Maternity and Pediatric Nursing 2nd Edition by Susan , Theresa Kyle Test Bank

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Maternity and Pediatric Nursing 2nd Edition by Susan , Theresa Kyle Test Bank

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WITH ANSWERS
Maternity and Pediatric Nursing 2nd Edition by Susan , Theresa Kyle Test Bank

 

Chapter 2

1. The nurse is caring for a 2-week-old girl with a metabolic disorder. Which of the following activities would deviate from the characteristics of family-centered care?
  A) Softening unpleasant information or prognoses
  B) Evaluating and changing the nursing plan of care
  C) Collaborating with the child and family as equals
  D) Showing respect for the familys beliefs and wishes

 

 

2. The nurse is providing home care for a 6-year-old girl with multiple medical challenges. Which of the following activities would be considered the tertiary level of prevention?
  A) Arranging for a physical therapy session
  B) Teaching the parents to administer albuterol
  C) Reminding the parents to give the full course of antibiotics
  D) Giving the DTaP vaccination at proper intervals

 

 

3. The nurse is caring for a 4-year-old boy with Ewings sarcoma who is scheduled for a CT scan tomorrow. Which of the following best reflects therapeutic communication?
  A) Telling him he will get a shot when he wakes up tomorrow morning
  B) Telling him how cool he looks in his baseball cap and pajamas
  C) Using family-familiar words and soft words when possible
  D) Describing what it is like to get a CT scan using words he understands

 

 

4. The nurse is educating the parents of a 7-year-old girl who has just been diagnosed with epilepsy. Which of the following teaching techniques would be most appropriate?
  A) Assessing the parents knowledge of anticonvulsant medications
  B) Demonstrating proper seizure safety procedures
  C) Discussing the surgical procedures for epilepsy
  D) Giving the parents information in small amounts at a time

 

 

5. The nurse is making a home visit to a client who had a cesarean birth 3 days ago. Assessment reveals that she is complaining of intermittent pain, rating it as 8 on a scale of 1 to 10. She states, Im pretty tired. And with this pain, I havent been drinking and eating like I should. The medication helps a bit but not much. My mom has been helping with the baby. Her incision is clean, dry, and intact. Which nursing diagnosis would the nurse identify as the priority for this client?
  A) Impaired skin integrity related to cesarean birth incision
  B) Fatigue related to effects of surgery and caretaking activities
  C) Imbalanced nutrition, less than body requirements, related to poor fluid and food intake
  D) Acute pain related to incision and cesarean birth

 

 

6. When caring for childbearing families from cultures different from ones own, which of the following must the nurse accomplish first?
  A) Adapting to the practices of the familys culture
  B) Determining similarities between both cultures
  C) Assessing personal feelings about that culture
  D) Learning as much as possible about that culture

 

 

7. After teaching a group of students about the changes in health care delivery and funding, which of the following, if identified by the group as a current trend seen in the maternal and child health care settings, would indicate that the teaching was successful?
  A) Increase in ambulatory care
  B) Decrease in family poverty level
  C) Increase in hospitalization of children
  D) Decrease in managed care

 

 

8. The nurse would recommend the use of which supplement as a primary prevention strategy to prevent neural tube defects in pregnant women?
  A) Calcium
  B) Folic acid
  C) Vitamin C
  D) Iron

 

 

9. Which action would the nurse include in a primary prevention program in the community to help reduce the incidence of HIV infection?
  A) Provide treatment for clients who test positive for HIV.
  B) Monitor viral load counts periodically.
  C) Educate clients about how to practice safe sex.
  D) Offer testing for clients who practice unsafe sex.

 

 

10. When assuming the role of discharge planner for a child requiring ventilator support at home, the nurse would do which of the following?
  A) Confer with the school nurse or teacher.
  B) Teach new self-care skills to the child.
  C) Determine if there is a need for backup power.
  D) Discuss coverage with the familys insurance company.

 

 

11. The parents of an 8-year-old with cancer are telling the nurse their problems and successes when caring for their child. In response, the nurse arranges for social services to meet with the parents to help them obtain financial assistance for the equipment and supplies. The nurse is acting in which role?
  A) Educator
  B) Advocate
  C) Case manager
  D) Direct care provider

 

 

12. When explaining community-based nursing versus nursing in the acute care setting to a group of nursing students, the nurse describes the challenges associated with community-based nursing. Which of the following would the nurse include?
  A) Increased time available for education
  B) Improved access to resources
  C) Decision making in isolation
  D) Greater environmental structure

 

 

13. When integrating the principles of family-centered care for a pregnant woman and her family, the nurse would integrate understanding of which of the following?
  A) Childbirth is viewed as a medical event.
  B) Families are unable to make informed choices.
  C) Childbirth results in changes in relationships.
  D) Families require little information to make appropriate decisions.

