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Pediatric Nursing An Introductory Text 10th Edition By Price -Test Bank
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Pediatric Nursing An Introductory Text 10th Edition By Price -Test Bank
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Pediatric Nursing An Introductory Text 10th Edition By Price -Test Bank
Price: Pediatric Nursing, 10th Edition
Test Bank
Chapter 6: Disorders of the Newborn
MULTIPLE CHOICE
- Congenital malformations of the infant may include:
| a. | Abnormal structure |
| b. | Abnormal function |
| c. | Abnormal metabolism |
| d. | All of the above |
ANS: D
All of the abnormalities listed are potential congenital malformations.
DIF: Cognitive Level: Knowledge REF: Page 85 OBJ: 2
TOP: Malformations Present at Birth KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A neonate is diagnosed with having an inborn error of metabolism. The nurse knows which of the following disorders could be caused by this problem:
| a. | A missing limb |
| b. | Congenital hip dysplasia |
| c. | Cystic fibrosis |
| d. | A malformed fist |
ANS: C
The other answers are all abnormalities of structure. Cystic fibrosis is the only metabolic error listed.
DIF: Cognitive Level: Analysis REF: Page 85 OBJ: 2
TOP: Malformations Present at Birth KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A nurse is assessing the family dynamics of a neonate that is HIV-positive. The nurse would conclude that the family is adapting to the needs of the infant if the nurse observed the family:
| a. | Verbalizing their feelings about their role in the infants care |
| b. | Allowing the staff to provide total care of their infant |
| c. | Denying the need of help from external resources |
| d. | Being withdrawn and minimizing interaction with the infant |
ANS: A
The other selections are all signs that the family has not adapted and will need further intervention.
DIF: Cognitive Level: Analysis REF: Page 88 OBJ: 3
TOP: The Child with AIDS KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity
- A neonate has been diagnosed with infectious diarrhea. The nurse understands that this illness:
| a. | Is not serious and is easily treated |
| b. | Is not common outside the United States |
| c. | Is highly contagious and may be fatal |
| d. | Is usually caused by a specific organism and is easy to identify |
ANS: C
Infectious diarrhea is serious and may be fatal. The organism is difficult to identify and may remain undetected. Diarrhea is a major problem with infants and young children worldwide.
DIF: Cognitive Level: Application REF: Page 89 OBJ: 4
TOP: Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
- The neonate will require careful nursing care. Which of the following interventions would the nurse expect to carry out?
| a. | Daily weights to determine the amount of water loss |
| b. | Estimate the intake and output |
| c. | Record the volume of IV fluids administered according to the infusion pump readout |
| d. | Apply ointment to buttocks after cleaning and while skin is still damp |
ANS: A
Daily weights are performed to estimate water loss. Strict I & O is assessed, not an estimated amount. The nurse does not rely solely on the infusion pump, but also observes the IV fluid levels. Pumps can make mistakes. Ointment is applied to dry skin, not moist.
DIF: Cognitive Level: Analysis REF: Page 90 OBJ: 4
TOP: Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A mother is caring for her child with diarrhea at home. She calls the nurse at the clinic and asks for diet instructions. The nurse would advise:
| a. | BRAT diet |
| b. | Ginger ale |
| c. | Broth |
| d. | Oral rehydration therapy with Pedialyte or similar product |
ANS: D
The BRAT diet has little nutritional value. Ginger ale is low in electrolytes and high in glucose. Broth has a high sodium content, which is contraindicated with diarrhea. Oral rehydration therapy provides the child with electrolytes and fluid, helping to restore balance.
DIF: Cognitive Level: Application REF: Page 90 OBJ: 4
TOP: Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse in the newborn nursery understands the importance of preventing the transmission of infection. Which of the following actions will help minimize the spread of organisms?
| a. | Contaminated nipples are washed carefully |
| b. | Clothing or blankets that touch the floor are dusted off before using |
| c. | Handwashing is encouraged |
| d. | Formula is prepared with the undivided attention of the staff |
ANS: D
Contaminated nipples are replaced, not washed. Clothing that touches the floor is removed for washing. Handwashing is required, not encouraged. The formula must be prepared with undivided attention to prevent or identify contamination.
