Test Bank for Wong’s Essentials of Pediatric Nursing, 10th Edition – Test Bank

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Test Bank for Wong’s Essentials of Pediatric Nursing, 10th Edition – Test Bank

 

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Chapter 06: Childhood Communicable and Infectious Diseases

Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. Which term best describes the identification of the distribution and causes of disease, injury, or illness?
a. Nursing process
b. Epidemiologic process
c. Community-based statistics
d. Mortality and morbidity statistics

 

 

ANS:  B

Epidemiology is the science of population health applied to the detection of morbidity and mortality in a population. It identifies the distribution and causes of diseases across a population. Nursing process is a systematic problem-solving approach for the delivery of nursing care. Morbidity and mortality statistics, along with natal rates, may provide an objective picture of a community’s health status.

 

DIF:    Cognitive Level: Remember           REF:   p. 157

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is taking care of a 7-year-old child with a skin rash called a papule. Which clinical finding should the nurse expect to assess with this type of skin rash?
a. A lesion that is elevated, palpable, firm, and circumscribed; less than 1 cm in diameter
b. A lesion that is elevated, flat-topped, firm, rough, and superficial; greater than 1 cm in diameter
c. An elevated lesion, firm, circumscribed, palpable; 1 to 2 cm in diameter
d. An elevated lesion, circumscribed, filled with serous fluid; less than 1 cm in diameter

 

 

ANS:  A

A papule is elevated; palpable; firm; circumscribed; less than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A plaque is an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be coalesced papules. A nodule is elevated, 1 to 2 cm in diameter, firm, circumscribed, palpable, and deeper in the dermis than a papule. A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with serous fluid.

 

DIF:    Cognitive Level: Understand          REF:   p. 178

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
a. Cyst
b. Papule
c. Pustule
d. Vesicle

 

 

ANS:  D

A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A papule is elevated, palpable, firm, circumscribed, less than 1 cm in diameter, and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid.

 

DIF:    Cognitive Level: Remember           REF:   p. 178

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
a. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter
b. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size
c. Flat, brown mole less than 1 cm in diameter
d. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter

 

 

ANS:  C

A macule is flat; nonpalpable; circumscribed; less than 1 cm in diameter; and brown, red, purple, white, or tan. A patch is a flat, nonpalpable, and irregularly shaped macule that is greater than 1 cm in diameter. Scale is heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size, and silver white or tan. A plaque is an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be coalesced papules.

 

DIF:    Cognitive Level: Understand          REF:   p. 178

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which nursing consideration is important when caring for a child with impetigo contagiosa?
a. Apply topical corticosteroids to decrease inflammation.
b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
c. Carefully wash hands and maintain cleanliness when caring for an infected child.
d. Examine child under a Wood lamp for possible spread of lesions.

 

 

ANS:  C

A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough hand washing before and after contact with the affected child. Corticosteroids are not indicated in bacterial infections. Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis.

 

DIF:    Cognitive Level: Understand          REF:   p. 177

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child’s skin after the infection has subsided and healed. Which answer should the nurse give?
a. There will be no scarring.
b. There may be some pigmented spots.
c. It is likely there will be some slightly depressed scars.
d. There will be some atrophic white scars.

 

 

ANS:  A

Impetigo contagiosa tends to heal without scarring unless a secondary infection occurs.

 

DIF:    Cognitive Level: Apply                  REF:   p. 177

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. What is cellulitis often caused by?
a. Herpes zoster
b. Candida albicans
c. Human papillomavirus
d. Streptococcus or Staphylococcus organisms

 

 

ANS:  D

Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C. albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with various types of human warts.

 

DIF:    Cognitive Level: Remember           REF:   p. 176

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is conducting a staff in-service on appearance of childhood skin conditions. Lymphangitis (“streaking”) is frequently seen in which condition?
a. Cellulitis
b. Folliculitis
c. Impetigo contagiosa
d. Staphylococcal scalded skin

 

 

ANS:  A

Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually required for parenteral antibiotics. Lymphangitis is not associated with folliculitis, impetigo, or staphylococcal scalded skin.

 

DIF:    Cognitive Level: Understand          REF:   p. 176

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse should expect to assess which causative agent in a child with warts?
a. Bacteria
b. Fungus
c. Parasite
d. Virus

 

 

ANS:  D

Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and parasites does not result in warts.

 

DIF:    Cognitive Level: Understand          REF:   p. 177

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse should implement which prescribed treatment for a child with warts?
a. Vaccination
b. Local destruction
c. Corticosteroids
d. Specific antibiotic therapy

 

 

ANS:  B

Local destructive therapy individualized according to location, type, and number—including surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies—is used. Vaccination is prophylaxis for warts and is not a treatment. Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts.

 

DIF:    Cognitive Level: Apply                  REF:   p. 178

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Herpes zoster is caused by the varicella virus and has an affinity for:
a. sympathetic nerve fibers.
b. parasympathetic nerve fibers.
c. posterior root ganglia and posterior horn of the spinal cord.
d. lateral and dorsal columns of the spinal cord.

 

 

ANS:  C

The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the spinal cord, and skin. The zoster virus does not involve sympathetic or parasympathetic nerve fibers and the lateral and dorsal columns of the spinal cord.

 

DIF:    Cognitive Level: Understand          REF:   p. 178

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is taking care of a 7-year-old child with herpes simplex virus (type 1 or 2). Which prescribed medication should the nurse expect to be included in the treatment plan?
a. Corticosteroids
b. Oral griseofulvin
c. Oral antiviral agent
d. Topical and/or systemic antibiotic

 

 

ANS:  C

Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids are not effective for viral infections. Griseofulvin is an antifungal agent and not effective for viral infections. Antibiotics are not effective in viral diseases.

 

DIF:    Cognitive Level: Apply                  REF:   p. 178

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. What causes tinea capitis (ringworm)?
a. Virus
b. Fungus
c. Allergic reaction
d. Bacterial infection

 

 

ANS:  B

Ringworm is caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin. Virus and bacterial infection are not the causative organisms for ringworm. Ringworm is not an allergic response.

 

DIF:    Cognitive Level: Understand          REF:   p. 179

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. What should the nurse expect the therapeutic management of this child to include?
a. Administering oral griseofulvin
b. Administering topical or oral antibiotics
c. Applying topical sulfonamides
d. Applying Burow solution compresses to affected area

 

 

ANS:  A

Treatment with the antifungal agent griseofulvin is part of the treatment for the fungal disease ringworm. Oral griseofulvin therapy frequently continues for weeks or months. Antibiotics, sulfonamides, and Burow solution are not effective in fungal infections.

