Wong’s Nursing Care of Infants and Children  9th Edition by Marilyn J. Hockenberry, David Wilson  – Test Bank

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Wong’s Nursing Care of Infants and Children  9th Edition by Marilyn J. Hockenberry, David Wilson  – Test Bank

 

Sample  Questions

 

Hockenberry: Wong’s Nursing Care of Infants and Children, 9th Edition

 

Chapter 05: Hereditary Influences on Health Promotion of the Child and Family

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of the following genetic terms refers to a person who possesses one copy of an affected gene and one copy of an unaffected gene and is clinically unaffected?
a. Allele
b. Carrier
c. Pedigree
d. Multifactorial

 

 

ANS:  B

An individual who is a carrier is asymptomatic, but possesses a genetic alteration, either in the form of a gene or chromosome change. Alleles are alternative expression of genes at a different locus. A pedigree is a diagram that describes family relationships, gender, disease, status, or other relevant information about a family. Multifactorial describes a complex interaction of both genetic and environmental factors that produce an effect on the individual.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 80

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following genetic terms refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage?
a. Trisomy
b. Monosomy
c. Translocation
d. Nondisjunction

 

 

ANS:  C

Translocation is the transfer of all or part of a chromosome to a different chromosome after chromosome breakage. It can be balanced, producing no phenotypic effects, or unbalanced, producing severe or lethal effects. Trisomy is an abnormal number of chromosomes caused by the presence of an extra chromosome, which is added to a given chromosome pair and results in a total of 47 chromosomes per cell. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction is the failure of homologous chromosomes or chromatids to separate during mitosis or meiosis.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 81

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following is a birth defect or disorder that occurs as a new case in a family and is not inherited?
a. Sporadic
b. Polygenic
c. Monosomy
d. Association

 

 

ANS:  A

Sporadic describes a birth defect previously unidentified in a family. It is not inherited. Polygenic inheritance involves the inheritance of many genes at separate loci whose combined effects produce a given phenotype. Monosomy is an abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. A nonrandom cluster of malformations without a specific cause is an association.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 81

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assessing a neonate who was born 1 hour ago to healthy, Caucasian parents in their early forties. Which of the following findings would be most suggestive of Down syndrome?
a. Hypertonia
b. Low-set ears
c. Micrognathia
d. Long, thin fingers and toes

 

 

ANS:  B

Children with Down syndrome have low-set ears. Infants with Down syndrome have hypotonia, not hypertonia. Micrognathia is common in trisomy 16, not Down syndrome. Children with Down syndrome have short hands with broad fingers.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 109

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following abnormalities is a common sex chromosome defect?
a. Down
b. Turner
c. Marfan
d. Hemophilia

 

 

ANS:  B

Turner syndrome is caused by an absence of one of the X chromosomes. Down syndrome is caused by trisomy 21 (three copies rather than two copies of chromosome 21). Marfan syndrome is a connective tissue disorder inherited in an autosomal dominant pattern. Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 86

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Turner syndrome is suspected in an adolescent girl with short stature. This is caused by which of the following?
a. Absence of one of the X chromosomes
b. Presence of an incomplete Y chromosome
c. Precocious puberty in an otherwise healthy child
d. Excess production of both androgens and estrogens

 

 

ANS:  A

Turner syndrome is caused by an absence of one of the X chromosomes. Most girls who have this disorder have one X chromosome missing from all cells. No Y chromosome is present in individuals with Turner syndrome. These young women have 45 rather than 46 chromosomes.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 107

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following is a sex chromosome abnormality that is caused by the presence of one or more additional X chromosomes in a male?
a. Turner
b. Triple X
c. Klinefelter
d. Trisomy 13

 

 

ANS:  C

Klinefelter syndrome is characterized by one or more additional X chromosomes. These individuals are tall with male secondary sexual characteristics that may be deficient, and they may be learning disabled. An absence of an X chromosome results in Turner syndrome. Triple X and trisomy 13 are not abnormalities that involve one or more additional X chromosomes in a male (Klinefelter syndrome).

 

DIF:    Cognitive Level: Comprehension   REF:   p. 86

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following statements is characteristic of autosomal dominant inheritance?
a. Females are affected with greater frequency than males.
b. Unaffected children of affected individuals will have affected children.
c. Each child of a heterozygous affected parent has a 50% chance of being affected.
d. Any child of two unaffected heterozygous parents has a 25% chance of being affected.

 

 

ANS:  C

In autosomal dominant inheritance only one copy of the gene is necessary to cause the disorder. When a parent is affected, there is a 50% chance that the chromosome with the gene for disorder will be contributed to each pregnancy. Males and females are equally affected. The disorder does not “skip” a generation. If the child is not affected, then most likely he or she is not a carrier of the gene for the disorder. In autosomal recessive inheritance any child of two unaffected heterozygous parents has a 25% chance of being affected.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 90

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following is characteristic of autosomal recessive inheritance?
a. Affected individuals have unaffected parents.
b. Affected individuals have one affected parent.
c. Affected parents have a 50% chance of having an affected child.
d. Affected parents will have unaffected children.

 

 

ANS:  A

Parents who are carriers of a recessive gene are asymptomatic. For a child to be affected, both parents must have a copy of the gene, which is passed to the child. Both parents are asymptomatic, but can have affected children. In autosomal recessive inheritance, there is a 25% chance that each pregnancy will result in an affected child. In autosomal dominant inheritance affected parents can have unaffected children.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 95

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following is characteristic of X-linked recessive inheritance?
a. There are no carriers.
b. Affected individuals are principally males.
c. Affected individuals are principally females.
d. Affected individuals will always have affected parents.

 

 

ANS:  B

In X-linked recessive disorders the affected individuals are usually male. With recessive traits, usually two copies of the gene are needed to produce the effect. Since the male only has one X chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disorders. The X chromosome that does not have the recessive gene will produce the “normal” protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A father with an X-linked recessive disorder asks the nurse what the probability is that his sons will have the disorder. The nurse answers:
a. male children will be carriers.
b. all male children will be affected.
c. none of the sons will have the disorder.
d. it cannot be determined without more data.

 

 

ANS:  C

When a male has an X-linked recessive disorder, he has one copy of the allele on his X chromosome. The father passes only his Y chromosome (not the X chromosome) to his sons. Therefore none of his sons will have the X-linked recessive gene. They will not be carriers or be affected by the disorder. No additional data are needed to answer this question.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The inheritance of which of the following is X-linked recessive?
a. Hemophilia A
b. Marfan syndrome
c. Neurofibromatosis
d. Fragile X syndrome

 

 

ANS:  A

Hemophilia A is inherited as an X-linked recessive trait. Marfan syndrome and neurofibromatosis are inherited as autosomal dominant disorders. Fragile X is inherited as an X-linked dominant trait.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 97

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Chromosome analysis of the fetus is usually accomplished through the testing of which of the following?
a. Fetal serum
b. Maternal urine
c. Amniotic fluid
d. Maternal serum

 

 

ANS:  C

Amniocentesis is the most common method to retrieve fetal cells for chromosome analysis. Viable fetal cells are sloughed off into the amniotic fluid and, when a sample is taken, can be cultured and analyzed. It is difficult to obtain a sample of the fetal blood. It is a high-risk situation for the fetus. Fetal cells are not present in the maternal urine or blood.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 107

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A couple asks the nurse about the optimal time for genetic counseling. They do not plan to have children for several years. When should the nurse recommend they begin genetic counseling?
a. As soon as the woman suspects that she may be pregnant
b. Whenever the couple is ready to start their family
c. Now, if one of them has a family history of congenital heart disease
d. Now, if the couple are members of a population at risk for certain diseases

 

 

ANS:  D

Persons who seek genetic evaluation and counseling must first be aware if there is a genetic or potential problem in their families. Genetic testing should be done now if the couple is part of a population at risk. It is not feasible at this time to test for all genetic diseases. The optimal time for genetic counseling is before pregnancy occurs. During the pregnancy, genetic counseling may be indicated if a genetic disorder is suspected. Congenital heart disease is not a single-gene disorder.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 108

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman, age 43, is 6 weeks pregnant. It is important that she be informed of the:
a. need for a therapeutic abortion.
b. increased risk for Down syndrome.
c. increased risk for Turner syndrome.
d. need for an immediate amniocentesis.