 

 

14. A 3-year-old boy with encephalitis is scheduled for a lumbar puncture. Which of the following actions by the nurse would demonstrate atraumatic care?
  A) Applying an anesthetic cream before the lumbar puncture
  B) Having his anxious mother stay in the waiting room
  C) Explaining, using medical terms, what will happen
  D) Starting the childs intravenous infusion in his room

 

 

15. The nurse is caring for a 14-year-old girl with multiple health problems. Which of the following activities would best reflect evidence-based practice by the nurse?
  A) Following blood pressure monitoring recommendations
  B) Determining how often vital signs are monitored
  C) Using hospital protocol for ordering diagnostic tests
  D) Deciding on the medication dose

 

 

16. The nurse is providing care to an ill child and his family. Which of the following activities would deviate from the basic principles of case management?
  A) Collaborating with the family throughout the care path
  B) Focusing on both the clients and the familys needs
  C) Coordinating care provided by the interdisciplinary team
  D) Ensuring quality care regardless of the cost

 

 

17. A nursing student is reviewing information about documenting client care and education in the medical record and the purposes that it serves. The student demonstrates a need for additional study when the student identifies which of the following as a reason for documentation?
  A) Serves as a communication tool for the interdisciplinary team
  B) Demonstrates education the family has received if legal matters arise
  C) Permits others access to allow refusal of medical insurance coverage
  D) Verifies meeting client education standards set by the Joint Commission

 

 

18. A pregnant client tells her nurse that she is interested in arranging a home birth. After educating the client on the advantages and disadvantages, which statement would indicate that the client understood the information?
  A) I like having the privacy, but it might be too expensive for me to set up in my home.
  B) I want to have more control, but I am concerned if an emergency would arise.
  C) It is the safest method for giving birth because there are no interferences.
  D) The midwife is trained to resolve any emergency, and she can bring any pain meds.

 

 

19. After teaching a group of students about the different levels of prevention, the instructor determines a need for additional teaching when the students identify which of the following as an activity at the tertiary prevention level in community-based health care?
  A) Teaching women to take folic acid supplements to prevent neural tube defects
  B) Working with women who are victims of domestic violence
  C) Working with clients at an HIV clinic to provide nutritional and CAM therapies
  D) Teaching hypertensive clients to monitor blood pressure

 

 

20. A nursing instructor is describing trends in maternal and newborn health care and the rise in community-based care for childbearing women. The instructor addresses the length of stay for vaginal births during the past decade, citing that which of the following denotes the average stay?
  A) 2448 hours or less
  B) 7296 hours or less
  C) 4872 hours or less
  D) 96120 hours or less

 

 

21. A nurse is educating a client about a care plan. Which of the following would the nurse use to assess the clients learning ability?
  A) Did you graduate from high school; how many years of schooling did you have?
  B) Do you have someone in your family who would understand this information?
  C) Many people have trouble remembering information; is this a problem for you?
  D) Would you prefer that the doctor give you more detailed medical information?

 

 

22. A nurse is developing cultural competence. Which of the following indicates that the nurse is in the process of developing cultural knowledge? Select all that apply.
  A) Examining personal sociocultural heritage
  B) Reviewing personal biases and prejudices
  C) Seeking resources to further understanding of other cultures
  D) Becoming familiar with other culturally diverse lifestyles
  E) Performing a competent cultural assessment
  F) Advocating for social justice to eliminate disparities

 

 

23. A nurse is considering a change in employment from the acute care setting to community-based nursing. The nurse is focusing her job search on ambulatory care settings. Which of the following would the nurse most likely find as a possible setting? Select all that apply.
  A) Urgent care center
  B) Hospice care
  C) Immunization clinic
  D) Physicians office
  E) Day surgery center
  F) Nursing home

 

 

24. A nursing instructor is presenting a class for a group of students about community-based nursing interventions. The instructor determines that additional teaching is needed when the students identify which of the following as a role of the community-based nurse?
  A) Conducting childbirth education classes
  B) Counseling a pregnant teen with anemia
  C) Consulting with a parent of a child who is vomiting
  D) Performing epidemiologic investigations

 

 

25. During class, a nursing student asks, I read an article that was talking about integrative medicine. What is that? Which response by the instructor would be most appropriate?
  A) It refers to the use of complementary and alternative medicine in place of traditional therapies for a condition.
  B) It means that complementary and alternative medicine is used together with conventional therapies to reduce pain or discomfort.
  C) It means that mainstream medical therapies and complementary and alternative therapies are combined based on scientific evidence for being effective.
  D) It refers to situations in which a client and his or her family prefer to use an unproven method of treatment over a proven one.