 

DIF:    Cognitive Level: Understand          REF:   p. 179

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

 

  1. Parents tell the nurse that their child keeps scratching the areas where he has poison ivy. The nurse’s response should be based on which knowledge?
a. Poison ivy does not itch and needs further investigation.
b. Scratching the lesions will not cause a problem.
c. Scratching the lesions will cause the poison ivy to spread.
d. Scratching the lesions may cause them to become secondarily infected.

 

 

ANS:  D

Poison ivy is a contact dermatitis that results from exposure to the oil urushiol in the plant. Every effort is made to prevent the child from scratching because the lesions can become secondarily infected. The poison ivy produces localized, streaked or spotty, oozing, and painful impetiginous lesions. Itching is a common response. Scratching the lesions can result in secondary infections. The lesions do not spread by contact with the blister serum or by scratching.

 

DIF:    Cognitive Level: Apply                  REF:   p. 185

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is taking care of a child with scabies. Which primary clinical manifestation should the nurse expect to assess with this disease?
a. Edema
b. Redness
c. Pruritus
d. Maceration

 

 

ANS:  C

Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. Edema, redness, and maceration are not observed in scabies.

 

DIF:    Cognitive Level: Understand          REF:   p. 180

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which is usually the only symptom of pediculosis capitis (head lice)?
a. Itching
b. Vesicles
c. Scalp rash
d. Localized inflammatory response

 

 

ANS:  A

Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized inflammatory response are not symptoms of head lice.

 

DIF:    Cognitive Level: Understand          REF:   p. 182

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis?
a. “You will need to cut the hair shorter if infestation and nits are severe.”
b. “You can distinguish viable from nonviable nits, and remove all viable ones.”
c. “You can wash all nits out of hair with a regular shampoo.”
d. “You will need to remove nits with an extra-fine-tooth comb or tweezers.”

 

 

ANS:  D

Treatment consists of the application of pediculicide and manual removal of nit cases. An extra-fine-tooth comb facilitates manual removal. Parents should be cautioned against cutting the child’s hair short; lice infest short hair as well as long. It increases the child’s distress and serves as a continual reminder to peers who are prone to tease children with a different appearance. It is not possible to differentiate between viable and nonviable eggs. Regular shampoo is not effective; a pediculicide is necessary.

 

DIF:    Cognitive Level: Apply                  REF:   p. 182

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Which bite causes Rocky Mountain spotted fever?
a. Flea
b. Tick
c. Mosquito
d. Mouse or rat

 

 

ANS:  B

Rocky Mountain spotted fever is caused by a tick. The tick must attach and feed for at least 1 to 2 hours to transmit the disease. The usual habitat of the tick is in heavily wooded areas. Fleas, mosquitoes, and mice or rats do not transmit Rocky Mountain spotted fever.

 

DIF:    Cognitive Level: Understand          REF:   p. 186

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease?
a. Difficult to prevent
b. Treated with oral antibiotics in stages 1, 2, and 3
c. Caused by a spirochete that enters the skin through a tick bite
d. Common in geographic areas where the soil contains the mycotic spores that cause the disease

 

 

ANS:  C

Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeved shirts and long pants tucked into socks should be the attire. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores.

 

DIF:    Cognitive Level: Understand          REF:   p. 186

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. What is most likely the cause of the diaper rash?
a. Impetigo
b. Candida albicans
c. Urine and feces
d. Infrequent diapering

 

 

ANS:  B

  1. albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact with the diaper, but sparing the folds, are likely to be caused by chemical irritation, especially urine and feces.

 

DIF:    Cognitive Level: Analyze               REF:   p. 179

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A school nurse assesses a case of tinea capitis (ringworm) on a 6-year-old child. Which figure depicts the characteristic lesion of tinea capitis?
a.
b.
c.
d.

 

 

ANS:  C

Tinea capitis is characterized by lesions in the scalp configured of scaly, circumscribed patches or patchy, scaling areas of alopecia. Generally the lesions are asymptomatic but a severe, deep inflammatory reaction may occur that manifests as boggy, encrusted lesions (kerions). Impetigo contagiosa is depicted in the figure showing the vesicular lesion around the nares area that has become vesicular. The lesions rupture easily, leaving superficial, moist erosions that tend to spread peripherally in sharply marginated irregular outlines. The exudate dries to form heavy, honey-colored crusts. The figure depicting inflammation on the cheek is cellulitis. Inflammation of skin and subcutaneous tissues is characterized by intense redness, swelling, and firm infiltration. Cellulitis may progress to abscess formation. The figure depicting “streaked blisters” surrounding one large blister is characteristic of contact dermatitis from poison ivy contact.

 

DIF:    Cognitive Level: Analyze               REF:   p. 180

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. Airborne isolation is required for a child who is hospitalized with:
a. mumps.
b. chickenpox.
c. exanthema subitum (roseola).
d. erythema infectiosum (fifth disease).

 

 

ANS:  B

Chickenpox is communicable through direct contact, droplet spread, and contaminated objects. Mumps is transmitted from direct contact with saliva of infected person and is most communicable before onset of swelling. The transmission and source of the viral infection exanthema subitum (roseola) is unknown. Erythema infectiosum (fifth disease) is communicable before onset of symptoms.

 

DIF:    Cognitive Level: Understand          REF:   p. 163

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Safe and Effective Care Environment

 

  1. Acyclovir (Zovirax) is given to children with chickenpox to:
a. minimize scarring.
b. decrease the number of lesions.
c. prevent aplastic anemia.
d. prevent spread of the disease.

 

 

ANS:  B

Acyclovir decreases the number of lesions; shortens duration of fever; and decreases itching, lethargy, and anorexia. Treating pruritus and discouraging itching minimize scarring. Aplastic anemia is not a complication of chickenpox. Strict isolation until vesicles are dried prevents spread of disease.

 

DIF:    Cognitive Level: Understand          REF:   p. 163

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
a. Reassure the parent that it is not necessary to stay home with the child.
b. Explain that no medication will shorten the course of the illness.
c. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
d. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.

 

 

ANS:  C

Acyclovir is effective in treating the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. It is important the parent stay with the child to monitor fever. Acyclovir lessens the severity of chickenpox. VariZIG is given only to high-risk children.

