Maternity and Pediatrics Ricci, Kyle and Carman- Ch 43
Questions and Verified Answers
1. The nurse is caring for a child who is experiencing an acute renal transplant
rejection and is to receive muromonab-CD3. What would the nurse most likely
expect to assess after the first dose is administered?
A) Fever with chills, chest tightness
B) Cough, hyperkalemia
C) Photosensitivity, gastrointestinal (GI) upset
D) Urinary retention, decreased appetite - correct questions and answersAns: A
Feedback:
The first dose of muromonab-CD3 can cause fever, chills, chest tightness,
wheezing, nausea, and vomiting. Cough and hyperkalemia are associated with
angiotensin-converting enzyme inhibitors. Photosensitivity and GI upset are often
associated with diuretics. Urinary retention and decreased appetite are associated
with imipramine.
2. The nurse is visually inspecting a urine specimen from a 12-year-old boy. The
nurse documents gross hematuria with a specimen of which color?
A) Cloudy yellow
B) Cola colored
C) Pale to almost clear urine
,D) Light orange to moderately yellow colored - correct questions and answersAns:
B
Feedback:
Gross hematuria causes the urine to appear tea, cola, or even dirty green colored.
Cloudy urine is typically a sign of infection. Normal urine ranges from moderately
yellow to pale or almost clear. Orange-colored urine can occur because of
medication.
3. The nurse is caring for a 4-year-old with a suspected urinary tract infection.
What would be most appropriate when obtaining a urine specimen from the
child?
A) "I will need a urine sample."
B) "Let your mom help you tinkle in this cup."
C) "Please tinkle in this cup right now."
D) "Please void in this cup instead of the toilet." - correct questions and
answersAns: B
Feedback:
The nurse needs to use familiar terms to explain to the child what is needed and
to gain cooperation. The most positive approach would be to let the child's
mother help rather than demanding that he tinkle right now. Using the terms
"urine sample" or "void" is not appropriate for a 4-year-old.
, 4. The nurse is providing postsurgical care for an infant who has undergone a
hypospadias repair. Which action by the nurse would be most important to help
keep the area clean while maintaining proper position of the drainage tubing?
A) Keeping the drainage tube taped in an upright position
B) Administering antibiotics as ordered
C) Administering analgesics as prescribed
D) Using a double-diapering technique - correct questions and answersAns: D
Feedback:
Double diapering is a method used to protect a child's urethra and stent or
catheter after surgery and additionally helps to keep the area clean and free from
infection. Keeping the drainage tube taped in an upright position, administering
antibiotics, and administering analgesics are also important, but double diapering
keeps the area clean and helps prevent infection.
5. The nurse is caring for an infant with bladder exstrophy. As part of the infant's
preoperative plan of care, the nurse monitors for abdominal skin excoriation.
Which action would be most appropriate for promoting healing and preventing
further skin breakdown?
A) Cleaning the area well with a scented diaper wipe
B) Applying a barrier/healing cream or paste on skin
C) Keeping the bladder moist and covered with a sterile bag
Questions and Verified Answers
1. The nurse is caring for a child who is experiencing an acute renal transplant
rejection and is to receive muromonab-CD3. What would the nurse most likely
expect to assess after the first dose is administered?
A) Fever with chills, chest tightness
B) Cough, hyperkalemia
C) Photosensitivity, gastrointestinal (GI) upset
D) Urinary retention, decreased appetite - correct questions and answersAns: A
Feedback:
The first dose of muromonab-CD3 can cause fever, chills, chest tightness,
wheezing, nausea, and vomiting. Cough and hyperkalemia are associated with
angiotensin-converting enzyme inhibitors. Photosensitivity and GI upset are often
associated with diuretics. Urinary retention and decreased appetite are associated
with imipramine.
2. The nurse is visually inspecting a urine specimen from a 12-year-old boy. The
nurse documents gross hematuria with a specimen of which color?
A) Cloudy yellow
B) Cola colored
C) Pale to almost clear urine
,D) Light orange to moderately yellow colored - correct questions and answersAns:
B
Feedback:
Gross hematuria causes the urine to appear tea, cola, or even dirty green colored.
Cloudy urine is typically a sign of infection. Normal urine ranges from moderately
yellow to pale or almost clear. Orange-colored urine can occur because of
medication.
3. The nurse is caring for a 4-year-old with a suspected urinary tract infection.
What would be most appropriate when obtaining a urine specimen from the
child?
A) "I will need a urine sample."
B) "Let your mom help you tinkle in this cup."
C) "Please tinkle in this cup right now."
D) "Please void in this cup instead of the toilet." - correct questions and
answersAns: B
Feedback:
The nurse needs to use familiar terms to explain to the child what is needed and
to gain cooperation. The most positive approach would be to let the child's
mother help rather than demanding that he tinkle right now. Using the terms
"urine sample" or "void" is not appropriate for a 4-year-old.
, 4. The nurse is providing postsurgical care for an infant who has undergone a
hypospadias repair. Which action by the nurse would be most important to help
keep the area clean while maintaining proper position of the drainage tubing?
A) Keeping the drainage tube taped in an upright position
B) Administering antibiotics as ordered
C) Administering analgesics as prescribed
D) Using a double-diapering technique - correct questions and answersAns: D
Feedback:
Double diapering is a method used to protect a child's urethra and stent or
catheter after surgery and additionally helps to keep the area clean and free from
infection. Keeping the drainage tube taped in an upright position, administering
antibiotics, and administering analgesics are also important, but double diapering
keeps the area clean and helps prevent infection.
5. The nurse is caring for an infant with bladder exstrophy. As part of the infant's
preoperative plan of care, the nurse monitors for abdominal skin excoriation.
Which action would be most appropriate for promoting healing and preventing
further skin breakdown?
A) Cleaning the area well with a scented diaper wipe
B) Applying a barrier/healing cream or paste on skin
C) Keeping the bladder moist and covered with a sterile bag
