Chapter 7 My Nursing Test Banks

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

Question 1

Type: MCMA

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

Standard Text: Select all that apply.

1. Monitor feeding behaviors.

2. Perform a hearing screening.

3. Perform a heel stick to obtain blood for the newborn screen.

4. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids.

5. Administer folic-acid injection to the infant to prevent bleeding.

Correct Answer: 1,2,3

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

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 2

Type: MCSA

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

1. Providing pamphlets to reinforce information provided at the visit

2. Assessing the newborn-and-family interactions

3. Modeling infant-nurturing behaviors

4. Informing the parents of the infants gains in height and weight

Correct Answer: 2

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

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

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

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

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

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 3

Type: MCMA

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

Standard Text: Select all that apply.

1. Head circumference

2. Body length

3. Weight

4. Length of pregnancy

5. Hearing screens

Correct Answer: 1,2,3,4

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

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

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

Question 4

Type: MCSA

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

1. 7 pounds, 12 ounces

2. 8 pounds, 2 ounces

3. 8 pounds, 12 ounces

4. 9 pounds

Correct Answer: 2

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

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

Question 5

Type: MCSA

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

1. Bring hands to eyes and mouth.

2. Push up with hands, moving chest up.

3. Keep hands in a relaxed position.

4. Roll over from back to abdomen.

Correct Answer: 1

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

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

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

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

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

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

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

Question 6

Type: MCSA

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

1. Dont allow visitors for the first month.

2. Smoke outside only.

3. Take the newborn to weekly child-stimulation classes.

4. SIDS risk-reduction measures

Correct Answer: 4

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 7

Type: MCSA

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

1. The infant is not gaining enough weight.

2. The infant has gained a significant amount of weight.

3. The previous measurements were most likely inaccurate.

4. These measurements are most likely inaccurate.

Correct Answer: 2

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Evaluation

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

Question 8

Type: MCSA

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

1. My, you are dressing your infant warmly today.

2. Did you think it was cold when you left your home this morning?

3. I see that you have many layers of clothing on your baby. This may cause your babys temperature to rise.

4. When you leave the office, only put one layer of clothing on your baby.

Correct Answer: 3

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 9

Type: MCMA

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

Standard Text: Select all that apply.

1. Avoiding nursing or giving the infant a bottle at bedtime

2. Giving foods high in sugar only at breakfast time

3. Using a soft moist gauze for cleaning

4. Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt

Correct Answer: 1,3

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 10

Type: MCSA

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

1. Alteration in Growth Pattern Related to Parental Anxiety

2. Alteration in Growth Pattern Secondary to Familial Short Stature

3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns

4. At Risk for Constitutional Growth Delay Related to Decreased Appetite

Correct Answer: 1

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

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

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

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

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

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Diagnosis

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

Question 11

Type: MCSA

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

1. Weight should triple by 6 months of age.

2. Weight should double by 1 year of age.

3. Weight should double by 4 months of age.

4. Weight should triple by 1 year of age.

Correct Answer: 4

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 12

Type: MCSA

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

1. Within 48 hours of discharge

2. Within one week of discharge

3. Within two weeks of discharge

4. When the infant is 1 month old

Correct Answer: 1

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 13

Type: MCMA

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

Standard Text: Select all that apply.

1. Feeding pattern

2. Jaundice

3. Length

4. Vision screen

5. Sleep pattern

Correct Answer: 1,2,5

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

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

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

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

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

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

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Planning

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

Question 14

Type: MCSA

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

1. Lifts head momentarily when prone

2. Has well-developed pincer grasp

3. Transfers objects from one hand to the other

4. Rolls from front to back

Correct Answer: 3

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

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

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

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

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

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 15

Type: MCSA

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

1. Measure crib slat spacing at 2-3/8 inches or less.

2. Never leave an infant alone in a bath.

3. Position the infant on her back to sleep.

4. Use only approved restraint systems.

Correct Answer: 3

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Implementation

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

Question 16

Type: MCMA

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

Standard Text: Select all that apply.

1. Immunization record

2. Newborn screen results

3. Temperament during the visit

4. Feeding schedule

5. Sleep-wake patterns

Correct Answer: 3,4,5

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

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

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

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

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

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: Nursing Process: Assessment

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

Ball/Bindler/Cowen, Principles of Pediatric Nursing 6th Ed. Test Bank

Copyright 2015 by Pearson Education, Inc.

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