Test Bank for Principles of Pediatric Nursing 6th Ed By Ball

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Test Bank for Principles of Pediatric Nursing 6th Ed By Ball

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Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 6

Question 1

Type: MCSA

A nurse is helping the parents of 2-year-old twins cope with the daily demands of life in an active household. Which strategy is most appropriate for the nurse to use?

  1. Health maintenance
  2. Health promotion
  3. Health protection
  4. Health supervision

Correct Answer: 2

Rationale 1: In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance.

Rationale 2: In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance.

Rationale 3: In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance.

Rationale 4: In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance.

Global Rationale: In health promotion, nurses partner with families to promote family strategies in the areas of lifestyle and coping. The definition of health maintenance and health supervision makes the other answers incorrect. Health protection is another term for health maintenance.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.1 Define health promotion and health maintenance.

 

Question 2

Type: MCSA

A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child and notes that because the parents often miss routine healthcare visits the child has not received the second measles, mumps, and rubella (MMR) vaccine. Which action by the nurse is most appropriate in this situation?

  1. Speak firmly with the parents about the importance of being compliant.
  2. Notify the physician that the child’s immunizations are no longer up to date.
  3. Call the parents and encourage them to bring the child for recommended care.
  4. Plan to discuss the principles of health supervision at the next scheduled visit.

Correct Answer: 3

Rationale 1: The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed health care for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule.

Rationale 2: The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed health care for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule.

Rationale 3: The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed health care for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule.

Rationale 4: The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed health care for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule.

Global Rationale: The nurse in the pediatric healthcare setting is responsible for reviewing the health supervision of the child. Partnering with the parents and encouraging the parents to follow health-supervision guidelines are the best strategies to use. Speaking firmly with the parents about compliance will alienate the parents at this time. A discussion of the principles of health supervision without an intervention at this visit would mean a delay in needed health care for the child in this example. Discussing with the physician that the immunizations are not up to date is not necessary in an outpatient clinic. Immunizations are given per schedule.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.4 Analyze the nurse’s role in providing health promotion and health maintenance for children and families.

 

Question 3

Type: MCSA

A mother brings a child to the pediatric office for a sick visit. Which action by the nurse is the most appropriate?

  1. Focus exclusively on the reported illness.
  2. Review health-promotion and health-maintenance activities.
  3. Ask the mother to leave the room after obtaining the history.
  4. Obtain a comprehensive history, including sociodemographic data.

Correct Answer: 2

Rationale 1: A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit.

Rationale 2: A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit.

Rationale 3: A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit.

Rationale 4: A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit.

Global Rationale: A nurse should use every opportunity during an office visit to review health-promotion and health-maintenance activities. Focusing exclusively on the reported illnesses ignores the opportunity to use health-promotion strategies. There is not enough data in this scenario to determine whether the mother should be asked to leave the room. There is not enough information to indicate that a comprehensive history should be taken at this visit.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.4 Analyze the nurse’s role in providing health promotion and health maintenance for children and families.

 

Question 4

Type: MCSA

Which of these strategies would be most effective for a “teachable moment” during a routine office visit for the parents of a 6-year-old child?

  1. Select one topic and present a brief amount of information on the topic.
  2. Review all 6-year-old anticipatory guidelines with the parents.
  3. Review 7-year-old anticipatory guidelines with the parents.
  4. Discuss signs of malnutrition with the parents.

Correct Answer: 1

Rationale 1: Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

Rationale 2: Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

Rationale 3: Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

Rationale 4: Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

Global Rationale: Children and families often learn best when presented with small bits of information. Do not give too much information to the parents at one time; therefore, selecting one topic and presenting information is appropriate. It is not appropriate to discuss malnutrition with these parents, since nothing in the stem of the question indicates that the child has a problem with nutrition.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 6.3 Describe the components of a health supervision visit.

 

Question 5

Type: MCMA

The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which of these strategies can be identified as health promotion and health maintenance?

