Maternity And Pediatrics - Ch 44 With
All Passed And Approved Answers
Get It Right
1. The nurse is teaching the mother of a 5-year-old boy with a
myelomeningocele who has developed a sensitivity to latex. Which of the
following responses from his mother indicates a need for further teaching?
A) "He needs to get a medical alert identification."
B) "I will need to discuss this with his caregivers."
C) "A product's label indicates whether it is latex-free."
D) "He must avoid all contact with latex." - Ans--Ans: C
Feedback:
The Food and Drug Administration (FDA) requires that all medical supplies
be labeled if they contain latex, but this is not the case with consumer
products. The mother must be familiar with products that contain latex. The
Spina Bifida Association of America maintains an updated list of latex-
containing products. Getting a medical alert identification, talking with his
caregivers, and avoiding all contact with latex are correct.
2. The nurse is caring for an 8-year-old boy with myasthenia gravis and is
teaching his parents about the signs of cholinergic crisis. Which of the
following responses by the parents indicates a need for further teaching?
A) "Low blood pressure is a sign of crisis."
B) "He might have difficulty swallowing."
C) "He may start to sweat a lot."
D) "More saliva in the mouth is a common sign." - Ans--Ans: B
Feedback:
Dysphagia is a sign of myasthenic crisis. Increased salivation,
hypotension, and increased sweating are signs and symptoms of
cholinergic crisis.
3. The nurse is providing postoperative care for a 14-month-old girl who has
undergone a myelomeningocele repair. The girl's mother is extremely
anxious and tells the nurse she is afraid she will never learn how to care for
,her daughter at home. Which response by the nurse would be most
appropriate?
A) "I will help you become comfortable in caring for your daughter."
B) "You must learn how to care for your daughter at home."
C) "You will need to learn to collaborate with all the caregivers."
D) "There is a lot to learn, and you need a positive attitude." - Ans--Ans: A
Feedback:
The nurse needs to empower families to become the experts on their child's
needs and conditions via education and participation in care. The most
positive approach is to let the mother know the nurse will support her and
help her become an expert on her daughter's care. Telling the mother that
she must learn how to care for her daughter or that she must have a positive
attitude is not helpful. Telling her that she needs to collaborate with the
caregivers is true, but does not address her fears.
4. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy.
As part of the plan of care, the nurse focuses on maintaining his
cardiopulmonary function. Which intervention would the nurse implement
to best promote maximum chest expansion?
A) Deep-breathing exercises
B) Upright positioning
C) Coughing
D) Chest percussion
. - Ans--Ans: B
Feedback:
The nurse should emphasize that the child's position should be arranged to
promote maximum chest expansion. This is usually in the upright position.
Deep-breathing exercises are for strengthening/maintaining respiratory
muscles. Coughing helps clear the airways. Chest percussion helps loosen
secretions in lungs
5. A 6-year-old boy with cerebral palsy has been admitted to the hospital for
some tests. His condition is stable. The boy's mother remains with her son,
but she is obviously exhausted and stressed. Which response by the nurse
would be most appropriate?
A) "Would you like me to bring you a blanket and pillow?"
B) "You are doing such a wonderful job with your son."
C) "He's in good hands; consider going home to get some sleep."
,D) "Are you planning to spend the night or to go home?" - Ans--Ans: C
Feedback:
Providing daily, intense care can be quite demanding and tiring. When a
child with cerebral palsy is admitted to the hospital, this may serve as a time
of respite for family and primary caregivers. The nurse should remind the
mother that her son is in good hands and urge her to go home. Asking her
whether she is planning to stay might make the mother feel obligated to
stay. Asking if she wants a blanket or pillow does not encourage the mother
to leave the hospital. Telling the mother she is doing a good job is nice, but
does not encourage her to take a break.
6. A nurse is caring for a 14-year-old girl following myelography. Which of
the following would be the priority nursing action?
A) Monitoring for a decrease in spasticity
B) Observing for signs of meningeal irritation
C) Assessing motor function
D) Observing for mental confusion or hallucinations - Ans--Ans: B
Feedback:
Following myelography, the nurse should carefully observe for signs of
meningeal irritation because of what is involved in this procedure.
Monitoring for a decrease in muscle spasticity, assessing motor function,
and observing for mental confusion or hallucinations is appropriate
following an intrathecal test dose of baclofen.
