noticed
4. Food and specific vitamins that should be given to infants
Answer 3
Raonale 1. The nurse should gather more data to determine the basis for the
problem.
Rationale 2. More data are needed before recommendations can be made.
Rationale 3. When taking a health history, all areas of concern should be
explored fully before deciding how to address the problem.
Rationale 4. The data are inadequate to focus on nutrition.
Integrated Process/Nursing Process: Communication/Documentation,
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38. The
mother of a 2-year-old child tells the nurse she is having difficulty
disciplining her child. What is the nurses most appropriate response to this
comment?
1. This is a difficult age that your child is going through right now.
2. Tell me more about your difficulty. Im not sure what you mean by that.
3. its important to be consistent with toddlers when they need disciplining.
4. I can understand what you mean. Thats why this age is called the terrible
twos. Answer 2
Rationale 1.Atthough this may be true, it cuts off communication: further
communication should be encouraged
Rationale 2. The nurse should obtain clarification as to the mothers specific
concerns regarding the childs behavior
Rationale 3. This response assumes the mother has been inconsistent: the nurse
needs more information.
Rationale 4. This is inappropriate because the nurse is explaining a
developmental factor without exploring what the mother means.
Integrated ProcesslNursing Process: CommunicationlDocumentation.
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39.
Which nursing intervention provides the most support to the parents of a
newborn
with an obvious physical defect?
1. Encourage them to express their concerns.
2. Discourage them from talking about their baby.
3. Tell them not to worry because the defect can be repaired.
4. Show them postoperative photographs of infants who had similar defects.
Answer 1
Rabonale 1. This helps and encourages parents to put their fears and feelings
into words. Once these sentiments are expressed. they can then be examined
and addressed.
Rationale 2. This would not assist the parents in coping with the problem: neither
would it demonstrate the supportive, empathetic role of the nurse.
Rationale 3. This response lacks insight. Parents will worry about their infant
anyway. Rationale 4. This may or may not be helpful.
Client Need: Psychosocial Integrity

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40.
When planning to prOvide teaching about self-administration of insulin to a
schoolage child newly diagnosed with diabetes mellitus. the nurse should first:
1.Assess the childs developmental level
2. Determine familys understanding of the procedure
3. Discuss community resources for the child in the future
4. Collaborate with the school nurse for ensuring continuity of care in school
Answer 1
Rationale 1. Teaching methods in each age-group are different depending on the
childrens cognitive ability: individual differences depend on a variety of factors
including intelligence and emotional status; the childs readiness to learn must be
assessed before developing a teaching plan that will bring success.
Rationale 2. This would be important later, but not initially.
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41. Based
on developmental norms for a 5-year-old child, the nurse should
withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the practitioner
when the childs apical pulse rate first drops below:
1.60 beats/mm
2. 70 beats/mm
3.90 beats/mm
4. 100 beats/mm
Answer 2
Rationale 1. This rate is well below that which necessitates withholding Lanoxin
for
children: it is the correct rate for withholding Lanoxin in adults.
Rationale 2. The purpose of digoxmn (Lanoxin) is to slow and strengthen the
apical rate. The apical rate for a healthy child of 5 years is 70 to 110 beats/mm. If
the apical rate is slow (10 to 20 beats below normal), administration of the drug
may lower the apical rate to an unsafe level.
Rationale 3. This is within the normal range of the heart rate of 5 year olds and
does not necessitate withholding Lanoxin.
Rationale 4. This is within the normal range of the heart rate of 5 year olds and
does not necessitate withholding Lanoxin.
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42. A
2-week-old boy is admitted with a tentative diagnosis of a ventncular
septal defect. The parents report that their baby has had difficulty feeding
since he has been home. The nurse explains that:
1. Feeding problems are common in neonates
2. Inadequate sucking is not significant in the absence of cyanosis
3. Ineffective sucking and swallowing may be early indications of a heart
defect
4. Many neonates retain mucus and this may interfere with feeding for
several weeks
Answer 3
RaonaIe 1. When
a feeding problem persists in a neonate, it is generally an
indication of some pathology.

Rationale 2.
Inadequate sucking is never insignificant: it may be indicative of
many problems, such as CNS involvement or immaturity as well as heart

disease. Rabonale 3. Compromised heart functioning caused decreased
cardiac output: this often results in cyanosis and fatigue from ineffective
sucking and swallowing Rationale 4. Generally most newborns are free from
mucus within 24 to 48 hours after birth.
Chent Need: Physiological Adaptation
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Inc.
43. The
nurse is administering IV fluids to a dehydrated infant. Which
intervention is
necessary?
1. Ensuring the sterility of equipment
2. Calculating the total necessary intake
3. Continuing the prescribed rate of flow
4. Maintaining the fluid at body temperature
Answer 3
Rationale 1. This is important for everyone receiving IV fluids, not just
infants.
Rationale 2. This is the practitioners role.
Rationale 3M infants intravascular compartment is limited and cannot
accommodate a large volume of fluid administered in a short time.
Equipment such as an infusion pump with a volume-control chamber should
be used because it controls the prescribed amount of fluid to be infused.
Rationale 4. IV fluids are administered at room temperature.
44. A
4-month-old infant is in a spica cast. What should the nurse include in the
discharge instructions?
1. Obtain a specially designed car seat.
2. Change infants position every 8 hours.
3. Diapers alone should be used to reduce soiling of the cast.

4. Use the abduction bar between the infants legs for position changes.
Answer 1
Rationale 1. Standard seat belts and car seats are not readily adapted for use by
children in spica casts: specially designed devices are available to meet safety
requirements.
Rationale 2. This is inadequate, the childs position should be changed at least
every 2 hours.
Rationale 3. Other strategies in addition to diapers will be necessary to keep the
cast clean.
Rationale 4. Using the abduction bar for lifting or turning could weaken the cast:
the abduction bar is designed to keep the hips in alignment.
Integrated Process/Nursing Process: Teaching/Learning,
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45.
A child with cystic fibrosis has been hospitalized with bacterial pneumonia
The nurse determines that the child has no known allergies. Selection of the
antibiotic to treat the pneumonia depends primarily on the:
1. Tolerance of the child
2. Selectivity of the bacteria
3. Sensitivity of the bacteria
4. Preference of the practitioner
Answer 3
Rahonale 1. The tolerance of the child to the particular antibiotic is unknown
since up
to this time the child has not developed any allergies.
Rationale 2.
Bacteria are not selective.
Rationale 3.
When the causative organism is isolated, it is tested for
antimicrobial susceptibility (sensitivity) to various antimicrobial agents. When

an organism is sensitive to a medication, the medication is capable of
destroying the organism.