DIF: Cognitive Level: Analysis REF: Page 90 OBJ: 5
TOP: Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A neonate has been diagnosed with tuberculosis (TB). The nurse knows that an appropriate intervention to minimize the spread of infection would be:
| a. | Place the infant in respiratory isolation |
| b. | Instruct staff to avert their face while assessing respirations |
| c. | Encourage as many family members as possible to come visit |
| d. | Keep the child in the hospital until TB is resolved |
ANS: A
The neonate with TB should be placed in respiratory isolation. Averting the face while assessing respirations is not an effective method of infection control. Visitors should be kept to a minimum. The child cannot be hospitalized until resolution because this may take many months.
DIF: Cognitive Level: Synthesis REF: Page 91 OBJ: 6
TOP: Tuberculosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
- A neonate with TB is being discharged from the unit. Medications are taught during discharge teaching. Which statement by the caregiver would indicate understanding of the TB medications?
| a. | INH and rifampin should be given until the symptoms resolve |
| b. | INH will be given alone for 2 months |
| c. | INH and rifampin will be given for 6 months |
| d. | Pyrazinamide will be added at the end of 6 months if the INH and rifampin are ineffective |
ANS: C
INH and rifampin are given for a 6-month period, regardless if symptoms have resolved. Pyrazinamide is added for the first 2 months. Streptomycin or ethambutol is added at the end of 6 months if the patient has a resistant strain of TB.
DIF: Cognitive Level: Application REF: Page 91 OBJ: 6
TOP: Tuberculosis KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
- A neonate has a positive skin test for TB. The baby has no obvious symptoms of disease. The nurse explains to the parents that:
| a. | The baby had a false positive |
| b. | The baby does not need treatment |
| c. | They should notify the doctor if the baby develops a cough |
| d. | The baby will be treated with medication for 9 months |
ANS: D
The nurse would not assume that the test is a false positive. The baby will be treated with medication (usually INH) for 9 months.
DIF: Cognitive Level: Application REF: Page 91 OBJ: 6
TOP: Tuberculosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
- A neonate is born with a cleft lip. The baby is scheduled for a repair in a few weeks. The parents are concerned about how to feed their baby. The nurse explains that:
| a. | The baby can be fed only by a bottle |
| b. | The baby can be fed only by breastfeeding |
| c. | Special nipples are used to help the baby feed |
| d. | The baby will be fed parentally or by gavage until the surgery |
ANS: C
The baby can be fed by bottle or by breastfeeding. Special nipples are used to help the baby feed.
DIF: Cognitive Level: Analysis REF: Page 101 OBJ: 9
TOP: Cleft Lip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse will carry out which of the following interventions while feeding this infant:
| a. | Hold the infant upright to prevent regurgitation |
| b. | Place nipple under the tongue |
| c. | Allow infant to feed as long as needed |
| d. | Avoid giving water so infant will take full feeding |
ANS: A
Infant is held upright to prevent regurgitation. The nipple is placed on top of the tongue. Feedings should be limited to 30 minutes to avoid fatigue. The feeding should be followed with sterile water to clean trapped food in the cleft.
DIF: Cognitive Level: Application REF: Page 102 OBJ: 10
TOP: Cleft Lip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A neonate is diagnosed with a tracheoesophageal fistula. The infant is having difficulty managing secretions. An appropriate intervention would be to:
| a. | Position infant supine to reduce pressure on the chest |
| b. | Maintain infant in an upright position to reduce risk of aspiration |
| c. | Provide small, frequent feedings to reduce oxygen demand |
| d. | Monitor respiratory status once each shift |
ANS: B
The infant needs to be placed in an upright position to prevent aspiration and promote respirations. The infant will be NPO. Respiratory status should be monitored closely, not only once per shift.
