Pediatric Primary Care: Practice Guidelines for Nurses 3rd Edition Test Bank

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Pediatric Primary Care 4thEdition RichardsonTestbank/StudyGuideChapter 1 Obtaining an Initial HistoryMULTIPLECHOICE1.Thenurseisseeinganadolescentandtheparentsintheclinicforthefirsttime.Whichshouldthenursedofirst?a.Introducehim-orherself.b.Makethefamilycomfortable.c.Giveassuranceofprivacy.d.Explainthepurposeoftheinterview.ANS:AThefirstthingthatnursesmustdoistointroducethemselvestothepatientandfamily.Parentsandotheradultsshouldbeaddressedwithappropriatetitlesunlesstheyspecifyapreferredname.Clarificationofthepurposeoftheinterviewandthenursesroleisthesecondthingthatshouldbedone.Duringtheinitialpartoftheinterview,thenurseshouldincludegeneralconversationtohelpmakethefamilyfeelatease.Theinterviewalsoshouldtakeplaceinanenvironmentasfreeofdistractionaspossible.Inaddition,thenurseshouldclarifywhichinformationwillbesharedwithothermembersofthehealthcareteamandanylimitstotheconfidentiality.2.Whichisconsideredablocktoeffectivecommunication?a.Usingsilenceb.Usingclichsc.Directingthefocusd.DefiningtheproblemANS:BUsingstereotypedcommentsorclichscanblockeffectivecommunication.Afterthenurseusessuchtritephrases,parentsoftendonotrespond.Silencecanbeaneffectiveinterviewingtool.Silencepermitstheintervieweetosortoutthoughtsandfeelingsandsearchforresponsestoquestions.Tobeeffective,thenursemustbeabletodirectthefocusoftheinterviewwhileallowingmaximumfreedomofexpression.Byusingopen-endedquestionsandguidingquestions,thenursecanobtainthenecessaryinformationandmaintainarelationshipwiththefamily.Thenurseandparentmustcollaborateanddefinetheproblemthatwillbethefocusofthenursingintervention.3.Whichisthesinglemostimportantfactortoconsiderwhencommunicatingwithchildren?a.Presenceofthechildsparentb.Childsphysicalconditionc.Childsdevelopmentallevel

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d.ChildsnonverbalbehaviorsANS:CThenursemustbeawareofthechildsdevelopmentalstagetoengageineffectivecommunication.Theuseofbothverbalandnonverbalcommunicationshouldbeappropriatetothedevelopmentallevel.Nonverbalbehaviorsvaryinimportancebasedonthechildsdevelopmentallevelandphysicalcondition.Althoughthechildsphysicalconditionisaconsideration,developmentallevelismuchmoreimportant.Thepresenceofparentsisimportantwhencommunicatingwithyoungchildrenbutmaybedetrimentalwhenspeakingwithadolescents.4.Becausechildrenyoungerthan5yearsareegocentric,thenurseshoulddowhichwhencommunicatingwiththem?a.Focuscommunicationonthechild.b.Useeasyanalogieswhenpossible.c.Explainexperiencesofotherstothechild.d.Assurethechildthatcommunicationisprivate.ANS:ABecausechildrenofthisageareabletoseethingsonlyintermsofthemselves,thebestapproachistofocuscommunicationdirectlyonthem.Childrenshouldbeprovidedwithinformationaboutwhattheycandoandhowtheywillfeel.Withchildrenwhoareegocentric,analogies,experiences,andassurancesthatcommunicationisprivatewillnotbeeffectivebecausethechildisnotcapableofunderstanding.5.Thenursesapproachwhenintroducinghospitalequipmenttoapreschoolerwhoseemsafraidshouldbebasedonwhichprinciple?a.Thechildmaythinktheequipmentisalive.b.Explainingtheequipmentwillonlyincreasethechildsfear.c.Onebriefexplanationwillbeenoughtoreducethechildsfear.d.Thechildistooyoungtounderstandwhattheequipmentdoes.ANS:AYoungchildrenattributehumancharacteristicstoinanimateobjects.Theyoftenfearthattheobjectsmayjump,bite,cut,orpinchallbythemselveswithouthumandirection.Equipmentshouldbekeptoutofsightuntilneeded.Simple,concreteexplanationsaboutwhattheequipmentdoesandhowitwillfeelwillhelpalleviatethechildsfear.Preschoolersneedrepeatedexplanationsasreassurance.6.Whenthenurseinterviewsanadolescent,whichisespeciallyimportant?a.Focusthediscussiononthepeergroup.b.Allowanopportunitytoexpressfeelings.c.Usethesametypeoflanguageastheadolescent.d.Emphasizethatconfidentialitywillalwaysbemaintained.ANS:BAdolescents,likeallchildren,needopportunitiestoexpresstheirfeelings.Oftentheyinterjectfeelingsintotheirwords.Thenursemustbealerttothewordsandfeelingsexpressed.Thenurse

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shouldmaintainaprofessionalrelationshipwithadolescents.Toavoidmisunderstandingormisinterpretationofwordsandphrasesused,thenurseshouldclarifythetermsused,whatinformationwillbesharedwithothermembersofthehealthcareteam,andanylimitstoconfidentiality.Althoughthepeergroupisimportanttothisagegroup,theinterviewshouldfocusontheadolescent.7.Thenurseispreparingtoassessa10-month-oldinfant.Heissittingonhisfatherslapandappearstobeafraidofthenurseandofwhatmighthappennext.Whichinitialactionsbythenurseshouldbemostappropriate?a.Initiateagameofpeek-a-boo.b.Asktheinfantsfathertoplacetheinfantontheexaminationtable.c.Talksoftlytotheinfantwhiletakinghimfromhisfather.d.Undresstheinfantwhileheisstillsittingonhisfatherslap.ANS:APeek-a-booisanexcellentmeansofinitiatingcommunicationwithinfantswhilemaintainingasafe,nonthreateningdistance.Thechildwillmostlikelybecomeupsetifseparatedfromhisfather.Asmuchoftheassessmentaspossibleshouldbedonewiththechildonthefatherslap.Thenurseshouldhavethefatherundressthechildasneededduringtheexamination.8.An8-year-oldgirlasksthenursehowthebloodpressureapparatusworks.Themostappropriatenursingactioniswhich?a.Askherwhyshewantstoknow.b.Determinewhysheissoanxious.c.Explaininsimpletermshowitworks.d.Tellhershewillseehowitworksasitisused.ANS:CSchool-agechildrenrequireexplanationsandreasonsforeverything.Theyareinterestedinthefunctionalaspectofallprocedures,objects,andactivities.Itisappropriateforthenursetoexplainhowequipmentworksandwhatwillhappentothechildsothatthechildcanthenobserveduringtheprocedure.Thenurseshouldrespondpositivelyforrequestsforinformationaboutproceduresandhealthinformation.Bynotresponding,thenursemaybelimitingcommunicationwiththechild.Thechildisnotexhibitinganxietyinaskinghowthebloodpressureapparatusworks,justrequestingclarificationofwhatwilloccur.9.Thenurseishavingdifficultycommunicatingwithahospitalized6-year-oldchild.Whichtechniqueshouldbemosthelpful?a.Recommendthatthechildkeepadiary.b.Providesuppliesforthechildtodrawapicture.c.Suggestthattheparentreadfairytalestothechild.d.Asktheparentifthechildisalwaysuncommunicative.ANS:BDrawingisoneofthemostvaluableformsofcommunication.Childrensdrawingstellagreatdealaboutthembecausetheyareprojectionsofthechildrensinnerself.Adiaryshouldbedifficultfora6-year-oldchild,whoismostlikelylearningtoread.Theparentreadingfairytalestothechildisapassiveactivityinvolvingtheparentandchild;itshouldnotfacilitate