Standard Text: Select all that apply.

  1. Administration of the flu vaccine for infants from 6 months to 23 months old.
  2. Daily feeding schedules for infants.
  3. Instruction to adolescents on how to use dental floss.
  4. Treatment for a child with a diagnosis of acute otitis media.

Correct Answer: 1,2,3

Rationale 1: Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and/or health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness.

Rationale 2: Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and/or health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness.

Rationale 3: Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and/or health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness.

Rationale 4: Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and/or health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness.

Global Rationale: Administering flu vaccines, discussion of feeding schedules, and instructions to adolescents are all health-promotion and/or health-maintenance topics. Treatment of an acute ear infection (otitis media) would not be a topic for health promotion and health maintenance since it is an acute illness.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.1 Define health promotion and health maintenance.

 

Question 6

Type: MCSA

A mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office.  Which response by the nurse is the most appropriate?

  1. “What do you usually do or say during a temper tantrum?”
  2. “Let’s ignore this behavior; it will stop sooner or later.”
  3. “Pick up and cuddle your child now, please.”
  4. “This is definitely a temper tantrum; I know exactly what you are feeling right now.”

Correct Answer: 1

Rationale 1: Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem solve for temper tantrums.

Rationale 2: Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem solve for temper tantrums.

Rationale 3: Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem solve for temper tantrums.

Rationale 4: Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem solve for temper tantrums.

Global Rationale: Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior, instructing the mother to cuddle the child, or sympathizing with the mother (“I know exactly what you are feeling”) are not effective ways to problem solve for temper tantrums.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.8 Apply the nursing process in assessment, diagnosis, goal setting, intervention, and evaluation of health promotion and health maintenance activities for children and families.

 

Question 7

Type: MCSA

A nurse says to the mother of a 6-month-old infant, “Does the baby sit without assistance, and is the baby crawling?” Which process is the nurse using in this interaction?

  1. Health promotion
  2. Health maintenance
  3. Disease surveillance
  4. Developmental surveillance

Correct Answer: 4

Rationale 1: The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers “health promotion” and “health maintenance” are incorrect. The questions asked in the stem are not classified as disease-surveillance questions.

Rationale 2: The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers “health promotion” and “health maintenance” are incorrect. The questions asked in the stem are not classified as disease-surveillance questions.

Rationale 3: The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers “health promotion” and “health maintenance” are incorrect. The questions asked in the stem are not classified as disease-surveillance questions.

Rationale 4: The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers “health promotion” and “health maintenance” are incorrect. The questions asked in the stem are not classified as disease-surveillance questions.

Global Rationale: The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health-promotion and health-maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones; therefore, the answers “health promotion” and “health maintenance” are incorrect. The questions asked in the stem are not classified as disease-surveillance questions.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 6.6 Synthesize the areas of assessment and intervention for health supervision visits—growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 8

Type: MCSA

A parent says to a nurse, “How do you know when my child needs these screening tests the doctor just mentioned?” Which response by the nurse is the most appropriate?

  1. “Screening tests are administered at the ages when a child is most likely to develop a condition.”
  2. “Screening tests are done in the newborn nursery and from these results, additional screening tests are ordered throughout the first two years of life.”
  3. “Screening tests are most often done when the doctor suspects something is wrong with the child.”
  4. “Screening tests are done at each office visit.”

Correct Answer: 1

Rationale 1: Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit.

Rationale 2: Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit.

Rationale 3: Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit.

Rationale 4: Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit.

Global Rationale: Screening tests administered at ages when a child is most likely to develop a condition provide a good basis for health promotion. The remaining answers all provide incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. Screening tests are done to detect the possibility of problems, not when a problem is suspected; at that point, a child needs diagnostic testing. Screening tests are not done at each office visit.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.7 Plan health promotion and health maintenance strategies employed during health supervision visits.

 

Question 9

Type: MCMA

Which nursing assessment activities should be included for the child and family at each health-supervision visit?

