maternal child

1. A client in the 28th week gestation comes to the emergency department because she thinks that she is in labor. To confirm a diagnosis of preterm labor, the nurse would expect physical examination to reveal: a. Irregular uterine contractions with no cervical dilatation b. Painful contractions with no cervical dilatation c. Regular uterine contractions with cervical dilatation d. Regular uterine contractions with no cervical dilatation Ans: C – regular uterine contractions (every 10 minutes or more) along with cervical dilation before 36 weeks’ gestation or rupture of fluids indicates preterm labor. Uterine contractions without cervical change don’t indicate preterm labor. 2. A client in the active phase of labor has reactive fetal monitor strip and has been encouraged to walk. When she returns to bed for a monitor check, she complains of an urge to push. When performing vaginal examination, the nurse accidentally ruptures the amniotic membranes, the umbilical cord comes out. What should be done next? a. Put the client in a knee-chest position b. Call the physician or midwife c. Push down on the uterine fundus d. Set up for a fetal blood sampling to assess for fetal acidosis Ans: A – the knee–to–chest position gets the weight off the baby and umbilical cord, which would prevent blood flow. Calling d physician or midwife and setting up for blood sampling is important, but they have a lower priority than getting d baby off the cord. Pushing down on d fundus would increase d danger by further compromising blood flow. 3. A client is attempting to deliver vaginally despite the fact that her previous delivery was by cesarean section. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100 seconds. Suddenly, the client complaints of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse recognizes that which of the following has occurred? a. Abruptio placentae b. Prolapsed cord c. Partial placenta previa d. Complete uterine rupture Ans: D – in complete uterine rupture, the client would feel a sharp pain in the lower abdomen and contractions would cease. Fetal heart rate would also cease within a few minutes. Uterine irritability would continue to be indicated by the fetal heart monitor tracing with abruption placentae. With a prolapsed cord, contractions would continue and there would be no pain from d prolapse itself. There would be vaginal bleeding with a partial placenta previa, but no pain outside of the expected pain of contractions. 4. A client with gravida 3 para 2 at 40 weeks gestation is admitted with spontaneous contractions. The physician performs an amniotomy to augment her labor. The priority nursing action is to: a. Explain the rationale for the amniotomy to the client b. Assess fetal heart tones after the amniotomy c. Ambulate the client to strengthen the contraction pattern d. Position the client in a lithotomy position to administer perineal care Ans: B - the nurse should assess fetal heart tones. After an amniotomy is performed, the umbilical cord may be washed down below the presenting part and cause umbilical cord compression, which would be indicated by variable deceleration on the fetal heart tracing. An explanation of the rationale for amniotomy would be given before d procedure. After assessing the fetal response to the amniotomy, perineal care s provided. The nurse would ambulate client only if the presenting part were engaged. 5. The nurse can consider the fetus’s head to be engaged when: a. The presenting part moves through the pelvis b. The fetal head rotates to pass through the ischial spines c. The fetal head extends as it passes under the symphysis pubis d. The biparietal diameter passes the pelvic inlet Ans: D – d fetus’s head s considered engaged when the biparietal diameter passes d pelvic inlet. The presenting part moving through d pelvis s called descent. The head flexing so that the chin moves closer to d chest s called flexion. Rotation of the head to pass through the ischial spines is called internal rotation. Extension of the head as it passes under d symphysis pubis s called extension. 6. A client is experiencing true labor when her contraction pattern shows: a. Occasional irregular contractions b. Irregular contractions that increase in intensity c. Regular contractions that remain the same d. Regular contractions that increase in frequency and duration Ans: D- regular contractions that increase in frequency and duration as well as intensity indicate true labor. The other choices don’t describe d contraction pattern of true labor. 7. A client is admitted to the hospital with contractions that are about 1 to 2 minutes apart and reveal that her cervix is dilated 8 cm. The client is in which stage of labor? a. Latent phase b. Active phase c. Third stage d. Transitional phase Ans: D- d client is in d transitional phase of labor. This phase of labor is characterized by cervical dilation of 8 to 10 cm and contractions that are about 1 to 2 minutes apart and last for 60 to 90 seconds with strong intensity. In the latent phase, the cervix is dilated 0 to 3 cm and contractions are irregular. During the active phase, the cervix is dilated to 4 to 7 cm and contractions are about 5 to 8 minutes apart and last 45 to 60 seconds with moderate to strong intensity. The 3rd stage of labor extends from delivery of the neonate to expulsion of the placenta and lasts from 5 to 30 minutes. 8. A client in the second stage of labor experiences rupture of membranes. The most appropriate intervention by the nurse is to: a. Assess the client’s vital signs immediately b. Observe for prolapsed cord and monitor fetal heart rate c. Administer oxygen through a face mask at 6-10 L per min d. Position the client on her side Ans: B – the nurse should immediately check for prolapsed cord and monitor FHR. When the membranes rupture, the cord may become compressed between the fetus and maternal cervix or pelvis, thus compromising fetoplacental perfusion. It isn’t necessary to position the client on her left side, monitor maternal vital signs, or administer oxygen when the client’s membrane rupture. 9. A client in labor is being monitored by an internal electronic device to evaluate fetal station. The nurse measures the duration of her contractions by: a. Measuring from the beginning of the increment to the end of the decrement b. Measuring from the beginning of one contraction to the beginning of the next c. Measuring from the beginning of the decrement to the end of the increment d. Using an intrauterine catheter that measures increases in contraction Ans: A- the duration of a contraction is measured from the beginning of the increment to the end of the decrement. Measuring from the beginning of one contraction to the beginning of the next reveals frequency. Measuring from the beginning of one contraction to the beginning of the next reveals frequency. Measuring during the acme phase of a contraction reveals intensity (measured with an intrauterine catheter or by palpation). 