Maternity Exam 3

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A. "As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities." a. Rationale This response defers to another authority figure, rather than providing the parent with an answer. A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply.) A. Measles, mumps rubella (MMR) B. Diphtheria, tetanus and acellular pertussis (DTaP) C. Varicella (VAR) D. Rotavirus (RV) E. Human papillomavirus (HPV4) A. Measles, mumps rubella (MMR) C. Varicella (VAR) A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen A. At the end Rationale: When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows. A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book A. Large building blocks Rationale: Large building blocks are age-appropriate toys for a 12-month-old toddler. A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? A. An anxiety reaction B. Regression C. Resentment toward the mother D. Developing autonomy A. An anxiety reaction Rationale: Hospitalization is stressful, regardless of the age of the client. However, for an 18- month-old toddler, separation from parents adds to that stress. The toddler's behavior indicates an anxiety reaction to the stress of hospitalization. Separation anxiety initially causes demonstrations of protest. Remaining sad and quiet when a parent leaves indicates the second response to separation anxiety, which is despair. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support A. Closed posterior fontanel Rationale: The infant's posterior fontanel should close by about 8 weeks of age. A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? A. Set of building blocks B. Toy hammer and pounding board C. Picture book about hospitals D. Stuffed animal B. Toy hammer and pounding board Rationale: A toy hammer and pounding board helps the child to express the anger and frustration he feels about the parent leaving but lacks the verbal ability to express. We have an expert-written solution to this problem! A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? A. Restrain the child physically. B. Ignore the temper tantrums. C. Tell the child that temper tantrums are not acceptable. D. Distract the child by offering to play a game. B. Ignore the temper tantrums. Rationale: Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly. A nurse is assessing a child in an area struck by an earthquake. The child, who is crying, walks well, can state their first name, and repeatedly says "All done" and "Go bye-bye now" during the assessment. The child has 20 deciduous teeth and their anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old? A. 12 B. 18 C. 24 D. 30 D. 30 Rationale: The nurse should estimate that the child is at least 30 months old because the child has completed their primary dentition (20 deciduous teeth), which occurs by 30 months of age. In addition, the nurse should recognize that the child is at least 18 months old because the anterior fontanel is closed and should recognize that the child is at least 24 months old because the child speaks in two- and three-word A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? A. Carotid artery B. Apex of the heart C. Brachial artery D. Radial artery B. Apex of the heart Rationale: The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart. A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take? A. Assess the rest of the child's body for a rash. B. Refer the family to child protective services. C. Question the parents about how the marks occurred on the child's cheeks. D. Obtain the child's temperature. A. Assess the rest of the child's body for a rash. Rationale: Fifth disease presents with erythema on the face, which resembles slap marks. The nurse should further assess the child's body and extremities to determine if the child has Fifth disease. A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names? A. Chickenpox B. Whooping cough C. Mumps D. Fifth disease B. Whooping cough Rationale: Whooping cough is the common name for pertussis A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? A. Imaginary playmates B. Erikson's stage of initiative versus guilt C. Demonstrations of sexual curiosity D. Negative behaviors characterized by the need for autonomy D. Negative behaviors characterized by the need for autonomy Rationale: Assertion of autonomy is seen in toddlers as they begin their language and social development. A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Management of tantrums B. How to establish trust C. How to encourage cooperative play D. Dental care E. Need for increased caloric intake A. Management of tantrums D. Dental care A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? A. 3 years B. 4 years C. 5 years D. 6 years A. 3 years Rationale: At age 3, children can typically ascend stairs using alternating feet but still descend by placing both feet on each step. A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months B. 6 months Rationale: Birth weight typically doubles by 6 months of age. A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures. A. Have a parent stay with the child during procedures. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. A nurse is teaching a parent of a 2-year-old child about safe food choices. Which of the following foods should the nurse recommend? A. Grapes B. Bananas C. Celery D. Raw carrots B. Bananas Rationale: Bananas are a safe choice for a 2-year-old child because they are easy to chew and swallow. A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings? A. Place the infant in a prone position. B. Place the infant in an infant seat. C. Place the infant on his left side. D. Place the infant on his right side. B. Place the infant in an infant seat. Rationale: An infant seat provides elevation and decreases the risk of aspiration. A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. C. Install accordion style gates. D. Set the water heater at 65.6° C (150° F). E. Fit the mattress so that it is snug against the sides of the crib. A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. E. Fit the mattress so that it is snug against the sides of the crib. . A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which of the following findings should the nurse expect? A. Skips and hops on one foot B. Has a vocabulary of 1,500 words C. Walks backwards heel to toe D. Stands on one foot for a few seconds D. Stands on one foot for a few seconds Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off of the bottom step. A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.) A. Weigh the infant in a diaper. B. Use a stadiometer to measure the infant. C. Place a disposable covering on the scale. D. Measure the infant from crown of the head to the heels of feet. E. Balance the scale to 0 prior to use. C. Place a disposable covering on the scale. D. Measure the infant from crown of the head to the heels of feet. E. Balance the scale to 0 prior to use. A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first? A. Ask the toddler what caused the bruises. B. Notify the provider. C. Ask the parents what caused the bruises. D. Notify social services. C. Ask the parents what caused the bruises. Rationale: The nurse should gather additional data. Inconsistencies between the history and the injury are the most important criterion on which to base the decision to report suspected abuse. A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide? A. "This technique opens the ear canal, allowing medication to reach the inner ear region." B. "When this technique is used, the toddler experiences less pain." C. "This is the safest and easiest way to administer this medication." D. "When this technique is used, the medication will not run out of the ear." C. "This technique opens the ear canal, allowing medication to reach the inner ear region." Rationale: For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ear. A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot stand upright without support. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob. B. The toddler cannot stand upright without support. Rationale: The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay. A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." B. "My child has recently lost both front top teeth." C. "My child often cheats when we play board games." D. "Sometimes my child acts bossy with his friends." A. "The teacher says my child has to squint to see the board." Answer Rationale: Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching? A. "I only need to catheterize myself twice every day." B. "I carry a water bottle with me because I drink a lot of water." C. "I use a suppository every night to have a bowel movement." D. "I do wheelchair exercises while watching TV." A. "I only need to catheterize myself twice every day." Answer Rationale: The client has paralysis from the level of the defect down. In the majority of cases, this condition affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent emptying of the bladder can result in stasis and urinary tract infections. A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Inspection B. Superficial palpation C. Deep palpation D. Auscultation A. Inspection D. Auscultation B. Superficial palpation C. Deep palpation A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make? A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." B. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." C. "Your child did not seem upset, so I wouldn't worry about it if I were you." D. "Why does it bother you that your child has wet the bed?" A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." Answer Rationale: A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. The nurse should reassure the parents that regression is an expected behavior in children who are hospitalized and that her child will regain bladder control when she is feeling better.