Rationale 4.
Although the practitioner may have a preference for a particular
antibiotic, it first must be determined if the bacteria have exhibited sensitivity

to it.
Chent Need: Pharmacological and Parenteral Therapies
Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier
Inc.
46. What
should the nurse include in the teaching plan for parents of an infant
diagnosed with PKU?

1. Mental retardation occurs if PKU is untreated.
2. Testing for PKU is done immediately after birth.
3. Treatment for PKU includes lifelong medications.
4. PKU is transmitted by an autosomal dominant gene.
Answer 1
Rationale 1. In PKU the absence of the hepatic
enzyme phenylalanine
hydroxylase prevents metabolism (hydroxylation to tyrosine) of the

amino acid phenylalanine. The increased fluid levels of
phenylalanine in the body and the alternate metabolic by-products
(phenylketones) are associated with severe mental retardation if not
identified and treated early.
Rationale 2. Testing for PKU cannot be done until after several days of milk
ingestion.
Rationale 3. Medications are not part of therapy.
Rationale 4. PKU is transmitted by an autosomal recessive gene.
Cognitive Level: Comprehension
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47. AS-month-old
infant has been diagnosed with congenital hypothyroidism.
What is
the probable effect on the childs future if treatment is not begun in early infancy?
1. Lifelong myxedema
2. More severe mental retardation
3. Development of spastic paralysis
4. Repeated episodes of thyrotoxicosis
Answer 2
Rationale 1. Congenital hypothyroidism does not become myxedema.
Rationale 2. Congenital hypothyroidism is the result of insufficient secretion by
the thyroid gland because of an embryonic defect. Decreased thyroid hormone
affects the fetus before birth during cerebral development. so it is likely that there
will be some cognitive impairments at birth. Treatment before 3 months will
prevent further damage
Rationale 3. This could only occur if the infant had cerebral palsy
Rationale 4. Thyrotoxicosis is another term for hyperthyroidism: it is not expected
but it can occur with an overdose of exogenous thyroid hormone.
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48. What
nursing intervention best meets a major developmental need of a
newborn in
the immediate postoperative period?
1. Give a pacifier to the infant.
2. Put a mobile over the infants crib.
3. Provide the infant with a soft cuddly toy.
4. Warm the infants formula before feeding
Answer 1
Rationale 1. Sucking meets oral needs, which are primary during infancy.
Rationale 2.An infant a few days old is too young to focus well on a mobile,
in addition, the newborn will be placed in a side-lying position

postoperatively and thus would not be able to see the mobile.
Rationale 3. A 2-day-old infant is not developmentally capable of enjoying a
soft. cuddly toy.
Rationale 4. This is not a developmental need.
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49. Before
surgery to relieve an intestinal obstruction, a 3-month-old infant is kept
NPO and has a nasogastnc tube in place. Which nursing intervention will help to
calm the infant, as well as meet developmental needs?
1.Allow the infant to suck on a pacifier.
2. Offer the infant a favorite toy to hold.
3. Hang a brightly colored mobile in the infants crib.
4. Place the infant on the abdomen to permit crawling.
Answer I
Rationale I. Sucking is a primary need of infancy. It decreases anxiety and does
not
interfere with gastric decompression.
Rationale 2. This would be more helpful if the child were a toddler.
Rationale 3. Usually this does not help to calm the infant.
Rationale 4. This will probably increase the pain from abdominal distention: 3month- old infants are not developmentally ready to crawl: infants should not be
placed on their abdomens because this practice is associated with SIDS.
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50. A
newborn has been diagnosed with Down syndrome. The nurse recognizes
that these infants usually have several problems in conjunction with Down
syndrome. On what should the nurse focus when doing the initial assessment?
1. Reflex responses for hypotonicity
2. Eye examination for congenital cataracts
3. Sensory stimulation for muscle flaccidity
4. Cardiac irregularities for congenital heart disease
Answer I
Rabonale 1. Children with Down syndrome have a high incidence of congenital
heart defects as indicated by altered heart sounds. Without treatment the heart
defect may become life-threatening.
Rationale 2. This is expected and is not life-threatening.
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51.
When caring for a child with croup. what should be the nurses priority action?
1. Initiate measures to reduce fever.

2. Continually assess respiratory status.
3. Ensure delivery of humidified 2
4. Provide support to reduce apprehension.
Answer 2
Rationale 1. This is important, but maintenance of respirations has priority.
Rationale 2. Laryngeal spasms can occur abruptIy patency of the airNay is
determined by constant assessment for signs of respiratory distress.
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52. When
an infants vomiting is uncontroed. it is most important for the nurse to
assess for which complication?

1. Acidosis
2. Alkalosis
3. Hyperkalemia
4. Hypernatremia
Answer 2
Rabonale 1. This is caused by retention of hydrogen ions and a loss of base
bicarbonates, which is more likely to occur with diarrhea
Rationale 2. Excessive vomiting causes an increased loss of hydrogen ions
(hydrochloric acid), which leads to metabolic alkalosis. an excess of base
bicarbonate
Rationale 3. Hypokalemia. not hyperkalemia. will occur.
Rationale 4. With the loss of chloride ions. hyponatremia is more likely to occur.
Cognitive Level: Anaiysis
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53. A
mother brings her 1-week-old infant to the clinic because the infant
continually regurgitates. Chalasia is suspected. What instructions should the

nurse give the mother?
1. Keep the infant prone following feedings.
2. Prevent the infant from crying for prolonged periods.
3. Be sure the infant drinks a full bottle of formula at each feeding
4. Keep the infant in a semi-sitting position. particularly after feedings.
Answer 4
Rationale 1. This will promote regurgitation: it is an unsafe position because of
the
danger of SIDS.
Rationale 2. This will probably have little effect on chalasia.