10. A client is receiving magnesium sulfate to help suppress preterm labor. The nurse should watch for which sign of magnesium toxicity? a. Headache b. Loss of deep tendon reflexes c. Palpitations d. Dyspepsia Ans: B – magnesium toxicity causes signs of central nervous system depression, such as loss of deep tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision, slurred speech, and confusion. Headache may be an adverse effect of calcium channel blockers, which are sometimes used to treat preterm labor. Palpitations are an adverse effect of terbutaline and ritodrine, which are also used to treat preterm labor. Dyspepsin may occur as an adverse effect of indomethacin, a prostaglandin synthesize inhibitor, used to suppress preterm labor. 11. When assessing a postpartum client for uterine bleeding, the nurse finds the fundus to be boggy. After fundal massage, the physician prescribes 0.2 mg of methylergonovine (Methergine) by mouth. What should the nurse tell the client? a. “Methergine is commonly used to help the uterus contract so that the bleeding will decrease. You may experience more cramping as your uterus becomes firmer.” b. “You will probably take this medication until you are discharged from the hospital. Every patient usually needs to take this medication.” c. “If your blood pressure is low, you won’t be able to take this medication; I will establish a new IV line so I can start Pitocin again.” d. “Most people don’t experience additional pain or cramping from taking this medication.” Ans: A – Methylergonovine, an ergot alkaloid, is commonly given to stimulate sustained uterine contraction. It allows the uterus to remain contracted and firm, thus decreasing postpartum bleeding. Abdominal cramping, which may become painful, is a common adverse effect. Methergine is discontinued when the lochia flow has decreased or the client complains of severe cramping. Clients may need only a few doses of Methergine to keep the uterus contracted. Taking Methergine is contraindicated in clients with hypertension. 12. The nurse is providing care for a postpartum client. Which of the following conditions would place this client at greater risk for postpartum hemorrhage? a. Hypertension b. Uterine infection c. Placenta previa d. Severe pain Ans: C – d client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the lower uterine segment doesn’t contract as well as the fundal part of the uterus; therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don’t place the client at increased risk for postpartum hemorrhage. 13. A client has delivered twins. What is the most important intervention for the nurse to perform? a. Assess fundal tone and lochia flow b. Apply a cold pack to the perineal area c. Administer analgesics as ordered d. Encourage voiding by offering the bedpan Ans: A – women who experience a twin delivery are at a higher risk for postpartum hemorrhage due to overdistention of d uterus, which causes uterine atony. Assessing fundal tone and lochia flow helps to determine risks for hemorrhage. Applying cold packs to d perineum, administering analgesics as ordered, and offering d bedpan r all significant nursing interventions, however, detecting and preventing postpartum hemorrhage s most important. 14. Which of the following is a normal physiological response in the early postpartum period? a. Urinary urgency and dysuria b. Rapid diuresis c. Decrease in blood pressure d. Increased motility of the GI system Ans: B – in d early postpartum period there s an increase in the glomerular filtration rate and a drop in progesterone levels, which result in rapid diuresis. There should be no urinary urgency, although a woman may be anxious about voiding. There is minimal change n blood pressure following childbirth and a residual decrease in gastrointestinal motility. 15. During the 3rd postpartum day, which of the following would the nurse be most likely to find in the client? a. She’s interested in learning more about newborn care b. She talks a lot about her birth experience c. She sleeps whenever the baby isn’t present d. She requests help in choosing a name for the baby Ans: A – d 3rd to 10th days of postpartum care are the “taking–hold” phase, in which the new mother strives for independence and s eager for her baby. B, C & D – describe d phase n which d mother relives her birth experience. 16. Which of the following circumstances is most likely to cause uterine atony, leading to postpartum hemorrhage? a. Hypertension b. Cervical and vaginal tears c. Urine retention d. Endometriosis Ans: C – urine retention is most likely to cause uterine atony and subsequent postpartum hemorrhage. Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents d uterus from contracting. The uterus needs to remain contacted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause postpartum hemorrhage, but in the postpartum period, a full bladder is the most common cause of uterine bleeding. Endometritis, an infection of the inner lining of the endometrium, and maternal hypertension don’t cause postpartum hemorrhage. 17. When assessing a client’s episiotomy, the nurse should be especially careful to observe: a. Location b. Discharge and odor c. Edema and approximation d. Subinvolution Ans: C – an episiotomy should be assessed for edema and approximation of incision. An edematous perineum causes more tension of d suture line and increased pain. Although d sutures may be difficult to visualize, the suture line should be intact. Episiotomy location is important, but not as important as the presence of edema. Discharge and odor refer to an assessment of lochia. Subinvolution refers to the complete return of the uterus to its prepregnancy size and shape. 18. In performing a routine fundal assessment, the nurse finds that the client’s fundus is boggy. The nurse should first: a. Call the physician b. Massage the fundus c. Assess lochia flow d. Obtain an order for methylergonovine Ans: B – the nurse should begin to massage the uterus so that it will be stimulated to contract. Assessing lochia flow can be done while the uterus is being massaged. The nurse shouldn’t leave the client to call the physician. If the fundus remains boggy and the uterus continues to bleed, the nurse should use the call button to ask another nurse to call d physician. Methylergonovine may be prescribed, if needed. 19. Which type of lochia should the nurse expect to find in a client who is 2 days postpartum? a. Foul smelling b. Serosa c. Alba d. Rubra Ans: D – lochia rubra lasts about 4 days followed by lochia serosa, which extends through the 7th day, and then lochia alba, which occurs during the 2nd and 3rd postpartum weeks. Foul–smelling lochia s a sign of infection. 