 

 

26. While a nurse is obtaining a health history, the client tells the nurse that she practices aromatherapy. The nurse interprets this as which of the following?
  A) Use of essential oils to stimulate the sense of smell to balance the mind and body
  B) Application of pressure to specific points to allow self-healing
  C) Use of deep massage of areas on the foot or hand to rebalance body parts
  D) Participation in chanting and praying to promote healing

 

 

27. A pregnant woman asks the nurse about giving birth in a birthing center. She says, Im thinking about using one but Im not sure. Which of the following would the nurse need to integrate into the explanation about this birth setting? Select all that apply.
  A) An alternative for women who are uncomfortable with a home birth
  B) The longer length of stay needed when compared to hospital births
  C) Focus on supporting women through labor instead of managing labor
  D) View of labor and birth as a normal process requiring no intervention
  E) Care provided primarily by obstetricians with midwives as backup care

 

 

28. A nurse is preparing a teaching plan for a woman who is pregnant for the first time. Which of the following would the nurse incorporate into the teaching plan to foster the clients learning? Select all that apply.
  A) Teach survival skills first.
  B) Use simple, nonmedical language.
  C) Refrain from using a hands-on approach.
  D) Avoid repeating information.
  E) Use visual materials such as photos and videos.

 

 

29. A group of nurses is engaged in developing cultural competence. The students demonstrate achievement of this goal after developing which of the following?
  A) Cultural knowledge
  B) Cultural skills
  C) Cultural encounter
  D) Cultural awareness

 

 

30. The nurse who is scheduled to work in a clinic in a Hispanic neighborhood takes time to research Hispanic cultural norms to better provide culturally competent care to people at work. This behavior is an example of which of the following cultural components?
  A) Cultural awareness
  B) Cultural knowledge
  C) Cultural skills
  D) Cultural encounter

 

 

 

Answer Key

 

1. A
2. A
3. D
4. D
5. D
6. C
7. A
8. B
9. C
10. C
11. B
12. C
13. C
14. A
15. A
16. D
17. C
18. B
19. A
20. A
21. C
22. C, D
23. A, D, E
24. D
25. C
26. A
27. A, C, D
28. A, B, E
29. C
30. B

 

Chapter 16

1. A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute. Which of these actions should the nurse take?
  A) Document the finding, as it is a normal finding at this time.
  B) Contact the physician, as it indicates early DIC.
  C) Contact the physician, as it is a first sign of postpartum eclampsia.
  D) Obtain an order for a CBC, as it suggests postpartum anemia.

 

 

2. To decrease the pain associated with an episiotomy immediately after birth, which action by the nurse would be most appropriate?
  A) Offer warm blankets.
  B) Encourage the woman to void.
  C) Apply an ice pack to the site.
  D) Offer a warm sitz bath.

 

 

3. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following medications to be ordered?
  A) Ferrous sulfate (Feosol)
  B) Methylergonovine (Methergine)
  C) Docusate (Colace)
  D) Bromocriptine (Parlodel)

 

 

4. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?
  A) You have your daddys eyes.
  B) He looks like a frog to me.
  C) Where did you get all that hair?
  D) He seems to sleep a lot.

 

 

5. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?
  A) Presence of lochia serosa
  B) Frequent scant voiding
  C) Fundus firm, below umbilicus
  D) Milk filling in both breasts

 

 

6. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort?
  A) Express some milk from your breasts every so often to relieve the distention.
  B) Remove your bra to relieve the pressure on your sensitive nipples and breasts.
  C) Apply ice packs to your breasts to reduce the amount of milk being produced.
  D) Take several warm showers daily to stimulate the milk let-down reflex.

 

 

7. The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from:
  A) Becoming Rh positive
  B) Developing Rh sensitivity
  C) Developing AB antigens in her blood
  D) Becoming pregnant with an Rh-positive fetus

 

 

8. Which of the following factors in a clients history would alert the nurse to an increased risk for postpartum hemorrhage?
  A) Multiparity, age of mother, operative delivery
  B) Size of placenta, small baby, operative delivery
  C) Uterine atony, placenta previa, operative procedures
  D) Prematurity, infection, length of labor

 

 

9. After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following?
  A) Reciprocity
  B) Engrossment
  C) Bonding
  D) Attachment

 

 

10. A nurse is working as part of a committee to establish policies to promote bonding and attachment. Which practice would be least effective in achieving this goal?
  A) Allowing unlimited visiting hours on maternity units
  B) Offering round-the-clock nursery care for all infants
  C) Promoting rooming-in
  D) Encouraging infant contact immediately after birth