 

 

ANS:  B

Women who are over age 35 at the birth of a single child or 31 at the birth of twins are advised to have prenatal diagnosis. The risk of having a child with Down syndrome increases with maternal age. There is no indication of a need for a therapeutic abortion at this stage. Turner syndrome is not associated with advanced maternal age. Amniocentesis cannot be done at a gestational age of 6 weeks.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 109

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A couple has given birth to their first child, a boy with a recessive disorder. The genetic counselor tells them that the risk of recurrence is 1:4. Which of the following statements is a correct interpretation of this information?
a. The risk factor remains the same for each pregnancy.
b. The risk factor will change when they have a second child.
c. Because the parents have one affected child, the next three children should be unaffected.
d. Because the parents have one affected child, the next child is four times more likely to be affected.

 

 

ANS:  A

Each pregnancy has the same risks for an affected child. Since an odds ratio reflects the risk, this does not change over time. The statement by the genetic counselor refers to a probability. This does not change over time. The statement “Because the parents have one affected child, the next child is four times more likely to be affected” does not reflect autosomal recessive inheritance.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 109

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A couple expecting their first child has a positive family history for several congenital defects and disorders. Prenatal diagnostic testing is recommended. The couple tells the nurse that they are opposed to abortion for religious reasons. Which of the following should the nurse consider when counseling this couple?
a. Couple should be encouraged to have recommended diagnostic testing.
b. Couple needs counseling regarding advantages and disadvantages of pregnancy termination.
c. Diagnostic testing is required by law in this situation.
d. Diagnostic testing is of limited value if termination of pregnancy is not an option.

 

 

ANS:  A

The benefits of prenatal diagnostic testing extend beyond decisions concerning abortion. Should the child have congenital disorders, decisions can be made about fetal surgery if indicated. In addition, if the child is expected to require neonatal intensive care at birth, the mother is encouraged to deliver at a level III neonatal center. The couple is counseled about the advantages and disadvantages of prenatal diagnosis, not pregnancy termination, although the family cannot be forced to have prenatal testing. The information gives the parents time to grieve and plan for their child if congenital disorders are present. If the child is free of defects, then the parents are relieved of a major worry.

 

DIF:    Cognitive Level: Comprehension   REF:   pp. 106,107

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. The nurse is teaching a group of new nurses who will be working in the neonatal intensive care unit. Which of the following assessment findings for genetic disorders should the nurse include in the teaching? Select all that apply.
a. Poor urinary output
b. Limb abnormalities
c. Hypertonic muscle tone
d. Increased respiratory rate
e. Cardiac defect

 

 

ANS:  B, C, E

A variety of assessment clues, including limb abnormalities, hypertonic muscle tone, and cardiac defects, point to the possibility of a genetic disorder. Poor urinary output and increased respiratory rate are not indications of a genetic problem.

 

DIF:    Cognitive Level: Application          REF:   p. 109

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following can be directly attributed to a single-gene disorder? Select all that apply.
a. Cleft lip
b. Cystic fibrosis
c. Turner syndrome
d. Klinefelter syndrome
e. Neurofibromatosis

 

 

ANS:  B, E

Cystic fibrosis is a single-gene disorder inherited as an autosomal recessive trait, and neurofibromatosis is a single-gene disorder inherited as an autosomal dominant trait. Cleft lip is classified as a multifactorial disorder, in which a genetic susceptibility and appropriate environment appear to play important roles. Turner and Klinefelter syndromes are disorders of sex chromosome number.

 

DIF:    Cognitive Level: Application          REF:   pp. 90, 95

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

Hockenberry: Wong’s Nursing Care of Infants and Children,

9th Edition

 

Chapter 07: Pain Assessment and Management in Children

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of the following is the most consistent and commonly used data for assessment of pain in infants?
a. Self-report
b. Behavioral
c. Physiologic
d. Parental report

 

 

ANS:  B

Behavioral assessment is useful for measuring pain in young children and preverbal children who do not have the language skills to communicate they are in pain. Infants are not able to self-report. Physiologic measures are not able to distinguish between physical responses to pain and to other forms of stress. Parental report without a structured tool may not accurately reflect the degree of discomfort.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 222

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

 

  1. Children as young as age 3 years can use facial scales for discrimination. Suggested anchor words for the preschool age-group include:
a. “No hurt.”
b. “Red pain.”
c. “Zero hurt.”
d. “Least pain.”

 

 

ANS:  A

“No hurt” is a phrase that is simple, concrete, and appropriate to the preoperational stage of the child. Using color is complicated for this age-group. First the child needs to identify colors and pain levels and then choose an appropriate symbolic color. This is appropriate for an older child. Zero is an abstract construct not appropriate for this age-group. “Least pain” is less concrete than “no hurt.”

 

DIF:    Cognitive Level: Application          REF:   p. 185

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

 

  1. Which of the following is an important consideration when using the FACES pain rating scale with children?
a. Children color the face with the color they choose to best describe their pain.
b. Scale can be used with most children as young as 3 years.
c. Scale is not appropriate for use with adolescents.
d. FACES scale is useful in pain assessment but not as accurate as physiologic responses.

 

 

ANS:  B

The FACES scale is validated for use with children ages 3 years and older. Children point to the face that best describes their level of pain. The scale can be used through adulthood. The child’s estimate of the pain should be used. The physiologic measures may not reflect more long-term pain.

 

DIF:    Cognitive Level: Application          REF:   p. 182

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

 

  1. Nonpharmacologic strategies for pain management:
a. may reduce pain perception.
b. usually take too long to implement.
c. make pharmacologic strategies unnecessary.
d. trick children into believing they do not have pain.

 

 

ANS:  A

Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child’s pain severity and taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child’s experience with mild pain, but the child will still know the discomfort was present.

 

DIF:    Cognitive Level: Analysis               REF:   p. 194            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

 

  1. Which of the following nonpharmacologic interventions appears to be effective in decreasing neonatal procedural pain?
a. Tactile stimulation
b. Commercial warm packs
c. Doing procedure during infant sleep
d. Oral sucrose and nonnutritive sucking

 

 

ANS:  D

Nonnutritive sucking attenuates behavioral, physiologic, and hormonal responses to pain. The addition of sucrose has been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. No evidence supports commercial warm packs as a pain control measure. With resulting increased blood flow to the area, pain may be greater. The infant should not be disturbed during the sleep cycle. It makes it more difficult for the infant to begin organization of sleep and awake cycles.

 

DIF:    Cognitive Level: Analysis               REF:   p. 194            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

 

  1. A child age 6 years has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. Your explanation to the parents should include:
a. the child will continue to sleep and be pain free.
b. parents cannot administer additional medication with the button.
c. the pump can deliver baseline and bolus dosages.
d. there is a high risk of overdose so monitoring is done every 15 minutes.

 

 

ANS:  C

The PCA prescription can be set for a basal rate for a continuous infusion of pain medication. Additional doses can be administered by the patient, parent, or nurse as necessary. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child the age of 6, the parents and nurse must assess the child to ensure that adequate medication is being given, since the child may not understand the concept of pushing a button. Evidence-based practice suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 204

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. Which of the following drugs is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period?
a. Codeine
b. Morphine
c. Methadone
d. Meperidine

 

 

ANS:  B

The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone in parenteral form is is not used in a PCA but is given po or IV for pain in the infant. Meperidine is not used for continuous and extended pain relief.