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communicationwiththenurse.Thechildisinastressfulsituationandisprobablyuncomfortablewithstrangers,notalwaysuncommunicative.10.Whichdatashouldbeincludedinahealthhistory?a.Reviewofsystemsb.Physicalassessmentc.Growthmeasurementsd.RecordofvitalsignsANS:AAreviewofsystemsisdonetoelicitinformationconcerninganypotentialhealthproblems.Thisfurtherguidestheinterviewprocess.Physicalassessment,growthmeasurements,andarecordofvitalsignsarecomponentsofthephysicalexamination.11.Thenurseistakingahealthhistoryofanadolescent.Whichbestdescribeshowthechiefcomplaintshouldbedetermined?a.Requestadetailedlistingofsymptoms.b.Asktheadolescent,Whydidyoucomeheretoday?c.Interviewtheparentawayfromtheadolescenttodeterminethechiefcomplaint.d.Usewhattheadolescentsaystodetermine,incorrectmedicalterminology,whattheproblemis.ANS:BThechiefcomplaintisthespecificreasonforthechildsvisittotheclinic,office,orhospital.Becausetheadolescentisthefocusofthehistory,thisisanappropriatewaytodeterminethechiefcomplaint.Requestingadetailedlistofsymptomsmakesitdifficulttodeterminethechiefcomplaint.Theparentandadolescentmaybeinterviewedseparately,butthenurseshoulddeterminethereasontheadolescentisseekingattentionatthistime.Thechiefcomplaintisusuallywritteninthewordsthattheparentoradolescentusestodescribethereasonforseekinghelp.12.Thenurseisinterviewingthemotherofaninfant.Themotherreports,Ihadadifficultdelivery,andmybabywasbornprematurely.Thisinformationshouldberecordedunderwhichheading?a.Historyb.Presentillnessc.Chiefcomplaintd.ReviewofsystemsANS:AThehistoryreferstoinformationthatrelatestopreviousaspectsofthechildshealth,nottothecurrentproblem.Thedifficultdeliveryandprematurityareimportantpartsoftheinfantshistory.Thehistoryofthepresentillnessisanarrativeofthechiefcomplaintfromitsearliestonsetthroughitsprogressiontothepresent.Unlessthechiefcomplaintisdirectlyrelatedtotheprematurity,thisinformationisnotincludedinthehistoryofthepresentillness.Thechiefcomplaintisthespecificreasonforthechildsvisittotheclinic,office,orhospital.Itshouldnotincludethebirthinformation.Thereviewofsystemsisaspecificreviewofeachbodysystem.Itdoesnotincludetheprematurebirthbutmightincludesequelaesuchaspulmonarydysfunction.13.Whereinthehealthhistorydoesarecordofimmunizationsbelong?

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a.Historyb.Presentillnessc.Reviewofsystemsd.PhysicalassessmentANS:AThehistorycontainsinformationrelatingtoallpreviousaspectsofthechildshealthstatus.Theimmunizationsareappropriatelyincludedinthehistory.Thepresentillness,reviewofsystems,andphysicalassessmentarenotappropriateplacestorecordtheimmunizationstatus.14.Thenurseistakingasexualhistoryonanadolescentgirl.Whichisthebestwaytodeterminewhethersheissexuallyactive?a.Askher,Areyousexuallyactive?b.Askher,Areyouhavingsexwithanyone?c.Askher,Areyouhavingsexwithaboyfriend?d.Askboththegirlandherparentifsheissexuallyactive.ANS:BAskingtheadolescentgirlifsheishavingsexwithanyoneisadirectquestionthatiswellunderstood.Thephrasesexuallyactiveisbroadlydefinedandmaynotprovidespecificinformationforthenursetoprovidenecessarycare.Thewordanyoneispreferredtousinggender-specifictermssuchasboyfriendorgirlfriend.Usinggender-neutraltermsisinclusiveandconveysacceptancetotheadolescent.Questioningaboutsexualactivityshouldoccurwhentheadolescentisalone.15.WhendoinganutritionalassessmentonaHispanicfamily,thenurselearnsthattheirdietconsistsmainlyofvegetables,legumes,andstarches.Thenurseshouldrecognizethatthisdietiswhich?a.Lackinginproteinb.Indicatingtheyliveinpovertyc.Providingsufficientaminoacidsd.NeedingenrichmentwithmeatandmilkANS:CAdietthatcontainsvegetables,legumes,andstarchesmayprovidesufficientessentialaminoacidseventhoughtheactualamountofmeatordairyproteinislow.Combinationsoffoodscontaintheessentialaminoacidsnecessaryforgrowth.Manyculturesusedietsthatcontainthiscombinationoffoods.Itisnotindicativeofpoverty.Adietaryassessmentshouldbedone,butmanyvegetariandietsaresufficientforgrowth.16.Whichparametercorrelatesbestwithmeasurementsoftotalmusclemass?a.Heightb.Weightc.Skinfoldthicknessd.UpperarmcircumferenceANS:D

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Upperarmcircumferenceiscorrelatedwithmeasurementsoftotalmusclemass.Muscleservesasthebodysmajorproteinreserveandisconsideredanindexofthebodysproteinstores.Heightisreflectiveofpastnutritionalstatus.Weightisindicativeofcurrentnutritionalstatus.Skinfoldthicknessisameasurementofthebodysfatcontent.17.Thenurseispreparingtoperformaphysicalassessmentona10-year-oldgirl.Thenursegiveshertheoptionofhermotherstayingintheroomorleaving.Thisactionshouldbeconsideredwhich?a.Appropriatebecauseofchildsageb.Appropriate,butthemothermaybeuncomfortablec.Inappropriatebecauseofchildsaged.InappropriatebecausechildissamesexasmotherANS:AItisappropriatetogiveolderschool-agechildrentheoptionofhavingtheparentpresentornot.Duringtheexamination,thenurseshouldrespectthechildsneedforprivacy.Childrenwhoare10yearsoldareminors,andparentsareresponsibleforhealthcaredecisions.Themotherofa10-year-oldchildwouldnotbeuncomfortable.Thechildshouldhelpdeterminewhoispresentduringtheexamination.18.WiththeNationalCenterforHealthStatisticscriteria,whichbodymassindex(BMI)for-agepercentilesshouldindicatethepatientisatriskforbeingoverweight?a.10thpercentileb.75thpercentilec.85thpercentiled.95thpercentileANS:CChildrenwhohaveBMI-for-agegreaterthanorequaltothe85thpercentileandlessthanthe95thpercentileareatriskforbeingoverweight.Childrenwhoaregreaterthanorequaltothe95thpercentileareconsideredoverweight.ChildrenwhoseBMIisbetweenthe10thand75thpercentilesarewithinnormallimits.19.Rectaltemperaturesareindicatedinwhichsituation?a.Inthenewbornperiodb.Wheneveraccuracyisessentialc.Rectaltemperaturesareneverindicatedd.WhenrapidtemperaturechangesareoccurringANS:BRectaltemperaturesarerecommendedwhendefinitivemeasurementsarenecessaryininfantsolderthanage1month.Rectaltemperaturesarenotdoneinthenewbornperiodtoavoidtraumatotherectalmucosa.Rectaltemperatureisanintrusiveprocedurethatshouldbeavoidedwheneverpossible.20.Whatistheearliestageatwhichasatisfactoryradialpulsecanbetakeninchildren?a.1yearb.2years

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c.3yearsd.6yearsANS:BSatisfactoryradialpulsescanbetakeninchildrenolderthan2years.Ininfantsandyoungchildren,theapicalpulseismorereliable.21.Thenurseneedstotakethebloodpressureofasmallchild.Ofthecuffsavailable,oneistoolargeandoneistoosmall.Thebestnursingactioniswhich?a.Usethesmallcuff.b.Usethelargecuff.c.Useeithercuffusingthepalpationmethod.d.Waittotakethebloodpressureuntilapropercuffcanbelocated.ANS:BIfbloodpressuremeasurementisindicatedandtheappropriatesizecuffisnotavailable,thenextlargersizeisused.Thenurserecognizesthatthismaybeafalselylowbloodpressure.Usingthesmallcuffwillgiveanincorrectlyhighreading.Thepalpationmethodwillnotimprovetheinaccuracyinherentinthecuff.22.Whereisthebestplacetoobserveforthepresenceofpetechiaeindark-skinnedindividuals?a.Faceb.Buttocksc.Oralmucosad.PalmsandsolesANS:CPetechiae,smalldistinctpinpointhemorrhages,aredifficulttoseeindark-skinnedindividualsunlesstheyareinthemouthorconjunctiva.23.Duringaroutinehealthassessment,thenursenotesthatan8-month-oldinfanthasasignificantheadlag.Whichisthemostappropriateaction?a.Recheckheadcontrolatnextvisit.b.Teachtheparentsappropriateexercises.c.Schedulethechildforfurtherevaluation.d.Referthechildforfurtherevaluationiftheanteriorfontanelisstillopen.ANS:CSignificantheadlagafterage6monthsstronglyindicatescerebralinjuryandisreferredforfurtherevaluation.Headcontrolispartofnormaldevelopment.Exerciseswillnotbeeffective.Thelackofachievementofthisdevelopmentalmilestonemustbeevaluated.24.Thenursehasjuststartedassessingayoungchildwhoisfebrileandappearsill.Thereishyperextensionofthechildshead(opisthotonos)withpainonflexion.Whichisthemostappropriateaction?a.Asktheparentwhentheneckwasinjured.b.Referforimmediatemedicalevaluation.c.Continueassessmenttodeterminethecauseoftheneckpain.