Standard Text: Select all that apply.

  1. Interview to obtain an updated health history.
  2. Performing an age-appropriate development assessment.
  3. Monitoring parents’ ability to pay for services.
  4. Performing age-appropriate screening examinations.
  5. Physical assessment for genetic abnormalities.

Correct Answer: 1,2,4

Rationale 1: The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents’ financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Rationale 2: The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents’ financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Rationale 3: The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents’ financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Rationale 4: The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents’ financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Rationale 5: The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents’ financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

Global Rationale: The interview, the developmental assessment, and age-appropriate screenings are all included in the nursing assessment of a child and family during each health-supervision visit. A nurse would not assess the parents’ financial status at each health-supervision visit. Physical assessments for genetic abnormalities would be done based on history and/or physical findings, not at each routine visit.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.3 Describe the components of a health supervision visit.

 

Question 10

Type: MCSA

The nurse of an outpatient clinic is sitting with the parents while their adolescent goes for a test. The parents are complaining about their child’s behavior. Which statement by the nurse fosters family-centered communication?

  1. “I agree with you, discipline is an important part of parenting.”
  2. “I know just how you feel. I had the same experience with my children.”
  3. “You are so right. Adolescents function in the me-first mode all the time.”
  4. “Tell me what concerns you about your child’s behavior.”

Correct Answer: 4

Rationale 1: Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication.

Rationale 2: Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication.

Rationale 3: Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication.

Rationale 4: Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication.

Global Rationale: Using an open-ended question allows the parents to discuss a family concern. All the other questions or statements are blocking statements and would not foster family-centered communication.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.2 Describe how health promotion and health maintenance are addressed by partnering with families during health supervision visits.

 

Question 11

Type: MCSA

The nurse is assessing an adolescent client whose weight is in the 5th percentile. Based on this information, which question is most appropriate for the nurse to ask the adolescent client?

  1. “Do you eat the school lunches?”
  2. “Do you have any concerns about your weight?”
  3. “Do you eat fruits, vegetables, and drink milk?”
  4. “How many meals do you eat each day?”

Correct Answer: 2

Rationale 1: The only question that addresses the adolescent’s weight, which is below the expected norm, is “Do you have any concerns about your weight?” Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent.

Rationale 2: The only question that addresses the adolescent’s weight, which is below the expected norm, is “Do you have any concerns about your weight?” Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent.

Rationale 3: The only question that addresses the adolescent’s weight, which is below the expected norm, is “Do you have any concerns about your weight?” Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent.

Rationale 4: The only question that addresses the adolescent’s weight, which is below the expected norm, is “Do you have any concerns about your weight?” Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent.

Global Rationale: The only question that addresses the adolescent’s weight, which is below the expected norm, is “Do you have any concerns about your weight?” Asking about school lunches, eating fruits and vegetables, and how many meals eaten each day should be used to obtain a nutritional history; however, those questions do not address the underweight status of the adolescent.

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 6.8 Apply the nursing process in assessment, diagnosis, goal setting, intervention, and evaluation of health promotion and health maintenance activities for children and families.

 

Question 12

Type: MCSA

In the pediatric well-child clinic, the nurse explains the reason for an immunization series to the child’s mother. This action represents which item?

  1. Health assessment
  2. Health promotion
  3. Health maintenance
  4. Health screening

Correct Answer: 2

Rationale 1: The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed.

Rationale 2: The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed.

Rationale 3: The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed.

Rationale 4: The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed.

Global Rationale: The explanation to the mother by the nurse provides an understanding of the immunization series to the mother and enables the mother to make an intelligent choice. While administering immunizations is considered health maintenance, the activity described in the question is clearly health promotion. A health assessment would be completed to determine what immunizations are needed. Health maintenance is the actual administration of the immunization and health screening involves looking at the immunization record to determine which immunizations are needed.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.2 Describe how health promotion and health maintenance are addressed by partnering with families during health supervision visits.