Rationale 3. This will promote vomiting because it is too much formula for a 1week- old infant.
Rationale 4. Chalasia is an incompetent cardiac sphincter, which allows a reflux
of gastric contents into the esophagus and eventual regurgitation. Placing the
infant in an upright position keeps the gastric contents in the stomach by gravity
and limits the pressure against the cardiac sphincter.
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54. A
10 year old is diagnosed with lymphocytic thyroiditis (Hashimotos disease).
The
nurse should explain to the parents and child that this condition is:
1. Chronic
2. Inherited
3. Difficult to treat
4. Probably temporary
Answer 4
Rationale 1.ThiS is not a chronic disease.
Rationale 2. There seems to be a strong genetic predisposition. but no mode of
inheritance has been identified.
Rationale 3. This is not an untreatable or fatal disorder: it can be controlled with a
medical regimen.
Rationale 4. The goiter associated with Hashimotos disease is usually transient
and regresses spontaneously in 1 or 2 years. The child usually is euthyroid but
may show signs of hypothyroidism or hyperthyroidism.
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55. The
nurse is caring for a 3-month-old infant whose abdomen is distended
and whose vomitus is bile stained. The nurse, suspecting an intestinal

obstruction. should observe the infant for:
1. High-pitched cry and weak pulse
2. Constant pain and absence of stools
3. Irregular heart rate and hypotonicity
4. Paroxysmal pain and grunting respirations
Answer 4
Rationale 1. These usually do not accompany intestinal obstruction.
Rationale 2.
The pain of intestinal obstruction is paroxysmal.
Rationale 3. These
are not characteristic of intestinal obstruction.
Rationale 4. Paroxysmal
pain is related to peristaltic action associated with
intestinal obstruction. Abdominal distention pushes the diaphragm upward,

causing
respiratory distress characterized by grunting respirations.
Mosby items and derived items @ 2009, 2006. 2005 by Mosby, Inc.. an affiliate of Elsevier
Inc.
56. The
most critical factor in the immediate care of an infant after repair of a
cleft lip
is:
1. Preventing vomiting
2. Maintaining a patent airway
3. Monitoring parenteral fluid infusions
4.Administenng medications that reduce oral secretions
Answer 2
Rationale 1.Although this is important. maintaining a patent airway is
essential.
Rationale 2. These infants frequently have difficulty swallowing secretions
as well as difficulty breathing after surgery. Nursing measures. such as
placing the infant in a partial side-lying position or gently aspirating
secretions from the mouth or
nasopharynx. may be necessary to prevent aspiration and respiratory
complications.
Rationale 3. Fluids are usually administered carefully by mouth.
Rationale 4. This is not necessary.
Integrated Process/Nursing Process: TeachinglLeaming,
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57. Play
during infancy is important because it enhances:
1. Social development
2. Physical development
3. Cognitive development
4. Emotional development
Answer 2
Rationale 1.Although social development is important. it requires human
interaction.
Rationale 2. Play during infancy (solitary play) promotes physical development:
mobiles strengthen eye movement, rattles promote fine finger movement, and
soft toys encourage tactile sense
Rationale 3. The infant is too young to use play for cognition.
Rationale 4. Although emotional development is important. it requires human
interaction.
Integrated Process/Nursing Process: AssessmentlAnalysis
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58.
When explaining the occurrence of febrile seizures to a parents class,
what
information should the nurse include?
1. They may occur in minor illnesses.
2. The cause is usually readily identified.
3. They usually do not occur during the toddler years.
4. The frequency of occurrence is greater in females than males.
Answer 1
Rationale 1. Febrile
seizures usually are not associated with major neurologic
problems. From 95% to 98% of these children do not develop epilepsy or

other neurologic problems.
Rationale 2.
The cause of febrile seizures is still uncertain.
Rationale 3.
Most febnle seizures occur after 6 months of age and before age
3 years. with the average age of onset between 18 and 22 months.

Rationale 4.
Boys are affected about twice as often as girls.

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59. An
infant has had corrective surgery for hypertrophic pyloric stenosis. To
reduce vomiting, the nurse should teach the mother that immediately afler
feeding the infant, she should:
1. Rock the infant
2. Place the infant in an infant seat
3. Place the infant flat on the right side
4. Keep the infant awake with sensory stimulation
Answer 2
Rationale 1. Movement increases the chance of vomiting.
Rationale 2. An elevated position allows gravity to aid in preventing vomiting
Rationale 3. This would not prevent reflux and could result in aspiration.
Rationale 4. Activity increases the chance of vomiting.
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60.
An infant is diagnosed as having communicating hydrocephalus. When
helping the parents understand the practitioners explanation of their babys

problem. the nurse should respond:
1. Too much CSF is produced within the ventricles of the brain.
2. The flow of CSF through the brain cells does not empty effectively into the
spinal cord.
3. The CSF is prevented from adequate absorption by a blockage in the
ventricles of the brain.
4. There is a part of the brain surface that usually absorbs CSF after its
production that is not functioning adequately.
Answer 4
Rationale 1. This is often caused by a choroid plexus tumor and does not
interfere with the flow of CSF through the ventricles.
Rationale 2. This is an inaccurate answer: brain cells and the spinal cord are not
involved
Rationale 3. This reflects the pathophysiologic process of noncommunicating
hydrocephalus.
Rationale 4. This is what occurs in communicating hydrocephalus.
Integrated Process/Nursing Process: TeactiinglLearning,
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61. When
assessing infants and children with cardiac disorders, the nurse
understands that one of the last signs of heart failure in infants and children is:
1. Tachypnea
2. Tachycardia
3. Peripheral edema
4. Penorbital edema
Answer 3
Raonale 1. This is an early attempt by the body to compensate for decreased
cardiac output.
Rationale 2. This is an early attempt by the body to compensate for decreased
cardiac output.
Rationale 3. Heart failure is characterized by a decrease in the blood flow to the
kidneys, causing sodium and water reabsorption. resulting in peripheral edema.
The peripheral edema indicates severe cardiac decompensation.
Rationale 4. This occurs most noticeably in children with post streptococcal
glomerulonephritis.
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62. At
a visit to the well-baby clinic, a mother is upset because her 9-month-old
son has a severe diaper rash: the mother wants to know how to treat it and
prevent it from recurring What explanation should the nurse give the mother
about the etiology of diaper dermatitis?
1. Use of disposable diapers
2. Prolonged contact with an irritant
3. Too early introduction of solid foods
4. Decreased pH of the urine infants unne output
Answer 2
Rationale 1. Both cloth and disposable diapers can cause diaper dermatitis if not
changed frequently.
Rationale 2. Diaper dermatitis is caused by prolonged repetitive contact with an
irritant (e.g.. urine, feces, soaps. detergents. ointments, and friction). Rationale
3.Achange in diet may contribute, but there is no evidence that this is directly
related.
Rationale 4.An increased pH or alkaline urine can contribute to diaper dermatitis.
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63.
Anticipating that a 4-year-old child, scheduled for open-heart surgery. will
have chest tubes in place postoperatively the nurse informs the parents that
the chest tubes will:
1. Increase tidal volumes
2. Promote drainage of air and fluid
3. Maintain positive intrapleural pressure
4. Regulate pressure on the pencardium and chest wall
Answer 2
Rationale 1. The tidal volume increases as the lung reexpands, but it is not
the reason for the insertion of chest tubes.
Rationale 2. The intrapleural space must be drained of fluid and air to
facilitate the reestablishment of negative pressure in the intrapleural space.
Rationale 3. Closed chest drainage is related to intrapleural pressure. not
pericardial and chest wall pressure.
Rationale 4. Intrapleural pressure should be negative, not positive: positive
intrapleural pressure would cause collapse of the lung.
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64. An
infant is admitted to the pediatric intensive care unit after open-heart
surgery
for the repair of a ventricular septal defect. A nursing priority is to:
1. Monitor the infants urinary output
2. Ascertain the infants pulmonary status