7. The nurse has developed a plan of care for a 6-year-old with muscular
dystrophy. He was recently injured when he fell out of bed at home. Which
intervention would the nurse suggest to prevent further injury?
A) Recommend the bed's side rails be raised throughout the day and night.
B) Suggest a caregiver be present continuously to prevent falls from bed.
C) Encourage a loose restraint to be used when he is in bed.
D) Recommend raising the bed's side rails when a caregiver is not present. -
Ans--Ans: D
Feedback:
The nurse should recommend that side rails on the bed be elevated when a
caregiver is not present. The use of restraints should be avoided if at all
possible. Suggesting that a caregiver be present at all times places undue
stress on the family. Close observation is more appropriate.
, Recommending side rails be elevated at all times may be upsetting to the
child and make him feel like a "baby."
8. The nurse is caring for a 2-month-old with cerebral palsy. The infant is
limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting
movements. Which of the following would the nurse use when documenting
these observations?
A) Spastic
B) Athetoid
C) Ataxic
D) Mixed - Ans--Ans: B
Feedback:
Athetoid cerebral palsy is characterized by abnormal, involuntary
movement. It affects all four extremities with possible involvement of the
face, neck, and tongue. The movements increase in periods of stress.
Dysarthria and drooling may be present as well. Spastic cerebral palsy is
characterized by poor control of posture, balance, and movement;
exaggeration of deep tendon reflexes; and hypertonicity of affected
extremities. Ataxic is characterized by poor coordination, unsteady gait,
and wide-based gait.
9. The nurse is caring for a child with a spinal cord injury and providing
instruction to the parents on promoting skin integrity. Which response from
the mother indicates a need for further teaching?
A) "I need to monitor his skin at least twice a week."
B) "I must monitor skin affected by his adaptive equipment."
C) "He must change positions frequently."
D) "We must avoid harsh cleaning products." - Ans--Ans: A
Feedback:
The nurse needs to emphasize to the mother that she must monitor the
condition of the entire surface of the skin several times daily to provide a
baseline and allow for early identification of areas at risk. Monitoring the
skin affected by adaptive equipment, changing positions frequently, and
avoiding harsh cleaning products are appropriate.
10. The nurse is teaching a group of students about myelinization in a child.
Which statement by the students indicates that the teaching was
successful?
All Passed And Approved Answers
Get It Right
1. The nurse is teaching the mother of a 5-year-old boy with a
myelomeningocele who has developed a sensitivity to latex. Which of the
following responses from his mother indicates a need for further teaching?
A) "He needs to get a medical alert identification."
B) "I will need to discuss this with his caregivers."
C) "A product's label indicates whether it is latex-free."
D) "He must avoid all contact with latex." - Ans--Ans: C
Feedback:
The Food and Drug Administration (FDA) requires that all medical supplies
be labeled if they contain latex, but this is not the case with consumer
products. The mother must be familiar with products that contain latex. The
Spina Bifida Association of America maintains an updated list of latex-
containing products. Getting a medical alert identification, talking with his
caregivers, and avoiding all contact with latex are correct.
2. The nurse is caring for an 8-year-old boy with myasthenia gravis and is
teaching his parents about the signs of cholinergic crisis. Which of the
following responses by the parents indicates a need for further teaching?
A) "Low blood pressure is a sign of crisis."
B) "He might have difficulty swallowing."
C) "He may start to sweat a lot."
D) "More saliva in the mouth is a common sign." - Ans--Ans: B
Feedback:
Dysphagia is a sign of myasthenic crisis. Increased salivation,
hypotension, and increased sweating are signs and symptoms of
cholinergic crisis.
3. The nurse is providing postoperative care for a 14-month-old girl who has
undergone a myelomeningocele repair. The girl's mother is extremely
anxious and tells the nurse she is afraid she will never learn how to care for
,her daughter at home. Which response by the nurse would be most
appropriate?
A) "I will help you become comfortable in caring for your daughter."
B) "You must learn how to care for your daughter at home."
C) "You will need to learn to collaborate with all the caregivers."
D) "There is a lot to learn, and you need a positive attitude." - Ans--Ans: A
Feedback:
The nurse needs to empower families to become the experts on their child's
needs and conditions via education and participation in care. The most
positive approach is to let the mother know the nurse will support her and
help her become an expert on her daughter's care. Telling the mother that
she must learn how to care for her daughter or that she must have a positive
attitude is not helpful. Telling her that she needs to collaborate with the
caregivers is true, but does not address her fears.
4. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy.
As part of the plan of care, the nurse focuses on maintaining his
cardiopulmonary function. Which intervention would the nurse implement
to best promote maximum chest expansion?
A) Deep-breathing exercises
B) Upright positioning
C) Coughing
D) Chest percussion
. - Ans--Ans: B
Feedback:
The nurse should emphasize that the child's position should be arranged to
promote maximum chest expansion. This is usually in the upright position.
Deep-breathing exercises are for strengthening/maintaining respiratory
muscles. Coughing helps clear the airways. Chest percussion helps loosen
secretions in lungs
5. A 6-year-old boy with cerebral palsy has been admitted to the hospital for
some tests. His condition is stable. The boy's mother remains with her son,
but she is obviously exhausted and stressed. Which response by the nurse
would be most appropriate?
A) "Would you like me to bring you a blanket and pillow?"
B) "You are doing such a wonderful job with your son."
C) "He's in good hands; consider going home to get some sleep."
,D) "Are you planning to spend the night or to go home?" - Ans--Ans: C
Feedback:
Providing daily, intense care can be quite demanding and tiring. When a
child with cerebral palsy is admitted to the hospital, this may serve as a time
of respite for family and primary caregivers. The nurse should remind the
mother that her son is in good hands and urge her to go home. Asking her
whether she is planning to stay might make the mother feel obligated to
stay. Asking if she wants a blanket or pillow does not encourage the mother
to leave the hospital. Telling the mother she is doing a good job is nice, but
does not encourage her to take a break.
6. A nurse is caring for a 14-year-old girl following myelography. Which of
the following would be the priority nursing action?
A) Monitoring for a decrease in spasticity
B) Observing for signs of meningeal irritation
C) Assessing motor function
D) Observing for mental confusion or hallucinations - Ans--Ans: B
Feedback:
Following myelography, the nurse should carefully observe for signs of
meningeal irritation because of what is involved in this procedure.
Monitoring for a decrease in muscle spasticity, assessing motor function,
and observing for mental confusion or hallucinations is appropriate
following an intrathecal test dose of baclofen.
7. The nurse has developed a plan of care for a 6-year-old with muscular
dystrophy. He was recently injured when he fell out of bed at home. Which
intervention would the nurse suggest to prevent further injury?
A) Recommend the bed's side rails be raised throughout the day and night.
B) Suggest a caregiver be present continuously to prevent falls from bed.
C) Encourage a loose restraint to be used when he is in bed.
D) Recommend raising the bed's side rails when a caregiver is not present. -
Ans--Ans: D
Feedback:
The nurse should recommend that side rails on the bed be elevated when a
caregiver is not present. The use of restraints should be avoided if at all
possible. Suggesting that a caregiver be present at all times places undue
stress on the family. Close observation is more appropriate.
, Recommending side rails be elevated at all times may be upsetting to the
child and make him feel like a "baby."
8. The nurse is caring for a 2-month-old with cerebral palsy. The infant is
limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting
movements. Which of the following would the nurse use when documenting
these observations?
A) Spastic
B) Athetoid
C) Ataxic
D) Mixed - Ans--Ans: B
Feedback:
Athetoid cerebral palsy is characterized by abnormal, involuntary
movement. It affects all four extremities with possible involvement of the
face, neck, and tongue. The movements increase in periods of stress.
Dysarthria and drooling may be present as well. Spastic cerebral palsy is
characterized by poor control of posture, balance, and movement;
exaggeration of deep tendon reflexes; and hypertonicity of affected
extremities. Ataxic is characterized by poor coordination, unsteady gait,
and wide-based gait.
9. The nurse is caring for a child with a spinal cord injury and providing
instruction to the parents on promoting skin integrity. Which response from
the mother indicates a need for further teaching?
A) "I need to monitor his skin at least twice a week."
B) "I must monitor skin affected by his adaptive equipment."
C) "He must change positions frequently."
D) "We must avoid harsh cleaning products." - Ans--Ans: A
Feedback:
The nurse needs to emphasize to the mother that she must monitor the
condition of the entire surface of the skin several times daily to provide a
baseline and allow for early identification of areas at risk. Monitoring the
skin affected by adaptive equipment, changing positions frequently, and
avoiding harsh cleaning products are appropriate.
10. The nurse is teaching a group of students about myelinization in a child.
Which statement by the students indicates that the teaching was
successful?