 

Question 13

Type: MCSA

A pediatric nurse who is employed in a busy ambulatory clinic setting is informed by the nurse manager that average nursing time allocated for each child and family is being reduced to 10 minutes to more efficiently manage the clinic. The nursing activities must include a nursing assessment and discussion on anticipatory guidance. Which of these strategies should the nurse utilize in the plan of care delivery?

  1. Attempt to complete the assessment and education in 10 minutes, but extend the time whenever the nurse deems necessary.
  2. Plan to do the anticipatory guidance first since either the nurse practitioner or the physician can perform the assessment of the child.
  3. Encourage the parent to ask for specific time to talk with the nurse privately at each office visit.
  4. Focus anticipatory guidance strategies on topics that the parent or child have expressed as an area of interest.

Correct Answer: 4

Rationale 1: With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit.

Rationale 2: With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit.

Rationale 3: With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit.

Rationale 4: With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit.

Global Rationale: With limited time for each visit, the nurse should focus on anticipatory guidance strategies that will most benefit the parent and child during that office visit.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.4 Analyze the nurse’s role in providing health promotion and health maintenance for children and families.

 

Question 14

Type: MCSA

Which assessment would not be included with a 17-year-old’s screening during a routine health supervision visit?

  1. STI evaluation
  2. Autism screening
  3. Hemoglobin test
  4. Vision screening

Correct Answer: 2

Rationale 1: Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old.

Rationale 2: Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old.

Rationale 3: Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old.

Rationale 4: Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old.

Global Rationale: Autism screening would not be appropriate at this age. If autism were present, it would have presented before this age. STI evaluation, hemoglobin test, and vision screening are all appropriate for a 17-year-old.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.3 Describe the components of a health supervision visit.

 

Question 15

Type: MCSA

A nurse is discussing health promotion activities with parents of a 4-year-old client. What health-promotion activity is most appropriate for this family?

  1. Make arrangements to tour the kindergarten in which the child will enroll next year.
  2. Plan a “movie afternoon” with the child’s big brother.
  3. Maintain appropriate immunizations.
  4. Teach the child the proper method for brushing the teeth.

Correct Answer: 4

Rationale 1: Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity.

Rationale 2: Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity.

Rationale 3: Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity.

Rationale 4: Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity.

Global Rationale: Teaching proper oral hygiene through proper teeth brushing is a health-promotion activity. Touring the kindergarten might alleviate anxiety, but is not health promotion. A movie afternoon with the big brother is sedentary, and also not a health-promotion activity. Maintaining immunizations is a health-maintenance, not health-promotion, activity.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 6.6 Synthesize the areas of assessment and intervention for health supervision visits—growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

 

Question 16

Type: MCMA

 

The nurse educator is teaching a group of students about the key concepts of a medical home during the developmental years of the pediatric client. Which items should the educator include in the teaching session?

Standard Text: Select all that apply.

  1. Financial accessibility
  2. Consistent, ongoing care
  3. Coordination of care
  4. No individualization of care
  5. A paternalistic view of care

Correct Answer: 1,2,3

 

Rationale 1: All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

 

Rationale 2: All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

 

Rationale 3: All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

 

Rationale 4: All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

 

Rationale 5: All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

 

Global Rationale: All children need a medical home, where accessible, continuous, and coordinated health supervision is provided during the developmental years. Accessibility refers to both financial and geographic access; continuous indicates that the care is ongoing with consistent care providers; coordination refers to the need for communication among health professionals to provide for the needs of the child. Care is individualized and is not paternalistic.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 6.5 Perform the general observations made of children and their families as they come to the pediatric healthcare home for health supervision visits.

 

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 7

Question 1

Type: MCMA

A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life?

Standard Text: Select all that apply.

