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Maternal/child Chapter 20 Neurological Development, Disorde... Neurological and sensory disorder OB Exa
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A 6-month-old infant with congestive heart Apical heart rate of 60.
failure (CHF) is receiving digoxin elixir.
Which observation by the nurse warrants A heart rate of 60 (A) is much lower than normal for a 6-month-old and warrants
immediate intervention? immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 BPM
Apical heart rate of 60. when awake, and a rate of 70 while sleeping is considered within normal limits. (B
Sweating across the forehead. and C) are expected symptoms of heart failure in an infant. (D) is within normal limits
Doesn't suck well. for an infant.
Respiratory rate of 30 breaths per minute.
The nurse is teaching the parents of a 5- Administer aerosol therapy followed by postural drainage before meals.
year-old with cystic fibrosis about
respiratory treatments. Which statement Postural drainage for a child with cystic fibrosis is most effective when performed
indicates to the nurse that the parents after nebulization and before meals (C) or at least 1 hour after eating to prevent
understand? nausea and vomiting. Postural drainage uses gravity to promote mucous removal
Perform postural drainage before starting after nebulization (A) treatments which open the airways. Pulmonary toileting or
aerosol therapy. respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).
Give respiratory treatments when the child
is coughing a lot.
Administer aerosol therapy followed by
postural drainage before meals.
Ensure respiratory therapy is done daily
during any respiratory infection.
A female teenager is taking oral Use sunscreen when lying by the pool.
tetracycline HCL (Achromycin V) for acne
vulgaris. What is the most important Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy.
instruction for the nurse to include in this Severe sunburn can occur with minimal sun exposure and clients should be
client's teaching plan? instructed to avoid sunlight and to use sunscreen (A). (B and D) are not related to
Use sunscreen when lying by the pool. tetracycline HCL (Achromycin V) therapy. (C) should be avoided because dairy
Cleanse the skin at least 4 times a day. products interfere with the absorption of tetracyclines.
Take the medication with a glass of milk.
Menstrual periods may become irregular.
,What preoperative nursing intervention Observe for projectile vomiting.
should be included in the plan of care for
an infant with pyloric stenosis? Projectile vomiting (D), which contributes to metabolic alkalosis (A), is the classic sign
Monitor for signs of metabolic acidosis. of pyloric stenosis. (B) is not indicated. (C) is dangerous, due to the potential for
Estimate the quantity of diarrhea stools. aspiration with frequent vomiting.
Place in a supine position after feeding.
Observe for projectile vomiting.
An infant is born with a ventricular septal Prevent the return of oxygenated blood to the lungs.
defect (VSD) and surgery is planned to
correct the defect. The nurse recognizes Closure of VSDs stops oxygenated blood from being shunted from the left ventricle
that surgical correction is designed to to the right ventricle (C). VSDs are acyanotic defects, which means that no
achieve which outcome? unoxygenated blood enters the systemic circulation (A and B). (D) is common with
Stop the flow of unoxygenated blood into Tetrology of Fallot, which is a cyanotic defect.
systemic circulation.
Increase the flow of unoxygenated blood
to the lungs.
Prevent the return of oxygenated blood to
the lungs.
Reduce peripheral tissue hypoxia and
nailbed clubbing
A 3-week-old newborn is brought to the A. Monitor the the infant's weight and number of wet diapers per day.
clinic for follow-up after a home birth. The B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
mother reports that her child bottle feeds D. Allow the infant to rest and refeed on demand or every 2 hours.
for 5 minutes only and then falls asleep. The E. Use a softer nipple or increase the size of the nipple opening.
nurse auscultates a loud murmur
characteristic of a ventricular septal defect Antibiotic prophylaxis is recommended for infants with VSDs, but should not be
(VSD), and finds the newborn is acyanotic mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is
with a respiratory rate of 64 breaths per consumed.
minute. What instruction should the nurse
provide the mother to ensure the infant is They should be monitored for weight gain and at least 6 wet diapers per day (A). A
receiving adequate intake? (Select all that one-month old infant should ingest 2 to 4 ounces of formula per feeding and
apply.) progress to about 30 ounces per day by 4-months of age (B)
A. Monitor the the infant's weight and
number of wet diapers per day.
