NUFT 431: Nurs Care of Childbearing Fam Questions With
Complete Solutions
A charge nurse in an emergency department is preparing an in-
service for a group of newly licensed nurses about the
manifestations of child maltreatment. Which of the following
manifestations should the charge nurse include as a potential
indication of physical abuse? correct answers Symmetric burns
of the lower extremities
Rationale: The nurse should include that symmetric burns to the
lower extremities can indicate physical abuse. The patterns are
usually characteristic of the method or object used, such as cigar
or cigarette burns, or burns in the shape of an iron.
A charge nurse is preparing to make a room assignment for a
newly admitted school-age child. Which of the following
considerations is the nurse's priority? correct answers Disease
process
Rationale: The transmission of infectious diseases is the greatest
risk to this child and other children on the unit. Therefore, the
child's disease process is the nurse's priority consideration.
A community health nurse is assessing an 18-month-old toddler
in a community day care. Which of the following findings
should the nurse identify as a potential indication of physical
neglect? correct answers Poor personal hygiene
Rationale: A toddler's poor personal hygiene can be a potential
indication of physical neglect. Because toddlers are still
,dependent on their parents or guardians for help with hygiene
needs, poor personal hygiene can indicate a lack of supervision.
A nurse in a health department is caring for an emancipated
adolescent who has an STI and is unaccompanied by a guardian.
Which of the following actions should the nurse take? correct
answers Have the adolescent sign a consent form for treatment.
Rationale: The nurse should identify that an emancipated minor
can sign the consent form for treatment of an STI or any other
form of medical treatment requiring consent.
A nurse in a pediatric emergency department is planning care for
an adolescent. Based on the information in the adolescent's
medical record, which of the following actions should the nurse
plan to take?
Select all that apply. correct answers Apply supplemental
oxygen
Rationale: According to the medical record and chest x-ray
report, the adolescent could potentially have a pneumothorax.
Also according to the medical record and chest x-ray report, the
adolescent's oxygen saturation level is decreasing, which
indicates hypoxia. Therefore, the nurse should plan to administer
supplemental oxygen.
Prepare for chest tube insertion
Rationale: According to the medical record and chest x-ray
report, the adolescent could potentially have a pneumothorax. A
pneumothorax is the presence of air in the pleural cavity, which
,results in decreased lung expansion. The adolescent could
experience dyspnea, tachypnea, tachycardia, hypoxia, and pain.
This requires prompt intervention by the provider, such as the
placement of a chest tube into the thoracic cavity to remove air
and fluid from the pleural space, if present, allowing the lung to
re-expand.
A nurse in a provider's office is preparing to administer
immunizations to a toddler during a well-child visit. Which of
the following actions should the nurse plan to take? (Click on
the "Exhibit" button for additional information about the client.
There are three tabs that contain separate categories of data.)
Provider PrescriptionsTuberculin skin test (TST)Measles,
mumps, and rubella (MMR) vaccineInactivated influenza
vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine
Graphic Re correct answers Withhold the measles, mumps, and
rubella (MMR) vaccine.
Rationale: The nurse should recognize that an allergy to
neomycin with an anaphylactic reaction is a contraindication for
receiving the MMR vaccine. Clients who have a severe allergy
to eggs or gelatin should not receive this vaccine.
A nurse in an emergency department is caring for a school-age
child who has epiglottitis. Which of the following actions should
the nurse take? correct answers Monitor the child's oxygen
saturation
, Rationale: The nurse should monitor the child's oxygen
saturation level because the child is experiencing acute
respiratory distress and it is necessary to determine if the child is
responding to treatment.
A nurse in an emergency department is caring for a school-age
child who is experiencing an anaphylactic reaction. Which of the
following is the priority action by the nurse? correct answers
Administer epinephrine IM
Rationale: When using the urgent vs. non-urgent approach to
client care, the nurse should determine that the priority action is
administering epinephrine IM to the child. During an
anaphylactic reaction, histamine release causes
bronchoconstriction and vasodilation. This is an emergency
because ultimately it causes decreased blood return to the heart.
A nurse in an emergency department is caring for an adolescent
who has severe abdominal pain due to appendicitis. Which of
the following locations should the nurse identify as McBurney's
point? (You will find "hot spots" to select in the artwork below.
Select only the hot spot that corresponds to your answer.)
correct answers A
Rationale: The nurse should identify this area of the client's
abdomen as McBurney's point. This area of the right lower
quadrant located about two-thirds of the way between the
umbilicus and the client's anterosuperior iliac spine is the area
where a client who has appendicitis is most likely to report pain
and tenderness.