20. A client treated with magnesium sulfate during labor is now on the postpartum unit. The nurse should be aware that the client is at risk for which of the following complications of magnesium sulfate therapy? a. Hypotension b. Uterine infection c. Postpartum hemorrhage d. Postpartum depression Ans: C – because magnesium sulfate produces a smooth muscle depressive effect, the uterus should be assessed for uterine atony. The uterus may be unable to maintain a firm tone, thus increasing the risk of postpartum hemorrhage. Uterine infection and postpartum depression aren’t associated with magnesium sulfate therapy. Magnesium sulfate does decrease blood pressure, but it’s considered more of ananticonvulsant drug than an antihypertensive drug. 21. The nurse is assessing an infant with tracheoesophageal fistula. Which finding would the nurse expect to encounter? a. Increase in saliva b. Gastric tube easily passed c. Feeding without difficulty d. Normal chest x-ray Ans: A – d infant’s inability to swallow saliva leads to an increase in saliva. The other options aren’t likely findings in tracheoesophageal fistula. The infant is unable to pass a gastric tube. During feedings, the infant is at risk for choking and cyanosis. Pulmonary infiltrates, labor collapse, and atelectasis frequently appear on the chest x – ray. 22. A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should: a. Ask her to void b. Instruct her to drink 1 liter of fluid c. Prepare her for IV anesthesia d. Place her on her side Ans: A – to prepare a client for amnioceptesis, the nurse should ask d client to empty her bladder to reduce the risk of bladder perforation. The nurse may instruct the client to drink 1 L of fluid to fill d bladder before transabdominal ultrasound (unless ultrasound is done before amniocentesis to locate the placenta). I.V. anesthesia isn’t given for amniocentesis. The client should be supine during the procedure; after ward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output. 23. Six hours after birth, a neonate is transferred to the nursery. The nurse is planning interventions to prevent hypothermia. What is a common source of radiant heat loss? a. Low room humidity b. Cold weight scale c. Cool incubator walls d. Cool room temperature Ans: C – common sources of radiant heat loss include cool incubator walls and windows. Low room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss. 24. A client is in the 25th week of pregnancy. Which procedure is used to detect anomalies? a. Amniocentesis b. Chorionic villi sampling c. Fetoscopy d. Ultrasound Ans: D – ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the 3rd trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 week’s gestation to detect genetic disease. Fetoscopy is done at about 18 weeks’ gestation to observe the fetus directly and obtain a skin specimen or blood sample. 25. Which nursing intervention has priority when feeding an infant with a cleft lip or palate? a. Directing the flow of milk in the center of the mouth b. Providing frequent, small feedings c. Avoiding breastfeeding d. Infrequent burping Ans: B – frequent small feedings help to prevent fatigue and frustration in the infant. The flow of milk should be directed to side of the mouth. Breastfeeding may be possible. These infant’s need frequent burping because of d large amount of air swallowed while feeding. 26. During physical examination, a client in her 32nd week of pregnancy becomes pale, dizzy and light-headed while supine. Which intervention takes priority? a. Turning the client onto her left side b. Asking the client to breathe deeply c. Listening to fetal heart tones d. Measuring the client’s blood pressure Ans: A - as the uterus enlarges, pressure on the inferior vena cava increased, compromising venous return and causing blood pressure to drop. This may lead to syncope and other symptoms when the client is supine. Turning the client onto her left side relieves pressure on the vena cava, restoring normal venous return and blood pressure. Deep breathing wouldn’t relieve this client’s symptoms. Listening to fetal heart tones and measuring the client’s blood pressure don’t provide relevant information. 27. A client has meconium-stained amniotic fluid. The fetal monitor strip shows fetal bradycardia. Fetal blood sampling indicates a pH of 7.12. Based on this finding, which nursing intervention is called for? a. Administer oxygen, as prescribed b. Prepare for cesarean delivery c. Reposition the client d. Start IV oxytocin infusion, as prescribed Ans: B – fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium–stained amniotic fluid and bradycardia are additional signs of fetal distress that warrant cesarean delivery. Oxygen administration and client repositioning may improve uteroplacental perfusion but are only temporary measures. Oxytoxin administration increased contractions, exacerbating fetal stress. 28. Which of the following phases of uterine contractions is described as the letting-down phase? a. Increment b. Decrement c. Acme d. Variability Ans: B – decrement is the letting–down phase of uterine contractions. Increment refers to the building–up phase, and acme is the peak of the contraction. Variability refers to the normal variation in the heart rate, caused by continuous interplay other parasympathetic and sympathetic nervous systems. 29. Which diagnostic procedure will best determine whether a client in labor has spontaneous rupture of amniotic membranes? a. Complete blood count b. Fern test c. Urinalysis d. Vaginal examination Ans: B – a fern test indicates spontaneous rapture of amniotic membranes. The name of this test refers to the microscopic fernlike pattern produced by sodium chloride crystallization in dried amniotic fluid, which indicates the presence of ruptured amniotic membranes. A complete blood count might indicate infection (if white blood cells are increased), but it won’t indicate whether the amniotic sac had ruptured. Urinalysis doesn’t test for d presence of amniotic fluid. A vaginal examination may determine whether the membranes have ruptured but isn’t conclusive. 30. A client is admitted to the hospital in preterm labor. To halt her uterine contractions, the nurse expects to administer: a. Magnesium sulfate b. Dinoprostone c. Ergonovine maleate d. Terbutaline Ans: D – terbutaline, a beta 2–receptor agonist, is used to inhibit preterm uterine contractions. Magnesium sulfate is used to treat pregnancy–induced hypertension. Dinoprostone is used to induce fetal expulsion and promote cervical dilation and softening. Ergonovine maleate is used to stop uterine blood flow, for example, in hemorrhage. 31. A 2-year-old child is admitted to the hospital with Hirschprung’s disease. During the nursing history, the mother describes the child’s stools to the nurse as foul-smelling and: a. Small, hard pebbles b. Large and frothy c. Cordlike d. Ribbonlike Ans: D – choices A and C are not characteristic of Hirschprung’s disease. Choice B is characteristic of cystic fibrosis. Ribbonlike stool pattern is characteristic of agangionic colon. 32. The nurse explains to a toddler’s parents that the treatment of choice for congenital aganglionic megacolon would be: a. Surgical removal of affected colon b. Modified diet high in fiber c. Medication to stimulate the colon d. Permanent colostomy Ans: A – the aganglionic section of the colon is removed so the remaining intestines can function. Diet changes will not make a difference owing to the lack of peristalsis. There is no medication that will make an aganglionic colon function. A permanent colostomy is not necessary. A temporary colostomy is performed using a two or three stage procedure to correct the problem. 