  1. Monitor feeding behaviors.
  2. Perform a hearing screening.
  3. Perform a heel stick to obtain blood for the newborn screen.
  4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids.
  5. Administer folic-acid injection to the infant to prevent bleeding.

Correct Answer: 1,2,3

Rationale 1: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Rationale 2: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Rationale 3: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Rationale 4: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Rationale 5: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Global Rationale: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 2

Type: MCSA

The nurse is planning care for clients seen in a newborn clinic. Which is the priority for a newborn client during the first clinic visit?

  1. Providing pamphlets to reinforce information provided at the visit
  2. Assessing the newborn-and-family interactions
  3. Modeling infant-nurturing behaviors
  4. Informing the parents of the infant’s gains in height and weight

Correct Answer: 2

Rationale 1: The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant’s gains in height and weight, this activity does not take priority.

Rationale 2: The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant’s gains in height and weight, this activity does not take priority.

Rationale 3: The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant’s gains in height and weight, this activity does not take priority.

Rationale 4: The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant’s gains in height and weight, this activity does not take priority.

Global Rationale: The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant’s gains in height and weight, this activity does not take priority.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.2 Plan health promotion and health maintenance strategies employed during health supervision visits of newborns and infants.

 

Question 3

Type: MCMA

The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, what will the nurse include in the assessment?

Standard Text: Select all that apply.

  1. Head circumference
  2. Body length
  3. Weight
  4. Length of pregnancy
  5. Hearing screens

Correct Answer: 1,2,3,4

Rationale 1: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Rationale 2: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Rationale 3: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Rationale 4: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Rationale 5: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Global Rationale: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 4

Type: MCSA

An infant weighs 9 pounds, 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age?

  1. 7 pounds, 12 ounces
  2. 8 pounds, 2 ounces
  3. 8 pounds, 12 ounces
  4. 9 pounds

Correct Answer: 2

Rationale 1: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant’s weight should be 8 pounds, 2 ounces at 7 days of age. A weight loss to 7 pounds, 12 ounces would be too much for this infant. A decline to 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

Rationale 2: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant’s weight should be 8 pounds, 2 ounces at 7 days of age. A weight loss to 7 pounds, 12 ounces would be too much for this infant. A decline to 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

Rationale 3: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant’s weight should be 8 pounds, 2 ounces at 7 days of age. A weight loss to 7 pounds, 12 ounces would be too much for this infant. A decline to 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

Rationale 4: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant’s weight should be 8 pounds, 2 ounces at 7 days of age. A weight loss to 7 pounds, 12 ounces would be too much for this infant. A decline to 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

Global Rationale: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant’s weight should be 8 pounds, 2 ounces at 7 days of age. A weight loss to 7 pounds, 12 ounces would be too much for this infant. A decline to 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 5

Type: MCSA

The nurse is teaching a new mother developmental expectations. Which activity should the nurse expect a newborn to do within the first month of life?

  1. Bring hands to eyes and mouth.
  2. Push up with hands, moving chest up.
  3. Keep hands in a relaxed position.
  4. Roll over from back to abdomen.

Correct Answer: 1

Rationale 1: Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

Rationale 2: Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

Rationale 3: Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

Rationale 4: Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

Global Rationale: Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 6

Type: MCSA

The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which instruction should the nurse give as a strategy for illness/disease prevention?

  1. Don’t allow visitors for the first month.
  2. Smoke outside only.
  3. Take the newborn to weekly child-stimulation classes.
  4. SIDS risk-reduction measures

Correct Answer: 4

Rationale 1: Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

Rationale 2: Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

Rationale 3: Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

Rationale 4: Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

Global Rationale: Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.3 Recognize the importance of family in newborn and infant health care, and include family assessment in each health supervision visit.

 

Question 7

Type: MCSA

A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the previous measurements two months ago were at the 25th percentile. Which interpretation by the nurse is the most accurate?

  1. The infant is not gaining enough weight.
  2. The infant has gained a significant amount of weight.
  3. The previous measurements were most likely inaccurate.
  4. These measurements are most likely inaccurate.

