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Maternal: Exam 3

QuestionAnswer
A nurse is collecting data from a 3-year old child. Which of the following findings should the nurse expect? Stands on one foot for a few second (A 3 year-old child should be able to stand on one foot for a few seconds)
True/False: A 4 year-old child should have a vocabulary of 3,000 words. FALSE: A 4 year-old child should have a vocabulary of 1,500 words
At what age should a child be expected to tie their own shoelaces? A 5 year-old child should be able to tie shoelaces.
Who is more likely to be able to throw a ball overhead, a 3 year-old or a 4-year old? A 4 year-old child should be able to throw a ball overhead
A nurse is collecting data from a 6-month old infant in the well child clinic. Which of the following findings should the nurse expect? Posterior fontanel is closed (Small, triangle-shaped fontanel on the back of the infant's head should close by the time the infant is 8 weeks)
Should a nurse expect a 6 month old to Sit well without support? NO, the nurse should NOT expect a 6-month-old infant to sit without support. At 6 months, they can only sit WITH support or leaning forward on their arms
TRUE/FALSE: An infants birth weight tipples at 6 months FALSE: 6 month old birth weight should have DOUBLED
Should Lateral incisors be present on a 6-month-old? NO, Lateral incisors should erupt between 9 and 16 months of age
When administering ear drops to a toddler a nurse pulls by the auricle down and back. Mother asks "Why are you pulling the ear that way?" Which of the following responses should the nurse make? "This opens the ear canal, allowing medication to reach the inner ear region." (For children younger than 3, the nurse should PULL the auricle down and back to fully open the ear canal)
How can a nurse promote comfort when applying Otic (ear) drops? The nurse can warm the solution by holding the bottle between her hands. Warm solution can promote comfort and is less likely to cause Never stimulation and Pain.
How does a nurse prevent the medication from an Otic (ear) drop from running back out of the canal? Once the drops are in the ear, the nurse should gently place pressure on the tragus and have the child move into a Side-lying position.
A nurse is reinforcing teaching about nutritional considerations with a parent of a toddler. Which of the following statements by the parent indicates understanding of the teaching? "My child should receive one-fourth of an adult portion serving size." (Another guideline parents can follow to determine a child's serving size is to provide 1 tbsp of solid food per year of age)
TRUE/FALSE: Mother of a toddler states, "My child's average daily intake should be 2,000 calories." FALSE: A toddler's caloric intake should be between 1,000 and 1,500 calories per day
A parent of a toddler states, "I should limit my child's apple juice intake to 20 oz a day." What should the nurse instruct to the parent? Apple juice is a good source of vitamin C, however, a high intake of juice can lead to diarrhea and under nutrition. The parent should limit the child's juice intake to 4 to 6 oz per day.
A parent of a toddler states, "I should allow my child 10 minutes to eat each meal." What should the nurse instruct to the parent? The nurse should educate the parent on how they should provide the child with pleasant mealtimes that are NOT rushed. Parents should allow 20 to 30 min for the child to eat.
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level? FLACC (FLACC pain scale is appropriate to use with infant and children between the ages of 2 months and 7 year)
At what age is it appropriate to use the Oucher pain scale? The Oucher pain scale is appropriate to use with children between the ages of 3 and 13 years
At what age is it appropriate to use the FACES pain scale? The FACES pain scale is appropriate to use with children as young as 3 years of age.
At what age is it appropriate to use the Visual Analog Scale for a pain scale? The Visual Analog Scale is appropriate to use with children as young as 4 1/2 years of age
The father of a toddler asks a nurse at a well-child clinic what to do when his child kicks and screams during temper tantrums. Which of the following responses should the nurse make? "You should ignore your toddler's temper tantrums." (Ignoring toddler attention-seeking behavior makes the child realize that expressing himself in this method is NOT an effective way to communicate)
A father states he told his toddler, who was throwing a tantrum, "Temper tantrums are not acceptable. What should the nurse instruct to the father? Telling the child that temper tantrums are not acceptable is not a developmentally appropriate response to the child's behavior.
Preconceptual Phase Age Range A child between the ages of 2 and 4 years old is in the preconceptual phase of cognitive development. The child will have an egocentric approach to problems.
Intuitive Thought Phase Age Range A child between the ages of 4 and 7 years old is in the intuitive thought phase of cognitive development. The child is able to think of one idea at a time and will associate words with objects.
Concrete Operations Phase Age Range A child between the ages of 7 and 11 years old is in the Concrete Operations Phase of Cognitive development. The child is able to understand the concept of reversibility, acknowledge other view points and sort objects by different characteristics.
Former Operations Phase Age Range A child between the ages of 11 and 15 years old is in the Formal Operations Phase of Cognitive Development. The child is able to think rationally and use deductive reasoning.
A nurse is reinforcing teaching about nutrition with a parent of a toddler. Which of the following statements should the nurse include in the teaching? Toddlers have a decreased nutritional need (Toddlers have a decrease in nutritional needs and tend to eat less because their growth rate has slowed)
TRUE/FALSE: Toddlers have increased appetites FALSE: Toddlers experience a DECREASE in appetite
TRUE/FALSE: A parent should offer their Toddler foods that are mixed together. FALSE: Toddlers prefer to have food choices separated and visually appealing.