33. A 7-year-old child is admitted to the hospital with nephritic syndrome. In the assessment phase, the nurse is aware that a classic symptom is: a. Increased urine output b. Hematuria c. Elevated blood pressure d. Proteinuria Ans: D – there is decreased urine output. Hematuria is positive in glomerulonephritis. The blood pressure is normal or slightly below normal. There is a massive proteinuria. 34. During the edematous phase of nephritic syndrome, an important nursing intervention is to: a. Provide meticulous skin care b. Encourage fluid intake c. Encourage moderate activity d. Weigh the client every other day Ans: A – edema increases the potential for skin breakdown, so skin care is extremely important. Fluid intake is limited to decrease the workload on the circulatory system with the excess fluid. The child should e weighed at least daily and often twice a day. 35. In evaluating the effectiveness of the prednisone therapy, the nurse realizes that a child with nephritic syndrome will continue to take the drug until after: a. Edema has disappeared b. Urine no longer contains protein c. Hematuria has resolved d. His “moon” face has disappeared Ans: B – some edema may continue even after the drug has been stopped. Prednisone is continued as long as there is protein in the urine. Hematuria is a symptom of glomerulonephritis and not nephrosis. His “moon” face is a side effect of the drug and will continue as long as prednisone is taken. 36. A mother brings her 3-year-old son to the emergency room. He is crying with apparent acute abdominal pain. After initial assessment, intussusception is suspected. What type of characteristic stool would the mother most likely report? a. Black tarlike b. Ribbonlike c. Red currant-jellylike d. Frothy and foul-smelling Ans: C – choice A would indicate old blood in the stool. Choice B is characteristic of Hirschprung’s disease. Choice C is characteristic of intussusception and indicates fresh blood. Choice D is characteristic of cystic fibrosis. 37. A one-moth-old infant is at the physician’s office for a follow-up visit after surgery for pyloric stenosis. Which of the following is the best indicator that the infant is recovering well from his surgery? a. Mother reports infants feeding well every 4 hours b. The infant has demonstrated a satisfactory weight gain c. The infant is in the 90% in length on the growth chart d. Mother reports infant has a normal stool pattern Ans: B – choice A is subjective information and therefore not the best answer. Choice B is objective information that indicates the infant is maintaining and absorbing his feedings. Choice C is not directly related to food absorption. Choice D is subjective information and not the best indicator of food intake and absorption. 38. A baby has died from sudden infant death syndrome (SIDS). SIDS is often initially mistaken for: a. Failure to thrive b. Viral infection c. Meningitis d. Child abuse Ans: D – choice A, B and C and conditions that have no symptoms that could be mistaken for SIDS. Bruising occurs due to the pooling and settling of blood once the infant has died. This gives the appearance that the child has been beaten. 39. During the initial assessment of a child with Reye’s syndrome, the mother reports that about a week ago, the child had: a. Mumps b. Meningitis c. Influenza d. Cellulites Ans: C – choices A, B and D are conditions not associated with Reye’s syndrome. Influenza usually precedes Reye’s syndrome. 40. The most important nursing intervention in caring for a child with Reye’s syndrome is to: a. Prevent skin breakdown b. Monitor intake and output c. Do range-of-motion exercises d. Turn every 2 hours Ans: B – this is not a life-threatening problem. Careful monitoring of intake and output aids in preventing cerebral edema or dehydration. Choice c is not associated with a life-threatening problem. This intervention is not as important as preventing cerebral edema or dehydration. 41. Because of liver involvement associated with Reye’s syndrome, the nurse should use which special caution when caring for children with this condition: a. Administering IM injections b. Monitoring output from the catheter c. Assessing the level of consciousness d. Turning the child Ans: A – prolonged bleeding may occur owing to impaired coagulation. Pressure should be applied to the injection site for a longer period of time. Choices B, C and D are not related to liver function. 42. A one-year-old infant is admitted to the hospital to rule out cystic fibrosis. During the admission process the infant passes a stool. The nurse realizing that his stool is symptomatic of cystic fibrosis, charts it as: a. Small and constipated b. Green and odorous c. Large and bulky d. Yellow and loose Ans: C – choice A and D type of stool are not symptomatic of CF. Stools are not green but are foul smelling. Nondigested food, owing to malabsorption, is excreted, causing an increase in amount and bulk of stools. 43. A child is diagnosed with cystic fibrosis. He is receiving pancreatic enzymes. Once the pancreatic enzymes the child is taking are effective, he will: a. Have normal bowel movements b. Increase 2 lb in weight per week c. Have decreased NaCl in his sweat d. Have fewer respiratory infections per year Ans: A – pancreatic enzymes aid in absorption of nutrients from the intestines so the stools become normal. Choice B is not a realistic weight gain. Pancreatic enzymes are not related to the respiratory system. Pancreatic enzymes are not related to the respiratory system. Pancreatic enzymes are not related to the NaCl level in the sweat. 44. A 6-year-old is hospitalized with acute lymphocytic leukemia. She is placed on protective isolation, which concerns her parents. The nurse should explain that this will: a. Protect her from too many visitors b. Protect her from infectious organisms c. Provide a quiet, private environment for her d. Keep other children away from the child Ans: B – the purpose of protective isolation is to protect the child from exposure to organisms from other people. With leukemia, changes in the blood cell number and composition make the child susceptible to infection. The purpose of protective isolation is to protect the child from exposure to organisms from other people. Choice D is not the purpose of protective isolation. Preventing infection through direct contact with anyone is the purpose. 