Correct Answer: 2

Rationale 1: A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

Rationale 2: A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

Rationale 3: A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

Rationale 4: A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

Global Rationale: A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 8

Type: MCSA

A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation?

  1. “My, you are dressing your infant warmly today.”
  2. “Did you think it was cold when you left your home this morning?”
  3. “I see that you have many layers of clothing on your baby. This may cause your baby’s temperature to rise. ”
  4. “When you leave the office, only put one layer of clothing on your baby.”

Correct Answer: 3

Rationale 1: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

Rationale 2: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

Rationale 3: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

Rationale 4: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

Global Rationale: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 9

Type: MCMA

The nurse working with a family has observed that the older children have a large number of dental caries and plans to provide the mother with information to prevent the development of dental caries in her new infant. Which interventions will prevent the development of dental caries in the infant?

Standard Text: Select all that apply.

  1. Avoiding nursing or giving the infant a bottle at bedtime
  2. Giving foods high in sugar only at breakfast time
  3. Using a soft moist gauze for cleaning
  4. Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt

Correct Answer: 1,3

Rationale 1: The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

Rationale 2: The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

Rationale 3: The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

Rationale 4: The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

Global Rationale: The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 10

Type: MCSA

A nurse is assessing an 11-month-old infant and notes that the infant’s height and weight are at the 5th percentile on the growth chart. Family history reveals that the infant’s two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority?

  1. Alteration in Growth Pattern Related to Parental Anxiety
  2. Alteration in Growth Pattern Secondary to Familial Short Stature
  3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns
  4. At Risk for Constitutional Growth Delay Related to Decreased Appetite

Correct Answer: 1

Rationale 1: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Rationale 2: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Rationale 3: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Rationale 4: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Global Rationale: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 7.5 Evaluate data about the family and other social relationships to promote and maintain health of newborns and infants.

 

 

Question 11

Type: MCSA

While teaching parents of a newborn about normal growth and development, which statement is most appropriate for the nurse to include in the session?

  1. Weight should triple by 6 months of age.
  2. Weight should double by 1 year of age.
  3. Weight should double by 4 months of age.
  4. Weight should triple by 1 year of age.

Correct Answer: 4

Rationale 1: An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

Rationale 2: An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

Rationale 3: An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

Rationale 4: An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

Global Rationale: An infant should triple its birth weight by 1 year of age. The other answers are not appropriate weight gains.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 12

Type: MCSA

A mother who is bottle feeding her newborn asks to be discharged 24 hours post delivery, because she also has twin 2-year-old children at home. When should the nurse schedule the first office visit for this newborn?

  1. Within 48 hours of discharge
  2. Within one week of discharge
  3. Within two weeks of discharge
  4. When the infant is 1 month old

Correct Answer: 1

Rationale 1: Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting one week and/or two weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old.

Rationale 2: Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting one week and/or two weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old.

Rationale 3: Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting one week and/or two weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old.

Rationale 4: Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting one week and/or two weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old.

Global Rationale: Newborns discharged before 48 hours old should be seen within 48 hours of discharge. Waiting one week and/or two weeks after discharge of a 24-hour-old infant increases the chance that several common newborn conditions can go undiagnosed (e.g., jaundice, failure to gain weight). Waiting one month is too long for any infant who is discharged at 24 hours old.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.5 Evaluate data about the family and other social relationships to promote and maintain health of newborns and infants.

 

Question 13

Type: MCMA

A follow-up visit for a newborn client is scheduled with the pediatric nurse practitioner 3 days after discharge. What will the nurse include in the assessment during the scheduled visit for this newborn?

Standard Text: Select all that apply.

  1. Feeding pattern
  2. Jaundice
  3. Length
  4. Vision screen
  5. Sleep pattern

Correct Answer: 1,2,5

Rationale 1: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age.

Rationale 2: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age.

Rationale 3: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age.