Complete Solutions
A charge nurse in an emergency department is preparing an in-
service for a group of newly licensed nurses about the
manifestations of child maltreatment. Which of the following
manifestations should the charge nurse include as a potential
indication of physical abuse? correct answers Symmetric burns
of the lower extremities
Rationale: The nurse should include that symmetric burns to the
lower extremities can indicate physical abuse. The patterns are
usually characteristic of the method or object used, such as cigar
or cigarette burns, or burns in the shape of an iron.
A charge nurse is preparing to make a room assignment for a
newly admitted school-age child. Which of the following
considerations is the nurse's priority? correct answers Disease
process
Rationale: The transmission of infectious diseases is the greatest
risk to this child and other children on the unit. Therefore, the
child's disease process is the nurse's priority consideration.
A community health nurse is assessing an 18-month-old toddler
in a community day care. Which of the following findings
should the nurse identify as a potential indication of physical
neglect? correct answers Poor personal hygiene
Rationale: A toddler's poor personal hygiene can be a potential
indication of physical neglect. Because toddlers are still
,dependent on their parents or guardians for help with hygiene
needs, poor personal hygiene can indicate a lack of supervision.
A nurse in a health department is caring for an emancipated
adolescent who has an STI and is unaccompanied by a guardian.
Which of the following actions should the nurse take? correct
answers Have the adolescent sign a consent form for treatment.
Rationale: The nurse should identify that an emancipated minor
can sign the consent form for treatment of an STI or any other
form of medical treatment requiring consent.
A nurse in a pediatric emergency department is planning care for
an adolescent. Based on the information in the adolescent's
medical record, which of the following actions should the nurse
plan to take?
Select all that apply. correct answers Apply supplemental
oxygen
Rationale: According to the medical record and chest x-ray
report, the adolescent could potentially have a pneumothorax.
Also according to the medical record and chest x-ray report, the
adolescent's oxygen saturation level is decreasing, which
indicates hypoxia. Therefore, the nurse should plan to administer
supplemental oxygen.
Prepare for chest tube insertion
Rationale: According to the medical record and chest x-ray
report, the adolescent could potentially have a pneumothorax. A
pneumothorax is the presence of air in the pleural cavity, which
,results in decreased lung expansion. The adolescent could
experience dyspnea, tachypnea, tachycardia, hypoxia, and pain.
This requires prompt intervention by the provider, such as the
placement of a chest tube into the thoracic cavity to remove air
and fluid from the pleural space, if present, allowing the lung to
re-expand.
A nurse in a provider's office is preparing to administer
immunizations to a toddler during a well-child visit. Which of
the following actions should the nurse plan to take? (Click on
the "Exhibit" button for additional information about the client.
There are three tabs that contain separate categories of data.)
Provider PrescriptionsTuberculin skin test (TST)Measles,
mumps, and rubella (MMR) vaccineInactivated influenza
vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine
Graphic Re correct answers Withhold the measles, mumps, and
rubella (MMR) vaccine.
Rationale: The nurse should recognize that an allergy to
neomycin with an anaphylactic reaction is a contraindication for
receiving the MMR vaccine. Clients who have a severe allergy
to eggs or gelatin should not receive this vaccine.
A nurse in an emergency department is caring for a school-age
child who has epiglottitis. Which of the following actions should
the nurse take? correct answers Monitor the child's oxygen
saturation
, Rationale: The nurse should monitor the child's oxygen
saturation level because the child is experiencing acute
respiratory distress and it is necessary to determine if the child is
responding to treatment.
A nurse in an emergency department is caring for a school-age
child who is experiencing an anaphylactic reaction. Which of the
following is the priority action by the nurse? correct answers
Administer epinephrine IM
Rationale: When using the urgent vs. non-urgent approach to
client care, the nurse should determine that the priority action is
administering epinephrine IM to the child. During an
anaphylactic reaction, histamine release causes
bronchoconstriction and vasodilation. This is an emergency
because ultimately it causes decreased blood return to the heart.
A nurse in an emergency department is caring for an adolescent
who has severe abdominal pain due to appendicitis. Which of
the following locations should the nurse identify as McBurney's
point? (You will find "hot spots" to select in the artwork below.
Select only the hot spot that corresponds to your answer.)
correct answers A
Rationale: The nurse should identify this area of the client's
abdomen as McBurney's point. This area of the right lower
quadrant located about two-thirds of the way between the
umbilicus and the client's anterosuperior iliac spine is the area
where a client who has appendicitis is most likely to report pain
and tenderness.