 

 

11. When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure?
  A) Early parentinfant contact following birth
  B) Expert medical care for the labor and birth
  C) Good nutrition and prenatal care during pregnancy
  D) Grandparent involvement in infant care after birth

 

 

12. A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following would be least effective in helping to stimulate voiding?
  A) Pouring warm water over her perineal area
  B) Having her hear the sound of water running nearby
  C) Placing her hand in a basin of cool water
  D) Standing her in the shower with the warm water on

 

 

13. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following would be a priority?
  A) Placing the call light within her reach
  B) Teaching her how the sitz bath works
  C) Telling her to use the sitz bath for 30 minutes
  D) Cleaning the perineum with the peri-bottle

 

 

14. A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which of the following? (Select all that apply.)
  A) History of diabetes
  B) Labor of 12 hours
  C) Rupture of membranes for 16 hours
  D) Hemoglobin level 10 mg/dL
  E) Placenta requiring manual extraction

 

 

15. A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?
  A) Lochia rubra with a fleshy odor
  B) Respiratory rate of 16 breaths per minute
  C) Temperature of 101 F
  D) Pain rating of 2 on a scale from 0 to 10

 

 

16. The nurse is assessing a postpartum clients lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which of the following?
  A) Scant
  B) Light
  C) Moderate
  D) Large

 

 

17. When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following?
  A) Superficial structures above the muscle
  B) Through the perineal muscles
  C) Through the anal sphincter muscle
  D) Through the anterior rectal wall

 

 

18. A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which of the following would the nurse be observing?
  A) Mother placing the newborn next to bare breast.
  B) Mother making eye-to-eye contact with the newborn
  C) Mother gently stroking the newborns face
  D) Mother holding the newborn upright at the shoulder

 

 

19. After teaching a group of students about risk factors associated with postpartum hemorrhage, the instructor determines that the teaching was successful when the students identify which of the following as a risk factor? (Select all that apply.)
  A) Prolonged labor
  B) Placenta previa
  C) Null parity
  D) Hydramnios
  E) Labor augmentation

 

 

20. A postpartum woman who is breast-feeding tells the nurse that she is experiencing nipple pain. Which of the following would be least appropriate for the nurse to suggest?
  A) Use of a mild analgesic about 1 hour before breast-feeding
  B) Application of expressed breast milk to the nipples
  C) Application of glycerin-based gel to the nipples
  D) Reinstruction about proper latching-on technique

 

 

21. A nurse is developing a teaching plan for a postpartum woman who is breast-feeding about sexuality and contraception. Which of the following would the nurse most likely include? (Select all that apply.)
  A) Resumption of sexual intercourse about two weeks after delivery
  B) Possible experience of fluctuations in sexual interest
  C) Use of a water-based lubricant to ease vaginal discomfort
  D) Use of combined hormonal contraceptives for the first three weeks
  E) Possibility of increased breast sensitivity during sexual activity

 

 

22. After teaching a postpartum woman about breast-feeding, the nurse determines that the teaching was successful when the woman states which of the following?
  A) I should notice a decrease in abdominal cramping during breast-feeding.
  B) I should wash my hands before starting to breast-feed.
  C) The baby can be awake or sleepy when I start to feed him.
  D) The babys mouth will open up once I put him to my breast.

 

 

23. A postpartum woman who is bottle-feeding her newborn asks the nurse, About how much should my newborn drink at each feeding? The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding?
  A) 1 to 2 ounces
  B) 2 to 4 ounces
  C) 4 to 6 ounces
  D) 6 to 8 ounces

 

 

24. A nurse is observing a postpartum woman and her partner interact with their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which of the following? (Select all that apply.)
  A) Frequently ask for the newborn to be taken from the room
  B) Identify common features between themselves and the newborn
  C) Refer to the newborn as having a monkey-face
  D) Make direct eye contact with the newborn
  E) Refrain from checking out the newborns features

 

 

25. After reviewing information about postpartum blues, a group of students demonstrate understanding when they state which of the following about this condition?
  A) Postpartum blues is a long-term emotional disturbance.
  B) Sleep usually helps to resolve the blues.
  C) The mother loses contact with reality.
  D) Extended psychotherapy is needed for treatment.