45. The nurse discusses mouth care with a 6-year-old girl who has acute lymphocytic leukemia and her mother. The nurse explains that when tooth-brushing is contraindicated, the most effective way to clean teeth is: a. Rinsing with water b. Chewing gum after eating c. Rinsing with hydrogen peroxide d. Use a Water Pik Ans: D – choice A is not very effective and does not stimulate the gums. Choice B is not very effective and does not stimulate the gums. Choice C does not stimulate the gums and prevent gingivitis. Choice D will effectively rinse the mouth and stimulate the gums. 46. A 12-year-old girl hospitalized with a diagnosis of rheumatic fever. To minimize her joint pain during acute episodes, the nurse should teach the parents to: a. Immobilize the joints in a functional position b. Do full range of motion on all joints daily c. Apply heat to the involved joints d. Massage joints briskly with lotion after her bath Ans: A – immobilization allows rest and healing. The pain can be so intense that even the weight of a blanket can hurt. Movement of joints (choices B and D) causes pain. The pressure of the healing pad or hot water bottle can cause pain. 47. Discharge planning of a child with rheumatic fever should include teaching the child and parents to recognize which of the following toxic symptoms of sodium salicylate? a. Blurred vision and itching b. Chills and fever c. Acetone breath odor d. Tinnitus and nausea Ans: D – Choice A, B and C are not toxic symptoms. Choice D are common toxic symptoms of salicylates. 48. A neonate in the newborn nursery is suspected of having a tracheoesophageal fistula. A major symptom the nurse observed was: a. Hypersensitive gag reflex b. Dry mouth with no drooling c. Cyanosis d. Lethargy Ans: C – Choice A and D are not symptoms of this condition. TEF symptoms are excessive salivation and drooling. Cyanosis is due to the fistula from the trachea and the esophagus. 49. A 3-year-old child is diagnosed with Kawasaki’s disease. The nurse observes which of the following symptoms? a. Below-normal temperature b. Strawberry tongue c. Edema of the face d. Swelling in the groin Ans: B – with this disease, there is fever for more than 5 days. Strawberry tongue is a symptom of the disease. There is also reddening of the rest of the oropharynx. There is edema of the hands and feet as well as redness. Swelling occurs in the cervical lymph nodes with this disease. 50. The therapeutic management for a child who has been diagnosed with Kawasaki’s disease will include administering which of the following medications? a. Acetaminophen (Tylenol) b. Globulin c. Antibiotics d. Steroids Ans: B – aspirin is usually given to reduce inflammation. Globulin is given to minimize possible cardiac complications. Antibiotics and steroids are not usually given for this condition. 51. A mother is being instructed on the best method of administering syrup of ipecac in the initial home management of an accidental ingestion. The nurse should inform her that syrup of ipecac should be administered with: a. Milk b. Activated charcoal c. One to two glasses of tepid water d. Large amounts of cold water Ans: C – milk or carbonated drinks should be avoided with administration of syrup of ipecac because they may delay emesis. The purpose of administering activated charcoal is to bind with the poison so that body absorption of the poison will be decreased. Because the purpose of syrup of ipecac is to induce vomiting, these drugs would decrease effectiveness of each other. The therapeutic action of S of I is facilitated by following the dose with 100 to 200 ml of tepid water or other clear liquids in children (200 – 300 ml in adults). There could be a problem with water intoxication and decreased effectiveness of S of I with the administration of large amounts of cold water. 52. A 7-year-old child has been taking phenytoin and Phenobarbital for control of chronic recurrent seizures. In the physical exam, the nurse notes that the child has hyperplasia of the gums. The nurse should recognize that hyperplasia of the gums is: a. A common occurrence with chronic recurrent seizures b. A common side effect of phenytoin c. Not related to the drugs or the disease d. An unusual side effects of phenobarbital Ans: B – many children who have seizures do have this side effect. However, it has nothing specifically to do with the seizure. Hyperplasia of the gums is a side effect of phenytoin. Phenytoin administration is seen most commonly in children and adolescents. It never occurs in edentulous clients. Hyperplasia of the gums is a side effect of phonation. Phenytoin administration is seen most commonly in children and adolescents. It never occurs in edentulous client. Hyperplasia of the gums is not a side effect of Phenobarbital. 53. A 7-month-old infant has been on antibiotic therapy. The nurse notes that the child has white patches in his mouth that will not rub off. The physician orders nystatin (Mycostatin) 1 ml, PO, QID. The nurse should realize that the appropriate technique in administering this medication is to: a. Give 0.5 ml in each side of the mouth b. Give with milk or food c. Give through a nipple d. Follow with water Ans: A – nystatin is a local antibiotic and must come into contact with the infected area to be effective. Giving half of the dose on each side of the mouth will increase the area of contact and consequently increase the effectiveness of the drug. Giving with milk or food, through a nipple, or following medication with water (choices B, C and D) would decrease effectiveness by decreasing direct contact of the medication with the infected area. 54. A primary objective for planning nursing care of an edematous child with nephritic syndrome would be to: a. Ambulation b. A low-carbohydrate diet c. A high-protein diet d. A low-protein diet Ans: C – the child with nephrosis should be on bed rest in the edematous state. Highcarbohydrate diet is needed for energy and the caloric intake. Protein replacement is critical because of the massive proteinuria and hypoalbuminemia with nephrosis. High=protein diet is needed for protein replacement. 55. The predominant purpose of the first APGAR score of a newborn is to: a. Determine gross abnormal motor function b. Obtain a baseline for comparison with the infant’s future adaptation to the environment c. Evaluate the infant’s vital function d. Determine the extent of congenital malformation Ans: A- Apgar scores are not related to the infant’s care, but to the infant’s physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation. (C) the purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resusciation. (D) congenital malformations are not one of the areas assessed with Apgar scores. 