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d.Recordheadlagontheassessmentrecordandcontinuetheassessmentofthechild.ANS:BHyperextensionofthechildsheadwithpainonflexionisindicativeofmeningealirritationandneedsimmediateevaluation.Noindicationofinjuryispresent.Thissituationisnotdescriptiveofheadlag.25.Duringafunduscopicexaminationofaschool-agechild,thenursenotesabrilliant,uniformredreflexinbotheyes.Thenurseshouldrecognizethatthisiswhich?a.Anormalfindingb.Asignofapossiblevisualdefectandaneedforvisionscreeningc.Anabnormalfindingrequiringreferraltoanophthalmologistd.Asignofsmallhemorrhages,whichusuallyresolvespontaneouslyANS:AAbrilliant,uniformredreflexisanimportantnormalfinding.Itrulesoutmanyseriousdefectsofthecornea,aqueouschamber,lens,andvitreouschamber.26.Whichexplainstheimportanceofdetectingstrabismusinyoungchildren?a.Colorvisiondeficitmayresult.b.Amblyopia,atypeofblindness,mayresult.c.Epicanthalfoldsmaydevelopintheaffectedeye.d.Corneallightreflexesmayfallsymmetricallywithineachpupil.ANS:BBytheageof3to4months,infantsareabletofixateononevisualfieldwithbotheyessimultaneously.Instrabismus,orcross-eye,oneeyedeviatesfromthepointoffixation.Ifmisalignmentisconstant,theweakeyebecomeslazy,andthebraineventuallysuppressestheimageproducedfromthateye.Ifstrabismusisnotdetectedandcorrectedbyage4to6years,blindnessfromdisuse,knownasamblyopia,mayoccur.Colorvisionisnottheonlyconcern.Epicanthalfoldsarenotrelatedtoamblyopia.Inchildrenwithstrabismus,thecorneallightreflexwillnotbesymmetricforeacheye.27.Whichisthemostfrequentlyusedtestformeasuringvisualacuity?a.Snellenletterchartb.Ishiharavisiontestc.Allenpicturecardtestd.DenvereyescreeningtestANS:ATheSnellenletterchart,whichconsistsoflinesoflettersofdecreasingsize,isthemostfrequentlyusedtestforvisualacuity.TheIshiharaVisionTestisusedforcolorvision.TheAllenpicturecardtestandDenvereyescreeningtestinvolvesinglecardsforchildrenages2yearsandolderwhoareunabletousetheSnellenletterchart.28.Thenurseistestinganinfantsvisualacuity.Bywhichageshouldtheinfantbeabletofixonandfollowatarget?a.1month

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b.1to2monthsc.3to4monthsd.6monthsANS:CVisualfixationandabilitytofollowatargetshouldbepresentbyages3to4months.Oneto2monthsistooyoungforthisdevelopmentalmilestone.Ifaninfantisnotabletofixandfollowby6months,furtherophthalmologicevaluationisneeded.29.Duringanotoscopicexaminationonaninfant,inwhichdirectionisthepinnapulled?a.Upandbackb.Upandforwardc.Downandbackd.DownandforwardANS:CIninfantsandtoddlers,theearcanaliscurvedupward.Tovisualizetheearcanal,itisnecessarytopullthepinnadownandbacktothe6to9oclockrangetostraightenthecanal.Inchildrenolderthanage3yearsandadults,thecanalcurvesdownwardandforward.Thepinnaispulledupandbacktothe10oclockposition.Upandforwardanddownandforwardarepositionsthatdonotfacilitatevisualizationoftheearcanal.Chapter 2 Obtaining an IntervalHistory1.Whatisanappropriatescreeningtestforhearingthatthenursecanadministertoa5-year-oldchild?

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a.Rinnetestb.Webertestc.Puretoneaudiometryd.ElicitingthestartlereflexANS:CPuretoneaudiometryusesanaudiometerthatproducessoundsatdifferentvolumesandpitchesinthechildsears.Thechildisaskedtorespondinsomewaywhenthetoneisheardintheearphone.TheRinneandWebertestsmeasureboneconductionofsound.Elicitingthestartlereflexmaybeusefulininfants.2.Whatistheappropriateplacementofatonguebladeforassessmentofthemouthandthroat?a.Onthelowerjawb.Sideofthetonguec.Againstthesoftpalated.CenterbackareaofthetongueANS:BThesideofthetongueisthecorrectposition.Itavoidsthegagreflexyetallowsvisualization.Onthelowerjawandagainstthesoftpalatearenotappropriateplacesforthetongueblade.Placementinthecenterbackareaofthetongueelicitsthegagreflex.3.Whenassessingapreschoolerschest,whatshouldthenurseexpect?a.Respiratorymovementstobechieflythoracicb.Anteroposteriordiametertobeequaltothetransversediameterc.Retractionofthemusclesbetweentheribsonrespiratorymovementd.MovementofthechestwalltobesymmetricbilaterallyandcoordinatedwithbreathingANS:DMovementofthechestwallshouldbesymmetricbilaterallyandcoordinatedwithbreathing.Inchildrenyoungerthan6or7years,respiratorymovementisprincipallyabdominalordiaphragmatic.Theanteroposteriordiameterisequaltothetransversediameterduringinfancy.Asthechildgrows,thechestincreasesinthetransversedirection,sothattheanteroposteriordiameterislessthanthelateraldiameter.Retractionsofthemusclesbetweentheribsonrespiratorymovementareindicativeofrespiratorydistress.4.Whenauscultatinganinfantslungs,thenursedetectsdiminishedbreathsounds.Whatshouldthenurseinterpretthisas?a.Suggestiveofchronicpulmonarydiseaseb.Suggestiveofimpendingrespiratoryfailurec.Anabnormalfindingwarrantinginvestigationd.Anormalfindingininfantsyoungerthan1yearofageANS:CAbsentordiminishedbreathsoundsarealwaysanabnormalfinding.Fluid,air,orsolidmassesinthepleuralspaceallinterferewiththeconductionofbreathsounds.Furtherdataarenecessaryfordiagnosisofchronicpulmonarydiseaseorimpendingrespiratoryfailure.Diminishedbreath

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soundsincertainsegmentsofthelungscanalertthenursetopulmonaryareasthatmaybenefitfromchestphysiotherapy.Furtherevaluationisneededinallagegroups.5.Whichtypeofbreathsoundisnormallyheardovertheentiresurfaceofthelungsexceptfortheupperintrascapularareaandtheareabeneaththemanubrium?a.Vesicularb.Bronchialc.Adventitiousd.BronchovesicularANS:AThisisthedefinitionofvesicularbreathsounds.Theyareheardovertheentiresurfaceofthelungs,withtheexceptionoftheupperintrascapularareaandtheareabeneaththemanubrium.Bronchialbreathsoundsareheardonlyoverthetracheanearthesuprasternalnotch.Adventitiousbreathsoundsarenotusuallyheardoverthechest.Thesesoundsoccurinadditiontonormalorabnormalbreathsounds.Bronchovesicularbreathsoundsareheardoverthemanubriumandintheupperintrascapularregions,wherethetracheaandbronchibifurcate.6.Thenurseisassessingachildscapillaryrefilltime.Thiscanbeaccomplishedbydoingwhat?a.Inspectthechest.b.Auscultatetheheart.c.Palpatetheapicalpulse.d.Palpatethenailbedwithpressuretoproduceaslightblanching.ANS:DCapillaryrefilltimeisassessedbypressinglightlyontheskintoproduceblanchingandthennotingtheamountoftimeittakesfortheblanchedareatorefill.Inspectingthechest,auscultatingtheheart,andpalpatingtheapicalpulsewillnotprovideanassessmentofcapillaryrefilltime.7.Whichheartsoundisproducedbyvibrationswithintheheartchambersorinthemajorarteriesfromtheback-and-forthflowofblood?a.S1andS2b.S3andS4c.Murmurd.PhysiologicsplittingANS:CMurmursarethesoundsthatareproducedintheheartchambersormajorarteriesfromtheback-and-forthflowofblood.S1andS2arenormalheartsounds.S1istheclosureofthetricuspidandmitralvalves,andS2istheclosureofthepulmonicandaorticvalves.S3isanormalheartsoundsometimesheardinchildren.S4israrelyheardasanormalheartsound.Ifitisheard,medicalevaluationisrequired.PhysiologicsplittingisthedistinctionofthetwosoundsinS2,whichwidensoninspiration.Itisasignificantnormalfinding.8.Examinationoftheabdomenisperformedcorrectlybythenurseinwhichorder?a.Inspection,palpation,percussion,andauscultation