 

DIF:    Cognitive Level: Analysis               REF:   p. 199

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A child is in the intensive care unit after a motor vehicle collision. The child has numerous fractures and is in pain that is rated 9 or 10 on a 10-point scale. In planning the care, the nurse recognizes that the indicated action is to:
a. give only an opioid analgesic at this time.
b. increase dosage of analgesic until the child is adequately sedated.
c. plan a preventive schedule of pain medication around the clock.
d. give the child a clock and explain when she or he can have pain medications.

 

 

ANS:  C

For severe postoperative pain, a preventive around the clock (ATC) schedule is necessary to prevent decreased plasma levels of medications. The opioid analgesic will help for the present, but it is not an effective strategy. Increasing the dosage requires an order. The nurse should give the drug on a regular schedule and evaluate the effectiveness. Using a clock is counterproductive. It focuses the child’s attention on how long he will need to wait for pain relief.

 

DIF:    Cognitive Level: Analysis               REF:   p. 207            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The parents of a preterm infant in a neonatal intensive care unit are concerned about their infant experiencing pain from so many procedures. The nurse’s response should be based on knowledge that preterm infants:
a. may react to painful stimuli but are unable to remember the pain experience.
b. perceive and react to pain in much the same manner as children and adults.
c. do not have the cortical and subcortical centers that are needed for pain perception.
d. lack neurochemical systems associated with pain transmission and modulation.

 

 

ANS:  B

Numerous research studies have indicated that preterm and newborn infants perceive and react to pain in the same manner as children and adults. Preterm infants can have significant reactions to painful stimuli. Pain can cause oxygen desaturation and global stress response. These physiologic effects must be avoided by use of appropriate analgesia. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response.

 

DIF:    Cognitive Level: Analysis               REF:   p. 188

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A preterm infant has just been admitted to the neonatal intensive care unit. The infant’s parents ask the nurse about anesthesia and analgesia when painful procedures are necessary. The nurse’s explanation should be based on knowledge that:
a. nerve pathways of neonates are not sufficiently myelinated to transmit painful stimuli.
b. the risks accompanying anesthesia and analgesia are too great to justify any possible benefit of pain relief.
c. neonates do not possess sufficiently integrated cortical function to interpret or recall pain experiences.
d. pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates.

 

 

ANS:  D

Pain pathways and neurochemical systems associated with pain transmission are intact and functional in neonates. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response. The pathways are sufficiently myelinated to transmit the painful stimuli and produce the pain response. Local and systemic pharmacologic agents are available to permit anesthesia and analgesia for neonates.

 

DIF:    Cognitive Level: Analysis               REF:   p. 188

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A bone marrow aspiration and biopsy are needed on a school-age child. The most appropriate action to provide analgesia during the procedure is to:
a. administer TAC (tetracaine, adrenalin, and cocaine) 15 minutes before the procedure.
b. use a combination of fentanyl and midazolam for conscious sedation.
c. apply EMLA (eutectic mixture of local anesthetics) 1 hour before the procedure.
d. apply transdermal fentanyl (Duragesic) “patch” immediately before the procedure.

 

 

ANS:  B

A bone marrow biopsy is a painful procedure. The combination of fentanyl and midazolam should be used to provide conscious sedation. TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on a wound for suturing. It is not sufficient for a bone marrow biopsy. EMLA is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. For this procedure, systemic analgesia is required. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control.

 

DIF:    Cognitive Level: Analysis               REF:   p. 221

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A significant, common side effect that occurs with opioid administration is:
a. euphoria.
b. diuresis.
c. constipation.
d. allergic reactions.

 

 

ANS:  C

Constipation is one of the most common side effects of opioid administration. Preventive strategies should be implemented to minimize this problem. Sedation is a more common result than euphoria. Urinary retention, not diuresis, may occur with opiates. Rarely, some individuals may have pruritus.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 211            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is caring for a child receiving continuous IV low dose infusion of morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse first to do which of the following?
a. Administer naloxone (Narcan).
b. Discontinue intravenous infusion.
c. Discontinue morphine until child is fully awake.
d. Stimulate child by calling name, shaking gently, and asking to breathe deeply.

 

 

ANS:  A

The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, then IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.

 

DIF:    Cognitive Level: Analysis               REF:   p. 211

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is teaching a staff development program about levels of sedation in the pediatric population. Which of the following statements by one of the participants would indicate a correct understanding of the teaching?
a. “With minimal sedation the patient’s respiratory efforts are affected and cognitive function is not impaired.”
b. “With general anesthesia the patient’s airway cannot be maintained but cardiovascular function is maintained.”
c. “During deep sedation the patient can be easily aroused by loud verbal commands and tactile stimulation.”
d. “During moderate sedation the patient responds to verbal commands but may not respond to light tactile stimulation.”

 

 

ANS:  D

When discussing levels of sedation, the participants should understand that during moderate sedation the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation the patient responds to verbal commands and may have impaired cognitive function; the respiratory and cardiovascular systems are unaffected. In deep sedation the patient cannot be easily aroused except by painful stimuli, the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained. With general anesthesia the patient loses consciousness and cannot be aroused with painful stimuli, the airway cannot be maintained, and ventilation is impaired; cardiovascular function may or may not be impaired.

 

DIF:    Cognitive Level: Analysis               REF:   p. 216

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

MULTIPLE RESPONSE

 

  1. Which of the following are components of the FLACC scale? Select all that apply.
a. Color
b. Capillary refill time
c. Leg position
d. Facial expression
e. Activity

 

 

ANS:  C, D, E

Facial expression, consolability, cry, activity, and leg position are components of the FLACC scale. Color is a component of the Apgar scoring system. Capillary refill time is a physiologic measure that is not a component of the FLACC.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 180

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

 

  1. The nurse is using the CRIES pain assessment tool on a preterm infant in the neonatal intensive care unit. Which of the following is a component of this tool? Select all that apply.
a. Color
b. Moro reflex
c. Oxygen saturation
d. Posture of arms and legs
e. Sleeplessness
f. Facial expression

 

 

ANS:  C, E, F

Need for increased oxygen, crying, increased vital signs, expression, and sleeplessness are components of the CRIES pain assessment tool used with neonates. Color, Moro reflex, and posture of arms and legs are not components of the CRIES scale.

 

DIF:    Cognitive Level: Application          REF:   p. 188

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Basic Care and Comfort

Hockenberry: Wong’s Nursing Care of Infants and Children, 9th Edition

 

Chapter 09: Health Problems of the Newborn

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of the following is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
a. Hydrocephalus
b. Cephalhematoma
c. Caput succedaneum
d. Subdural hematoma

 

 

ANS:  C

Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. The swelling consists of serum and/or blood accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It would not be visible on the scalp.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 280

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which of the following findings on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
a. Positive scarf sign
b. Asymmetric Moro reflex
c. Swelling of fingers on affected side
d. Paralysis of affected extremity and muscles

 

 

ANS:  B

An infant with a broken clavicle may have no symptoms. The Moro reflex, which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities, will most likely be asymmetric. The scarf sign that is used to determine gestational age should not be performed if a broken clavicle is suspected. Swelling of fingers on affected side and paralysis of the affected extremity and muscles are not signs of a fractured clavicle.

 

DIF:    Cognitive Level: Analysis               REF:   p. 282

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The parents of a neonate ask the nurse what caused the baby’s facial nerve paralysis. The nurse’s response is based on knowledge that this is caused by which of the following?
a. Birth injury
b. Genetic defect
c. Spinal cord injury
d. Inborn error of metabolism

 

 

ANS:  A

Pressure on the facial nerve (cranial nerve VII) during delivery may result in injury to the nerve. Genetic defects, spinal cord injuries, and inborn errors of metabolism did not cause the facial nerve paralysis. The paralysis usually disappears in a few days but may take as long as several months.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 282

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is which of the following?
a. Easily treated
b. Benign and transient
c. Usually not contagious
d. Usually not disfiguring

 

 

ANS:  B

Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The rash usually lasts about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not contagious. Successive crops of lesions heal without pigmentation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 284

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Nursing care of the newborn with oral candidiasis (thrush) includes which of the following?
a. Avoid use of pacifier.
b. Continue medication for prescribed number of days.
c. Remove characteristic white patches with a soft cloth.
d. Apply medication to oral mucosa, being careful that none is ingested.