56. Provide the one-minute APGAR score for an infant born with the following findings: respiratory effort, slow and irregular; muscle tone, some flexion of extremities; reflex irritability, vigorous cry and; color, body pink, blue extremities. a. 7 b. 10 c. 8 d. 9 Ans: A- seven out of possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flexion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). (B) for a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry , active motion, and be completely pink. (C) for an Apgar score of 8 the respiratory rate, muscle tone, or color wouldneed to fall into the 2 point rather than the 1point category. (D) for this infant to receive an Apgar score of 9, four of t he areas evaluated would need ratings of 2 points and one area a rating of 1 point 57. An 8-year-old child comes to the physician’s clinic complaining of swelling and pain in the knees. His mother says, “The swelling occurred for no reason, and it keeps getting worse.” The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history? a. A decreased urinary output and flank pain b. A fever over 103oF occurring over the last 2 – 3 weeks c. Rashes covering the palms of the hands and the soles of the feet d. Headaches, malaise or sore throat Ans: A- urinary tract symptoms are not commonly associated with Lyme disease. (B) a fever of 103.oF is not characteristic of lYme disease. (C) the rash that is associated with Lyme disease does not appear on the palms of the hands and the soles of the feet. (D) classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly., conjunctivitis, sore throat, a abdominal pain, and cough 58. The most commonly known vectors of Lyme disease are: a. Mites b. Fleas c. Ticks d. Mosquitoes Ans: A- mites are not common vector of Lyme disease. (B) fleas are not the common vector of Lyme disease (C) ticks are the common vector of lyme disease. (D) mosquitos are not the common vector of Lyme disease 59. A specific laboratory technique specific for diagnosing Lyme disease is: a. Polymerase chain reaction b. Heterophil antibody test c. Decreased serum calcium level d. Increased serum potassium level Ans: A-nursing process phase; analysis; client need; physiological integrity area: pediatrics polymerase chain reaction is the laboratory technique specific for lyme disease (B) heterophil antibody test is used to diagnose mononucleosis. (C) lyme disease does not decrease the serum calcium level. (D) lyme disease does not increase the serum potassium level 60. The nurse would expect to include which of the following when planning the management of the client with Lyme disease? a. Complete bed rest for 6-8 weeks b. Tetracycline treatment c. IV amphotericin B d. High-protein with limited fluids Ans: A- the client is not placed on complete bed rest for 6 weeks. (B) tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for histoplasmosis. (D) the client is not restricted to a highprotein diet with limited fluids 2. 61. A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching of the parents, the nurse states that: a. Sustained temperature elevation over 103oF is generally related to febrile seizures b. Febrile seizures do not usually recur c. There is little risk of neurological deficit and mental retardation as sequele to febrile seizures d. Febrile seizures are associated with disease of the central nervous system Ans: A-the temperature elevation related to febrile seizures generally exceeds 101oF, and seizures occur during the temperature rise rather than after a prolonged elevation. (B) febrile seizures may recur and are more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of neurological deficit mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile seizures are associated with disease of the central nervous system 1. After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis? a.)Supportive child-parent interaction (speaking, listening, touching, and eye-to-eye contact b.)Parents' active participation in child's physical or emotional care c.)Parents' failure to use available support systems or agencies to assist in coping d.)Evidence of adaptation to parental role changes C. RATIONALE: A failure to use available support systems or agencies is one of the defining characteristics of this diagnosis. Supportive child-parent interaction, parents' active participation in the child's care, and evidence of adaptation to parental role changes don't suggest this diagnosis. 2. An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation? a.)Ask the parents not to visit the child until he has adjusted to the new environment. b.)Ask the physician to explain to the child why he needs to stay in the health care facility. c.)Explain to the child that he must act like an adult while he's in the facility. d.)Have the parents stay with the child and participate in his care. D. RATIONALE: Allowing the parents to stay and participate in the child's care can provide support to the parents and the child. The other interventions won't address the client's diagnosis and may exacerbate the problem. 3. A 13 year old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: a.)send the child home to recover. b.)inspect the child for uneven shoulder height or uneven hip height. c.)arrange for the child to have spinal X-rays as soon as possible. d.)ask the child's parent to take him to a physician immediately. B. RATIONALE: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child. 4. The nurse is caring for a child who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report: a.)pain at the injection site. b.)generalized urticaria. c.)mild temperature elevation. d.)local swelling at the injection site. B. RATIONALE: Generalized urticaria can herald the onset of a life-threatening episode and medical assistance should be sought immediately. A child may experience some pain, redness at the sight, mild temperature elevation, or localized swelling. These reactions can be treated symptomatically and aren't life-threatening. 5. The nurse is caring for a child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action wouldn't be appropriate for the nurse to take? a.)Helping the child and family obtain necessary equipment, supplies, and medication b.)Pointing out to the parents ways in which they might have done things differently c.)Providing referrals to local community agencies and the Cystic Fibrosis Foundation d.)Encouraging the parents to allow their child to follow as normal a childhood as possible B. RATIONALE: The nurse should avoid being critical when talking with parents about how they have handled their child's disease or condition. The nurse can help this family by assisting them with finding appropriate financial, psychological, and social support. Providing referrals to local community agencies and the Cystic Fibrosis Foundation is also an appropriate intervention. The child should be treated as much like a normal child as possible. 6. The nurse is caring for a client who was involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: a.)reintroduce the tube and attach it to water seal drainage. b.)call the physician and obtain a chest tray. c.)cover the opening with petroleum gauze. d.)clean the wound with povidone-iodine and apply a gauze dressing. C. RATIONALE: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress, as tension pneumothorax may develop. If so, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions. 7. A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by: a.)decreasing respiratory tract edema. b.)lowering anxiety. c.)drying secretions. d.)increasing fluid intake. A. RATIONALE: The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them and it doesn't increase the child's fluid intake. 