 

DIF:    Cognitive Level: Apply                  REF:   p. 163

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
a. Acyclovir (Zovirax)
b. Varicella globulin
c. Diphenhydramine hydrochloride (Benadryl)
d. VCZ immune globulin (VariZIG)

 

 

ANS:  D

VariZIG is given to high-risk children to prevent the development of chickenpox. Acyclovir decreases the severity, not the development, of chickenpox. Varicella globulin is not effective because it is not the immune globulin. Diphenhydramine may help pruritus but not the actual chickenpox.

 

DIF:    Cognitive Level: Understand          REF:   p. 163

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Vitamin A supplementation may be recommended for the young child who has which disease?
a. Mumps
b. Rubella
c. Measles (rubeola)
d. Erythema infectiosum

 

 

ANS:  C

Evidence shows vitamin A decreases morbidity and mortality in measles. Mumps is treated with analgesics for pain and antipyretics for fever. Rubella is treated similarly to mumps. Erythema infectiosum is treated similarly to mumps and rubella.

 

DIF:    Cognitive Level: Understand          REF:   p. 166

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents know that the child is considered to be no longer contagious when which occurs?
a. When fever is absent
b. When lesions are crusted
c. 24 hours after lesions erupt
d. 8 days after onset of illness

 

 

ANS:  B

When the lesions are crusted, the chickenpox is no longer contagious. This may be a week after onset of disease. Chickenpox is still contagious when child has fever. Children are contagious after lesions erupt. If lesions are crusted at 8 days, the child is no longer contagious.

 

DIF:    Cognitive Level: Apply                  REF:   p. 163

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is assessing a child and notes Koplik spots. In which of these communicable diseases are Koplik spots present?
a. Rubella
b. Measles (rubeola)
c. Chickenpox (varicella)
d. Exanthema subitum (roseola)

 

 

ANS:  B

Koplik spots are small irregular red spots with a minute, bluish white center found on the buccal mucosa 2 days before systemic rash. Rubella occurs with rash on the face, which rapidly spreads downward. Varicella appears with highly pruritic macules, followed by papules and vesicles. Roseola is seen with rose-pink macules on the trunk, spreading to face and extremities.

 

DIF:    Cognitive Level: Apply                  REF:   p. 166

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form?
a. Erythema infectiosum
b. Roseola
c. Rubeola
d. Rubella

 

 

ANS:  D

Rubella causes teratogenic effects on the fetus. There is a low risk of fetal death to those in contact with children affected with fifth disease. Roseola and rubeola are not dangerous to the fetus.

 

DIF:    Cognitive Level: Understand          REF:   p. 168

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is the causative agent of scarlet fever?
a. Enteroviruses
b. Corynebacterium organisms
c. Scarlet fever virus
d. Group A b-hemolytic streptococci (GABHS)

 

 

ANS:  D

GABHS infection causes scarlet fever. Enteroviruses do not cause the same complications. Corynebacterium organisms cause diphtheria. Scarlet fever is not caused by a virus.

 

DIF:    Cognitive Level: Understand          REF:   p. 169

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A parent reports to the nurse that her child has inflamed conjunctivae of both eyes with purulent drainage and crusting of the eyelids, especially on awakening. These manifestations suggest:
a. viral conjunctivitis.
b. allergic conjunctivitis.
c. bacterial conjunctivitis.
d. conjunctivitis caused by foreign body.

 

 

ANS:  C

Bacterial conjunctivitis has these symptoms. Viral or allergic conjunctivitis has watery drainage. Foreign body causes tearing and pain, and usually only one eye is affected.

 

DIF:    Cognitive Level: Analyze               REF:   p. 171

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is an important nursing consideration when caring for a child with herpetic gingivostomatitis (HGS)?
a. Apply topical anesthetics before eating.
b. Drink from a cup, not a straw.
c. Wait to brush teeth until lesions are sufficiently healed.
d. Explain to parents how this is sexually transmitted.

 

 

ANS:  A

Treatment for HGS is aimed at relief of pain. Drinking bland fluids through a straw helps avoid painful lesions. Mouth care is encouraged with a soft toothbrush. HGS is usually caused by herpes simplex virus type 1, which is not associated with sexual transmission.

 

DIF:    Cognitive Level: Apply                  REF:   p. 172

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A parent has asked the nurse about how her child can be tested for pinworms. The nurse responds by stating that which is the most common test for diagnosing pinworms in a child?
a. Lower gastrointestinal (GI) series
b. Three stool specimens, at intervals of 4 days
c. Observation for presence of worms after child defecates
d. Laboratory examination of a fecal smear

 

 

ANS:  D

Laboratory examination of substances containing the worm, its larvae, or ova can identify the organism. Most are identified by examining fecal smears from the stools of persons suspected of harboring the parasite. Fresh specimens are best for revealing parasites or larvae. Lower GI series is not helpful for diagnosing enterobiasis. Stool specimens are not necessary to diagnose pinworms. Worms will not be visible after child defecates.

 

DIF:    Cognitive Level: Understand          REF:   p. 174

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A clinic nurse is assessing a child with erythema infectiosum (fifth disease). Which figure depicts the rash the nurse should expect to assess?
a.
b.
c.
d.

 

 

ANS:  A

Erythema infectiosum rash appears in three stages: erythema on face, chiefly on cheeks (“slapped face” appearance); disappears by 1-4 days. Chicken pox rash begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time. Roseola rash is discrete rose-pink macules or maculopapules appearing first on trunk and then spreading to neck, face, and extremities; nonpruritic; fades on pressure; lasts 1-2 days. Rubeola rash—appears 3-4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3-4 days, assumes brownish appearance, and fine desquamation occurs over area of extensive involvement.

 

DIF:    Cognitive Level: Apply                  REF:   p. 164

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication should the nurse expect to be prescribed?
a. Metronidazole (Flagyl)
b. Amoxicillin clavulanate (Augmentin)
c. Clarithromycin (Biaxin)
d. Prednisone (Orapred)

 

 

ANS:  A

The drugs of choice for treatment of giardiasis are metronidazole (Flagyl), tinidazole (Tindamax), and nitazoxanide (Alinia). These are classified as antifungals. Amoxicillin and clarithromycin are antibiotics that treat bacterial infections. Prednisone is a steroid and is used as an anti-inflammatory medication.

 

DIF:    Cognitive Level: Apply                  REF:   p. 174

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?
a. This cannot be prevented.
b. Infants do not feel pain as adults do.
c. This is not a good reason for refusing immunizations.
d. A topical anesthetic, EMLA, can be applied before injections are given.

 

 

ANS:  D

Several topical anesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented and minimized by using the principles of atraumatic care. With preparation, the injection site can be properly anesthetized to decrease the amount of pain felt by the infant. Infants have the neural pathways to feel pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process.