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b.Inspection,percussion,auscultation,andpalpationc.Palpation,percussion,auscultation,andinspectiond.Inspection,auscultation,percussion,andpalpationANS:DThecorrectorderofabdominalexaminationisinspection,auscultation,percussion,andpalpation.Palpationisalwaysperformedlastbecauseitmaydistortthenormalabdominalsounds.Auscultationisperformedbeforepercussion.Theactofpercussioncaninfluencethefindingsonauscultation.9.Superficialpalpationoftheabdomenisoftenperceivedbythechildastickling.Whichmeasurebythenurseismostlikelytominimizethissensationandpromoterelaxation?a.Palpateanotherareasimultaneously.b.Askthechildnottolaughormoveifittickles.c.Beginwithdeeperpalpationandgraduallyprogresstosuperficialpalpation.d.Havethechildhelpwithpalpationbyplacinghisorherhandoverthepalpatinghand.ANS:DHavingthechildhelpwithpalpationbyplacinghisorherhandoverthepalpatinghandwillhelpminimizethefeelingofticklingandenlistthechildscooperation.Palpatinganotherareasimultaneouslywillcreatethesensationofticklingintheotherareaalso.Askingthechildnottolaughormovewillbringattentiontotheticklingandmakeitmoredifficultforthechild.Superficialpalpationisdonebeforedeeppalpation.10.Duringexaminationofatoddlersextremities,thenursenotesthatthechildisbowlegged.Thenurseshouldrecognizethatthisfindingiswhich?a.Abnormalandrequiresfurtherinvestigationb.Abnormalunlessitoccursinconjunctionwithknock-kneec.Normaliftheconditionisunilateralorasymmetricd.NormalbecausethelowerbackandlegmusclesarenotyetwelldevelopedANS:DLateralbowingofthetibia(bowlegged)isanexpectedfindingintoddlerswhentheybegintowalk.Itusuallypersistsuntilalloftheirlowerbackandlegmusclesarewelldeveloped.Furtherevaluationisneededifitpersistsbeyondages2to3years,especiallyinAfricanAmericanchildren.11.ThenurseiscaringforanonEnglish-speakingchildandfamily.Whichshouldthenurseconsiderwhenusinganinterpreter?a.Poseseveralquestionsatatime.b.Usemedicaljargonwhenpossible.c.Communicatedirectlywithfamilymemberswhenaskingquestions.d.CarryonsomecommunicationinEnglishwiththeinterpreteraboutthefamilysneeds.ANS:C

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Whenusinganinterpreter,thenurseshouldcommunicatedirectlywithfamilymemberswhenaskingquestionstoreinforceinterestinthemandtoobservenonverbalexpressions.Questionsshouldbeposedoneatatimetoelicitonlyoneansweratatime.Medicaljargonshouldbeavoidedwheneverpossible.ThenurseshouldavoiddiscussingthefamilysneedswiththeinterpreterinEnglishbecausesomefamilymembersmayunderstandsomeEnglish.12.Whichactionshouldthenurseimplementwhentakinganaxillarytemperature?a.Takethetemperaturethroughonelayerofclothing.b.Addadegreetotheresultwhenrecordingthetemperature.c.Placethetipofthethermometerunderthearminthecenteroftheaxilla.d.Holdthechildsarmawayfromthebodywhiletakingthetemperature.ANS:CThethermometertipshouldbeplacedunderthearminthecenteroftheaxillaandkeptclosetotheskin,notclothing.Thetemperatureshouldnotbetakenthroughanyclothing.Thechildsarmshouldbepressedfirmlyagainsttheside,notheldawayfromthebody.Thetemperatureshouldberecordedwithoutadegreeaddedanddesignatedasbeingtakenbytheaxillarymethod.13.Thenurseisawarethatskinturgorbestestimateswhat?a.Perfusionb.Adequatehydrationc.Amountofbodyfatd.AmountofanemiaANS:BSkinturgorisoneofthebestestimatesofadequatehydrationandnutrition.Itdoesnotindicateamountofbodyfatandisnotatestforanemia.14.TheAsianparentofachildbeingseenintheclinicavoidseyecontactwiththenurse.Whatisthebestexplanationforthisconsideringculturaldifferences?a.Theparentfeelsinferiortothenurse.b.Theparentisshowingrespectforthenurse.c.Theparentisembarrassedtoseekhealthcare.d.Theparentfeelsresponsibleforherchildsillness.ANS:BInsomeethnicgroups,eyecontactisavoided.IntheVietnameseculture,anindividualmaynotlookdirectlyintothenurseseyesasasignofrespect.Thenurseprovidingculturallycompetentcarewouldrecognizethattheotheranswerslistedarenotwhytheparentavoidseyecontactwiththenurse.15.Thenurseisperforminganotoscopicexaminationonachild.Whicharenormalfindingsthenurseshouldexpect?(Selectallthatapply.)a.Ashengrayareasb.Awell-definedlightreflexc.Asmall,round,concavespotnearthecenterofthedrum

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d.Thetympanicmembraneisanontransparentgrayishcolore.AwhitishlineextendingfromtheumboupwardtothemarginofthemembraneANS:B,C,ENormalfindingsincludethelightreflexandbonylandmarks.Thelightreflexisafairlywell-defined,cone-shapedreflectionthatnormallypointsawayfromtheface.Thebonylandmarksoftheeardrumareformedbytheumbo,ortipofthemalleus.Itappearsasasmall,round,opaque,concavespotnearthecenteroftheeardrum.Themanubrium(longprocessorhandle)ofthemalleusappearstobeawhitishlineextendingfromtheumboupwardtothemarginofthemembrane.Thetympanicmembraneshouldbelightpearlypinkorgrayandtranslucent,notnontransparent.Ashengrayareasindicatesignsofscarringfromapreviousperforation.16.Thenurseisassessingbreathsoundsonachild.Whichareexpectedauscultatedbreathsounds?(Selectallthatapply.)a.Wheezesb.Cracklesc.Vesiculard.Bronchiale.BronchovesicularANS:C,D,ENormalbreathsoundsareclassifiedasvesicular,bronchovesicular,orbronchial.Wheezesorcracklesareabnormaloradventitioussounds.17.Thenurseisperforminganoralexaminationonapreschoolchild.Whichstrategiesshouldthenurseusetoencouragethechildtoopenthemouthfortheexamination?(Selectallthatapply.)a.Lightlybrushthepalatewithacottonswab.b.Performtheexaminationinfrontofamirror.c.Letthechildexaminesomeoneelsesmouthfirst.d.Havethechildbreathedeeplyandholdhisorherbreath.e.Useatonguebladetohelpthechildopenhisorhermouth.ANS:A,B,C,DToencourageachildtoopenthemouthforexamination,thenursecanlightlybrushthepalatewithacottonswab,performtheexaminationinfrontofamirror,letthechildexaminesomeoneelsesmouthfirst,andhavethechildbreathedeeplyandholdhisorherbreath.Atongueblademayelicitthegagreflexandshouldnotbeused.18.Whichareeffectiveauscultationtechniques?(Selectallthatapply.)a.Askthechildtobreatheshallowly.b.Applylightpressureonthechestpiece.c.Useasymmetricandorderlyapproach.d.Placethestethoscopeoveronelayerofclothing.e.Warmthestethoscopebeforeplacingitontheskin.ANS:C,E