DIF: Cognitive Level: Analysis REF: Page 105 OBJ: 11
TOP: Esophageal Atresia and Tracheoesophageal Fistula Atresia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- An infant is delivered and diagnosed with an omphalocele. The nurse develops a plan of care for this infant. The nurse understands that an omphalocele:
| a. | Is a small defect involving the bowel |
| b. | Is a large defect involving bowel, liver, spleen, bladder, uterus, or ovaries |
| c. | Should be ruptured as soon as possible |
| d. | Does not require surgical repair |
ANS: B
The nurse should understand that an omphalocele is a large defect involving many of the abdominal organs. It should not be ruptured, and great care is taken to maintain its integrity until surgical repair can be accomplished.
DIF: Cognitive Level: Application REF: Page 104 OBJ: 13
TOP: Gastroschisis and Omphalocele KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- An infant has had an omphalocele reduced. During the postoperative period, the infant is at risk for which of the following complications:
| a. | Infection |
| b. | Hypothermia |
| c. | Dehydration |
| d. | All of the above |
ANS: A
All of the above complications are possible. In addition, the baby is also at risk for shock and reduced circulation of the lower extremities.
DIF: Cognitive Level: Application REF: Page 104 OBJ: 12
TOP: Gastroschisis and Omphalocele KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- An infant has been placed in a body cast. An appropriate intervention would be to:
| a. | Tuck plastic wrap or cloth tape around the edges of the cast at the leg openings |
| b. | Change the diaper less frequently to decrease movement |
| c. | Instruct parents that they cannot hold the infant until the cast is removed |
| d. | Lift the legs simultaneously by using the cross bars in the cast. |
ANS: A
The edges of the leg openings can be covered with plastic wrap or tape. The diaper should be changed more frequently to keep the cast clean. The parents should be allowed to hold their baby. The baby and parents need this interaction. The parent should wait until the cast is dry. The legs should be lifted simultaneously, but never by the cross bars of the cast.
DIF: Cognitive Level: Analysis REF: Page 109 OBJ: 13
TOP: Turning and Positioning a Child in a Body Cast
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nursing care of an infant with spina bifida would include which of the following interventions:
| a. | Placing moist, sterile dressings on the sac |
| b. | Observing the sac for leakage |
| c. | Protection of the sac |
| d. | All of the above |
ANS: D
The nurse will do all of the above to protect the sac.
DIF: Cognitive Level: Application REF: Page 114 OBJ: 15
TOP: Myelodysplasia/Spina Bifida KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- Following surgery to repair spina bifida, the nurse would immediately report which of the following symptoms to the nurse in charge:
| a. | Vomiting |
| b. | Incontinence of urine |
| c. | Dribbling of feces |
| d. | Lack of sensation below the spinal lesion |
ANS: A
Vomiting is a sign of increased intracranial pressure and should be reported immediately. The other symptoms are normal for a patient with spina bifida.
DIF: Cognitive Level: Application REF: Page 114 OBJ: 16
TOP: Myelodysplasia/Spina Bifida KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- The nurse is caring for an infant with a congenital heart defect. The nurse should carry out which of the following interventions:
| a. | Provide frequent bedding changes to reduce risk of infection |
| b. | Ensure that the child is maintained on a strict feeding schedule to maintain caloric intake |
| c. | The infant should be fed with a nipple that has a small hole to prevent aspiration |
| d. | The nurse should organize care of the infant to avoid disturbing the infant |
ANS: D
The nurse needs to disturb the baby as little as possible to conserve energy. The child is fed early if awake early and is fed late if sleeping. If caloric intake becomes a problem, IV or gavage feedings are used. The infant is fed with a nipple that allows sucking with minimum effort, so a nipple with a large hole is used.