 

DIF:    Cognitive Level: Apply                  REF:   p. 151

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The community health nurse is teaching parents about prevention of the spread and reoccurrence of pediculosis (head lice). Which should the nurse include in the teaching session? (Select all that apply.)
a. Dryclean nonwashable items.
b. Spray the environment with an insecticide.
c. Seal nonwashable items in a plastic bag for 5 days.
d. Boil combs and brushes for 10 minutes.
e. Discourage sharing of personal items.

 

 

ANS:  A, D, E

To prevent the spread and reoccurrence of pediculosis the nurse should teach the parents to: dryclean nonwashable items, boil combs and brushes for 10 minutes or soak for 1 hour in a pediculicide, and discourage the sharing of personal items, such as combs, hats, scarves and other headgear. Spraying with insecticide is not recommended because of the danger to children and animals. Nonwashable items should be sealed for 14 days in a plastic bag.

 

DIF:    Cognitive Level: Apply                  REF:   p. 182

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

 

  1. A nurse is preparing to administer routine immunizations to a 4-month-old infant. The infant is currently up to date on all previously recommended immunizations. Which immunizations will the nurse prepare to administer? (Select all that apply.)
a. Measles, mumps, and rubella (MMR)
b. Rotavirus (RV)
c. Diphtheria, tetanus, pertussis (DTaP)
d. Varicella
e. Haemophilus influenzae type b (HIB)
f. Inactivated poliovirus (IPV)

 

 

ANS:  B, C, E, F

Recommended immunization schedule for a 4-month-old, up to date on immunizations, would be to administer the rotavirus (RV), diphtheria, tetanus, pertussis (DTaP), Haemophilus influenza type b (HIB), and inactivated poliovirus (IPV) vaccinations. The measles, mumps, and rubella (MMR) and varicella would not be administered until the child is at least 1 year of age.

 

DIF:    Cognitive Level: Apply                  REF:   p. 151

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

Chapter 07: Health Promotion of the Newborn and Family

Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition

 

MULTIPLE CHOICE

 

  1. Which is the most critical physiologic change required of the newborn?
a. Closure of fetal shunts in the heart
b. Stabilization of fluid and electrolytes
c. Body-temperature maintenance
d. Onset of breathing

 

 

ANS:  D

The onset of breathing is the most immediate and critical physiologic change required for transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. This affects the fetus’s adjustment to extrauterine life. Closure of fetal shunts in the heart, stabilization of fluid and electrolytes, and body-temperature maintenance are important changes that must occur in the transition to extrauterine life, but breathing and the exchange of oxygen for carbon dioxide must come first.

 

DIF:    Cognitive Level: Understand          REF:   p. 190

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is a function of brown adipose tissue (BAT) in the newborn?
a. Provides ready source of calories in the newborn period
b. Insulates the body against lowered environmental temperature
c. Protects the newborn from injury during the birth process
d. Generates heat for distribution to other parts of body

 

 

ANS:  D

Brown fat is a unique source of heat for the newborn. It has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than does ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. It is effective in heat production only. The newborn has a thin layer of subcutaneous fat, which does not provide for conservation of heat. Brown fat is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum. These areas would not protect the newborn from injury during the birth process.

 

DIF:    Cognitive Level: Understand          REF:   p. 191

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which characteristic is representative of the newborn’s gastrointestinal tract?
a. Stomach capacity is approximately 90 ml.
b. Peristaltic waves are relatively slow.
c. Overproduction of pancreatic amylase occurs.
d. Intestines are shorter in relation to body size.

 

 

ANS:  A

Newborns require frequent small feedings because their stomach capacity is approximately 90 ml. Peristaltic waves are rapid. A deficiency of pancreatic lipase limits the absorption of fats. Newborn’s intestines are longer in relation to body size than those of an adult.

 

DIF:    Cognitive Level: Understand          REF:   p. 191

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse notes the first stool of a newborn is black and tarry. Which term is used to describe this type of stool?
a. Meconium
b. Transitional
c. Miliaria
d. Milk stool

 

 

ANS:  A

Meconium is composed of amniotic fluid and its constituents, intestinal secretions, shed mucosal cells, and possibly blood. It is the newborn’s first stool. Transitional stools usually appear by the third day after the beginning of feeding. They are usually greenish brown to yellowish brown, thin, and less sticky than meconium. Miliaria are distended sweat glands that appear as minute vesicles, primarily on the face. Milk stool usually occurs by the fourth day. The appearance varies, depending on whether the neonate is breastfed or formula-fed.

 

DIF:    Cognitive Level: Remember           REF:   p. 191

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse notes that a 12-hour-old newborn has not had the first meconium stool. The nurse documents this finding and continues to monitor the newborn because, in term newborns, the first meconium stool occurs within how many hours of birth?
a. 6 to 8
b. 8 to 12
c. 12 to 24
d. 24 to 48

 

 

ANS:  D

The first meconium stool should occur within the first 24 to 48 hours. It may be delayed up to 7 days in very low birth weight newborns. Although it may occur earlier, the expected range is the first 24 to 48 hours of life.

 

DIF:    Cognitive Level: Remember           REF:   p. 191

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is doing an assessment on a newborn. Which is characteristic of a newborn’s vision at birth and an expected finding during the assessment?
a. Ciliary muscles are mature.
b. Blink reflex is absent.
c. Tear glands function.
d. Pupils react to light.

 

 

ANS:  D

Although at birth the eye is still structurally incomplete, the pupils do react to light. The ciliary muscles are immature, limiting the eyes’ ability to focus on an object for any length of time. The blink reflex is responsive to minimal stimulus. The tear glands do not begin to function until ages 2 to 4 weeks.

 

DIF:    Cognitive Level: Remember           REF:   p. 193

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The Apgar score of a newborn 5 minutes after birth is 8. Which is the nurse’s best interpretation of this?
a. Resuscitation is likely to be needed.
b. Adjustment to extrauterine life is adequate.
c. Additional scoring in 5 more minutes is needed.
d. Maternal sedation or analgesia contributed to the low score.

 

 

ANS:  B

The Apgar reflects the newborn’s status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Scores of 7 to 10 indicate an absence of difficulty adjusting to extrauterine life. Scores of 0 to 3 indicate severe distress, and scores of 4 to 6 indicate moderate difficulty. The Apgar score is not used to determine the newborn’s need for resuscitation at birth. All newborns are rescored at 5 minutes. The newborn does not have a low score.

