Complete Study guide
The nurse judges teaching as successful when the parent of a child with myasthenia gravis
states which of the following? Select all that apply.
1. “My child should play on the school’s basketball team.”
2. “My child should meditate every day.”
3. “My child should be allowed to do what other kids do.”
4. “My child should be watched carefully for signs of illness.”
5. “My child should sleep in my room so that I can watch him better.”
3, 4.
1. Children with myasthenia gravis should not
play strenuous sports. The increased stress from being in a competitive sport tends to
negatively impact children, and they should learn strategies to decrease stress.
2. It is important that children with myasthenia gravis have activities they can participate in
without causing stress. Activities such as board games, horseback riding, and hiking should be
encouraged. Some children would benefit from meditation but may take time to appreciate the
results.
3. Children with myasthenia gravis can do many things other children do. They should be
advised not to play strenuous sports, and they should learn how to control stress.
4. Children are watched for signs of illness because of the exacerbation of signs of myasthenia
gravis.
5. It’s not recommended that children sleep in the same bedroom as their parents unless it
can’t be avoided.
TEST-TAKING HINT: The test taker must know the physiology of the illness and consider that this
is a chronic disease. The child is first a child, so he will have all the growth and development
issues children without a chronic disease have.
,The parent of a newborn asks, "Will my baby spit out the formula if it is too hot or too cold?"
Which is the nurse's best response?
1. "Babies have a tendency to reject hot fluids but not cold fluids, which could result in
abdominal discomfort."
2. "Babies have a tendency to reject cold fluids but not hot fluids, which could result in
esophageal burns."
3. "Your baby would most likely spit out formula that was too hot, but your baby could
swallow some of it, which could result in a burn."
4. "Your baby is too young to be physically capable of spitting out fluids and will automatically
swallow anything."
1. Swallowing is a reflex in neonates; infants younger than 6 weeks cannot voluntarily control
swallowing.
2. Swallowing is a reflex in neonates; infants younger than 6 weeks cannot voluntarily control
swallowing.
3. The infant is not capable of selectively rejecting fluid because swallowing is a reflex until 6
weeks.
4. Swallowing is a reflex in infants younger than 6 weeks.
TEST-TAKING HINT: Swallowing is a reflex that is present until the age of 6 weeks. The test taker
should eliminate answers 1, 2,and 3 because they suggest that the infant is capable of
selectively rejecting fluids.
,The mother of a newborn asks the nurse why the infant has to nurse so frequently. Which is
the best response?
1. Formula tends to be more calorically dense, and formula-fed babies require fewer feedings
than breastfed babies.
2. The newborn's stomach capacity is small, and peristalsis is slow.
3. The newborn's stomach capacity is small, and peristalsis is more rapid than in older children.
4. Breastfed babies tend to take longer to complete a feeding than formula-fed babies.
1. The caloric content of breast milk and formula tends to be similar.
2. Peristalsis in infants is greater than in older
children.
3. The small-stomach capacity and rapid movement of fluid through the digestive system
account for the need for small, frequent feedings.
4. Breastfed babies and formula-fed babies do not necessarily have a difference in feeding time.
TEST-TAKING HINT: The test taker should eliminate answers 1 and 4 because they both form
generalizations that are not supported by current literature.
A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is fussy, and the
anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying.
Which task will help confirm the diagnosis of dehydration?
1. Urinalysis obtained by bagged specimen.
, 2. Urinalysis obtained by sterile catheterization.
3. Analysis of serum electrolytes.
4. Analysis of cerebrospinal fluid.
1. The information obtained from a urinalysis of an infant is not as helpful as serum electrolytes.
The infant has limited ability to concentrate urine, so the specific gravity is not usually affected.
2. The information obtained from a urinalysis of an infant is not as helpful as serum electrolytes.
The infant has limited ability to concentrate urine, so the specific gravity is not usually affected.
A urinalysis does not need to be obtained by catheterization.
3. The analysis of serum electrolytes offers the most information and assists with the diagnosis
of dehydration.
4. Although critical in diagnosing meningitis, a lumber puncture and analysis of cerebrospinal
fluid are not done to confirm dehydration.
TEST-TAKING HINT: Infants have limited ability to concentrate urine, so answers 1 and 2 can be
eliminated immediately.
A 4-month-old is brought to the emergency department with severe dehydration. The heart
rate is 198, and her blood pressure is 68/38. The infant's anterior fontanel is sunken. The
nurse notes that the infant does not cry when the intravenous line is inserted. The child's
parents state that she has not "held anything down" in 18 hours. The nurse obtains a finger-
stick blood sugar of 94. Which would the nurse expect to do immediately?
1. Administer a bolus of normal saline.
2. Administer a bolus of D10W.
3. Administer a bolus of normal saline with 5% dextrose added to the solution.