DIF: Cognitive Level: Synthesis REF: Page 99 OBJ: 7
TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- An infant has had surgery to correct a congenital heart defect. The physician placed a chest tube in the infant. The nurse should carry out which of the following interventions to maintain the integrity of the tubes:
| a. | Maintain the bottles above the level of the chest |
| b. | Keep rubber-shod Kelly clamps available at all times |
| c. | Have a sterile gauze dressing available to place over the site if the tube is removed |
| d. | Do not allow the infant to be transported until the tubes are removed |
ANS: B
The drainage bottles must be kept below the level of the chest to prevent the backflow of drainage. The rubberized Kelly clamps must be available at all times in case the tube breaks. A sterile petroleum gauze is also always available to place over the site when the tubes are removed. The infant can be transported, but with care to maintain integrity of the suction.
DIF: Cognitive Level: Analysis REF: Page 100 OBJ: 8
TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MATCHING
Match the following congenital heart defects with their definitions:
| a. | Atrial ductus arteriosis |
| b. | Ventricular septal defect |
| c. | Tetralogy of Fallot |
| d. | Coarctation of the aorta |
- Opening between the right and left ventricles of the heart
- Constriction or narrowing of the aortic arch or the descending aorta
- Abnormal opening between the right and left atria
- Four defects: narrowing of the pulmonary artery, hypertrophy of the right ventricle, dextroposition of the aorta, and ventricular septal defect
- ANS: B DIF: Cognitive Level: Knowledge REF: Pages 93-94
OBJ: 2 TOP: Key Terms KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- ANS: D DIF: Cognitive Level: Knowledge REF: Pages 93-94
OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- ANS: A DIF: Cognitive Level: Knowledge REF: Pages 93-94
OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- ANS: C DIF: Cognitive Level: Knowledge REF: Pages 93-94
OBJ: 2 TOP: Key Terms KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Match the following terms with their definitions:
| a. | Choroid plexus |
| b. | Transillumination |
| c. | Tenesmus |
| d. | Tuberculosis |
- Inspection of a cavity or organ by means of a light passed through its walls
- Infection caused by mycobacterium tuberculosis
- Primary site for formation of cerebral spinal fluid
- Involuntary straining to empty the bowel
- ANS: B DIF: Cognitive Level: Knowledge REF: Page 88
OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- ANS: D DIF: Cognitive Level: Knowledge REF: Page 88
OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- ANS: A DIF: Cognitive Level: Knowledge REF: Page 88
OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- ANS: C DIF: Cognitive Level: Knowledge REF: Page 88
OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Match the following terms and their descriptions:
| a. | Thrush |
| b. | Functional diarrhea |
| c. | Diarrhea |
| d. | Infectious diarrhea |
- Excessive loss of water and electrolytes in stools
- Infection of mucous membranes of the mouth caused by Candida
- Caused by an infection
- Caused by organic disease
- ANS: B DIF: Cognitive Level: Knowledge REF: Page 89
OBJ: 2 TOP: Infections KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- ANS: A DIF: Cognitive Level: Knowledge REF: Page 89
OBJ: 2 TOP: Infections KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- ANS: D DIF: Cognitive Level: Knowledge REF: Page 89
OBJ: 2 TOP: Infections KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- ANS: C DIF: Cognitive Level: Knowledge REF: Page 89
OBJ: 2 TOP: Infections KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
SHORT ANSWER
- List three goals of nursing care for neonates with congenital heart disease.