 

DIF:    Cognitive Level: Understand          REF:   p. 193

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
a. The newborn’s length and weight are the most accurate indicators of gestational age.
b. The newborn’s Apgar score and the mother’s estimated date of confinement (EDC) are combined to determine gestational age.
c. The newborn’s posture at rest and arm recoil are two physical signs used to determine gestational age.
d. The newborn’s chest circumference compared to the head circumference is the determinant for gestational age.

 

 

ANS:  C

With the newborn quiet and in a supine position, the degree of flexion in the arms and legs and the arm recoil can be used to help determine gestational age. Length, weight, and the chest/head circumference reflect the newborn’s size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity. The Apgar score is an indication of the newborn’s adjustment to extrauterine life, and the mother’s EDC is of no importance in determining gestational age.

 

DIF:    Cognitive Level: Apply                  REF:   p. 193

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing a 3-day-old, breastfed newborn who weighed 7 pounds, 8 ounces at birth. The newborn’s mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most appropriate nursing intervention?
a. Recommend supplemental feedings of formula.
b. Explain that this weight loss is within normal limits.
c. Assess child further to determine cause of excessive weight loss.
d. Encourage mother to express breast milk for bottle feeding the newborn.

 

 

ANS:  B

The newborn normally loses about 10% of the birth weight by age 3 or 4 days. The birth weight is usually regained by the tenth day of life. Because this is an expected occurrence, no further action is needed. The mother should be taught about normal newborn feeding and growing patterns.

 

DIF:    Cognitive Level: Apply                  REF:   p. 196

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Why are rectal temperatures not recommended in the newborn?
a. They are inaccurate.
b. They do not reflect core body temperature.
c. They can cause perforation of rectal mucosa.
d. They take too long to obtain an accurate reading.

 

 

ANS:  C

Rectal temperatures are avoided in the newborn. If done incorrectly, the insertion of a thermometer into the rectum can perforate the mucosa. Rectal temperatures, if taken correctly, are considered an accurate reflection of core body temperature. The inherent risks and intrusive nature limit the use. The time it takes to determine body temperature is related to the equipment used, not the route only.

 

DIF:    Cognitive Level: Remember           REF:   p. 197

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse should expect the apical heart rate of a stabilized newborn to be in which range?
a. 60 to 80 beats/min
b. 80 to 100 beats/min
c. 120 to 140 beats/min
d. 160 to 180 beats/min

 

 

ANS:  C

The pulse rate of the newborn varies with periods of reactivity. Usually the pulse rate is between 120 and 140 beats/min; 60 to 100 beats/min is too slow for a neonate and 160 to 180 beats/min is too fast for a neonate.

 

DIF:    Cognitive Level: Remember           REF:   p. 197

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is palpating a newborn’s fontanels. The nurse documents the anterior fontanel is which shape?
a. Circle
b. Triangle
c. Square
d. Diamond

 

 

ANS:  D

The anterior fontanel is diamond-shaped and measures from barely palpable to 4 to 5 cm. Neither of the fontanels is a circle or a square. The triangle is the shape of the posterior fontanel.

 

DIF:    Cognitive Level: Understand          REF:   p. 198

TOP:   Integrated Process: Communication and Documentation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which is the name of the suture separating the parietal bones at the top center of a newborn’s head?
a. Frontal
b. Coronal
c. Sagittal
d. Occipital

 

 

ANS:  C

The sagittal suture separates the parietal bones on top of the newborn’s head. The frontal suture separates the frontal bones. The coronal suture is said to “crown the head.” There is no occipital suture. The lambdoid suture is at the margin of the parietal and occipital bones.

 

DIF:    Cognitive Level: Remember           REF:   p. 198

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. In a newborn’s eyes, strabismus is a normal finding because of:
a. congenital cataracts.
b. lack of binocularity.
c. absence of red reflex.
d. inability of pupil to react to light.

 

 

ANS:  B

Newborns are unable to focus their eyes on an object. Binocularity does not develop until ages 3 to 4 months. Congenital cataracts, absence of red reflex, and inability of pupil to react to light are not normal findings and need further evaluation.

 

DIF:    Cognitive Level: Understand          REF:   p. 199

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse has determined that a newborn’s respiratory breathing is within a normal range. How should the nurse document this finding?
a. Irregular, abdominal, 30 to 60 breaths/min
b. Regular, abdominal, 25 to 35 breaths/min
c. Regular, noisy, 35 to 45 breaths/min
d. Irregular, quiet, 45 to 55 breaths/min

 

 

ANS:  A

The respirations of a normal newborn are irregular and abdominal, with a rate of 30 to 60 breaths/min. Newborn respirations are irregular. Pauses in respiration less than 20 seconds in duration are considered normal. The newborn is an abdominal breather with a wider range of respiratory rates.

 

DIF:    Cognitive Level: Understand          REF:   p. 197

TOP:   Integrated Process: Communication and Documentation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. When doing the first assessment of a male newborn, the nurse notes that the scrotum is large, edematous, and pendulous. This should be interpreted as a(n):
a. normal finding.
b. hydrocele.
c. absence of testes.
d. inguinal hernia.

 

 

ANS:  A

A large, edematous, and pendulous scrotum in a term newborn, especially in those born in a breech position, is a normal finding. A hydrocele is fluid in the scrotum, usually unilateral, which usually resolves within a few months. The presence or absence of testes would be determined on palpation of the scrotum and inguinal canal. Absence of testes may be an indication of ambiguous genitalia. An inguinal hernia may be present at birth. It is more easily detected when the child is crying.

 

DIF:    Cognitive Level: Apply                  REF:   p. 201

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
a. Perez
b. Sucking
c. Rooting
d. Extrusion

 

 

ANS:  C

Stroking the newborn’s cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck is a description of the rooting reflex, which usually disappears by ages 3 to 4 months but may persist for up to 12 months. The Perez reflex involves stroking the newborn’s back when prone; the child flexes extremities, elevating head and pelvis. It disappears at ages 4 to 6 months. The newborn begins strong sucking movements in response to circumoral stimulation. The reflex persists throughout infancy, even without stimulation. Newborns force their tongues outward, when the tongue is touched or depressed. This reflex usually disappears by age 4 months.

 

DIF:    Cognitive Level: Understand          REF:   p. 203

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Which statement best represents the first stage of the first period of reactivity in the newborn?
a. It begins when the newborn awakes from a deep sleep.
b. It ends when the amount of respiratory mucus has decreased.
c. It is an excellent time to acquaint the parents with the newborn.
d. It is an excellent time for mother to sleep and recover.