 

 

ANS:  B

The medication must be continued for the prescribed number of days. To prevent relapse, therapy should continue for at least 2 days after the lesions disappear. Pacifiers can be used. The pacifier should be replaced with a new one or boiled for 20 minutes once daily. One of the characteristics of thrush is that the white patches cannot be removed. The medication is applied to the oral mucosa and then swallowed to treat Candida albicans in the gastrointestinal tract.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 284            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. A mother brings her infant in at age 6 weeks with complaints of poor feeding, lethargy, fever, irritability, and a vesicular rash. The nurse suspects:
a. impetigo.
b. candidiasis.
c. neonatal herpes.
d. congenital syphilis.

 

 

ANS:  C

Neonatal herpes is one of the most serious viral infections in the newborn, with a mortality rate of up to 60% in those infants with disseminated disease. Bullous impetigo is an infectious superficial skin condition most often caused by Staphylococcus aureus. It is characterized by bullous vesicular lesions on previously untraumatized skin. Candidiasis is characterized by white adherent patches on the tongue, palate, and inner aspects of the cheeks. Congenital syphilis has multisystem manifestations, including hepatosplenomegaly, lymphadenopathy, hemolytic anemia, and thrombocytopenia.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 284

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Which of the following is a bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth?
a. Port-wine stain
b. Juvenile melanoma
c. Cavernous hemangioma
d. Strawberry hemangioma

 

 

ANS:  D

Strawberry hemangiomas (or capillary hemangiomas) are benign cutaneous tumors that involve only capillaries. They are bright red, rubbery nodules with rough surfaces and well-defined margin. They may or may not be apparent at birth but enlarge during the first year of life and tend to resolve spontaneously by ages 2 to 3 years. Port-wine stain is a vascular stain that is a permanent lesion and is present at birth. Initially it is a pink, red, or, rarely, purple stain of the skin that is flat at birth; it thickens, darkens, and proportionately enlarges as the child grows. Melanoma is not differentiated into juvenile and adult forms. A cavernous hemangioma involves deeper vessels in the dermis and has a bluish red color and poorly defined margins.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 286

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The newborn with severe jaundice is at risk for developing which of the following?
a. Encephalopathy
b. Bullous impetigo
c. Respiratory distress
d. Blood incompatibility

 

 

ANS:  A

Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Bullous impetigo is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 287

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. When should the nurse expect breast-feeding–associated jaundice to first appear in a normal newborn?
a. 0 to 12 hours
b. 12 to 24 hours
c. 2 to 4 days
d. After fifth day

 

 

ANS:  C

Breast-feeding–associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mother’s milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin. Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn. After the fifth day is too late. Jaundice associated with breast-feeding would have begun earlier because of decreased breast milk intake.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 289

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Which of the following interventions may decrease the incidence of physiologic jaundice in a healthy full-term infant?
a. Institute early and frequent feedings.
b. Bathe infant when axillary temperature is 36.3° C (97.5° F).
c. Place infant’s crib near window for exposure to sunlight.
d. Suggest that mother initiate breast-feeding when danger of jaundice is past.

 

 

ANS:  A

Physiologic jaundice is caused by the immature hepatic function of the infant’s liver coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot be excreted from the body. Feeding stimulates peristalsis and produces more rapid passage of meconium. Bathing does not affect physiologic jaundice. Placing the infant’s crib near window for exposure to sunlight is not a treatment of physiologic jaundice. Colostrum is a natural cathartic, which facilitates meconium excavation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 292

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. An important nursing intervention for a full-term infant receiving phototherapy is:
a. observing for signs of dehydration.
b. using sunscreen to protect infant’s skin.
c. keeping child diapered to collect frequent stools.
d. informing the mother why breast-feeding must be discontinued.

 

 

ANS:  A

Dehydration is a potential risk of phototherapy. The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration. Lotions are not used; they may contribute to a “frying” effect. The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights. Breast-feeding is encouraged. Intermittent phototherapy may be as effective as continuous therapy. The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.

 

DIF:    Cognitive Level: Application          REF:   p. 294

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Rh hemolytic disease is suspected in a mother’s second baby, a son. Which of the following factors is important in understanding how this could develop?
a. The first child was a girl.
b. Her first child was Rh positive.
c. Both parents have type O blood.
d. She was not immunized against hemolysis.

 

 

ANS:  B

Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell (RBC) destruction. The major causes of this are maternal-fetal Rh and ABO incompatibility. If an Rh-negative mother has previously been exposed to Rh-positive blood through pregnancy or blood transfusion, antibodies to this blood group antigen may develop so that she is isoimmunized. With further exposure to Rh-positive blood, the maternal antibodies agglutinate with the red cells of the fetus that has the antigen and destroy the cells. Hemolytic disease caused by ABO incompatibilities can be present with the first pregnancy. Gender of the first child is not a concern. Blood type is the important consideration. If both parents are type O blood, ABO incompatibility would not be a possibility.

 

DIF:    Cognitive Level: Analysis               REF:   p. 295

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. When should the nurse expect jaundice to be present in a full-term newborn with hemolytic disease?
a. At birth
b. Within 24 hours after birth
c. 25 to 48 hours after birth
d. 49 to 72 hours after birth

 

 

ANS:  B

In hemolytic disease of the newborn, jaundice is usually evident within the first 24 hours of life. Infants with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present. Twenty-five to 72 hours after birth is too late for hemolytic disease of the newborn. Jaundice at these ages is most likely due to physiologic or early-onset breast-feeding jaundice.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 289

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A woman who is Rh-negative is pregnant with her first child, and her husband is Rh-positive. During her 12-week prenatal visit she tells the nurse that she has been told that this is dangerous. The nurse should know that:
a. no treatment is necessary.
b. exchange transfusion will be necessary at birth.
c. no treatment is available until the infant is born.
d. administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation.

 

 

ANS:  D

The goal is to prevent isoimmunization. If the mother has not been previously exposed to the Rh-negative antigen, Rh immunoglobulin (RhIg) is administered at 26 to 28 weeks of gestation and again within 72 hours of birth. The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the newborn secondary to the Rh factor. Unless other problems coexist, the infant will not require transfusions at birth.

 

DIF:    Cognitive Level: Analysis               REF:   p. 298            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is planning care for a newborn receiving calcium gluconate for treatment of hypocalcemia. Which of the following routes of administration will be used?
a. Oral
b. Intramuscular
c. Intravenous
d. Intraosseous

 

 

ANS:  C

Calcium gluconate is administered intravenously over 10 to 30 minutes or as a continuous infusion. If it is given more rapidly than this, cardiac dysrhythmias and circulatory collapse may occur. Early feedings are indicated, but when the ionized calcium drops below 3.0 to 4.4 mg/dl, intravenous calcium gluconate is necessary. Intramuscular or intraosseous administration is not recommended.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 302            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. Phenylketonuria is a genetic disease that results in the body’s inability to correctly metabolize:
a. glucose.
b. thyroxine.
c. phenylalanine.
d. phenylketones.

 

 

ANS:  C

Phenylketonuria is an inborn error of metabolism caused by a deficiency or absence of the enzyme needed to metabolize the essential amino acid phenylalanine. Individuals with this disorder can metabolize glucose. Thyroxine is one of the principal hormones secreted by the thyroid gland. Phenylketones are metabolites of phenylalanine, excreted in the urine.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 304

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Early diagnosis of congenital hypothyroidism (CH) and phenylketonuria (PKU) is essential to prevent which of the following?
a. Obesity
b. Diabetes
c. Cognitive impairment
d. Respiratory distress

 

 

ANS:  C

Untreated, both PKU and CH cause cognitive impairment. With newborn screening and early intervention, cognitive impairment from these two disorders can be prevented. Obesity, diabetes, and respiratory distress do not result from both CH and PKU.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 304

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A breast-fed newborn has just been diagnosed with galactosemia. The therapeutic management of this includes which of the following?
a. Stop breast-feeding infant.
b. Add amino acids to breast milk.
c. Substitute a lactose-containing formula for breast milk.
d. Give the appropriate enzyme along with breast milk.