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Effectiveauscultationtechniquesincludeusingasymmetricapproachandwarmingthestethoscopebeforeplacingitontheskin.Breathsoundsarebestheardifthechildinspiresdeeply,notshallowly.Firm,notlight,pressureshouldbeusedonthechestpiece.Thestethoscopeshouldbeplacedontheskin,notoverclothing.19.Thenurseisassessingheartsoundsonaschool-agechild.Whichshouldthenursedocumentasabnormalfindingsiffoundontheassessment?(Selectallthatapply.)a.S4heartsoundb.S3heartsoundc.GradeIImurmurd.S1louderattheapexofthehearte.S2louderthanS1intheaorticareaANS:A,C,ES4israrelyheardasanormalheartsound;itusuallyindicatestheneedforfurthercardiacevaluation.AgradeIImurmurisnotnormal;itisslightlylouderthangradeIandisaudibleinallpositions.S3isnormallyheardinsomechildren.Normally,S1islouderattheapexoftheheartinthemitralandtricuspidarea,andS2isloudernearthebaseoftheheartinthepulmonicandaorticarea.20.Thenurseunderstandsthatblockstotherapeuticcommunicationincludewhat?(Selectallthatapply.)a.Socializingb.Useofsilencec.Usingclichsd.Defendingasituatione.Usingopen-endedquestionsANS:A,C,DBlockstocommunicationincludesocializing,usingclichs,anddefendingasituation.Useofsilenceandusingopen-endedquestionsaretherapeuticcommunicationtechniques.Chapter 3 Performing a Physical ExaminationQuestion1Type:MCSA

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The nurse istaking a health history from a family of a 3-year-old child. Which statement by thenurse would most likely establish rapport and elicit an accurate response from the family?1.Does any member of your family have a history of asthma, heart disease, or diabetes?2.Hello, I would like to talk with you and get some information on you and your child.3.Tell me about the concerns that brought you to the clinic today.4.You will need to fill out these forms; make sure that the information is as complete aspossible.CorrectAnswer:3GlobalRationale:Asking the parents to talk about their concerns is an open-ended question andone which is more likely to establish rapport and an understanding of the parents perceptions.Giving the family a list of items to answer at once may be confusing to the parents. Giving anintroduction before asking the parents for information is likely to establish rapport, but giving anexplanation of why the information would be needed would be even more effective atestablishing rapport and also for getting more accurate, pertinent information. Simply asking theparents to fill out forms is very impersonal, and more information is likely to be obtained andclarified if the nurse is directing the interview.Question2Type:MCSAWhenassessing the cognitive development, which technique would be appropriate to test theremote memory of a 5-year-old?1.Say the name of an object and after 5 minutes ask the child to tell you what you said the objectwas.2.Ask the child to repeat hisaddress.3.Ask the child to say a poem and listen to the childs speech articulation.4.Have the child point to various parts of the body as you name them.CorrectAnswer:2GlobalRationale:Repeating the name of an object after 510 minutes is assessingrecent memory.Asking the child to repeat his address is assessing remote memory. Listening to speecharticulation and pointing to body parts both assess communication skills.Question3Type:SEQPlace the nursing assessments of a toddler in the best order.StandardText:Click and drag the options below to move them up or down.Choice1.Examination of eyes, ears, and throatChoice2.Auscultation of chestChoice3.Palpation of abdomenChoice4.Developmental assessmentCorrectAnswer:4,2,3,1GlobalRationale:In examining a toddler, it is usually best to go from least invasive to mostinvasive examination in order to build her trust and cooperation. Developmental assessmentinvolves visual inspection and activities that the toddler may view as games andwill likelycooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if

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the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasiveexam for the toddler is most likely to be the examination of the eyes, ears, and throat, so thatshould be performed last.Question4Type:MCSAWhile assessing a 10-month-old African American infant, the nurse notices that the sclerae havea yellowish tint. Which organ system should the nurse further evaluate to determine an ongoingdisease process?1.Cardiac2.Respiratory3.Gastrointestinal4.GenitourinaryCorrectAnswer:3GlobalRationale:This infants sclerae are showing signs of jaundice, which most likely issecondary to a failure ormalfunction of the liver in the gastrointestinal system. Cyanosis of theskin and mucous membranes is generally a sign of problems with the cardiac and/or respiratorysystem. Tenting of the skin and dry mucous membranes could be a sign of dehydration, andedema could be a sign of fluid overload. Both of these conditions could be secondary toproblems with functioning of the genitourinary system.Question5Type:MCSAA nurse caring for a school-age client notices some swelling in the childs ankles. Thenursepresses against the ankle bone for five seconds, then releases the pressure and notices a markedlyslow disappearance of the indentation. Which priority nursing assessment is appropriate?1.Skin integrity, especially in the lower extremities2.Urine output3.Level of consciousness4.Range of motion and ankle mobilityCorrectAnswer:2GlobalRationale:Dependent, pitting edema, especially in the lower extremities, can be asymptom of both kidney and cardiac disorders. Decreases in urine output canalso indicatecompromise in both the renal and cardiac systems. Changes in level of consciousness, if present,would more than likely be a later effect in this situation. While ankle edema could lead to bothdecreased ankle mobility and compromise in skinintegrity, diagnosing and treating theunderlying cause of the edema is most important.Question6Type:MCSAA new mother is worried about a soft spot on the top of her newborn infants head. The nurseinforms her that this is a normal physical finding called the anterior fontanel. At what age willthe nurse educate the mother that the soft spot will close?1.2 to 3 months of age2.6 to 9 months of age3.12 to 18 months of age

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4.Approximately 2 years of ageCorrectAnswer:3GlobalRationale:The anterior fontanel is located at the top of the head and is the opening at theintersection of the suture lines. As the infant grows, the suture lines begin to fuse, and theanterior fontanel closes at 12 to 18 months of age.Question7Type:MCSAWhile inspecting a 5-year-old childs ears, the nurse notes that the right pinna protrudes outwardand that there is a mass behind the right ear. In light of these findings, which vital-sign parameterwould the nurse assess on priority?1.Temperature2.Heart rate3.Respirations4.Blood pressureCorrectAnswer:1GlobalRationale:Swelling behind an ear could indicate mastoiditis, and the presence of a feverwould indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.Question8Type:MCMAA 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physicalexamination, the nurse would expect which assessment findings?StandardText:Select all that apply.1.Wheezing2.Increased tactile fremitus3.Decreased vocal resonance4.Decreased tactile fremitus5.BronchophonyCorrectAnswer:1,3,4GlobalRationale:Wheezing is caused by air passing through mucus or fluids in a narrowedlower airway, which is a condition present in asthma exacerbations. The air trapping in the lungsthat occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase intactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensityand clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, whichcauses a decrease in vocal resonance.Question9Type:MCSAThe nurse is caring for a newly-admitted infant diagnosed with failure to thrive. The nurse beginsto implement the healthcare provider prescribed orders by taking blood pressures in all fourextremities. Which congenital cardiac defect does the nurse anticipate based on the prescribedorder?1.Tetralogy of Fallot2.Pulmonary atresia

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3.Coarctation of the aorta4.Ventricular septal defectCorrectAnswer:3Rationale1: Normally, blood pressures in the lower extremities are the same as or higherGlobalRationale:Normally, blood pressures in the lower extremities are the same as or higherthan upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aortacauses decreased blood flow to the lower extremities and thus lower-extremity blood-pressurereadings are significantly lower than upper-extremity readings. There are minimal differencesbetween upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, andventricular septal defect.Question10Type:MCSADuring an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurseevaluating with this action?1.Recent memory2.Languagedevelopment3.Remote memory4.Social-skill developmentCorrectAnswer:3GlobalRationale:Asking children to remember addresses, phone numbers, and dates assessesremote-memory development. To evaluate recent memory the nurse would have the child namesomething and then ask him to name it again in 10 to 15 minutes. Listening to how the child talksand his sentence structure evaluates the childs language development, and assessing how heinteracts with others evaluates social-skill development.Question11Type:MCSADuring the newborn examination, the nurse assesses the infant for signs of developmentaldysplasia of the hip. A finding that would strongly indicate this disorder would be:1.soles are flat with prominent fat pads.2.positive Babinski reflex.3.metatarsus varus.4.asymmetric thigh and gluteal folds.CorrectAnswer:4Rationale1: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsusvarus is an in-toeing of the feet that usually occurs secondary to intra-uterinepositioning andfrequently resolves on its own, but approximately 10 percent of infants with metatarsus varusalso have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positivefinding for developmental dysplasia of the hip requiring follow-up with ultrasound.Rationale2: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsusvarus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning andfrequently resolves on its own, but approximately 10 percent of infants with metatarsus varusalso have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positivefinding for developmental dysplasia of the hip requiring follow-up with ultrasound.

