Child Nursing

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: a. Hypoglycemia. c. Respiratory distress syndrome. b. Phrenic nerve...

Thermoregulation is not well developed in infants. As a result, babies are at risk for hypothermia. Kangaroo care is an effective way to prevent hypothermia in the infant. In this method, an unclothed, diapered infant is placed on the mother's bare chest. This provides physiological warmth to the infant. It is not advisable to give hot milk or hot water to the infant because it can damage their tissues. An unclothed infant must not be kept in the sun for a long time because the sun's ultra...

1. While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse's first priority is to: a. change the woman's position. b. notify the care provider. c. assist with amnioinfusion. d. insert a scalp electrode. ANS: A Late decelerations may be caused by materna...

A school aged child has had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough became productive in the past 24 hours. This assessment is most suggestive of what respiratory airway disorder? Bronchitis The nurse is caring for a child diagnosed with a Ute respiratory distress syndrome (ARDS) associated with sepsis. What nursing intervention should be included in the plan of care? Monitor pulse oximetry ...

The nurse is preparing to check the blood pressure (BP) of a school-age child. The maximum arm circumference of the child is 20 cm. Which size cuff does the nurse need to use to measure the BP? Width of 9 cm and length of 18 cm Rationale: To determine proper cuff size, the nurse should make sure the bladder cuff with is approximately 40% of measured arm circumference, and the length should cover 80% to 100% of measured arm circumference. The nurse is assessing the neurologic function of an ...

1. Which accomplishment would the nurse expect of a healthy 3-year-old child? a. Jump rope b. Ride a two-wheel bicycle c. Skip on alternate feet d. Balance on one foot for a few seconds ANS: D Three year olds are able to accomplish the gross motor skill of balancing on one foot. Jumping rope, riding a two-wheel bike, and skipping on alternate feet are gross motor skills of 5-year-old children. 2. In terms of fine motor development, what could the 3-year-old child be expected to do? a. Ti...

1. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of after birth hemorrhage in this woman is: a. retained placental fragments. b. unrepaired vaginal lacerations. c. uterine atony. d. puerperal infection. ANS: C This woman gave birth to a macrosomic boy after Pitocin augmentation. The most l...

1. The two primary functions of the ovaries are: a. normal female development and sex hormone release. b. ovulation and internal pelvic support. c. sexual response and ovulation. d. ovulation and hormone production. ANS: D The two functions of the ovaries are ovulation and hormone production. The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from the ovary; the ovaries ar...

1. In planning for home care of a woman with preterm labor, which concern must the nurse address? a. Nursing assessments will be different from those done in the hospital setting. b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor. c. Prolonged bed rest may cause negative physiologic effects. d. Home health care providers will be necessary. ANS: C Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting,...

1. A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman's fundus? a. One centimeter above the umbilicus b. Two centimeters below the umbilicus c. Midway between the umbilicus and the symphysis pubis d. Nonpalpable abdominally ANS: A Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. The fundus descends about 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm ab...