3. Determine the status of the operative site
4. Check the patency of the intravenous catheter
Answer 2
Raonale 1. This is important. but adequate ventilation is the priority.
Rabonale 2. A patent airway and adequate pulmonary ventilation are always
pnonties
after surgery
Rabonale 3. This is important. but adequate ventilation is the pnonty.
Rationale 4. The IV lines would be checked once the airway, breathing, and
circulation are determined to be functioning
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65. Surgery
to correct hypertrophic pylonc stenosis is performed on a 2-week-old
infant who had been formula-fed. Which postoperative feeding order is

appropriate?
1. Thickened formula 24 hours after surgery
2. Withholding feedings for the first 24 hours
3. Regular formula feeding within 24 hours after surgery
4. Additional glucose feedings as desired after the first 24 hours
Answer 3
Rabonale 1. Regular formula should be started within 24 hours after surgery in
an
attempt to gradually return the infant to a full feeding schedule.
Rationale 3. Initial feedings of glucose and electrolytes in water or breast milk are
given 4 to 6 hours after surgery. When clear fluids are retained, formula feedings
are begun within 24 hours.

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66. The
nurse is aware that an additional defect associated with exstrophy of the
bladder is:
1. Imperforate anus
2. Absence of one kidney
3. Congenital heart disease
4. Pubic bone malformation
Answer 4
Rationale 1. This defect is not associated with exstrophy of the bladder.
Rationale 2. This defect is not associated with exstrophy of the bladder. Rationale
3. This defect is not associated with exstrophy of the bladder.
Rationale 4. The pubic bone and the bladder form during the same time of
embryonic development.
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67. A
2-year-old child has a congenital cardiac malformation that causes right-to-
len
shunting of blood through the heart. What clinical finding should the nurse
expect?
1. Proteinuna
2. Peripheral edema
3. Elevated hematocnt
4. Absence of pedal pulses
Answer 3
Rationale 1. This is not characteristic of heart malformations that cause a right-toleft shunting of blood.
Rationale 2. Edema is not a common finding with heart malformations associated
with a right-to-left shunting of blood.
Rationale 3. Polycythemia. reflected in an elevated hematocnt. is a direct attempt
of the body to compensate for the decrease in 2 to all body cells caused by the
mixture of oxygenated and unoxygenated circulating blood.
Rationale 4. This is characteristic of coarctation of the aorta, an obstructive
malformation.
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68. What
is a common finding that the nurse can identify in most children with
symptomatic cardiac malformations?

1. Mental
retardation
2. Inherited genetic factors

3. Delayed physical growth
4. Clubbing of the fingertips
Answer 3
Rationale 1. Mental retardation is not a common finding in children with
congenital heart disease.
Rationale 2. Cardiac anomalies are more often a result of prenatal, rather
than genetic, factors.
Rationale 3. Children with cardiac malformations often use increased
energy in activities of daily living decreased 2 utilization and increased
energy output in the developing child result in a slow growth rate.
Rationale 4. Clubbing is not characteristic of most children with cardiac
anomalies, only of those with more severe hypoxia.

Integrated ProcesslNursing Process: AssessmentJAsialysis
69. An
infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric
unit.
When palpating this infants abdomen, the nurse expects:
1.Adistended colon
2. Marked tenderness around the umbilicus
3.An olive-sized mass in the right upper quadrant
4. Rhythmic peristaltic waves in the lower abdomen
Answer 3
Raonale 1. The obstruction is above the intestinal area: the colon is not involved.
Rabonale 2. There is no significant tenderness in the abdomen.
Rationale 3. The olivelike mass is caused by the thickened muscle (hypertrophy)
of the pylonc sphincter.
Rationale 4. There is little or no peristalsis in the intestines.
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70. What
is the most serious complication of meningitis in young children?
1. Epilepsy
2. Blindness
3. Peripheral circulatory collapse
4. Communicating hydrocephalus
Answer 3
Rationale 1. Although this may occur, it is controllable and not as serious as
peripheral circulatory collapse.
Rationale 2.
Although this may occur. it is not as serious a complication as
peripheral
circulatory collapse.
Rationale 3.
Peripheral circulatory collapse (Waterhouse-Friderichsen
syndrome) is a serious complication of meningococcal meningitis caused by

bilateral adrenal hemorrhage. The resultant acute adrenocortical
insufficiency causes profound shock. petechiae. ecchymotic lesions,
vomiting. prostration. and hypotension.
Rationale 4. Although
this may occur, it is rare and not as serious as peripheral
Inc.
71.
What is the most serious complication of meningitis in young children?
1. Epilepsy
2. Blindness
3. Peripheral circulatory collapse
4. Communicating hydrocephalus
Answer 3
Rationale 1. Although this may occur, it is controllable and not as serious as
peripheral circulatory collapse.
Rationale 2.
Although this may occur. it is not as serious a complication as
peripheral
Rationale 3.
Peripheral circulatory collapse (Waterhouse-Friderichsen
syndrome) is a serious complication of meningococcal meningitis caused by