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Rationale3: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsusvarus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning andfrequently resolves on its own, but approximately 10 percent of infants with metatarsus varusalso have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positivefinding for developmental dysplasia of the hip requiring follow-up with ultrasound.Rationale4: A positive Babinski reflex and flatsoles are normal newborn findings. Metatarsusvarus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning andfrequently resolves on its own, but approximately 10 percent of infants with metatarsus varusalso have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positivefinding for developmental dysplasia of the hip requiring follow-up with ultrasound.Question12Type:MCSAThe nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first?1.A child with a temperature of 101 degrees F2.A child who has stridor3.A child who has absent Babinski sign4.A child who has a pot belly appearanceCorrectAnswer:2GlobalRationale:A child with stridor is at risk for airway compromise; a child with atemperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child withan absent Babinski sign and the pot-bellied child are normal.Question13Type:MCSAThe nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart,the nurse would expect to:1.hear a quiet but easily heard murmur.2.hear a moderately loud murmur without a palpable thrill.3.hear a very loud murmur with easily palpable thrill.4.listen without a stethoscope and hear a murmur at chest wall.CorrectAnswer:2GlobalRationale:A quiet but easily heard murmur is a grade II. A moderately loud murmurwithout palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V.A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.Question14Type:MCSAThe nurse is measuring an abdominal girth on a child with abdominal distension. Identify thearea on the childs abdomen where the tape measure should be placed for an accurate abdominalgirth.1.Just above the umbilicus, around the largest circumference of the abdomen2.Below the umbilicus3.Just below the sternum4.Just above the pubic boneCorrectAnswer:1

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GlobalRationale:Anabdominal girth should be taken around the largest circumference of theabdomen, in this case, just above the umbilicus. The circumference below the umbilicus or justbelow the sternum would not be an accurate abdominal girth.Question15Type:MCMAThe nurse is preparing to assessment a toddler client. Which activities would gain cooperationfrom the toddler?StandardText:Select all that apply.1.Asking the parents to wait outside2.Allowing the client to sit in the parents lap3.Administering vaccinations prior to the assessment4.Handing the client a stethoscope while taking the health history5.Making a game out of the assessment processCorrectAnswer:2,4GlobalRationale:Allowing the client to stay on the parents lap and allowing the client to playwith instruments that will be used in the assessment process are activities the nurse canimplement to gain the toddlers cooperation during the assessment process. Asking the parents towait outside may cause the toddler to become fearful. Vaccinations should be administered at theend of the visit. While making a game out of the assessment process may be appropriate for olderchildren, this is not an appropriate strategy for a toddler client.Question16Type:MCMAThe nurse is assessing an infant client during a health supervision visit. Which assessmentfindings are considered normal variations for this client?StandardText:Select all that apply.1.Sucking pads in the mouth2.A rounded chest3.Hearing breath sounds over the entire chest4.Pubertal development5.Knock-kneesCorrectAnswer:1,2,3GlobalRationale:Normal variations for the infant client include sucking pads in the mouth, arounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.Question17Type:MCMAThe nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods areappropriate to monitor the infants growth pattern since birth?StandardText:Select allthat apply.1.Weight the infant twice and average together2.Measure the infants height

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3.Measure the infants head circumference4.Determine the infants body mass index5.Plot the infants growth on appropriate chartCorrectAnswer:1,3,5GlobalRationale:In order to determine the infants growth pattern the nurse will obtain twoweights and average them together, measure the infants head circumference, and obtain theinfants length, not height. After the measurements have been obtained the nurse willplot themeasurements on the appropriate growth chart and monitor the infants growth pattern. Bodymass index is not determined during infancy.18.A5-year-oldchildisintheclinicforacheckup.Thenursewouldexpecthimto:a.Needtobeheldonhismotherslap.b.Beabletositontheexaminationtable.c.Beabletostandonthefloorfortheexamination.d.Beabletoremainaloneintheexaminationroom.ANS:BAt4or5yearsold,achildusuallyfeelscomfortableontheexaminationtable.Olderinfantsandyoungchildrenaged6monthsto2or3yearsshouldbepositionedintheparentslap.19.Whichstatementistrueregardingtherecordingofdatafromthehistoryandphysicalexamination?a.Uselong,descriptivesentencestodocumentfindings.b.Recordthedataassoonaspossibleaftertheinterviewandphysicalexamination.c.Iftheinformationisnotdocumented,thenitcanbeassumedthatitwasdoneasastandardofcare.d.Theexaminershouldavoidtakinganynotesduringthehistoryandexaminationbecauseofthepossibilityofdecreasingtherapportwiththepatient.ANS:BThedatafromthehistoryandphysicalexaminationshouldberecordedassoonaftertheeventaspossible.Fromalegalperspective,ifitisnotdocumented,thenitwasnotdone.Briefnotesshouldbetakenduringtheexamination.Whendocumenting,thenurseshoulduseshort,clearphrasesandavoidredundantphrasesanddescriptions.20.Whenassessingtheneonate,thenurseshouldtestforhipstabilitywithwhichmethod?a.ElicitingtheMororeflexb.PerformingtheRombergtestc.CheckingfortheOrtolanisignd.AssessingthesteppingreflexANS:CThenurseshouldtestforhipstabilityintheneonatebytestingfortheOrtolanisign.Theothertestsarenotappropriatefortestinghipstability.21.Afemalepatienttellsthenursethatshehasfourchildrenandhashadthreepregnancies.Howshouldthenursedocumentthis?

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a.Gravida3,para4b.Gravida4,para3c.Thisinformationcannotbedocumentedusingthetermsgravidaandpara.d.Thepatientseemstobeconfusedabouthowmanytimesshehasbeenpregnant.ANS:AGravidareferstothenumberofpregnancies,andparareferstothenumberofchildren.Onepregnancywaswithtwins.22.Thenurseisdocumentingtheassessmentofaninfant.Duringtheabdominalassessment,thenursenoticedaveryloudsplashauscultatedovertheupperabdomenwhenthenurserockedherfromsidetoside.Thisfindingwouldindicate:a.Epigastrichernia.b.Pyloricobstruction.c.Hypoactivebowelsounds.d.Hyperactivebowelsounds.ANS:DAsuccussionsplash,whichisunrelatedtoperistalsis,isaveryloudsplashauscultatedovertheupperabdomenwhentheinfantisrockedsidetoside.Itindicatesincreasedairandfluidinthestomachasobservedwithpyloricobstructionorlargehiatushernia23.Whichoftheseactionsismostappropriatetoperformona9-month-oldinfantatawell-childcheckup?a.TestingforOrtolanisignb.Assessmentforstereognosisc.Bloodpressuremeasurementd.AssessmentforthepresenceofthestartlereflexANS:AUntiltheageof12months,theinfantshouldbeassessedforOrtolanisign.IfOrtolanisignispresent,thenitcouldindicatethepresenceofadislocatedhip.Theothertestsarenotappropriatefora9-month-oldchild.Chapter 4 Making Newborn RoundsMULTIPLECHOICE1.Whatisafunctionofbrownadiposetissue(BAT)innewborns?a.Generatesheatfordistributiontootherpartsofbodyb.Providesreadysourceofcaloriesinthenewbornperiodc.Protectsnewbornsfrominjuryduringthebirthprocessd.Insulatesthebodyagainstloweredenvironmentaltemperature