 

 

ANS:  A

The infant with galactosemia is fed a diet free of all milk and lactose-containing foods. This includes breast milk. Soy-protein formula is the formula of choice. Other strategies are being identified.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 308            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a newborn who will be discharged on home phototherapy. Which of the following instructions should the nurse include in the discharge teaching to the parents?
a. Apply an oil-based lotion to the infant’s skin two times per day to prevent the skin from drying out under the phototherapy light.
b. Keep the eye shields on the infant’s eyes even when the phototherapy light is turned off.
c. Take the infant’s temperature every 2 hours while the infant is under the phototherapy light.
d. Make a follow-up visit with the health care provider within 2 or 3 days after your infant has been on phototherapy.

 

 

ANS:  D

With short hospital stays, infants may be discharged with a prescription for home phototherapy. It is the responsibility of the nurse planning discharge to include important information such as the need for a follow-up visit with the health care provider in 2 or 3 days to evaluate feeding and elimination pattern and to have blood work done if needed. The parents should be taught to not apply oil or lotions to prevent increased tanning; the baby’s eye shields can come off when the phototherapy lights are turned off, and the infant’s temperature needs to be monitored but not taken every 2 hours.

 

DIF:    Cognitive Level: Analysis               REF:   p. 295

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a full-term infant who was born after an uneventful pregnancy and delivery. The infant’s blood glucose level is 36 mg/dl. Which of the following interventions should the nurse take?
a. Bring the infant to the mother and initiate breast-feeding.
b. Place a nasogastric tube and administer 5% dextrose water.
c. Start a peripheral intravenous line and administer 10% dextrose.
d. Monitor the infant in the nursery and obtain a blood glucose level in 4 hours.

 

 

ANS:  A

A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic, as indicated by a blood glucose level of 36 mg/dl, and who is clinically asymptomatic would probably reestablish normoglycemia with early institution of breast- or bottle-feeding. The infant does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose, since the blood glucose level is only borderline. The infant does need to be monitored, but breast- or bottle-feeding should be started and the blood glucose level checked in 1 to 2 hours.

 

DIF:    Cognitive Level: Analysis               REF:   p. 299

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. The nurse is teaching a new nurse about types of physical injuries that can occur at birth. Which of the following soft tissue injuries should the nurse include in the teaching? Select all that apply.
a. Petechiae
b. Retinal hemorrhage
c. Facial paralysis
d. Cephalhematoma
e. Subdural hematoma
f. Subconjunctival hemorrhage

 

 

ANS:  A, B, F

Soft tissue injuries that can occur at birth include petechiae, retinal hemorrhage, and subconjunctival hemorrhage. Facial paralysis and cephalhematoma are head injuries that occur at birth, and a subdural hematoma is considered a neurologic injury related to the birthing process.

 

DIF:    Cognitive Level: Application          REF:   p. 280

TOP:   Integrated Process: Teaching/Learning

MSC:  Client Needs: Physiological Integrity: Reduction of Risk Potential

Hockenberry: Wong’s Nursing Care of Infants and Children, 9th Edition

 

Chapter 11: Conditions Caused by Defects in Physical Development

 

Test Bank

 

MULTIPLE CHOICE

 

  1. Every organ, system, and body part goes through a stage during which it is especially susceptible to injurious influences. What is this period called?
a. Fetal
b. Sensitive
c. Embryonic
d. Differentiation

 

 

ANS:   B

During sensitive periods of development, the organism displays a marked susceptibility to injurious influences. Fetal development is the period of intrauterine growth beginning at 9 weeks. Embryonic development occurs during weeks 3 through 8. Differentiation is the process by which early cells are systematically modified and specialized to form all of the tissues necessary to ensure an organized, coordinated individual.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 391

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A mother has just given birth to an infant with a cleft lip. Sensing that something is wrong, she starts to cry and asks the nurse, “What is wrong with my baby?” The most appropriate nursing action is to:
a. encourage mother to express her feelings.
b. explain in simple language that the baby has a cleft lip.
c. provide emotional support until practitioner can talk to mother.
d. tell mother a pediatrician will talk to her as soon as the baby is examined.

 

 

ANS:   B

It is best to explain in simple terms the nature of the defect and to reinforce and help clarify information given by the practitioner before the infant is shown to the parents. Parents may not be ready to talk about their feelings during the first few days after birth. The nurse should provide information about the child’s condition while waiting for the practitioner to speak with the family after the examination. The mother needs simple explanations of what is wrong with her child during this period of waiting.

 

DIF:    Cognitive Level: Application             REF:    p. 394

TOP:    Nursing Process: Planning                  MSC:   Client Needs: Psychosocial Integrity

 

  1. A neonate requires surgery soon after birth for repair of a congenital defect. An important priority of the preoperative nursing care is:
a. initiating discharge teaching.
b. performing baseline physical and behavioral assessment.
c. observing for allergic reactions to preoperative antibiotics.
d. determining whether this defect exists in other family members.

 

 

ANS:   B

It is essential to assess the infant preoperatively to obtain a baseline. Postoperative changes can be identified and a determination can be made regarding pain or change in status. The parents are not ready for discharge teaching. Their focus is on the congenital defect and surgery. Although a remote possibility, allergic reactions rarely occur on the first dose. Determining whether this defect exists in other family members is an important part of the history, but not a priority preoperatively.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 414

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A critical nursing responsibility in the postoperative care of the neonate includes:
a. determining rectal temperature.
b. suctioning every hour and as needed.
c. carefully monitoring infant’s weight.
d. using only nonpharmacologic pain control measures.

 

 

ANS:   C

The infant’s weight is carefully monitored and compared with the preoperative weight for changes in fluid balance. Additional changes in fluid balance can be detected through weight changes. Rectal temperatures are avoided in neonates. Axillary or skin temperatures are monitored. Suctioning is not done on a routine basis. It is done when necessary. After surgery, pharmacologic and nonpharmacologic pain control measures should be used.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 430

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A recommendation to prevent neural tube defects (NTDs) is the supplementation of which of the following?
a. Vitamin A throughout pregnancy
b. Folic acid for all women of childbearing age
c. Folic acid during the first and second trimesters of pregnancy
d. Multivitamin preparations as soon as pregnancy is suspected

 

 

ANS:   B

The widespread use of folic acid among women of childbearing age has decreased the incidence NTDs. In the United States the rates of NTDs have declined from 1.3 per 1000 births in 1990 to 0.3 per 1000 after the introduction of mandatory folic acid supplementation in food in 1998. Vitamin A is not related to the prevention of NTDs. Folic acid supplementation is recommended for the preconceptual period, as well as during the pregnancy. The NTD is a failure of neural tube closure during early development, the first 3 to 5 weeks.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 399

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

 

  1. The nurse is caring for a family whose infant was just born with anencephaly. The most important nursing intervention is to:
a. implement measures to facilitate the attachment process.
b. help the family cope with birth of an infant with a fatal defect.
c. prepare the family for extensive surgical procedures that will be needed.
d. provide emotional support so the family can adjust to the birth of an infant with problems.

 

 

ANS:   B

Anencephaly is the most serious neural tube defect. The infants have an intact brainstem and, if born alive, may be able to maintain vital functions for a few hours to several weeks. The family requires emotional support and counseling to cope with the birth of an infant with a fatal defect. The parents should be encouraged to hold their infant and provide comfort measures. This facilitates the grieving process, since the infant has a limited life expectancy. Infants with anencephaly do not have cerebral hemispheres. There is no surgical correction available for this defect. Emotional support is needed as the family adjusts to the birth of a child who has a fatal defect.