ANS:
Reduce work of the heart
Improve respiration
Maintain proper nutrition
Prevent infection
Reduce anxiety of the patient
Support and instruct parents
DIF: Cognitive Level: Comprehension REF: Page 99 OBJ: 7
TOP: Congenital Heart Disease KEY: Nursing Process Step: Goals
MSC: NCLEX: Physiological Integrity
- A structural, functional, or body chemistry abnormality that exists at birth that causes physical or mental disability or death is called a:
ANS:
Birth defect
DIF: Cognitive Level: Knowledge REF: Page 88 OBJ: 2
TOP: Malformations Present at Birth KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Price: Pediatric Nursing, 10th Edition
Test Bank
Chapter 7: The Infant
MULTIPLE CHOICE
- The nurse is assessing the neurological status of an 8-month-old infant. Which reflexes would the nurse expect to find intact?
| a. | Grasp |
| b. | Extrusion |
| c. | Pincer |
| d. | Parachute |
ANS: D
The grasp and extrusion reflexes disappear at around 3 months. The pincer reflex is not well established until 12 months.
DIF: Cognitive Level: Application REF: Pages 119, 127, 131
OBJ: 8 TOP: General Characteristics and Development
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
- A parent discusses her concerns about her babys nutritional status. She has tried to feed her 3-month-old infant cereal, but reports that the baby pushed the food back out of the mouth. The nurse explains:
| a. | Her infant is demonstrating a developmental delay |
| b. | Her infant is allergic to cereal |
| c. | Her infant is too young for cereal and is displaying the extrusion reflex |
| d. | Her infant is demonstrating the rooting reflex and needs a neurological referral |
ANS: C
Infants should not be introduced to solid food until age 4 to 6 months. The baby is demonstrating an intact extrusion reflex, which is developmentally appropriate for an infant this age. No referral is needed.
DIF: Cognitive Level: Synthesis REF: Page 131 OBJ: 2
TOP: Nutritional Counseling for Parents KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
- The nurse is assessing the nutritional status of a 6-month-old infant. What factors would indicate adequate nutrition?
| a. | The infant gains 4 to 6 oz per week |
| b. | The parent reports frequent feedings |
| c. | The parent reports force-feeding the infant |
| d. | The infant is able to eat a variety of table foods |
ANS: A
The nurse would consider the weight gain as evidence that the baby is receiving adequate nutrition. Parental reports are important but are not objective data. The infant should be just beginning solid foods, not eating a variety of foods.
DIF: Cognitive Level: Application REF: Page 132 OBJ: 2
TOP: Nutritional Counseling for Parents KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- A parent is voicing concerns about the continued high cost of infant formula. She asks if her 9-month-old can begin drinking cows milk instead of formula. The nurse explains that:
| a. | As long as she gives the child whole milk instead of skim, it will be okay |
| b. | Cows milk will be easier to digest than the formula |
| c. | Cows milk will decrease the chance of the child developing iron-deficiency anemia |
| d. | Breast milk or formula should be used for the first year |
ANS: D
The infant should not be given cows milk until reaching the first year. Milk will increase the risk of iron-deficiency anemia. Whole milk should be given, but after the child is 1 year old.
DIF: Cognitive Level: Application REF: Page 132 OBJ: 2
TOP: Nutritional Counseling for Parents KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A parent states she would like to prepare her own baby food for her infant. The nurse would offer which of the following guidelines:
| a. | Overcook food to ensure all bacteria are killed |
| b. | Store the pureed food in the refrigerator |
| c. | Select high-quality foods |
| d. | Add honey or corn syrup to sweeten foods |
ANS: C
Overcooking food robs the food of its nutritional value and does not kill all bacteria. Pureed food should be stored in the freezer. Honey and corn syrup can increase the chance of contamination. High-quality food should be chosen.
DIF: Cognitive Level: Application REF: Page 133 OBJ: 2
TOP: Nutritional Counseling for Parents KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse instructs new parents on the safety precautions needed to protect their baby from injury. Which of the following is an appropriate recommendation?
| a. | The infant should be placed on the stomach for sleep |
| b. | Use a firm pillow in the crib |
| c. | Apply sunscreen before taking the baby outside |
| d. | Use a firm, tight-fitting mattress in the crib |
ANS: D
An infant should be placed on the back for sleep. Never use a pillow in a crib. Sunscreen is not used until the baby is at least 6 months old. The crib should have a firm, tight-fitting mattress.