Rationale 4: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age.

Rationale 5: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age.

Global Rationale: Feeding pattern, sleep pattern, and jaundice assessment would be appropriate 3 days after discharge. It would not be necessary to do a length or vision screen at this age.

 

 

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 14

Type: MCSA

A mother asks which developmental milestones she can expect when her baby is 6 months old. Which response by the nurse is the most appropriate?

  1. Lifts head momentarily when prone
  2. Has well-developed pincer grasp
  3. Transfers objects from one hand to the other
  4. Rolls from front to back

Correct Answer: 3

Rationale 1: Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months.

Rationale 2: Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months.

Rationale 3: Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months.

Rationale 4: Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months.

Global Rationale: Lifting head when prone is a milestone at 1 month. A well-developed pincer grasp is a milestone at 12 months. Transferring objects from one hand to the other is a milestone at 6 months. Rolling from front to back is a milestone at 4 months.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

 

Question 15

Type: MCSA

Injury prevention is an important aspect of parent teaching. Which injury prevention strategy would reduce the risk of suffocation?

  1. Measure crib slat spacing at 2-3/8 inches or less.
  2. Never leave an infant alone in a bath.
  3. Position the infant on her back to sleep.
  4. Use only approved restraint systems.

Correct Answer: 3

Rationale 1: Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury.

Rationale 2: Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury.

Rationale 3: Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury.

Rationale 4: Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury.

Global Rationale: Measuring crib slats will reduce strangulation. Not leaving an infant alone in a bath will reduce drowning. Positioning an infant on her back will reduce suffocation. Using approved restraint systems will reduce motor vehicle injury.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 7.1 Synthesize the areas of assessment and intervention for health supervision visits of newborns and infants: growth and developmental surveillance, nutrition, physical activity, oral health, mental and spiritual health, family and social relations, disease prevention strategies, and injury prevention strategies.

 

Question 16

Type: MCMA

 

The nurse is assessing an infant client and parents during a routine health supervision visit at 2 months of age.  Which items will the nurse assess to determine if the infant’s mental health needs are being addressed?

Standard Text: Select all that apply.

  1. Immunization record
  2. Newborn screen results
  3. Temperament during the visit
  4. Feeding schedule
  5. Sleep-wake patterns

Correct Answer: 3,4,5

 

Rationale 1: When addressing mental health issues, the nurse would assess the infant’s temperament during the visit, feeding schedule, and sleep-wake patterns. The infant’s mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child’s future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant’s mental health needs are being addressed.

 

Rationale 2: When addressing mental health issues, the nurse would assess the infant’s temperament during the visit, feeding schedule, and sleep-wake patterns. The infant’s mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child’s future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant’s mental health needs are being addressed.

 

Rationale 3: When addressing mental health issues, the nurse would assess the infant’s temperament during the visit, feeding schedule, and sleep-wake patterns. The infant’s mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child’s future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant’s mental health needs are being addressed.

 

Rationale 4: When addressing mental health issues, the nurse would assess the infant’s temperament during the visit, feeding schedule, and sleep-wake patterns. The infant’s mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child’s future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant’s mental health needs are being addressed.

 

Rationale 5: When addressing mental health issues, the nurse would assess the infant’s temperament during the visit, feeding schedule, and sleep-wake patterns. The infant’s mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child’s future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant’s mental health needs are being addressed.

 

Global Rationale: When addressing mental health issues, the nurse would assess the infant’s temperament during the visit, feeding schedule, and sleep-wake patterns. The infant’s mental health is related to early experiences, inborn characteristics such as temperament and resilience, and relationships with caregivers. The first year of life provides many opportunities for the infant to develop positive mental health; interventions during this important period can enhance the child’s future mental status. The immunization record and the newborn screen results will not provide the needed information for the nurse in terms of whether the infant’s mental health needs are being addressed.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 7.4 Integrate pertinent mental health care into health supervision visits for newborns and infants.