 

DIF:    Cognitive Level: Application             REF:    p. 400

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Psychosocial Integrity

 

  1. Which of the following refers to a hernial protrusion of a saclike cyst of meninges, spinal fluid, and a portion of the spinal cord with its nerves through a defect in the vertebral column?
a. Rachischisis
b. Meningocele
c. Encephalocele
d. Myelomeningocele

 

 

ANS:   D

A myelomeningocele has a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 400

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A woman who is 6 weeks pregnant tells the nurse that she is worried that, even though she is taking folic acid supplements, the baby might have spina bifida because of a family history. The nurse’s response should be based on which of the following?
a. Prenatal detection is not possible yet.
b. There is no genetic basis for the defect.
c. Chromosome studies done on amniotic fluid can diagnose the defect prenatally.
d. Open neural tube defects (NTDs) result in elevated concentrations of a-fetoprotein in amniotic fluid.

 

 

ANS:   D

Ultrasound scanning and measurement of a-fetoprotein may indicate the presence of anencephaly or myelomeningocele. The optimum time for performing this analysis is between 16 and 18 weeks. Prenatal diagnosis is possible through amniocentesis. A multifactorial origin is suspected, including drugs, radiation, maternal malnutrition, chemicals, and possibly a genetic mutation. Chromosome abnormalities are not present in NTDs.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 402

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The most important nursing intervention when caring for a child with myelomeningocele in the preoperative stage is which of the following?
a. Take vital signs every hour.
b. Place child on side to decrease pressure on the spinal sac.
c. Watch for signs that might indicate developing hydrocephalus.
d. Apply a heat lamp to facilitate drying and toughening of the sac.

 

 

ANS:   B

The spinal sac is protected from damage until surgery is performed. Early surgical closure is recommended to prevent local trauma and infection. Monitoring vital signs and watching for signs that might indicate developing hydrocephalus are important interventions, but preventing trauma to the sac is a priority. The sac is kept moist until surgical intervention is done.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 402

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Neuropathic bladder disorders are common among children with:
a. plagiocephaly.
b. meningocele.
c. craniosynostosis.
d. myelomeningocele.

 

 

ANS:   D

Myelomeningocele is one of the most common causes of neuropathic bladder dysfunction among children. Plagiocephaly is the flattening of a side of the child’s head. This is not associated with neuropathic bladder. Children with meningocele usually do not have neuropathic bladder. Craniosynostosis is the premature closure of one or more cranial sutures. It is not associated with neuropathic bladder.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 403

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Which of the following most accurately describes bowel function in children born with a myelomeningocele?
a. Incontinence cannot be prevented.
b. Enemas and laxatives are contraindicated.
c. Some degree of fecal continence can usually be achieved.
d. Colostomy is usually required by the time child reaches adolescence.

 

 

ANS:   C

With a combination of dietary modification, regular toilet habits, and prevention of constipation and impaction, some degree of fecal continence can usually be achieved. Incontinence can be minimized with the development of a regular bowel training program. A surgical intervention can assist with continence. Enemas and laxatives are part of a bowel training program. Colostomies are not indicated in children with myelomeningocele.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 405

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. The most appropriate way to position and feed this neonate is to place him:
a. prone with head turned to side for feeding.
b. on side to facilitate feeding.
c. supine in infant carrier for feedings.
d. supine, with defect supported with rolled blankets, and with nipple-feeding.

 

 

ANS:   A

The prone position with the head turned to side for feeding is the optimum position for the infant. It protects the spinal sac and allows the infant to be fed without trauma. The side-lying position is avoided preoperatively. It can place tension on the sac and affect hip dysplasia if present. The infant should not be placed in a supine position.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 405

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A goal for children with spina bifida is to reduce the chance of allergy development. A priority nursing intervention is to:
a. recommend allergy testing.
b. provide latex-free environment.
c. use only powder-free latex gloves.
d. limit use of latex products as much as possible.

 

 

ANS:   B

A latex-free environment is the goal. This includes eliminating the use of latex gloves and other medical devices containing latex. Allergy testing would provide information about whether the allergy has developed. It will not reduce the chances of developing the allergy. Although powder-free latex gloves are less allergenic, latex should not be used. Limiting the use of latex products is one component of providing a latex-free environment, but latex products should not be used.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 408

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. When a child develops latex allergy, which of the following foods may also cause an allergic reaction?
a. Yeast
b. Wheat
c. Peanuts
d. Bananas

 

 

ANS:   D

There are cross-reactions between allergies to latex and to a number of foods such as bananas, avocados, kiwi, and chestnuts. Although yeast, wheat, and peanuts are potential allergens, currently they are not known to cross-react with latex allergy.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 408

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. What clinical manifestations suggest hydrocephalus in an infant?
a. Closed fontanel, high-pitched cry
b. Bulging fontanel, dilated scalp veins
c. Constant low-pitched cry, restlessness
d. Depressed fontanel, decreased blood pressure

 

 

ANS:   B

Bulging fontanels, dilated scalp veins, and separated sutures are clinical manifestations of hydrocephalus in neonates. Closed fontanel, high-pitched cry, constant low-pitched cry, restlessness, depressed fontanel, and decreased blood pressure are not clinical manifestations of hydrocephalus, but all should be referred for evaluation.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 411

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A pregnant woman asks about prenatal diagnosis of hydrocephalus. The nurse’s response should be based on knowledge that it can be diagnosed:
a. only after birth.
b. by chromosome studies.
c. with fetal ultrasonography.
d. by measuring lecithin/sphingomyelin ratio.

 

 

ANS:   C

Hydrocephalus can be diagnosed by fetal ultrasonography as early as 14 weeks of gestation. Most incidents of hydrocephalus are not chromosomal in origin. The lecithin/sphingomyelin ratio can be used to determine fetal lung maturity.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 412

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A child is admitted for revision of a ventriculoperitoneal shunt for noncommunicating hydrocephalus. A common reason for elective revision of this shunt is which of the following?
a. Meningitis
b. Gastrointestinal upset
c. Hydrocephalus resolution
d. Growth of child since the initial shunting

 

 

ANS:   D

An elective revision of a ventriculoperitoneal shunt would most likely be done to accommodate the child’s growth. Meningitis would require an emergent replacement or revision of the shunt. Gastrointestinal upset alone would not indicate the need for shunt revision. Noncommunicating hydrocephalus would not resolve without surgical intervention.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 413

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. A priority of care when a child has an external ventricular drain (EVD) is:
a. irrigation of drain to maintain flow.
b. as-needed dressing changes if dressing becomes wet.
c. frequent assessment of amount and color of drainage.
d. maintaining the EVD below the level of the child’s head.

 

 

ANS:   C

The EVD is inserted into the child’s ventricle. Frequent assessment is necessary to determine amount of drainage and whether an infection is present. The EVD is a closed system and is not opened for irrigation. Antibiotics may be administered through the drain, but this is usually done by the neuropractitioner. The dressing is not changed. If it becomes wet, then the practitioner should be notified that cerebrospinal fluid (CSF) may be leaking. Unless ordered, maintaining the EVD below the level of the child’s head position will create too much pressure and potentially drain too much CSF.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 413

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. The nurse is discussing long-term care with the parents of a child who has a ventriculoperitoneal shunt. Which of the following issues should be addressed?
a. Most childhood activities must be restricted.
b. Cognitive impairment is to be expected with hydrocephalus.
c. Wearing head protection is essential until child reaches adulthood.
d. Shunt malfunction or infection requires immediate treatment.

 

 

ANS:   D

Because of the potentially severe sequelae, symptoms of shunt malfunction or infection must be assessed and treated immediately. Limits should be appropriate to the child’s developmental age. Except for contact sports, the child will have few restrictions. Cognitive impairment depends on the extent of damage before the shunt was placed.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 413

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. Postnatal plagiocephaly is believed to be caused by:
a. head trauma.
b. supine positioning.
c. folic acid deficiency.
d. inadequate parenting.