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ANS:ABrownfatisauniquesourceofheatfornewborns.Ithasalargercontentofmitochondrialcytochromesandagreatercapacityforheatproductionthroughintensifiedmetabolicactivitythandoesordinaryadiposetissue.Heatgeneratedinbrownfatisdistributedtootherpartsofthebodybytheblood.Itiseffectiveonlyinheatproduction.Brownfatislocatedinsuperficialareassuchasbetweenthescapulae,aroundtheneck,intheaxillae,andbehindthesternum.Theseareasshouldnotprotectthenewbornfrominjuryduringthebirthprocess.Thenewbornhasathinlayerofsubcutaneousfat,whichdoesnotprovideforconservationofheat.2.Whichcharacteristicisrepresentativeofafull-termnewbornsgastrointestinaltract?a.Transittimeisdiminished.b.Peristalticwavesarerelativelyslow.c.Pancreaticamylaseisoverproduced.d.Stomachcapacityisverylimited.ANS:DNewbornsrequirefrequentsmallfeedingsbecausetheirstomachcapacityisverylimited.Anewbornscolonhasarelativelysmallvolumeandresultingincreasedbowelmovements.Peristalticwavesarerapid.Adeficiencyofpancreaticlipaselimitstheabsorptionoffats.3.Whichtermisusedtodescribeanewbornsfirststool?a.Miliab.Milkstoolc.Meconiumd.TransitionalANS:CMeconiumiscomposedofamnioticfluidanditsconstituents,intestinalsecretions,shedmucosalcells,andpossiblyblood.Itisanewbornsfirststool.Miliainvolvesdistendedsweatglandsthatappearasminutevesicles,primarilyontheface.Milkstoolusuallyoccursbythefourthday.Theappearancevariesdependingonwhetherthenewbornisbreastorformulafed.Transitionalstoolsusuallyappearbythethirddayafterthebeginningoffeeding.Theyareusuallygreenishbrowntoyellowishbrown,thin,andlessstickythanmeconium.4.Intermnewborns,thefirstmeconiumstoolshouldoccurnolaterthanwithinhowmanyhoursafterbirth?a.6b.8c.12d.24ANS:DThefirstmeconiumstoolshouldoccurwithinthefirst24hours.Itmaybedelayedupto7daysinverylowbirth-weightnewborns.5.Whichistrueregardinganinfantskidneyfunction?a.Conservationoffluidandelectrolytesoccurs.b.Urinehascolorandodorsimilartotheurineofadults.

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c.Theabilitytoconcentrateurineislessthanthatofadults.d.Normally,urinationdoesnotoccuruntil24hoursafterdelivery.ANS:CAtbirth,allstructuralcomponentsarepresentintherenalsystem,butthereisafunctionaldeficiencyinthekidneysabilitytoconcentrateurineandtocopewithconditionsoffluidandelectrolytestresssuchasdehydrationoraconcentratedsoluteload.Infantsurineiscolorlessandodorless.Thefirstvoidingusuallyoccurswithin24hoursofdelivery.Newbornsvoidwhenthebladderisstretchedto15ml,resultinginabout20voidingsperday.6.TheApgarscoreofaninfant5minutesafterbirthis8.Whichisthenursesbestinterpretationofthis?a.Resuscitationislikelytobeneeded.b.Adjustmenttoextrauterinelifeisadequate.c.Additionalscoringin5moreminutesisneeded.d.Maternalsedationoranalgesiacontributedtothelowscore.ANS:BTheApgarreflectsaninfantsstatusinfiveareas:heartrate,respiratoryeffort,muscletone,reflexirritability,andcolor.Ascoreof8to10indicatesanabsenceofdifficultyadjustingtoextrauterinelife.Scoresof0to3indicateseveredistress,andscoresof4to7indicatemoderatedifficulty.Allinfantsarerescoredat5minutesoflife,andascoreof8isnotindicativeofdistress;thenewborndoesnothavealowscore.TheApgarscoreisnotusedtodeterminetheinfantsneedforresuscitationatbirth.7.Whichstatementbestrepresentsthefirststageorthefirstperiodofreactivityintheinfant?a.Beginswhenthenewbornawakesfromadeepsleepb.Isanexcellenttimetoacquainttheparentswiththenewbornc.Endswhentheamountsofrespiratorymucushavedecreasedd.ProvidestimeforthemothertorecoverfromthechildbirthprocessANS:BDuringthefirstperiodofreactivity,theinfantisalert,criesvigorously,maysuckhisorherfistgreedily,andappearsinterestedintheenvironment.Theinfantseyesareusuallywideopen,suggestingthatthisisanexcellentopportunityformother,father,andinfanttoseeeachother.Thesecondperiodofreactivitybeginswhentheinfantawakesfromadeepsleepandendswhentheamountsofrespiratorymucushavedecreased.Themothershouldsleepandrecoverduringthesecondstage,whentheinfantissleeping.8.Whichstatementreflectsaccurateinformationaboutpatternsofsleepandwakefulnessinthenewborn?a.Statesofsleepareindependentofenvironmentalstimuli.b.Thequietalertstageisthebeststagefornewbornstimulation.c.Cyclesofsleepstatesareuniforminnewbornsofthesameage.d.Muscletwitchesandirregularbreathingarecommonduringdeepsleep.ANS:B

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Duringthequietalertstage,thenewbornseyesarewideopenandbright.Thenewbornrespondstotheenvironmentbyactivebodymovementandstaringatclose-rangeobjects.Newbornsabilitytocontroltheirowncyclesdependontheirneurobehavioraldevelopment.Eachnewbornhasanindividualcycle.Muscletwitchesandirregularbreathingarecommonduringlightsleep.9.Thenurseobservesthatanewmotheravoidsmakingeyecontactwithherinfant.Whatshouldthenursedo?a.Askthemotherwhyshewontlookattheinfant.b.Examinetheinfantseyesfortheabilitytofocus.c.Assessthemotherforotherattachmentbehaviors.d.Recognizethisasacommonreactioninnewmothers.ANS:CAttachmentbehaviorsarethoughttoindicatetheformationofemotionalbondsbetweenthenewbornandmother.Amothersfailuretomakeeyecontactwithherinfantmayindicatedifficultieswiththeformationofemotionalbonds.Thenurseshouldperformamorethoroughassessment.Askingthemotherwhyshewillnotlookattheinfantisaconfrontationalresponsethatmightputthemotherinadefensiveposition.Infantsdonothavebinocularityandcannotfocus.Avoidingeyecontactisanuncommonreactioninnewmothers.10.Whichshouldthenurseusewhenassessingthephysicalmaturityofanewborn?a.Lengthb.Apgarscorec.Postureatrestd.ChestcircumferenceANS:CWiththenewbornquietandinasupineposition,thedegreeofflexioninthearmsandlegscanbeusedfordeterminationofgestationalage.Lengthandchestcircumferencereflectthenewbornssizeandweight,whichvaryaccordingtoraceandgender.Birthweightaloneisapoorindicatorofgestationalageandfetalmaturity.TheApgarscoreisanindicationofthenewbornsadjustmenttoextrauterinelife.11.Whatisthegrayishwhite,cheeselikesubstancethatcoversthenewbornsskin?a.Miliab.Meconiumc.Amnioticfluidd.VernixcaseosaANS:DThevernixcaseosaisthegrayishwhite,cheeselikesubstancethatcoversanewbornsskin.12.Whatismostdescriptiveoftheshapeoftheanteriorfontanelinanewborn?a.Circleb.Squarec.Triangled.Diamond

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ANS:DTheanteriorfontanelisdiamondshapedandmeasuresfrombarelypalpableto4to5cm.Theshapeoftheposteriorfontanelisatriangle.Neitherofthefontanelsisacircleorasquare.13.WhichtermdescribesirregularareasofdeepbluepigmentationseenpredominantlyininfantsofAfrican,Asian,NativeAmerican,orHispanicdescent?a.Acrocyanosisb.Mongolianspotsc.Erythematoxicumd.HarlequincolorchangeANS:BMongolianspotsareirregularareasofdeepbluepigmentation,whicharecommonvariationsfoundinnewbornsofAfrican,Asian,NativeAmerican,orHispanicdescent.Acrocyanosisiscyanosisofthehandsandfeet;thisisausualfindingininfants.Erythematoxicumisapinkpapularrashwithvesiclesthatmayappearin24to48hoursandresolveafterseveraldays.Harlequincolorchangesareclearlyoutlinedareasofcolorchange.Astheinfantliesonaside,thelowerhalfofthebodybecomespink,andtheupperhalfispale.14.Thenurseshouldexpecttheapicalheartrateofastabilizednewborntobeinwhichrange?a.60to80beats/minb.80to100beats/minc.120to140beats/mind.160to180beats/minANS:CThepulserateofthenewbornvarieswithperiodsofreactivity.Usuallythepulserateisbetween120and140beats/min.Sixtyto100beats/ministooslowforanewborn,and160to180beats/ministoofastforanewborn.15.Whichfindinginthenewbornisconsideredabnormal?a.Nystagmusb.Profusedroolingc.Darkgreenorblackstoolsd.SlightvaginalreddishdischargeANS:BProfusedroolingandsalivationarepotentialsignsofamajorabnormality.Newbornswithesophagealatresiacannotswallowtheiroralsecretions,resultinginexcessivedrooling.Nystagmusisaninvoluntarymovementoftheeyes.Thisisacommonvariationinnewborns.Meconium,thefirststoolofnewborns,isdarkgreenorblack.Apseudomenstruationmaybepresentinnormalnewborns.Thisisablood-tingedormucoidvaginaldischarge.16.Whendoingthefirstassessmentofamalenewborn,thenursenotesthatthescrotumislarge,edematous,andpendulous.Whatshouldthisbeinterpretedas?a.Ahydroceleb.Aninguinalhernia

