Maternal and Child Health Nursing Exam Notes
The nurse is preparing to assess a toddler during a routine health maintenance
visit. Which assessment will the nurse perform to determine the child's growth
milestone?
I) Blood pressure
J) Urine specimen
K) Hemoglobin level
L) Height and weight
Ans: D
Feedback (Response):
Growth milestones are assessed at every health maintenance visit and are determined by
measuring height and weight. Blood pressure does not assess a growth milestone. A
urine specimen would be done at specific times. A hemoglobin level would be
determined during specific times. Urine specimens and hemoglobin levels do not
measure growth milestones.
A mother brings a 15-month-old child to the clinic for a routine health maintenance
visit. Which immunization should the nurse prepare to administer to this child?
M) MMR
N) Rinne test
O) Oral polio
P) Hepatitis A
Ans: A Feedback
(Response):
The measles-mumps-rubella (MMR) vaccine is administered at either the 12-month or
15-month visit. Rinne test is not an immunization but rather a test for hearing. The oral
polio vaccination is not listed as an immunization needed for toddlers. Hepatitis A
vaccination is given at either the 12-month or 18-month visit.
The mother of a 2-year-old child tells the nurse that she is constantly scolding the child
for having wet pants. The child was toilet trained at 12 months, but since walking, the
child wets all of the time. Which nursing diagnosis should the nurse use guide
instruction for the mother?
Q) Total urinary incontinence related to delayed toilet training
R) Excess fluid volume related to inability to control urination
S) Ineffective coping related to lack of self-control of 2-year-old
T) Deficient parental knowledge related to inappropriate method for toilet
training Ans: D
Feedback (Response):
The mother is having difficulty understanding the principles of toilet training. The
diagnosis of deficient parental knowledge about toilet training is the most appropriate
for the nurse to use to guide instruction for the mother. The child is not experiencing
total urinary incontinence. The child does not have an excess in fluid volume. The
mother is not demonstrating ineffective coping.
, Maternal and Child Health Nursing Exam Notes
The nurse is identifying outcomes for a family with a preschool-age child who has
broken fluency. Which outcome would be the most appropriate for this family?
A) The parents will not call attention to the child's broken fluency.
B) The mother will encourage the child to practice speaking in the home.
C) The other children will help the child by finishing words and sentences.
D) The mother will correct the child only when other family members are absent.
Ans: A
Feedback (Response):
Calling attention to broken fluency can make the situation worse. The child should not
be encouraged to speak if he or she does not want to. The parents should intercept any
children who desire to finish the child with broken fluency's words or sentences. The
child should not be punished or corrected for broken fluency because this is a normal
part of speech development.
The nurse is helping parents develop the developmental task of initiative in their
preschool-age child. Which activity should the nurse suggest the parents implement?
E) Teach the child street-crossing safety.
F) Help the child learn how to follow rules.
G) Allow the child to experiment with molding clay.
H) Provide the child with clothes that snap rather than
button. Ans: C
Feedback (Response):
To gain a sense of initiative, preschoolers need exposure to a wide variety of play
materials so they can learn as much about how things work as possible. The parents
should be urged to provide play materials that encourage creative play such as modeling
clay. Any experience with free-form play is helpful. Street-crossing safety, following
rules, and providing clothes that snap will not support the developmental task of
initiative as much as providing a substance to experiment during play.
The nurse is preparing to assess a toddler during a routine health maintenance
visit. Which assessment will the nurse perform to determine the child's growth
milestone?
I) Blood pressure
J) Urine specimen
K) Hemoglobin level
L) Height and weight
Ans: D
Feedback (Response):
Growth milestones are assessed at every health maintenance visit and are determined by
measuring height and weight. Blood pressure does not assess a growth milestone. A
urine specimen would be done at specific times. A hemoglobin level would be
determined during specific times. Urine specimens and hemoglobin levels do not
measure growth milestones.
A mother brings a 15-month-old child to the clinic for a routine health maintenance
visit. Which immunization should the nurse prepare to administer to this child?
M) MMR
N) Rinne test
O) Oral polio
P) Hepatitis A
Ans: A Feedback
(Response):
The measles-mumps-rubella (MMR) vaccine is administered at either the 12-month or
15-month visit. Rinne test is not an immunization but rather a test for hearing. The oral
polio vaccination is not listed as an immunization needed for toddlers. Hepatitis A
vaccination is given at either the 12-month or 18-month visit.
The mother of a 2-year-old child tells the nurse that she is constantly scolding the child
for having wet pants. The child was toilet trained at 12 months, but since walking, the
child wets all of the time. Which nursing diagnosis should the nurse use guide
instruction for the mother?
Q) Total urinary incontinence related to delayed toilet training
R) Excess fluid volume related to inability to control urination
S) Ineffective coping related to lack of self-control of 2-year-old
T) Deficient parental knowledge related to inappropriate method for toilet
training Ans: D
Feedback (Response):
The mother is having difficulty understanding the principles of toilet training. The
diagnosis of deficient parental knowledge about toilet training is the most appropriate
for the nurse to use to guide instruction for the mother. The child is not experiencing
total urinary incontinence. The child does not have an excess in fluid volume. The
mother is not demonstrating ineffective coping.
, Maternal and Child Health Nursing Exam Notes
The nurse is identifying outcomes for a family with a preschool-age child who has
broken fluency. Which outcome would be the most appropriate for this family?
A) The parents will not call attention to the child's broken fluency.
B) The mother will encourage the child to practice speaking in the home.
C) The other children will help the child by finishing words and sentences.
D) The mother will correct the child only when other family members are absent.
Ans: A
Feedback (Response):
Calling attention to broken fluency can make the situation worse. The child should not
be encouraged to speak if he or she does not want to. The parents should intercept any
children who desire to finish the child with broken fluency's words or sentences. The
child should not be punished or corrected for broken fluency because this is a normal
part of speech development.
The nurse is helping parents develop the developmental task of initiative in their
preschool-age child. Which activity should the nurse suggest the parents implement?
E) Teach the child street-crossing safety.
F) Help the child learn how to follow rules.
G) Allow the child to experiment with molding clay.
H) Provide the child with clothes that snap rather than
button. Ans: C
Feedback (Response):
To gain a sense of initiative, preschoolers need exposure to a wide variety of play
materials so they can learn as much about how things work as possible. The parents
should be urged to provide play materials that encourage creative play such as modeling
clay. Any experience with free-form play is helpful. Street-crossing safety, following
rules, and providing clothes that snap will not support the developmental task of
initiative as much as providing a substance to experiment during play.