 

 

ANS:   B

The incidence of postnatal plagiocephaly has increased since 1992. This is believed to be related to the increased incidence of infants sleeping in the supine position. Head trauma, folic acid deficiency, and inadequate parenting are not related to the development of plagiocephaly.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 418

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. Which of the following statement by the parent would indicate a correct understanding of the teaching?
a. ”I should gently massage the skin under the straps once a day to stimulate circulation.”
b. “I will apply a lotion for sensitive skin under the straps after my baby has been given a bath to prevent skin irritation.”
c. “I should remove the harness several times a day to prevent contractures.”
d. “I will place the diaper over the harness, preferably using a superabsorbent disposable diaper that is relatively thin.”

 

 

ANS:   A

To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a Pavlik harness, the parent should gently massage the skin under the straps once a day to stimulate circulation. The parent should not apply lotions or powder, since this could irritate the skin. The parent should not remove the harness, except during a bath, and should place the diaper under the straps.

 

DIF:    Cognitive Level: Application             REF:    p. 423

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that:
a. traction is tried first.
b. surgical intervention is needed.
c. frequent, serial casting is tried first.
d. children outgrow this condition when they learn to walk.

 

 

ANS:   C

Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 424

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a functional prosthetic device?
a. As soon as possible after birth
b. When the infant is developmentally ready to stand up
c. At about ages 12 to 15 months, when most children are walking
d. At about 4 years, when the healthy limb is not growing so rapidly

 

 

ANS:   B

An infant should be fitted with a functional prosthetic leg when the infant is developmentally ready to pull to a standing position. When the infant begins limb exploration, a soft prosthesis can be used. The child should begin using the prosthesis as part of his or her normal development. This will match the infant’s motor readiness.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 426

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The association of cleft palate with otitis media is primarily the result of which of the following?
a. Coexisting defects of middle ear and eustachian tube
b. Lowered resistance because of poor nutritional status
c. Plugging of the eustachian tube with food particles
d. Inefficient function of eustachian tubes and improper middle ear drainage

 

 

ANS:   D

Improper drainage of the middle ear, as a result of inefficient function of the eustachian tube, contributes to recurrent otitis media with scarring of the tympanic membrane, which leads to hearing impairment. Coexisting defects of middle ear and eustachian tube, lowered resistance because of poor nutritional status, and plugging of the eustachian tube with food particles are not associated with recurrent otitis media.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 430

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. Caring for the newborn with a cleft lip and palate before surgical repair includes which of the following?
a. Gastrostomy feedings
b. Allowing little or no sucking
c. Providing satisfaction of sucking needs
d. Keeping infant in near-horizontal position during feedings

 

 

ANS:   C

Using special or modified nipples for feeding techniques helps to meet the infant’s sucking needs. Gastrostomy feedings are usually not indicated. The child requires both nutritive and nonnutritive sucking. Feeding is best accomplished with the infant’s head in an upright position.

 

DIF:    Cognitive Level: Application             REF:    p. 431

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A mother who intended to breast-feed has given birth to an infant with a cleft palate. Nursing interventions should include which of the following?
a. Give medication to suppress lactation.
b. Recommend using formula for feedings.
c. Encourage and help mother to breast-feed.
d. Teach mother to feed breast milk by gavage.

 

 

ANS:   C

The mother who wishes to breast-feed may need encouragement and support because the defect does present some logistical issues. The nipple is positioned and stabilized in the back of the infant’s oral cavity to enable the tongue to express milk. If the mother wishes to breast-feed, medications should not be given to suppress lactation. The infant will have difficulties with bottle-feeding. Special nipples can be used. Breast-feeding can actually be easier for the infant. Because breast-feeding can usually be accomplished, gavage feedings are not indicated.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 431

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infant’s postoperative care include which of the following?
a. Arm restraints, postural drainage, mouth irrigations
b. Cleansing suture line, supine and side-lying position, appropriate analgesia
c. Mouth irrigations, prone position, cleansing suture line
d. Supine and side-lying positions, postural drainage, arm restraints

 

 

ANS:   B

The suture line should be cleansed gently after feeding. The child should be positioned on back, on side, or in infant seat. The child is medicated with appropriate analgesia to calm him or her. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur. Arm restraints are used according to local practice.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 431

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A 4-month-old child is discharged home after surgery for the repair of a cleft lip. Instructions to the parents include:
a. provide crib toys for distraction.
b. breast- or bottle-feeding can begin immediately.
c. give pain medication to infant to minimize crying.
d. leave infant in crib at all times to prevent suture strain.

 

 

ANS:   C

Pain medication and comfort measures are used to minimize infant crying. Interventions are implemented to minimize stress on the suture line. Although crib toys are important, the child should not be left in the crib for prolonged periods. Feeding begins with alternative feeding devices. Sucking puts stress on the suture line in the immediate postoperative period. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 434

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse observes that a newborn is having problems after birth. Which of the following would indicate a tracheoesophageal fistula?
a. Jitteriness
b. Meconium ileus
c. Excessive frothy saliva
d. Increased need for sleep

 

 

ANS:   C

Excessive frothy saliva is indicative of tracheoesophageal fistula. The child is unable to swallow the secretions, so there are excessive amounts of saliva in the mouth. Jitteriness is associated with several disorders, including electrolyte imbalances. Meconium ileus is associated with cystic fibrosis. Increased need for sleep is not associated with tracheoesophageal fistula.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 437

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include which of the following?
a. Feed glucose water only.
b. Elevate head for feedings.
c. Raise head and give nothing by mouth.
d. Avoid suctioning unless infant is cyanotic.

 

 

ANS:   C

When a newborn is suspected of having tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 437

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. Nursing actions related to the gastrostomy tube include which of the following?
a. Keep tube clamped.
b. Suction tube as needed.
c. Leave tube open to gravity drainage.
d. Lower tube to a point below the level of the stomach.

 

 

ANS:   C

In the immediate postoperative period the gastrostomy tube is open to gravity drainage. This usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of secretions. Lowering the tube to a point below the level of the stomach would create too much pressure.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 437

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Preoperative care of the newborn with an anorectal malformation should include which of the following?
a. Frequent suctioning
b. Gastrointestinal decompression
c. Feedings with sterile water only
d. Supine position with head elevated

 

 

ANS:   B

Gastrointestinal decompression is an essential part of nursing care for a newborn with an anorectal malformation. This helps alleviate intraabdominal pressure until surgical intervention. Suctioning is not necessary for an infant with this type of anomaly. Feedings are not indicated until it is determined that the gastrointestinal tract is intact. Supine position with head elevated is indicated for infants with a tracheoesophageal fistula, not anorectal malformations.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 437

TOP:    Nursing Process: Implementation

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. A child who has just had definitive repair of a high rectal malformation is to be discharged. Which of the following should the nurse address in the discharge preparation of this family?
a. Safe administration of daily enemas
b. Necessity of firm stools to keep suture line clean
c. Bowel training beginning as soon as child returns home
d. Changes in stooling patterns to report to practitioner

 

 

ANS:   D

The parents are taught to notify the practitioner if any signs of an anal stricture or other complications develop. Constipation is avoided, since a firm stool will place strain on the suture line. Daily enemas are contraindicated after surgical repair of a rectal malformation. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the child’s developmental and physiologic readiness.

 

DIF:    Cognitive Level: Application             REF:    p. 441

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Which of the following should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia?
a. Prognosis for full recovery is excellent.
b. Death usually occurs by 6 months of age.
c. Liver transplantation may be needed eventually.
d. Children with surgical correction live normal lives.

 

 

ANS:   C

Untreated biliary atresia results in progressive cirrhosis and death usually by 2 years of age. Surgical intervention at 8 weeks of age is associated with somewhat better outcomes. Liver transplantation is also improving outcomes for 10-year survival. Even with surgical intervention, most children require supportive therapy. With early intervention, 10-year survival rates range from 27% to 75%.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 442

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. The best chance of survival for a child with cirrhosis is:
a. liver transplantation.
b. provision of nutritional support.
c. treatment with corticosteroids.
d. administration of immunoglobulin.