DIF: Cognitive Level: Application REF: Page 121 OBJ: 4
TOP: Physical Development, Social Behavior, Care and Guidance for the First 12 Months
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
- A 7-month-old infant has been admitted to the hospital. The nurse is concerned with protecting the baby from harm. Which of the following interventions would be most appropriate?
| a. | Ensure that no small, loose objects are in the crib |
| b. | Avoid giving any solid food |
| c. | Telling child, no, will stop dangerous behavior |
| d. | Check on the baby once per shift |
ANS: A
The nurse should make sure that no small, loose objects are in the crib. These are often left after starting an IV or opening supplies used in the babys care. A 7-month-old should be taking solid food. This would not be stopped to promote safety. The baby does not understand the meaning of no and will need to be stopped or prevented from doing something potentially dangerous. The baby should be checked much more often than once per shift.
DIF: Cognitive Level: Application REF: Pages 121-125
OBJ: 4
TOP: Physical Development, Social Behavior, Care and Guidance for the First 12 Months
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
- A couple expresses concern about the expense involved in immunizing their child. The parents state, I dont understand why this is necessary. None of these diseases are around any more. The nurses best response would be:
| a. | These diseases continue to occur in children today and would be very costly in both money and health terms |
| b. | Immunizations are not needed until the child is ready to attend school |
| c. | Children only need to be immunized if they will be taken into high-risk areas |
| d. | Parents can wait to vaccinate their child until the child begins to display symptoms of the disease |
ANS: A
The parents need to understand that these diseases still exist and can cause harm and death to the child. The cost of caring for a child with these diseases would be much greater than the cost of vaccination. Immunizations should begin as scheduled. Vaccinations are given to prevent illness, not stop them.
DIF: Cognitive Level: Analysis REF: Page 129 OBJ: 6
TOP: Immunizations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse is reviewing the immunization record of a 3-moth-old infant. Which of the following list of immunizations indicates that the infant has received all of the required vaccinations for a baby this age?
| a. | DTAP, HIB, MMR, Hep A, HPV |
| b. | Hep B, DTAP, HIB, IPV, PCV, rotavirus |
| c. | HPV, Hep B, DTAP, MMR, varicella |
| d. | Hep A, DTAP, MMR, HPV, rotavirus |
ANS: B
HPV and MMR are given when the child is older. The other lists omit needed vaccines.
DIF: Cognitive Level: Application REF: Page 130 OBJ: 6
TOP: Immunizations KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
- A 12-month-old received the MMR vaccine last week. The father of the infant calls because the baby has a low-grade fever and a rash. The nurse explains:
| a. | This is a sign of a serious reaction |
| b. | This is normal and will resolve in a few days |
| c. | This would have been avoided if the baby had been vaccinated at the proper age |
| d. | This indicates that the baby was immunosuppressed |
ANS: B
A fever and rash are normal 7-12 days after the vaccine. The baby is the appropriate age to receive this vaccine. There is no indication that the baby is immunosuppressed.
DIF: Cognitive Level: Application REF: Page 130 OBJ: 5
TOP: MMR KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A 4-month-old infant comes to the well-baby clinic to receive the recommended vaccines for this age. The nurse questions the parents about reactions from the first vaccinations. Which of the following reactions would indicate a need for further evaluation before administering the next set of vaccinations?
| a. | A mild fever and redness at injection site |
| b. | Fussiness, decrease in appetite |
| c. | Mild swelling at the injection site |
| d. | Fever of greater than 104.8 F or above within 48 hours of administration |
ANS: D
A fever of 104.8 F or greater could indicate a serious reaction and should be further investigated. The other symptoms are normal reactions to vaccine.