bilateral adrenal hemorrhage. The resultant acute adrenocortical
insufficiency causes profound shock. petechiae. ecchymotic lesions,
vomiting. prostration. and hypotension.
Rationale 4. Although
this may occur, it is rare and not as serious as peripheral
Inc.
72. Which
cardiac defects are associated with tetralogy of Fallot?
1. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve
stenosis
2. Origin of the aorta from the right ventricle and of the pulmonary artery from the
left ventricle
3. Right ventricular hypertrophy. ventricular septal defect. pulmonic stenosis, and
overriding aorta
4. Altered connection between the pulmonary artery and the aorta, right
ventricular hypertrophy. and an atnal septal defect
Answer 3
Rationale 1. Although there is right ventricular hypertrophy. the other defects are
not
associated with tetralogy of Fallot.
Rationale 2. These are the charactenstics of transposition of the great vessels.
Rationale 3. Tetralogy of Fallot consists of four defects. Three of them are
anatomic:
ventricular septal defect. pulmonic stenosis. and overriding aorta. The fourth
defect, right ventricular hypertrophy, is secondary to increased resistance to
blood flow in that ventricle.
Rationale 4. Although there is right ventricular hypertrophy, the other defects are
not associated with tetralogy of Fallot.
Integrated Process/Nursing Process: Assessment/Anaysis
Elsevier Inc.
73.
What should be the school nurses first action when a child complains of a
sore throat?
1. Examine the throat.
2. Have the child sent home.
3. Take the childs temperature.
4. Secure an order for an oral analgesic
Answer 1
Rabonale 1. The priority is to assess the throat to determine the extent of
inflammation. Significant swelling can create the potential for airway obstruction.
Rationale 2. Assessment of the childs problem must be done before initiating any
other actions
other actions.
other actions.
Elsevier Inc.
74.
When teaching a mother how to prevent accidents while caring for her 6-
month-old
infant, the nurse should emphasize that at this age. the infant can usually:
1. Sit up
2. Roll over
3. Crawl short distances
4. Stand while holding on to furniture
Answer 2
Raonale 1. Sitting up unsupported is accomplished by most infants at 7 to 8
months.
Raonale 2. Muscular coordination and percepuon are developed enough at 6
months for the infant to roll over. If unaware of this ability, the mother could leave
the infant unattended for a moment to reach for something and the infant could
roll off an elevated surface.
Rationale 3. Crawling takes place at about 9 months of age.

Rationale 4. Standing by holding on to furniture is accomplished by most infants
between 8 and 10 months of age.
Client Need: Salety and Inlection Control
Elsevier Inc.
75. A
6-year-old child is admitted to the hospital with pneumonia. What is the
priority need that must be included in the nursing care plan for this child?
1. Rest
2. Exercise
3. Nutrition
4. Elimination
Answer 1
Rationale 1. Rest reduces the need for 02 and minimizes metabolic needs during
the acute. febrile stage of the disease.
Rationale 2. The child requiring hospitalization for pneumonia is usually confined
to bed and needs to reduce activity to conserve 2
Rationale 3. This is not a priority: the child is expected to be anorectic during the
febnle phase.
Rationale 4. Elimination is not usually a problem. except as a result of immobility.
Elsevier Inc.
76. When
teaching a class of mothers about how to position their infants during
the
first few weeks of life, the nurse tells them that the safest position is on their.
1. Stomachs lying flat
2. Backs or sides lying flat

3. Stomachs with their heads slightly elevated
4. Right or left sides with their heads slightly elevated
Answer 2
Rationale 1. This position has been associated with the incidence of SIDS and
should be avoided.
Rationale 2. These positions offer the lowest risk for SIDS.
Rationale 3. This position has been associated with the incidence of SIDS and
should be avoided.
Rationale 4. These positions are safe. but lying on their backs is also safe and
using the three positions offers more variety.
Integrated Process/Nursing Process: TeachingiLeaming,
Elsevier Inc.
77. What
should nursing care for an infant after the surgical repair of a cleft lip
include?
1. Preventing the infant from crying
2. Placing the infant in a semi-sitting position
3. Keeping the infant NPO for 1 day after surgery
4. Feeding the infant with a spoon for 2 days after surgery
Answer 1
Rationale 1. Crying should be prevented because it places tension on the suture
line. Frequently an appliance called a Logan bow is taped to the cheeks to relax
the operative site. which helps prevent trauma.
Rationale 2. The infant may be positioned on the side and on the back with
surveillance.
Rationale 3. This is not necessary or desirable.
Rationale 4. The feeding method of choice is by a rubber-tipped syringe or
dropper.
Integrated Process/Nursing Process: Planning)lmplementation

Elsevier Inc.
78.
The mother of an 18-month-old boy with a cleft palate asks the nurse why the
pediatrician recommended that closure of the palate should be done before he is

2 years old. The nurse responds:
1. As he gets older the palate gets wider and more difficult to repair.
2. After age 2 surgery is very frightening and should be avoided if possible
3. The eruption of the 2-year molars often comphcates the surgical procedure.
4. Surgery should be performed before the child starts to use faulty speech
patterns.
Answer 4
Rationale 1.Although this may be true. this is not the reason why the repair is
made
at this age: these children may need multiple surgeries as the palate develops.
Rationale 2. This is not the reason the surgery is done at this age.
Rationale 3. Children with a cleft palate require orthodontic and prosthodontic
treatment for many years because of the malformed palate and the malposition of
the teeth: the eruption of the teeth may be considered relative to the timing of
surgery throughout childhood, but the 2-year molars are of little importance when
considering the overall problem.
Rationale 4.Achild with a cleft palate has distinctive speech because the airflow
required for speech cannot be controlled: although speech therapy is usually
needed after surgery. surgery is scheduled before the child starts to speak
because correct speech is easier to achieve.
Integrated Process/Nursing Process: TeachinglLeaming,
PlanningAmplementation
Elsevier Inc.
79. A
child sitting on a chair in a playroom starts to have a tonic-clonic seizure with
a
clenched jaw. What is the nurses best initial action?
1. Call for assistance.
2. Attempt to open the jaw.
3. Lower the child to the floor.
4. Place a large pillow under the head.
Answer 3
Rationale 1. Protecting the child is the priohty assistance at this time is futile.
Rationale 2. This is unsafe: attempting to open the jaw could result in injury.
Rationale 3. This limits the danger of falling and striking the head.
Raonale 4. This may cause airway occlusion by forcing the chin onto the neck.