 

 

ANS:  C

During the first period of reactivity, the newborn is alert, cries vigorously, may suck the fist greedily, and appears interested in the environment. The newborn’s eyes are usually wide open, suggesting that this is an excellent opportunity for mother, father, and child to see each other. The second period of reactivity begins when the newborn awakens from a deep sleep. The second period of reactivity ends when the amount of respiratory mucus has decreased. The mother should sleep and recover during the second stage, when the newborn is sleeping.

 

DIF:    Cognitive Level: Understand          REF:   p. 202

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
a. Examine newborn’s eyes for ability to focus.
b. Assess for other attachment behaviors.
c. Recognize this as a common reaction in new mothers.
d. Ask mother why she won’t look at newborn.

 

 

ANS:  B

Attachment behaviors are thought to indicate the formation of emotional bonds between the newborn and the mother. The mother’s failure to make eye contact with her newborn may indicate difficulties with the formation of emotional bonds. The nurse should perform a more thorough assessment. Newborns do not have binocularity and cannot focus. It is uncommon for a mother to avoid making eye contact with her newborn and it is confrontational to ask why; this would put the mother in a defensive position.

 

DIF:    Cognitive Level: Apply                  REF:   p. 205

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. At the time of birth, what is the grayish white, cheeselike substance that normally covers the newborn’s skin called?
a. Miliaria
b. Meconium
c. Amniotic fluid
d. Vernix caseosa

 

 

ANS:  D

The grayish white, cheeselike substance that normally covers the newborn’s skin is the vernix caseosa. Miliaria are distended sweat glands that appear as minute vesicles. Meconium is the newborn’s first stool. Amniotic fluid is produced in utero.

 

DIF:    Cognitive Level: Remember           REF:   p. 206

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What are distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period called?
a. Milia
b. Lanugo
c. Mongolian spots
d. Cutis marmorata

 

 

ANS:  A

Distended sebaceous glands that appear as tiny white papules on cheeks, chin, and nose in the newborn period are milia, which are common variations found in newborns. Lanugo is fine downy hair. Mongolian spots are irregular areas of deep blue pigmentation, usually in the sacral and gluteal areas. Cutis marmorata is transient mottling when the newborn is exposed to decreased body temperatures.

 

DIF:    Cognitive Level: Remember           REF:   p. 206

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?
a. Feet and hands
b. Bridge of nose
c. Circumoral area
d. Mucous membranes

 

 

ANS:  A

Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns. Cyanosis present at the bridge of the nose, the circumoral area, and the mucous membranes is a potential sign of distress or major abnormality.

 

DIF:    Cognitive Level: Analyze               REF:   p. 206

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent?
a. Acrocyanosis
b. Erythema toxicum
c. Mongolian spots
d. Harlequin color changes

 

 

ANS:  C

Irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent are Mongolian spots, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent. Acrocyanosis is cyanosis of the hands and feet that is a usual finding in newborns. Erythema toxicum consists of pink papular vesicles that may appear in 24 to 48 hours and resolve after several days. Harlequin color changes are clearly outlined areas of color change. As the newborn lies on one side, the lower half of the body becomes pink and the upper half is pale.

 

DIF:    Cognitive Level: Understand          REF:   p. 206

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The nurse observes flaring of nares in a newborn. This should be interpreted as:
a. nasal occlusion.
b. sign of respiratory distress.
c. common response to sneezing.
d. snuffles of congenital syphilis.

 

 

ANS:  B

Nasal flaring is an indication of respiratory distress. A nasal occlusion would prevent the child from breathing through the nose. Because newborns are obligatory nose breathers, this would require immediate referral. Sneezing and thin white mucus drainage are common in newborns and are not related to nasal flaring. Snuffles are indicated by a thick, bloody, nasal discharge without sneezing.

 

DIF:    Cognitive Level: Understand          REF:   p. 207

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
a. Nystagmus
b. Profuse drooling
c. Dark green or black stools
d. Slight vaginal reddish discharge

 

 

ANS:  B

Profuse drooling or salivation is a potential sign of a major abnormality. Newborns with esophageal atresia cannot swallow their oral secretions, resulting in excessive drooling. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Meconium, the first stool of newborns, is dark green or black. Pseudomenstruation may be present in normal newborns. This is a blood-tinged or mucoid vaginal discharge.

 

DIF:    Cognitive Level: Understand          REF:   p. 207

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Which is most important in the immediate care of the newborn?
a. Maintain patent airway.
b. Maintain stable body temperature.
c. Administer prophylactic eye care.
d. Establish identification of mother and baby.

 

 

ANS:  A

Maintaining a patent airway is the primary objective in the care of the newborn. The nurse uses a bulb syringe to clear the pharynx, followed by the nasal passages. Conserving the newborn’s body heat and maintaining a stable body temperature are important, but a patent airway must be established first. These are important functions, but physiologic stability is the first priority in the immediate care of the newborn.

 

DIF:    Cognitive Level: Analyze               REF:   p. 210

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. The nurse is careful to place the incubator away from cold windows or air-conditioning units. This is to conserve the newborn’s body heat by preventing heat loss through:
a. radiation.
b. conduction.
c. convection.
d. evaporation.

 

 

ANS:  A

Radiation is the loss of heat to a cooler solid object. The cold air from either the window or the air conditioner will cool the incubator walls and subsequently the newborn’s body. Conduction involves the loss of heat from the body because of direct contact of the skin with a cooler object. Convection is the loss of heat similar to conduction but aided by air currents. Evaporation is the loss of heat through moisture. The newborn should be quickly dried of the amniotic fluid.

 

DIF:    Cognitive Level: Apply                  REF:   p. 210

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
a. prevent bleeding.
b. enhance immune response.
c. prevent bacterial infection.
d. maintain nutritional status.

 

 

ANS:  A

Vitamin K is administered to prevent hemorrhagic disease of the newborn. Vitamin K is synthesized by the intestinal flora. Because the newborn’s intestine is sterile and breast milk is low in vitamin K, a supplemental source must be supplied. The purpose is not to enhance the immune response, prevent bacterial infection, or maintain nutritional status. The major function of vitamin K is to catalyze the liver synthesis of prothrombin, which is needed for blood clotting and coagulation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 211

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. In the newborn, intramuscular phytonadione (vitamin K) is administered into which muscle?
a. Deltoid
b. Dorsogluteal
c. Vastus medialis
d. Vastus lateralis

 

 

ANS:  D

The vastus lateralis is the traditionally recommended injection site. The deltoid and dorsogluteal sites are not recommended for the vitamin K administration. The ventrogluteal may be used as an alternative site to the vastus lateralis. The vastus medialis is not used for intramuscular injections.