 

 

 

Answer Key

 

1. A
2. C
3. C
4. B
5. B
6. C
7. B
8. C
9. C
10. B
11. A
12. C
13. A
14. A, D, E
15. C
16. B
17. C
18. B
19. B, D, E
20. A
21. B, C, E
22. B
23. B
24. B, D
25. A

 

Chapter 32

1. The nurse is conducting a health history for a 9-year-old child with stomach pains. Which of the following is a recommended guideline when approaching the child for information?
  A) Wear a white examination coat when conducting the interview.
  B) Allow the child to control the pace and order of the health history.
  C) Use quick deliberate gestures to get your point across.
  D) Do not make physical contact with the child during the interview.

 

 

2. For which of the following children would the nurse conduct an immediate comprehensive health history?
  A) A child who is brought to the emergency room with lacerations
  B) A child who is a new client in a pediatric office
  C) A child who is a routine client and presents with signs of a sinus infection
  D) A child whose condition is improving

 

 

3. The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which of the following questions would be most likely to elicit valuable information?
  A) Do you like your new school?
  B) Are you happy with your teacher?
  C) Do you enjoy reading a book?
  D) What are your new classmates like?

 

 

4. The nurse performing a health history on a child asks the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question?
  A) Endocrine
  B) Genitourinary
  C) Hematologic
  D) Neurologic

 

 

5. The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which of the following topics might the nurse include? Select all answers that apply.
  A) The childs toileting habits
  B) Use of car seats and other safety measures
  C) Problems with growth and development
  D) Prenatal and perinatal history
  E) The childs race and ethnicity
  F) Use of supplements and vitamins

 

 

6. The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?
  A) The child
  B) The parents
  C) Chief complaint
  D) Developmental age

 

 

7. The nurse is teaching the student nurse how to perform a physical assessment based on the childs developmental stage. Which of the following statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child?
  A) Keep up a running dialogue with the caregiver, explaining each step as you do it.
  B) Include the child in all parts of the examination; speak to the caregiver before and after the examination.
  C) Speak to the child using mature language and appeal to his or her desire for self-care.
  D) Address the child by name; speak to the caregiver and do the most invasive parts last.

 

 

8. Which of the following would be least effective in gaining the cooperation of a toddler during a physical examination?
  A) Tell the child that another child the same age wasnt afraid.
  B) Allow the child to touch and hold the equipment when possible.
  C) Permit the child to sit on the parents lap during the examination.
  D) Offer immediate praise for holding still or doing what was asked.

 

 

9. The nurse is performing a physical examination on a sleeping newborn. Which of the following body systems should the nurse examine last?
  A) Heart
  B) Abdomen
  C) Lungs
  D) Throat

 

 

10. The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?
  A) Inspection, palpation, percussion, auscultation
  B) Inspection, percussion, palpation, auscultation
  C) Palpation, percussion, inspection, auscultation
  D) Inspection, auscultation, palpation, percussion

 

 

11. The nurse is examining the posture of a male toddler and notes the condition lordosis. What would be the appropriate reaction of the nurse to this finding?
  A) Explain that the child will need a back brace.
  B) Refer the toddler to a physical therapist.
  C) Do nothing; this is a normal condition for toddlers.
  D) Notify the primary care physician about the condition.

 

 

12. The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child?
  A) Oral thermometer
  B) Axillary method
  C) Temporal scanning
  D) Rectal route

 

 

13. The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In order to get an accurate reading, what does the nurse need to do?
  A) Pull the earlobe back and down
  B) Direct the infrared sensor at the tympanic membrane
  C) Pull the earlobe down and forward
  D) Remove any visible cerumen from inside the ear canal

 

 

14. A mother brings her 31/2-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this childs temperature, which method would be least appropriate?
  A) Oral
  B) Tympanic
  C) Rectal
  D) Axillary

 

 

15. The nurse is assessing heart rate for children on the pediatric ward. Which of the following is a normal finding based on developmental age?
  A) An infants rate is 90 bpm.
  B) A toddlers rate is 150 bpm.
  C) A preschoolers rate is 130 bpm.
  D) A school-age childs rate is 50 bpm.

 

 

16. The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which of the following sites to obtain an accurate assessment?
  A) Radial pulse
  B) Brachial pulse
  C) Apical pulse at the third or fourth intercostal space
  D) Apical pulse at the fourth or fifth intercostal space at the midclavicular line

 

 

17. The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the childs heart rate will be in which of the following ranges?
  A) 80 to 150 bpm
  B) 70 to 120 bpm
  C) 65 to 110 bpm
  D) 60 to 100 bpm

 

 

18. The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate?
  A) Radial
  B) Brachial
  C) Pedal
  D) Femoral

 

 

19. While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as which of the following?
  A) Grade 1
  B) Grade 2
  C) Grade 3
  D) Grade 4

 

 

20. The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
  A) Your daughter has acrocy

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