Integrated Process/Nursing Process: Planning/I mpiementation
Elsevier Inc.
80. A
child undergoes heart surgery to repair the defects associated with tetralogy
of
Fallot. Postoperatively, it is essential that the nurse prevent:
1. Crying
2. Coughing
3. Hard stools
4. Unnecessary movement
Answer 3
Rationale 1. Crying is not a problem after cardiac surgery: it may. in fact, help
prevent respiratory complications.
Rationale 2. Coughing and deep breathing are essential for the prevention of
postoperative respiratory complications.
Rationale 3. Forceful evacuation results in the child taking a deep breath, holding
it. and straining (Valsalva maneuver). This increases intrathoracic pressure.
which puts excessive strain on the heart sutures.
Rationale 4. Activity is gradually increased.

Integrated Process/Nursing Process: PlanningAmplementation
Elsevier Inc.
81. A
5 month old develops severe diarrhea and is given IV fluids What is the
rationale
for frequent observation of the IV flow rate?
1. Restriction of output
2. Replacement of lost fluids
3. Avoidance of IV infiltration
4. Prevention of cardiac overload
Answer 4
Rationale 1. Increased output is not the primary consideration.
Rabonale 2. Although fluid replacement is important. prevention of cardiac
problems from fluid overload is critical.
Rationale 3. This is important, but an infiltrated IV is not as serious as a cardiac
complication
Rationale 4. If the circulation is overloaded with too much fluid or the rate is too
rapid. the stress on the heart becomes too great and cardiac overload may occur.
Elsevier Inc.
82. The
nurse is caring for a child with the diagnosis of meningitis. What sign or
symptom indicates an increase in intracranial pressure?

1. Bradycardia
2. Hyperalertness
3.Adecreased pulse pressure
4.A decreased systolic blood pressure
Answer 1
Rationale 1. Braclycardia is a classic sign of increased intracranial pressure.

Rationale 2. With increased intracranial pressure, there would be decreased
alertness or loss of consciousness.
Rationale 3. The pulse pressure increases with increased intracranial pressure.
Rationale 4. Systolic BP increases with increased intracranial pressure.
Elsevier Inc.
83. A
young child has coarctation of the aorta. What should the nurse expect to
identify when taking the childs vital signs?

IA weak radial pulse
2.An irregular heartbeat
3.A bounding femoral pulse
4.An elevated blood pressure in the arm
Answer 4
Rationale 1. This is not related to coarctation of the aorta.
Rationale 2. The femoral pulses are weak or absent.
Rationale 3. The radial pulses are bounding
Rationale 4. Coarctation of the aorta is a narrowing of the aorta, usually in the
thoracic segment. causing decreased blood flow below the constriction and
increased blood volume above it.
Elsevier Inc.
84.
A mother brings her 9-month-old son to the pediatric clinic and asks about the
introduction of new foods. What should the nurse suggest?

1. Introduce a new food after he has had his regular feeding.
2. Offer a new food every day until he likes one and then offer it again.
3. Offer a new food after he has had some milk when he is still hungry.
4. Mix the pureed food with formula and have him dnnk it from the bottle.
Answer 3
Rationale 1. Offering food after the regular feeding decreases the chance of
success. because the infants hunger is already satisfied.
Rationale 2. New foods should be initiated one at a time and continued for 4 to 5
days to assess for an allergic reaction.
Rationale 3. Offering a new food after giving some formula associates this activity
with eating and takes advantage of the infants unsatisfied hunger.
Rationale 4. Solid food should be introduced by spoon to acquaint the infant with
new tastes and textures, as well as the use of the spoon.

Elsevier Inc.
85.
When elevating the head of an infant in a spica cast. the nurse should:
1. Place 2 pillows under the shoulders

2. Limit this position to 1 hour at a time
3. Pad the edge of the cast with folded diapers
4. Raise the entire mattress at the head of the cnb
Answer 4
Rationale 1. Pillows under the head or shoulders of a child in a spica cast will
thrust
the chest forward against the cast. causing discomfort and respiratory distress.
Rationale 2. There is no reason to place a time limit on this position.
Rationale 3. This will not help elevate the infants head.
Rationale 4. When elevation of the head is desired. the entire mattress or crib
should be raised at the head of the cnb.
Elsevier Inc.
86.
When preparing for the admission of a child with acute
laryngotracheobronchitis
(croup). what should be the nurses priority intervention?
1. Pad the side rails of the crib.
2. Arrange for a quiet. cool room.

3. Obtain a cot so that a parent can stay.
4. Place a tracheotomy set at the bedside.
Answer 4
Rationale 1. Although this would be helpful. it is not the priority.
Rationale 2. This is unnecessary; it may be done if the child has a high fever or a
history of febrile seizures.
Rabonale 3. Although appropriate, this is not the priority.
Raonale 4. The priority is a patent airway, and necessary equipment must be
immediately available.
Elsevier Inc.
87.
What common adaptation of children with tetralogy of Fallot should the nurse
expect?
1. Slow respirations
2. Clubbing of fingers
3. Subcutaneous hemorrhages
4. Decreased RBC counts
Answer 2
Rationale 1. The respirations are generally rapid to compensate for 2
deprivation.
Rationale 2. Hypoxia leads to poor peripheral circulation: clubbing develops over
time as a result of tissue hypertrophy and additional capillary development in the
fingers.
Rationale 3. This is not an adaptation that occurs in children with tetralogy of
Fallot. Rationale 4. These children have polycythemia.
Integrated ProcessiNursing Process: Assessment/Analysis
Elsevier Inc.
88.
Which type of hernia involves an impaired blood supply?
1. Hiatal
2. Omphalocele
3. Incarcerated
4. Strangulated
Answer 4
Rationale 1. A hiatal hernia is the intrusion of an abdominal structure, usually the
stomach. through the esophageal hiatus.
Rationale 2. An omphalocele is the protrusion of intraabclominal tissue through a
defect in the abdominal wall at the umbilicus: the sac may be covered with
peritoneum. not skin.
Rationale 3. An incarcerated hernia is one that cannot be reduced manually.
Rationale 4. A strangulated hernia occurs when abdominal tissue is so
constricted as it protrudes through the abdominal musculature that the blood
supply is interrupted: gangrene will result unless the hemiation is reduced.
Cognitive Level: Knowledge
Elsevier Inc.
89. What
is the primary nursing intervention for an infant with a
myelomeningocele
before surgical correction?
1. Minimize infection.
2. Prevent trauma to the sac.