B. Increase the infant's intake per feeding
by 1 to 2 ounces per week.
C. Mix the dose of prophylactic antibiotic
in a full bottle of formula.
D. Allow the infant to rest and refeed on
demand or every 2 hours.
E. Use a softer nipple or increase the size
of the nipple opening.
Preoperative nursing care for a child with Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."
Wilms' tumor should include which
intervention? Prevention of abdominal palpation (D) minimizes the risk of rupturing the
Gently percuss the abdomen for evidence encapsulated tumor and subsequent metastasis. (A) is unnecessary, and this action
of trapped air. could traumatize the tumor in the same manner as palpation. (B and C) are incorrect
Observe the abdomen for any noticeable since the abdomen is not discolored and cold compresses are not indicated.
discolorations.
Apply cold compresses to the abdomen to
reduce edema.
Put a sign on the bed reading, "DO NOT
PALPATE ABDOMEN."
, At 8 a.m. the unlicensed assistive personnel Administer PRN prescription of nifedipine (Procardia) sublingually.
(UAP) informs the charge nurse that a
female adolescent client with acute Sublingual Procardia (B) lowers blood pressure very quickly, and this should be done
glomerulonephritis has a blood pressure of first. (A) may also be done, but oral diuretics do not work as rapidly as the sublingual
210/110. The 4 a.m. blood pressure reading antihypertensive. When notifying the healthcare provider, the first thing he/she will
was 170/88. The client reports to the UAP want to know is if the PRN antihypertensive has been administered (C). (D) does not
that she is upset because her boyfriend did consider the seriousness of this finding. The nurse should stay with the client until the
not visit last night. What action should the blood pressure is reduced.
nurse take first?
Give the client her 9 a.m. prescription for
an oral diuretic early.
Administer PRN prescription of nifedipine
(Procardia) sublingually.
Notify the healthcare provider and inform
the nursing supervisor of the client's
condition.
Attempt to calm the client and retake the
blood pressure in thirty minutes.
The nurse is assessing an 8-month-old child Clubbed fingers.
who has a medical diagnosis of Tetrology
of Fallot. Which symptom is this client most Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D)
likely to exhibit? due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart
Bradycardia. disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of
Machinery murmur. coarctation of the aorta.
Weak pedal pulses.
Clubbed fingers.
Surgery is being delayed for an infant with A trial of human chorionic gonadotrophic hormone.
undescended testes. In collaboration with
the healthcare provider and the family, A trial of HCG (human chorionic gonadotrophic hormone) (C) may aid in testicular
which prescription should the nurse descent, but does not replace surgical repair for true undescended testes.
anticipate? Undescended testes (cryptorchidism) may be found in the inguinal canal due to
A trial of adrenocorticotrophic hormone exaggerated cremasteric reflex. (A) is not indicated. Stimulation of the cremasteric
injections. reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may
Frequent stimulation of the cremasteric relax the cremasteric muscle, but may not cause the testes to descend.
reflex.
A trial of human chorionic gonadotrophic
hormone.
Frequent warm baths to gently dilate the
scrotal area.
Concern for body integrity.
A preschool-age child who is hospitalized
for hypospadias repair is most strongly
The preschooler's major stressor is concern for his body integrity (C). He fears that
influenced by which behavior?
his "insides will leak out." A child undergoing surgery to his genitalia is even more
Ability to communicate verbally.
concerned about body integrity. The preschooler is quite verbal, so comprehension
Response to separation from family.
of the words he uses or hears may be inaccurate, while his imagination and fears may
Concern for body integrity.
fantasize the reality (A). (B) is a concern for all children, but of most concern to the
Socialization with other children.
toddler. (D) is not a prime concern in this situation.