 

DIF:    Cognitive Level: Apply                  REF:   p. 211

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Recommendations for hepatitis B (HBV) vaccine include which statement?
a. First dose is given between birth and age 2 days.
b. First dose is given between ages 12 and 15 months.
c. It is not recommended for neonates who are at low risk for hepatitis B.
d. It is not recommended for neonates whose mothers are positive for HBV surface antigen.

 

 

ANS:  A

To reduce the incidence of HBV in children and its serious consequences in adulthood, the first of three doses is recommended soon after birth and before hospital discharge. Between 12 and 15 months is too late. The recommendation is for the first dose to be given soon after birth. It is recommended for all newborns. Newborns born to mothers who are HBV surface antigen positive should be given the vaccine within 12 hours of birth. They also should be given hepatitis B immune globulin.

 

DIF:    Cognitive Level: Understand          REF:   p. 211

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A newborn is being discharged at age 48 hours. The parents ask how the newborn should be bathed this first week home. How should the nurse recommend to bathe the newborn?
a. Daily with mild soap
b. Daily with an alkaline soap
c. Two or three times this week with plain water
d. Two or three times this week with mild soap

 

 

ANS:  C

The newborn newborn’s skin has a pH of approximately 5. This acidic pH has a bacteriostatic effect. The parents should be taught to use only plain warm water for the bath and to bathe the child no more than two or three times a week for the first 2 weeks. Soaps are alkaline. They will alter the acid mantle of the child’s skin, providing a medium for bacterial growth.

 

DIF:    Cognitive Level: Apply                  REF:   p. 213

TOP:   Integrated Process: Teaching/Learning | Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The stump of the umbilical cord usually separates in how many days?
a. 3
b. 10 to 14
c. 16 to 20
d. 28

 

 

ANS:  B

The average cord separates in 10 to 14 days; 3 days is too soon and 16 to 28 days is too late. The cord should be separated by these times.

 

DIF:    Cognitive Level: Remember           REF:   p. 213

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. The parents of a newborn plan to have him circumcised. They ask the nurse about pain associated with this procedure. What knowledge should the nurse’s response be based on?
a. Experience pain with circumcision
b. Do not experience pain with circumcision
c. Quickly forget about the pain of circumcision
d. Are too young for anesthesia or analgesia

 

 

ANS:  A

Circumcision is a surgical procedure. The American Academy of Pediatrics has recommended that, when circumcision is performed, procedural analgesia be provided. Pain is associated with surgical procedures. The newborn experiences pain, which can be alleviated with analgesia. Topical and injected analgesia are available for this procedure.

 

DIF:    Cognitive Level: Apply                  REF:   p. 214

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. Early this morning, a baby boy was circumcised by using the Plastibell method. When should the nurse tell the mother that the baby can be discharged?
a. The newborn voids
b. Receiving vitamin K
c. Yellow exudate forms over glans
d. The Plastibell rim falls off

 

 

ANS:  A

The circumcision site is evaluated for excessive bleeding every 30 minutes for at least 2 hours. After these observations and voiding, the newborn can be discharged. The newborn should have received vitamin K soon after delivery. This normal yellow exudate will usually form on the second day after the circumcision. Discharge can occur earlier. The Plastibell rim will separate and fall off within 5 to 8 days. The newborn should be discharged before this.

 

DIF:    Cognitive Level: Apply                  REF:   p. 215

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What does the American Academy of Pediatrics recommend as the best form of newborn nutrition?
a. Exclusive breastfeeding until age 2 months.
b. Exclusive breastfeeding until age 6 months.
c. Commercially prepared newborn formula for 1 year.
d. Commercially prepared newborn formula until age 4 to 6 months.

 

 

ANS:  B

The American Academy of Pediatrics has reaffirmed its position that a newborn be breastfed exclusively for the first six months of life. This group also supports programs that enable women to return to work and continue breastfeeding. Two months is too short of a period. The recommendation is for breastfeeding, not commercial formula. If the mother has stopped breastfeeding, then commercial formula, rather than whole milk, should be used until age 1 year.

 

DIF:    Cognitive Level: Understand          REF:   p. 216

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. On what is successful breastfeeding most dependent?
a. Mother’s socioeconomic level
b. Size of mother’s breasts
c. Mother’s desire to breastfeed
d. Birth weight of newborn

 

 

ANS:  C

The factors that contribute to successful breastfeeding are the mother’s desire to breastfeed, satisfaction with breastfeeding, and available support systems. The mother’s socioeconomic level may affect the mother’s need to return to work and available support systems, but with support, the mother can be successful. The size of the mother’s breasts does not affect the success of breastfeeding. Very low birth weight newborns may be unable to breastfeed. The mother can express milk, and it can be used for the child.

 

DIF:    Cognitive Level: Apply                  REF:   p. 216

TOP:   Integrated Process: Nursing Process: Planning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What should a nursing intervention to promote parent-newborn attachment include?
a. Delaying parent-newborn interactions until the second period of reactivity
b. Explaining individual differences among newborns to the parents
c. Alleviating stress for parents by decreasing their participation in the newborn’s care
d. Allowing a newborn to fuss for a period of time before soothing by holding

 

 

ANS:  B

Nurses can positively influence the attachment of parent and child by recognizing and explaining individual differences to the parents. The nurse should emphasize the normalcy of these variations and demonstrate the uniqueness of each newborn. The nurse should facilitate parent-newborn interaction during the first period of reactivity. Decreasing the parents’ participation in care will interfere with parent-newborn attachment. The parents should be encouraged to hold the newborn when he or she is fussy and learn how best to soothe their newborn.

 

DIF:    Cognitive Level: Apply                  REF:   p. 221

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A new mother wants to be discharged with her newborn as soon as possible. What should be done prior to discharge?
a. Newborn has voided at least once
b. Newborn does not spit up after feeding
c. Jaundice, if present, appeared before 24 hours
d. Appointment is made for home care or a primary care practitioner office visit within next 2 or 3 days

 

 

ANS:  D

The American Academy of Pediatrics recommends that newborns discharged early receive follow-up care within 48 hours of a short stay in either a primary practitioner’s office or the home. The child should void every 4 to 6 hours. Spitting up small amounts after feeding is a normal occurrence in newborns. It would not delay discharge. Jaundice within the first 24 hours of life must be evaluated.