3. Observe for increasing paralysis.
4. Assess the degree of bowel and bladder control.
Answer 2
Rationale 1.AlthOugh
this is always an important nursing measure, care of the
sac is even more important because an intact sac reduces a portal of entry
for microorganisms.
Rabonale 2.
The meningomyelocele is thinly covered and fragile: trauma to
the sac can damage functioning neural tissue: an intact sac reduces a
potential portal of entry for microorganisms.
Rationale 3.
Although observation of paralysis is an important nursing
measure, care of the meningomyelocele sac is of primary importance.

Rationale 4.
The extent of a meningomyelocele will influence the childs ability
to control these functions, but control is not developed until the toddler and
preschool years.
Inc.
90. The
nurse is assessing the oral cavity of a 6-month-old child. The nurse can
predict the appearance of incoming teeth by understanding that the teeth that bud
first tend to be the
1. Canines
2. Incisors
3. Upper molars
4. Lower molars
Answer 2
Rationale 1. The canine teeth appear at about 18 months.
Raonale 2. The bottom incisors are the first teeth to erupt at about 6 to 8 months
of age.
Rabonale 3. The first molars, both upper and lower, appear at about 20 months.
Rabonale 4. The first molars, both upper and lower, appear at about 20 months.
Client Need: Health Promotion and Marntenance

Cognitive Level: Knowledge
Elsevier Inc.
91. The
laboratory analysis for a 5-year-old child admitted for repair of tetralogy of
Fallot indicates an elevated RBC count. This polycythemia is a compensatory

mechanism for:
1. Low blood pressure
2. lissue 2 need
3. Diminished iron level
4. Hypertrophic cardiac muscle
Answer 2
Rationale 1. This is not a direct cause of polycythemia.
Rationale 2. Decreased tissue oxygenation stimulates erythropoiesis. resulting in
excessive production of RBC5.
Rationale 3. This may or may not affect the production of RBC5.
Rationale 4. This is not a direct cause of polycythemia.
Elsevier Inc.
92.
What should be included in the nursing care of an infant with increased
intracranial pressure?
1. Weigh the infant daily before feeding
2. Elevate the infants head higher than hips.
3. Check the infants reflexes at regular intervals.
4. Monitor the infants level of consciousness by stimulating frequently. Answer 2
Rationale 1. This would be done after the insertion of a shunt: if the infant is in
the intensive care unit, this would be done routinely.
Rationale 2. Elevation of the head helps decrease intracranial pressure by using

gravity.
Rationale 3. This may be disturbing to the infant and impair the ability to rest.
Rationale 4. Frequent stimulation may cause further irritability to an already
traumatized CNS.
Elsevier Inc.
93. The
discharge of a newborn with a surgically repaired myelomeningocele
is anticipated at about 2 weeks of age. What teaching should the nurse

include when preparing the parents for the disc harge9
1. Demonstration of restrictive positions to prevent the infant from turning
2. Discussion about the need to limit the infants fluid intake to formula only
3. Instructions on how to do passive range-of-motion exercises to the
infants lower extremities
4. Explanation of the need to provide the infant with a quiet environment to
reduce external stimuli
Answer 3
Rationale 1. Development should be encouraged: the infants movements
should not be restricted.
Rationale 2. Fluids should be encouraged to provide adequate kidney
function and prevent constipation.
Rationale 3. The affected limbs should be exercised to promote circulation
and prevent atrophy.
Rationale 4. The infant needs stimulation to develop mentally and socially.
94.
After many episodes of otitis media, a child is to have a mynngotomy with
tubes implanted surgically. What should the nurse include in the discharge
preparation for this family?
1.Apply an ointment to the ear canal daily.
2. Use cotton swabs to clean the inner ears.
3. Keep the child out of daycare for 1 week.
4. Have the child use ear plugs when bathing.
Answer 4
Rationale 1. This will clog the ear canal and serves no purpose.
Rationale 2. These may be used occasionally in the outer ear but should not be
inserted into the inner ear.
Rationale 3. There is no reason that the child cannot be around other children.
because there is no infectious process.
Rationale 4. Water in the ears after a mynngotomy may be a source of infection.
Elsevier Inc.
95.
An 11-year-old child has just received a cast for a fractured wrist. The wrist
and elbow are immobilized. What information should the nurse include in the
home care instructions before discharge? Select all that apply.
1. Resume usual activities.
2. Report swelling of fingers.
3. Elevate casted arm when standing
4. Keep affected shoulder immobilized.
Answer 2,3
1 Rest with elevation of the extremity is recommended, strenuous activity should
be avoided for several days.
2 When swelling of the fingers occurs, the cast can become too tight. resulting in
neurovascular damage permanent damage can occur in 6 to 8 hours.
3 The casted arm should be in a sling when the child is upright and elevated
when
resting to promote venous return.
4 Joints above and below the cast should be moved to maintain flexibility.
Rationale:
Elsevier Inc.
96. 2. Which of the following neonates is at highest risk for cold stress syndrome?
1. Infant of diabetic mother.
2. Infant with Rh incompatibility.
3. Postdates neonate.
4. Down syndrome neonate.
2. 1. Infants of diabetic mothers are often
large-for-gestational age, but they are
not especially at high risk for cold stress
syndrome.
2. Infants born with Rh incompatibility are
not especially at high risk for cold stress
syndrome.
3. Postdates babies are at high risk for
cold stress syndrome because while
still in utero they often metabolize
the brown adipose tissue for nourishment
when the placental function deteriorates.
4. Down syndrome babies are hypotonic,
but they are not especially at high risk
for cold stress syndrome.
TEST-TAKING TIP: The test taker must
know that cold stress syndrome results
from a neonates inability to create heat
through metabolic means. Brown adipose
tissue (BAT) and glycogen stores in the
liver are the primary substances used for
thermogenesis. The test taker must then
deduce that the infant most likely to have
poor supplies of BAT and glycogen is the
postdates infant.
97.3. Which of the following would lead the nurse to suspect cold stress syndrome in a
newborn with a temperature of 96.5F?
1. Blood glucose of 50 mg/dL.
2. Acrocyanosis.
3. Tachypnea.
4. Oxygen saturation of 96%.
3. 1. Infants with cold stress exhibit hypoglycemia.
A neonatal blood glucose of
50 mg/dL is normal.
2. Acrocyanosisbluish hands and feetis
normal for the neonate during the first
day or two.
3. Babies who have cold stress syndrome
will develop respiratory distress. One
symptom of the distress is tachypnea.