8. An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause: a.)cerebral edema. b.)dehydration. c.)heart failure. d.)hypovolemic shock. A. RATIONALE: Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Fluid overload won't cause dehydration. It would be unusual for an adolescent to develop heart failure unless the overhydration was extreme. Hypovolemic shock would occur with an extreme loss of fluid or blood. 9. The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply: a.)"Yes, you should have a Pap test after the onset of menstruation." b.)"No, you aren't sexually active." c.)"Yes, you're 16 years old." d.)"No, you aren't 21 years old." B. RATIONALE: A 16-year-old female client who isn't sexually active doesn't need a Pap test. When a client is sexually active or reaches age 18, a Pap test should be performed. 10. A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. She says that her baby can't sit alone or roll over. An appropriate response by the nurse would be: a.)"This is very abnormal, your child must be sick." b.)"Let's see about further developmental testing." c.)"Don't worry, this is normal for her age." d.)"Maybe you just haven't seen her do it." B. RATIONALE: At age 12 months, a child should be sitting up and rolling over. Therefore, this child may have developmental problems. Options A and D aren't therapeutic and can cut off communication with the mother. Option C misleads the mother with false reassurance. 11. An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include: a.)slapping, kicking, and punching others. b.)poor hygiene and weight loss. c.)loud crying and screaming. d.)pulling hair and hitting. B. RATIONALE: Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, punching, pulling hair, and hitting are examples of forms of physical abuse. Loud crying and screaming aren't abnormal findings in a 3-year-old child. 12. A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? a.)"I told my husband to give my son aspirin for his fever." b.)"I'll ask the physician about giving the baby an immunization shot." c.)"I don't have to worry because I've had the measles." d.)"I'll call my neighbor who is 2 months pregnant and tell her not to have contact with my son." D. RATIONALE: Fetal defects can occur during the first trimester of pregnancy if the pregnant woman gets rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Tylenol should be used instead of aspirin. Rubella immunization isn't recommended for children until age 12 to 15 months. Measles is rubeola and won't provide immunity for rubella. 13. The nurse is caring for an adolescent client who underwent surgery for a perforated appendix. When caring for this client, the nurse should keep in mind that the main life-stage task for an adolescent is to: a.)resolve conflict with parents. b.)develop an identity and independence. c.)develop trust. d.)plan for the future. B. RATIONALE: The adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures along with development. Adolescents rarely finalize plans for the future; this usually happens later in adulthood. 14. What's the best advice for a nurse to give to the parents of a 2-year-old child who frequently throws temper tantrums? a.)Move the toddler to a different setting. b.)Allow the toddler more choices. c.)Ignore the behavior when it happens. d.)Give in to the toddler's demands. C. RATIONALE: Ignore tantrum behavior because attention to the behavior can reinforce the undesirable behavior. Changing settings can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. It's ill-advised to give in to the toddler's demands because doing so only promotes tantrum behavior. 15. A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is: a.)developmental readiness of the child. b.)consistency in approach. c.)the mother's positive attitude. d.)developmental level of the child's peers. A. RATIONALE: If the child isn't developmentally ready, the child and parent will become frustrated. Consistency is important when toilet training is started. The mother's positive attitude is important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers isn't useful. 16. A mother complains to the nurse that her 4-year-old son often lies. What's the nurse's best response? a.)Let the child know that he'll be punished for lying. b.)Ask him why he isn't telling the truth. c.)It's probably due to his vivid imagination and creativity. d.)Acknowledge him by saying, "That's a pretend story." D. RATIONALE: It's important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said isn't real. Punishment isn't appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child isn't truly lying in the adult sense. Imagination and creativity need to be acknowledged. 17. A mother is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be? a.)6 months b.)4 months c.)8 months d.)10 months D. RATIONALE: A 10-month-old child can sit alone and understands object permanence, so he would look for the hidden toy. At 4 to 6 months of age, children can't sit securely alone. At 8 months of age, children can sit securely alone but can't understand the permanence of objects. 18. The mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake? a.)Allow the child to feed herself. b.)Use specially designed dishes for children; for example, a plate with the child's favorite cartoon character. c.)Only serve the child's favorite foods. d.)Allow the child to eat at a small table and chair by herself. A. RATIONALE: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. It's important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation. 19. The nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with: a.)diabetes. b.)leukemia. c.)asthma. d.)cystic fibrosis. B. RATIONALE: Leukemia causes immunosuppression, so inactivated rather than live viruses should be administered. Children with the other conditions listed can receive live virus vaccines because they aren't immunosuppressed. 20. A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should: a.)perform chest physiotherapy every 4 hours. b.)give pancreatic enzymes as ordered. c.)place the child in an oxygen tent and have oxygen administered continuously. d.)serve a highcalorie diet. A. RATIONALE: Chest physiotherapy aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients not in managing secretions. Oxygen therapy doesn't aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but doesn't facilitate respiratory effort. 21. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition related to impaired physical mobility. Which of the following is most likely to occur with this condition? a.)Decreased protein catabolism b.)Increased calorie intake c.)Increased digestive enzymes d.)Increased carbohydrate need D. RATIONALE: Carbohydrate need increases because healing and repair of tissue requires more carbohydrates. Increased not decreased protein catabolism is present. Decreased appetite not increased is a problem. Digestive enzymes are decreased not increased. 