 

 

ANS:   A

The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 442

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. The parents of a newborn with an umbilical hernia ask about treatment options. The nurse’s response should be based on knowledge that:
a. surgery is recommended as soon as possible.
b. the defect usually resolves spontaneously by 3 to 5 years of age.
c. aggressive treatment is necessary to reduce its high mortality.
d. taping the abdomen to flatten the protrusion is sometimes helpful.

 

 

ANS:   B

The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical hernias rarely become problematic. Incarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation.

 

DIF:    Cognitive Level: Application             REF:    p. 448

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. The narrowing of preputial opening of foreskin is called:
a. chordee.
b. phimosis.
c. epispadias.
d. hypospadias.

 

 

ANS:   B

Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.

 

DIF:    Cognitive Level: Comprehension       REF:    p. 449

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Identification and treatment of cryptorchid testes should be done by age 2 years. An important consideration is:
a. medical therapy is not effective after this age.
b. treatment is necessary to maintain ability to be fertile when older.
c. the younger child can tolerate the extensive surgery needed.
d. sexual reassignment may be necessary if treatment is not successful.

 

 

ANS:   B

The longer the testis is exposed to higher body heat, the greater the likelihood of damage. To preserve fertility, surgery should be done at an early age. Surgical intervention is the treatment of choice. Simple orchiopexy is usually performed as an outpatient procedure. The surgical procedure restores the testes to the scrotum. This helps the boy to have both testes in the scrotum by school age. Sexual reassignment is not indicated when the testes are not descended.

 

DIF:    Cognitive Level: Comprehension       REF:    pp. 451-452

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Congenital defects of the genitourinary tract, such as hypospadias, are usually repaired as early as possible to:
a. minimize separation anxiety.
b. prevent urinary complications.
c. increase acceptance of hospitalization.
d. promote development of normal body image.

 

 

ANS:   D

Promoting development of normal body image is extremely important. Surgery involving sexual organs can be upsetting to children, especially preschoolers who fear mutilation and castration. Proper preprocedure preparation can facilitate coping with these issues. Preventing urinary complications is important for defects that affect function, but for all external defects, repair should be done as soon as possible.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 454

TOP:    Nursing Process: Planning                  MSC:   Client Needs: Psychosocial Integrity

 

  1. Parents of a 2-year-old who had a repair of exstrophy of the bladder at birth ask when they can begin toilet training their son. The nurse replies based on the knowledge that:
a. most boys in the United States can be toilet trained at age 3 years.
b. training can begin when he has sufficient bladder capacity.
c. additional surgery may be necessary to achieve continence.
d. they should begin now, since he will require additional time.

 

 

ANS:   C

After repair of the bladder exstrophy, the child’s bladder is allowed to increase capacity. Several surgical procedures may be necessary to create a urethral sphincter mechanism to aid in urination and ejaculation. With the lack of a urinary sphincter, toilet training is unlikely. The child cannot hold the urine in the bladder. Bladder capacity is one component of continence. A functional sphincter is also needed.

 

DIF:    Cognitive Level: Application             REF:    p. 454

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. An infant has been diagnosed with bladder obstruction. Symptoms of this disorder include:
a. renal colic.
b. strong urinary stream.
c. urinary tract infections.
d. posturination dribbling.

 

 

ANS:   D

Symptoms of bladder obstruction include poor force of urinary stream, intermittency of voided stream, feelings of incomplete bladder emptying, and posturination dribbling. They may also include urinary frequency, nocturia, nocturnal enuresis, and urgency. Renal colic is a symptom of upper urinary tract obstruction. Children with bladder obstruction have a weak urinary stream. Urinary tract infections are not associated with bladder obstruction.

 

DIF:    Cognitive Level: Application             REF:    p. 456

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Physiological Adaptation

 

  1. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. The nurse’s intervention should include which of the following?
a. Explain the disorder so they can explain it to others.
b. Help parents understand that this is a minor problem.
c. Suggest that parents avoid family and friends until the gender is assigned.
d. Encourage parents not to worry while the tests are being done.

 

 

ANS:   A

Explaining the disorder to parents so they can explain it to others is the most therapeutic approach while the parents await the gender assignment of their child. Ambiguous genitalia is a serious issue for the family. Careful testing and evaluation are necessary to aid in gender assignment to avoid lifelong problems for the child. Suggesting that parents avoid family and friends until the gender is assigned is impractical and would isolate the family from their support system while awaiting test results. The parents will be concerned. Telling them not to worry without giving them specific alternative actions would not be effective.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 461

TOP:    Nursing Process: Implementation      MSC:   Client Needs: Psychosocial Integrity

 

  1. The parents of a neonate with adrenogenital hyperplasia tell the nurse that they will be afraid to have any more children. The nurse should explain that:
a. it is not hereditary.
b. genetic counseling is indicated.
c. only female children are affected.
d. all future children will have the disorder.

 

 

ANS:   B

Some forms of adrenogenital hyperplasia are hereditary; the parents should be referred for genetic counseling. There is an autosomal recessive form of adrenogenital hyperplasia. Both boys and girls are affected in utero. The complex nature of virilization offers numerous opportunities for disturbances in both boys and girls. If it is the heritable form, each pregnancy carries a 25% risk that the child will be affected.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 458

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. Parents of a newborn with ambiguous genitalia want to know how long they will have to wait to know whether they have a boy or a girl. The nurse answers the parents based on the knowledge that:
a. chromosome analysis will be complete in 7 days.
b. a physical examination will be able to provide a definitive answer.
c. additional laboratory testing is necessary to assign the correct gender.
d. gender assignment involves collaboration between the parents and a multidisciplinary team.

 

 

ANS:   D

Gender assignment is a complex decision-making process. Endocrine, genetic, social, psychologic, and ethical elements of sex assignment have been integrated into the process. Parent participation is included. The goal is to enable the affected child to grow into a well-adjusted, psychosocially stable person. Chromosome analysis usually takes 2 or 3 days. A physical examination reveals ambiguous genitalia, but additional testing is necessary. A “correct” gender may not be identifiable.

 

DIF:    Cognitive Level: Analysis                  REF:    p. 458

TOP:    Integrated Process: Teaching/Learning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

  1. The nurse is preparing to care for a newborn with an omphalocele. The nurse should understand that care of the infant would include which of the following interventions?
a. Initiating breast- or bottle-feedings to stabilize the blood glucose level
b. Maintaining pain management with an intravenous opioid
c. Covering the intact bowel with a nonadherent dressing to prevent injury
d. Performing immediate surgery

 

 

ANS:   C

Nursing care of an infant with an omphalocele includes covering the intact bowel with a nonadherent dressing to prevent injury or placing a bowel bag or moist dressings and a plastic drape if the abdominal contents are exposed. The infant is not started on any type of feeding but has a nasogastric tube placed for gastric decompression. Pain management is started after surgery, but surgery is not done immediately after birth. The infant is medically stabilized before different surgical options are considered.

 

DIF:    Cognitive Level: Application             REF:    p. 444

TOP:    Nursing Process: Planning

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential

 

MULTIPLE RESPONSE

 

  1. The nurse is caring for a newborn with suspected congenital diaphragmatic hernia. Which of the following findings would the nurse expect to observe? Select all that apply.
a. Loud, harsh murmur
b. Scaphoid abdomen
c. Poor peripheral pulses
d. Mediastinal shift
e. Inguinal swelling
f. Moderate respiratory distress

 

 

ANS:   B, D, F

Clinical manifestations of a congenital diaphragmatic hernia include a scaphoid abdomen, a mediastinal shift, and moderate to severe respiratory distress. The infant would not have a harsh, loud murmur or poor peripheral pulses. Inguinal swelling is indicative of an inguinal hernia.

 

DIF:    Cognitive Level: Application             REF:    p. 447

TOP:    Nursing Process: Assessment

MSC:   Client Needs: Physiological Integrity: Reduction of Risk Potential