4. The oxygen saturation is within normal
limits.
test taker to know the normal variations
seen in the neonatefor example, normal
blood glucoses are lower in neonates
than in the older child and adult and
acrocyanosis is normal for a neonates
first day or two.
98. 4. Four babies are in the newborn nursery. The nurse pages the neonatalogist to see
the baby who exhibits which of the following?
1. Intracostal retractions.
2. Erythema toxicum.
3. Pseudostrabismus.
4. Vernix caseosa.
4. 1. Intracostal retractions are symptomatic
of respiratory distress syndrome.
2. Erythema toxicum is the normal newborn
rash.
3. Pseudostrabismus is a normal newborn
finding.
4. Vernix caseosa is the cheesy material that
covers many babies at birth.
test taker to be familiar with the signs of
respiratory distress in the neonate. Babies
who are stressed by, for example,
cold, sepsis, or prematurity will often exhibit
signs of respiratory distress. The
neonatologist should be called promptly.
99. The
mother of a 2-year-old girl tells the nurse that whenever she takes her
toddler to a store the child has a screaming tantrum demanding a toy or candy on
the shelves. The mother asks the nurse how best to cope with this situation
without further embarrassment. The nurses best response is to advise the
mother to:
1. Take the child to another part of the store
2. Say nothing and allow the tantrum to continue until it ends
3. Hire a baby sitter when she shops until the child outgrows this typical toddler
behavior
4. Give the child the item while in the store and when the child loses interest
return
the item to the shelf
Answer 1
Rationale 1. Toddlers are easily distracted. Taking the child to another part of the
stor without acknowledging the tantrum will distract the child and avoid
embarrassment. Rationale 2. Allowing the tantrum to continue will not help the
mother cope with the embarrassing situation.
Rationale 3. It is unreasonable to ask the mother to spend money. which she may
not have, on a baby sitter.
Rationale 4. Giving the child the item acknowledges the tantrum and reinforces
the behavior.
Chent Need: Health Promotion and Maintenance
Integrated Process/Nursing Process: Teaching/Learning. Planning/I mplementat
ion
Elsevier Inc.
100.
When the working mother of a toddler is preparing to take her child home
after a prolonged hospitalization, she asks the nurse what type of behavior she
should expect to be displayed. What is the nurses most appropriate description
of her childs probable behavior?
1. Excessively demanding behavior
2. Hostile attitude toward the mother
3. Cheertul. with shallow attachment behaviors
4. Withdrawn, without emotional ties to the mother
Answer 4
Rationale 1. After trust has been reestablished, the child may then test the
parents
love by being very demanding
Raonale 2. At this stage of separation anxiety. the child would be too detached to
be
hostile.
Rationale 3. The child will be despairing and withdrawn.
Rationale 4. Until trust has been reestablished, the child will be unable to develop
an emotional tie to the mother.
Chent Need: Heafth Promotion and Maintenance
Integrated Process/Nursing Process: Teaching/Learning.. Planning/I mplementat
ion
Elsevier Inc.

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1. A nurse in a clinic is assessing the weight of an infant.

Which infants weight indicates to the nurse that

axillary temperature as 96.9F. Which of the following could explain

high bilirubin levels.

The nurse should explain to a client that breastfeecling is always

the transmission of infection.

At 10 hours of age an infant has a large amount of mucus and becomes

Integrated ProcessiNursing Process: Planningllmplementation

jitteriness. irregular respirations, and temperature instability. The nurse knows

The client response that indicates understanding of teaching regarding breast

care for the mother who is breastfeeding is. I will:

recommended for 2 to 3 weeks postpartum to provide support to breast tissue

temperature. However, they have several mechanisms to help them maintain

Rationale 1. This is an important part of record keeping for all newborns.

Integrated Process/Nursing Process: Assess mentlAnalysis

An infants intestines are sterile at birth, therefore lacking the bacteria

At 12 weeks gestation. a client who is Rh-negative completely expels the

not been sensitized previously, irrespective of the length of the gestation.

The nurse is aware that a healthy newborns respirations are:

1. Irregular. thoracic, 30 to 60/mm. deep

newborn usually should be nursed:

Cognitive Level: Application

nurse in the newborn nursery observes a yellowish skin color of an infant

nurse should know that an asymmetric Moro reflex is frequently

Integrated Process/Nursing Process: Assessment/Analysis

nurse understands that one of the factors influencing the availability of

3. Viewpoint of the womans family toward breastfeeding

assessment, observed immediately after birth, will probably necessitate

prolonged follow-up care of a newborn?

Integrated Process/Nursing Process: Assessment/Analysis

3. Time is convenient for the family

Rationale 2.Any significant change should be reported immediately.

2009, 2006. 2005 by Mosby, Inc.. an affiliate of

7-year-old girl develops a urinary tract infection. The practitioner orders a

sulfonamide preparation. What is a major nursing responsibility when

Rabonale 3. Monitoring temperature would be important with antipyretic drugs.

picked up by the mother or the nurse. an 8-month-old infant screams

mother of a 2-year-old child tells the nurse she is having difficulty

Which nursing intervention provides the most support to the parents of a

Cognitive Level: Application

When planning to prOvide teaching about self-administration of insulin to a

on developmental norms for a 5-year-old child, the nurse should

2-week-old boy is admitted with a tentative diagnosis of a ventncular

a feeding problem persists in a neonate, it is generally an

indication of some pathology.

Inadequate sucking is never insignificant: it may be indicative of

many problems, such as CNS involvement or immaturity as well as heart

nurse is administering IV fluids to a dehydrated infant. Which

3. Diapers alone should be used to reduce soiling of the cast.

Bacteria are not selective.

When the causative organism is isolated, it is tested for

antimicrobial susceptibility (sensitivity) to various antimicrobial agents. When

destroying the organism.

Although the practitioner may have a preference for a particular

antibiotic, it first must be determined if the bacteria have exhibited sensitivity

diagnosed with PKU?

hydroxylase prevents metabolism (hydroxylation to tyrosine) of the

infant has been diagnosed with congenital hypothyroidism.

nursing intervention best meets a major developmental need of a

in addition, the newborn will be placed in a side-lying position

surgery to relieve an intestinal obstruction, a 3-month-old infant is kept

1. Initiate measures to reduce fever.

an infants vomiting is uncontroed. it is most important for the nurse to

assess for which complication?