 

DIF:    Cognitive Level: Apply                  REF:   p. 224

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. What should nursing interventions to maintain a patent airway in a newborn include?
a. Sleeping in the prone (on abdomen) position
b. Wrapping neonate as snugly as possible
c. Positioning neonate supine while sleeping
d. Using bulb syringe to suction as needed, suctioning nose first, and then pharynx

 

 

ANS:  C

Supine is the position recommended by the American Academy of Pediatrics to prevent sudden infant death syndrome. Sleeping in the prone position is not advised because of the possible link between sleeping in the prone position and sudden infant death syndrome. The child can be wrapped snugly, but should be placed on side or back. A bulb syringe should be kept by the bedside if necessary, but the pharynx should be suctioned before the nose.

 

DIF:    Cognitive Level: Apply                  REF:   p. 210

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is assessing the presence of expected reflexes in a newborn. Which figure depicts the elicitation of the tonic neck reflex?
a.
b.
c.
d.

 

 

ANS:  B

The tonic neck reflex is elicited when the newborn’s head is turned to one side; the arm and leg extend on that side, and opposite arm and leg flex (fencing position). The Moro reflex is elicited by sudden jarring or change in equilibrium. The newborn has extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape followed by flexion and adduction of extremities; legs may weakly flex. The dancing reflex is elicited when the newborn is held so that the sole of the foot touches a hard surface; there is a reciprocal flexion and extension of the leg, simulating walking. The crawl reflex is elicited when the newborn is placed on the abdomen; the newborn makes crawling movements with arms and legs.

 

DIF:    Cognitive Level: Analyze               REF:   p. 204

TOP:   Integrated Process: Nursing Process: Assessment

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. A nurse is teaching a class on breastfeeding to expectant parents. Which are contraindications for breastfeeding? (Select all that apply.)
a. Human immunodeficiency virus (HIV) in mother
b. Mastitis
c. Inverted nipples
d. Maternal cancer therapy
e. Twin births

 

 

ANS:  A, D

HIV in the mother and maternal cancer therapy place the newborn at risk. HIV can be transmitted through breast milk, as can be the metabolites of chemotherapy. Mastitis, inverted nipples, and twin births are not contraindications.

 

DIF:    Cognitive Level: Apply                  REF:   p. 216

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is conducting discharge teaching for parents of a newborn. The nurse instructs the parents on which method of care for the umbilical cord? (Select all that apply.)
a. Covering the cord with the diaper
b. Cleansing the cord with water daily
c. Keeping the cord area free of urine and stool
d. Monitoring for signs of infection
e. Applying bacitracin ointment to the cord daily

 

 

ANS:  B, C, D

Parents are taught to keep the cord area free of urine and stool, cleanse daily with water if needed, and observe for any signs of infection. The diaper should not cover the cord. The diaper is folded in front below the cord to avoid irritation and wetness on the site. Bacitracin ointment should not be applied because the cord area should be kept dry, not moist.

 

DIF:    Cognitive Level: Apply                  REF:   p. 225

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
a. Limiting the feeding to 15 minutes
b. Propping the bottle for night feedings is acceptable
c. Proper technique for cleansing the bottles and nipples
d. Feeding infant on alternate sides of the lap
e. Use of bottled water without fluoride should be avoided to mix powdered formula.

 

 

ANS:  C, D, E

Parents preparing infant formula must wash their hands well and then wash all of the equipment used to prepare the formula (including the cans of formula) with soap and water. Sterilizing bottles and nipples 5 minutes in boiling water may be required when a hot-water dishwasher is not available. Similar to breastfed infants, bottle-fed infants need to be held on alternate sides of the lap to expose them to different stimuli. Bottled water should not be considered sterile unless otherwise indicated; bottled water without fluoride should be avoided for mixing infant formula. Propping the bottle during infant feedings at nighttime could cause the infant to aspirate. The feeding should not be hurried. Even though they may suck vigorously for the first 5 minutes and seem to be satisfied, infants should be allowed to continue sucking. Infants need at least 2 hours of sucking a day. If there are six feedings per day, then about 20 minutes of sucking at each feeding provide for oral gratification.

 

DIF:    Cognitive Level: Apply                  REF:   p. 218

TOP:   Integrated Process: Teaching/Learning

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

  1. A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is “term” if which findings are assessed? (Select all that apply.)
a. Posture with fully flexed arms and legs
b. Arm recoil brisk
c. Square window at 90 degrees
d. Scarf sign of elbow crossing over the midline
e. Popliteal angle less than 90 degrees

 

 

ANS:  A, B, E

A term newborn will have a posture that is fully flexed (arms and legs) and a brisk arm recoil. The popliteal angle in a term infant is less than 90 degrees. The square window should show no angle, the hand should lie flat on the ventral surface of the arm in the term newborn. In a term newborn, the elbow should not cross the midline during assessment of the scarf sign.

 

DIF:    Cognitive Level: Analyze               REF:   p. 193

TOP:   Integrated Process: Nursing Process: Evaluation

MSC:  Area of Client Needs: Health Promotion and Maintenance

 

SHORT ANSWER

 

  1. A nurse is performing a 1-minute Apgar on a newborn. The nurse assesses that the newborn has a heart rate over 100, a good strong cry, some flexion of extremities, sneezes, and has a pink body with blue extremities. The nurse records what number as the Apgar? Record your answer in a whole number.

 

ANS:

8

 

Sign 0 1 2
Heart rate Absent Slow, <100 beats/min >100 beats/min
Respiratory effort Absent Irregular, slow, weak cry Good, strong cry
Muscle tone Limp Some flexion of extremities Well flexed
Reflex irritability No response Grimace Cry, sneeze
Color Blue, pale Body pink, extremities blue Completely pink

 

The newborn gets 2 for heart rate, 2 for respiratory effort, 1 for muscle tone, 2 for reflex irritability and 1 for color = 8

 

DIF:    Cognitive Level: Apply                  REF:   p. 193

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity

 

  1. A nurse is preparing to administer a prescribed phytonadione (vitamin K) injection 0.5 mg intramuscularly to a newborn. The phytonadione (vitamin K) ampule is labeled 1 mg equals 0.5 ml. How many milliliters will the nurse administer? Record your answer using two decimal places.

 

ANS:

0.25

 

Formula:

Desired

Available ´ Volume =

0.5 mg

1 mg ´ 0.5 mL = 0.25 mL

 

DIF:    Cognitive Level: Apply                  REF:   p. 211

TOP:   Integrated Process: Nursing Process: Implementation

MSC:  Area of Client Needs: Physiologic Integrity