DIF: Cognitive Level: Analysis REF: Page 130 OBJ: 7
TOP: Immunizations KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
- The parents of a 2-month-old infant inform the nurse that they have decided to not vaccinate their child because of reports of dangerous side effects and complications. Which of the following responses by the nurse would be best?
| a. | It is against the law to refuse to vaccinate your child |
| b. | The benefit of protection will greatly outweigh the risk |
| c. | We will call child protective services if you dont vaccinate your child |
| d. | Only parents that dont love their child would refuse vaccinations |
ANS: B
Parents need to be given the appropriate information so that they can make a good decision. Parents have the right to withhold treatment for their children. The nurse should not assume the parents do not love their child. The nurse should be nonjudgmental in her approach to educating the parents.
DIF: Cognitive Level: Application REF: Page 129 OBJ: 6
TOP: Immunizations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- A mother calls the clinic to report problems with her baby. The baby was vaccinated earlier in the day. Which of the following concerns is not considered routine?
| a. | The baby is decreasingly responsive |
| b. | The baby cried for 1 hour |
| c. | The baby had a seizure |
| d. | Both A and C |
ANS: D
It is normal for a baby to cry for a couple of hours after a vaccination. The other signs are not normal and necessitate immediate attention.
DIF: Cognitive Level: Application REF: Page 129 OBJ: 7
TOP: Immunizations KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
- A mother is concerned because the grandparents believe she is spoiling the child by her attentiveness. The nurse explains:
| a. | The mother should let the baby cry for a while before picking him or her up |
| b. | She cannot spoil her infant by responding to its needs |
| c. | The baby should only be given affection as a reward |
| d. | She should follow the advice of the grandparents |
ANS: B
A baby needs to be comforted when it cries. The baby learns to develop trust when needs are met. Parents cannot spoil a baby by giving the needed attention and love. Affection should not be used as a reward.
DIF: Cognitive Level: Application REF: Page 119 OBJ: 9
TOP: General Characteristics and Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity
- Before discharge from the labor and delivery unit, a new mother asks what she should expect her new baby to do by the end of the first month. The nurse explains that:
| a. | The baby will smile when the mother speaks |
| b. | The baby will cry when it is hungry or uncomfortable |
| c. | The baby will be able to hold a rattle |
| d. | The baby will be able to lift up its head when placed on its abdomen |
ANS: B
At the end of 1 month, the baby will be able to cry when it is uncomfortable or hungry. The baby will not be able to do the other tasks at this time.
DIF: Cognitive Level: Application REF: Pages 121-122
OBJ: 8
TOP: Physical Development, Social Behavior, Care and Guidance for the First 12 Months
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- A new parent is interested in learning how to provide a safe and secure environment for the new infant. The nurse provides which of the following suggestions:
| a. | Keep the child at home as much as possible |
| b. | Limit exposure to new sights and sounds |
| c. | A change of environment can provide stimulation |
| d. | Leave the child constantly in the crib or playpen |
ANS: C
Both the child and the parent can benefit from a change of environment. The baby should be stimulated with new sights and sounds to aid in development. The baby should be held often and should not be left constantly in a crib or playpen.
DIF: Cognitive Level: Application REF: Pages 119-120
OBJ: 9 TOP: Health Promotion and Maintenance
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- A mother is concerned because her 12-month-old baby cannot walk unless he holds onto her hand. The nurse explains:
| a. | This is a significant developmental delay |
| b. | Babies do not walk alone before 15 months |
| c. | Not all babies are ready to walk at this age |
| d. | The baby has a neurological impairment |
ANS: C
Babies learn to walk at different ages. The baby is walking with help, so the mother should be informed that the baby is just not ready to walk alone.
DIF: Cognitive Level: Application REF: Page 127 OBJ: 10
TOP: Physical Development, Social Behavior, Care and Guidance for the First 12 Months
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse is counseling parents of an 8-month-old infant. The mother states that members of the extended family came for a visit. The baby cried and was reluctant to be held by the family members. The nurse would explain:
| a. | Babies often demonstrate fear of strangers at this age |
| b. | Their baby is
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