22. The nurse is interviewing a 16-year-old female at a clinic. It's her first visit and she says that she has been exposed to herpes by her boyfriend. Initially, with primary genital or type 2 herpes simplex, the nurse would expect the client to have: a.)dysuria and urine retention. b.)perineal ulcers and erosions. c.)bilateral inguinal lymphadenopathy. d.)burning or tingling on vulva, perineum, or vagina. D. RATIONALE: Burning and tingling genital discomfort is the most common initial finding. This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty erosion. The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and dysuria. 23. A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and: a.)a barking cough. b.)a high fever. c.)sudden onset. d.)dysphagia. A. RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low-grade. Croup has a gradual onset, and dysphagia isn't a symptom. 24. A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to assess the child's breath sounds. The best way to approach the 2-year-old child is to: a.)expose the child's chest quickly and auscultate breath sounds as quickly and efficiently as possible. b.)ask the mother to wait briefly outside until the assessment is over. c.)tell the child the nurse is going to listen to his chest with the stethoscope. d.)allow the child to handle the stethoscope before listening to his lungs. D. RATIONALE: Toddlers are naturally curious about their environment and letting them handle minor equipment is distracting and helps them gain trust with the nurse. The nurse should expose only one area at a time during assessment and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console her child. Also, comfort the child with objects with which he's familiar. The child should be given limited choices to allow autonomy, such as "Do you want me to listen first to the front of your chest or your back?" 25. A 2-year-old child is brought to the emergency department with suspected croup. Which of the following assessment findings reflects increasing respiratory distress? a.)Intercostal retractions b.)Bradycardia c.)Decreased level of consciousness d.)Flushed skin A. RATIONALE: Clinical manifestations of respiratory distress include tachypnea, tachycardia, restlessness, dyspnea, intercostal retractions, and cyanosis. 26. An emergency department nurse is caring for a child diagnosed with croup. The nebulizer treatment of choice for a child with croup is: a.)albuterol (Ventolin). b.)metaproterenol (Alupent). c.)racepinephrine. d.)ipratropium (Atrovent). C. RATIONALE: Racemic epinephrine is an adrenergic used to reduce inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma. 27. The nurse administers racemic epinephrine to a child. Ten minutes after administration, the nurse should be alert for: a.)respiratory distress. b.)profound tachycardia. c.)signs of improved oxygenation. d.)diminished cyanosis. A. RATIONALE: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea, restlessness, cyanosis). Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color). 28. An 8-month-old male is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of: a.)increased myelination. b.)intracranial hypotension. c.)cerebral hyperemia. d.)a slightly thicker cranium. C. RATIONALE: Cerebral hyperemia (excess blood in the brain) causes an initial increase in intracranial pressure in the head of an injured child. The brain is less myelinated in a child and more easily injured than an adult brain. Intracranial hypertension not hypotension places the child at greater risk for secondary brain injury. A child's cranium is thinner and more pliable, causing the child to receive a more severe injury. 29. The nurse is assessing an 8-month-old child for signs of neurologic deficit and increased intracranial pressure (ICP). These signs would include: a.)a depressed fontanel. b.)slurred speech. c.)tachycardia. d.)an altered level of consciousness. D. RATIONALE: One sign of neurologic deficit in an 8-month-old child includes a decreased or altered level of consciousness. The fontanel would bulge if he had increased ICP. The child can't speak at this age, but a change in cry may be noted. Bradycardia not tachycardia is a sign of increased ICP. 30. A 12-month-old child fell down the stairs and a basilar skull fracture is suspected. The nurse should look for: a.)cerebrospinal fluid otorrhea. b.)deafness. c.)raccoon eyes. d.)Battle's sign. A. RATIONALE: Basilar skull fracture is a fracture in any bone of the base of the skull frontal, ethmoid, sphenoid, temporal, or occipital. Otorrhea would be observed. Deafness doesn't commonly occur as a result of skull fracture. Raccoon eyes and Battle's sign occur primarily in orbital fractures. 31. A child arrives in the emergency department with a history of transient consciousness and unconsciousness. The nurse should suspect: a.)subdural hematoma. b.)epidural hematoma. c.)subarachnoid hemorrhage. d.)concussion. B. RATIONALE: An initial loss of consciousness followed by transient consciousness leading to unconsciousness is caused by epidural hematoma. Subdural hematoma results in rapid deterioration in level of consciousness. Subarachnoid hemorrhage causes irritability rather than loss of consciousness. Concussion may result in a brief loss of consciousness. 32. A visibly upset mother carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should: a.)take the infant from the mother and offer to help. b.)take the infant and mother to a treatment room. c.)call the resuscitation team and the supervisor. d.)call security and the hospital administration. B. RATIONALE: Taking the infant and mother into a treatment room for assessment provides privacy and a controlled environment. The mother should be allowed to remain with her child if she wishes. If she doesn't want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Security isn't warranted in this situation. 33. While assessing a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should: a.)attempt rescue breaths. b.)attempt to reposition the airway a third time. c.)administer five back blows. d.)attempt to ventilate with a handheld resuscitation bag. C. RATIONALE: The child's airway is blocked despite attempts to establish it. The next step is to clear the airway with back blows and chest thrusts. Breaths can't be administered until the airway is patent. After two attempts to position the airway, the nurse can assume the airway is blocked. The nurse can't ventilate the child with a handheld resuscitation bag until the airway is patent. 34. A nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds that he still isn't breathing and that he has no pulse. The nurse should then: a.)resume CPR beginning with breaths. b.)declare her efforts futile. c.)resume CPR beginning with chest compressions. d.)call for assistance. D. RATIONALE: After 1 minute of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions. 35. A neonate arrives at the emergency department in full cardiopulmonary arrest. Resuscitation efforts fail, and he's pronounced dead. The cause of death is sudden infant death