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c.Anormalfindingd.AnabsenceoftestesANS:CAlarge,edematous,andpendulousscrotuminatermnewborn,especiallyinthoseborninabreechposition,isanormalfinding.Ahydroceleisfluidinthescrotum,usuallyunilateral,whichusuallyresolveswithinafewmonths.Aninguinalherniamayormaynotbepresentatbirth.Itismoreeasilydetectedwhenthechildiscrying.Thepresenceorabsenceoftestesshouldbedeterminedonpalpationofthescrotumandinguinalcanal.Absenceoftestesmaybeanindicationofambiguousgenitalia.17.Whyarerectaltemperaturesnotrecommendedinnewborns?a.Theyareinaccurate.b.Theydonotreflectcorebodytemperature.c.Theycancauseperforationofrectalmucosa.d.Theytaketoolongtoobtainanaccuratereading.ANS:CRectaltemperaturesareavoidedinnewborns.Ifdoneincorrectly,theinsertionofathermometerintotherectumcancauseperforationofthemucosa.Thetimeittakestodeterminebodytemperatureisrelatedtotheequipmentused,notonlytheroute.18.Whichisthenameofthesutureseparatingtheparietalbonesatthetopofanewbornshead?a.Frontalb.Sagittalc.Coronald.OccipitalANS:BThesagittalsutureseparatestheparietalbonesatthetopofthenewbornshead.Thefrontalsutureseparatesthefrontalbones.Thecoronalsutureissaidtocrownthehead.Thelambdoidsutureisatthemarginoftheparietalandoccipital.19.Thenurseobservesflaringofnaresinanewborn.Whatshouldthisbeinterpretedas?a.Nasalocclusionb.Signofrespiratorydistressc.Snufflesofcongenitalsyphilisd.AppropriatenewbornbreathingANS:BNasalflaringisanindicationofrespiratorydistress.Anasalocclusionshouldpreventthechildfrombreathingthroughthenose.Becausenewbornsareobligatorynosebreathers,thisshouldrequireimmediatereferral.Snufflesareindicatedbyathick,bloodynasaldischargewithoutsneezing.Sneezingandthin,whitemucusdrainagearecommoninnewbornsandarenotrelatedtonasalflaring.20.Thenurseisassessingthereflexesofanewborn.Strokingtheoutersoleofthefootassesseswhichreflex?

Pediatric Primary Care: Practice Guidelines for Nurses 3rd Edition Test Bank - Page 30 preview image

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a.Graspb.Perezc.Babinskid.DanceorstepANS:CThisisadescriptionoftheBabinskireflex.Strokingtheoutersoleofthefootupwardfromtheheelacrosstheballofthefootcausesthebigtoestodorsiflexandtheothertoestohyperextend.Thisreflexpersistsuntilapproximatelyage1yearorwhenthenewbornbeginstowalk.Thegraspreflexiselicitedbytouchingthepalmsorsolesatthebaseofthedigits.Thedigitswillflexorgrasp.ThePerezreflexinvolvesstrokingthenewbornsbackwhenprone;thechildflexestheextremities,elevatingtheheadandpelvis.Thisdisappearsatages4to6months.Whenthenewbornisheldsothatthesoleofthefoottouchesahardsurface,thereisareciprocalflexionandextensionoftheleg,simulatingwalking.Thisreflexdisappearsbyages3to4weeks.21.Whichismostimportantintheimmediatecareofthenewborn?a.Maintainapatentairway.b.Administerprophylacticeyecare.c.Maintainastablebodytemperature.d.Establishidentificationofthemotherandbaby.ANS:AMaintainingapatentairwayistheprimaryobjectiveinthecareofthenewborn.First,thepharynxisclearedwithabulbsyringefollowedbythenasalpassages.Administeringprophylacticeyecareandestablishingidentificationofthemotherandbabyareimportantfunctions,butphysiologicstabilityisthefirstpriorityintheimmediatecareofthenewborn.Conservingthenewbornsbodyheatandmaintainingastablebodytemperatureareimportant,butapatentairwaymustbeestablishedfirst.22.Whatshouldnursinginterventionstomaintainapatentairwayinanewborninclude?a.Positioningthenewbornsupineafterfeedings.b.Wrappingthenewbornassnuglyaspossible.c.Placingthenewborntosleepintheprone(onabdomen)position.d.Usingabulbsyringetosuctionasneeded,suctioningthenosefirstandthenthepharynx.ANS:APositioningthenewbornsupineafterfeedingsisrecommendedbytheAmericanAcademyofPediatricstopreventsuddennewborndeathsyndrome.Thechildcanbewrappedsnuglybutshouldbeplacedonthesideorback.Placinganewborntosleepintheprone(onabdomen)positionisnotadvisedbecauseofthepossiblelinkbetweensleepinginthepronepositionandsuddennewborndeathsyndrome.Abulbsyringeshouldbekeptbythebedsideifnecessary,butthepharynxshouldbesuctionedbeforethenose.23.Thenursequicklydriesthenewbornafterdelivery.Thisistoconservethenewbornsbodyheatbypreventingheatlossthroughwhichmethod?a.Radiationb.Conduction

Pediatric Primary Care: Practice Guidelines for Nurses 3rd Edition Test Bank - Page 31 preview image

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c.Convectiond.EvaporationANS:DEvaporationisthelossofheatthroughmoisture.Thenewbornshouldbequicklydriedoftheamnioticfluid.Radiationisthelossofheattoacoolersolidobject.Thecoldairfromeitherthewindowortheairconditionerwillcoolthewallsoftheincubatorandsubsequentlythebodyofthenewborn.Conductioninvolvesthelossofheatfromthebodybecauseofdirectcontactoftheskinwithacoolerobject.Convectionissimilartoconductionbutisthelossofheataidedbyaircurrents.24.Aninfantisbeingdischargedat48hoursofage.Theparentsaskhowtheinfantshouldbebathedthisfirstweekhome.Whichisthebestrecommendationbythenurse?a.Bathetheinfantdailywithmildsoap.b.Bathetheinfantdailywithanalkalinesoap.c.Bathetheinfanttwoorthreetimesthisweekwithmildsoap.d.Bathetheinfanttwoorthreetimesthisweekwithplainwater.ANS:DAnewborninfantsskinhasapHofapproximately5.ThisacidicpHhasabacteriostaticeffect.Theparentsshouldbetaughttouseonlyplainwarmwaterforthebathandtobathetheinfantnomorethantwoorthreetimesthefirst2weeks.Soapsarealkaline.Theywillaltertheacidmantleoftheinfantsskin,providingamediumforbacterialgrowth.25.Thestumpoftheumbilicalcordusuallydropsoffinhowmanydays?a.3to6b.10to14c.16to21d.24to28ANS:BTheaverageumbilicalcordseparatesin10to14days.Threeto6daysistoosoon,and16to28daysistoolate.26.Theparentsofaninfantplantohavehimcircumcised.Theyaskthenurseaboutpainassociatedwiththisprocedure.Thenursesresponseshouldbebasedonwhich?a.Thatinfantsexperiencepainwithcircumcisionb.Thatinfantsaretooyoungforanesthesiaoranalgesiac.Thatinfantsdonotexperiencepainwithcircumcisiond.ThatinfantsquicklyforgetaboutthepainofcircumcisionANS:ACircumcisionisasurgicalprocedure.TheAmericanAcademyofPediatricshasrecommendedthatproceduralanalgesiabeprovidedwhencircumcisionisperformed.Thepaininfantsexperiencewithsurgicalprocedurescanbealleviatedwithanalgesia.Infantswhoundergocircumcisionwithoutanestheticagentsreactmoreintenselytoimmunizationinjectionsat4to6monthsofagecomparedwithinfantswhohadananesthetic.

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