Chapter 7 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 7

Question 1

Type: MCMA

A nurse in the newborn unit should perform all of these activities during the first 48 hours of newborn 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Identify assessment and intervention areas 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

In planning care for clients in a newborn clinic, the nurses main priority during the first clinic visit will be

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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe the general observations made of infants and their families as they come to the pediatric health-care home for health-supervision visits.

Question 3

Type: MCMA

The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, the nurse will assess which of the following?

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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Identify assessment and intervention areas 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Identify assessment and intervention areas 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 of these activities 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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 03. Identify assessment and intervention areas 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 of these instructions should the nurse give as strategies 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Integrate the family in newborn and infant health care, including 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. How should the nurse interpret these data?

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 no 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 no 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 no 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 no indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: LO 05. Apply the nursing process in assessment, diagnosis, goal setting, intervention, and evaluation of health-promotion and health-maintenance activities for the newborn and infant.

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 of these statements should the nurse make to the mother?

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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe the general observations made of infants and their families as they come to the pediatric health-care home for health-supervision visits.

Question 9

Type: MCMA

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

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Identify assessment and intervention areas 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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 05. Apply the nursing process in assessment, diagnosis, goal setting, intervention, and evaluation of health-promotion and health-maintenance activities for the newborn and infant.

Question 11

Type: MCSA

While teaching parents of a newborn about normal growth and development, the nurse informs them that their childs weight should:

1. Triple by 6 months of age.

2. Double by 1 year of age.

3. Double by 4 months of age.

4. 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Identify assessment and intervention areas 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. The nurse should schedule the office visit for the 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 02. Describe the general observations made of infants and their families as they come to the pediatric health-care home for health-supervision visits.

Question 13

Type: MCMA

A follow-up visit is scheduled with the pediatric nurse practitioner 3 days after discharge. Appropriate assessment would include:

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: LO 03. Identify assessment and intervention areas 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 what developmental milestones she can expect when her baby is 6 months old. The appropriate answer would be:

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:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 05. Apply the nursing process in assessment, diagnosis, goal setting, intervention, and evaluation of health promotion and maintenance activities for the newborn and infant.

Question 15

Type: MCSA

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

1. Measure crib slat spacing at 2 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:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 03. Identify assessment and intervention areas 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.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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