TRUE/FALSE: A parent should fill their Toddler's plate with multiple food choices. FALSE: Toddlers like small amounts of food as options at mealtime. A large amount of food is likely to overwhelm the toddler.
A nurse is providing care to a group of children at a pediatric clinic. Which of the following children meets the criteria to receive a varicella vaccine? A child who has a cold and nasal discharge (Presence of a minor illness is NOT a contraindication of the vaccine)
Which children at a pediatric clinic are NOT allowed to receive a Varicella vaccine? A child who received a blood transfusion 1 month ago, A child currently receiving chemotherapy, and A child currently receiving immunoglobulins
The mother of a 4-year-old child tells a nurse that her child is reluctant to go to bed at night. Which of the following responses should the nurse make? "Keep a night light on in your child's room." (Keeps child from being afraid)
Is it okay for a mother to stay with her child until he is asleep when he starts to cry before bed? NO, the mother should offer reassurance but should NOT remain with the child until he is asleep to ignore attention-seeking behaviors
A nurse is reinforcing teaching with the mother of a 10-month-old infant about expected developmental milestones at this age. Which of the following statements should the nurse make? "Your child should be able to stand while holding onto furniture." (Appropriate for 10-month-old)
TRUE/FALSE: A 15 month old should be ableto build a tower using two blocks. TRUE: A child who is 15 months should be able to build a tower using two blocks
TRUE/FALSE: A 10-month-old should be able to say 10 words. FALSE: A child who is 18 months should be able to say 10 or more words.
TRUE/FALSE: A 10 month old child should be able to turn many pages in a book at once. FALSE: A child who is 12 months old should be able to turn many pages in a book at once.
A nurse is reviewing the stages of sexual development with a 12-year-old male. The nurse should identify that which of the following pubertal changes occurs first? Reddening of scrotal skin (Testicular enlargement, along with reddening and thinning of scrotal skin, are the first pubertal changes in males)
What Develops during Midpuberty? Facial hair, Vocal changes, Coarse hair present across pubis
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse? Apical (Most reliable location on an infant is the apex of the heart)
A nurse in a pediatrician's office is reinforcing teaching with the parent's of a 24 month old toddler. Which of the following activates should the nurse recommend? Playing with pull toys
TRUE/FALSE: A toddler can catch a ball. FALSE: Psychomotor skills are not developed enough to catch, but toddler should be able to throw and kick a ball, undress self, and scribble.
Is a Preschooler likely to be able to jump rope? YES, jumping rope is an activity of the preschool child.
At what age is it appropriate for a child to Use Scissors? At age 4 children should be able to use scissors to cut out a picture by following the outline.
A nurse is reinforcing teaching about car safety with the parents of a preschool-age child. Which of the following findings indicates the correct use of a booster seat? The lap belt fits low across the child's hips
A nurse is caring for a 4 year old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make? "Children who are hospitalized often regress. The toileting skills will return when your child is feeling better."
A nurse in a clinic is preparing to administer pre-kindergarten vaccines. to a 5 year old child whose medical record indicates that his immunizations are up to date. Which of the following vaccines should the nurse plan to administer? Measles, Mumps, and Rubella (MMR) (First dose is administered at 12 to 15 months of age; second typically given prior to school entry at 4 to 6 years of age)
When is the Haemophilus influenzae type B (Hib) vaccine given? The Hib vaccine is given at 2 months, 4 months, and 6 months of age
When is the Pneumococcal conjugate vaccine (PCV) given? PCV vaccine is given at 2 months, 4 months, 6 months, and 12 to 18 months of age
When is the Hepatitis B (HBV) vaccine given? The HBV vaccine is given at birth, 2 months, and 6 to 18 months of age
A parent asks a nurse about toys to provide for a 10 months old infant. Which of the following toys should the nurse suggest? Push-pull toy (Helps 10 month old infant develop muscles and gross motor skills needed to walk unaided)
A nurse is reinforcing teaching with new parents on the proper way to use infant car seat. Which of the following statements by the parents should indicate to the nurse a need for further teaching? "My baby will be comforted in the back seat by being able to watch me while I drive." (Should be rear-facing)
A nurse is collecting date from an 8 month old infant. Which of the following findings should the nurse expect? Positive Babinski reflex (Does not disappear until a child is 12 months old)
When does the Crawl reflex disappear? The Crawl reflex disappears at 6 weeks of age.
Should an 8 month old be expected to Change from a prone to a sitting position? NO, an infant who is 10 months old should be able to change from a prone to a sitting position)
A nurse is collecting data from an infant. Which of the following developmental skills should a 1 month old infant be able to do? Follow movements with eyes
When can an infant Display a social smile? An infant who is 2 months old should be able to display a social smile
When can an infant Make babbling sounds? An infant who is 3 months old should be able to make a babbling sound
Expected Reference Range for BP by age and height in preschool age BOY is- -is 86/44 to 115/77
Expected Reference Range for BP by age and height in preschool age GIRL is- -is 86/47 to 114/78
A nurse is collecting data from a preschool age child during a routine wellness checkup. Which of the following findings indicates the need for further evaluation? The child has a BP of 122/80 mm Hg (Outside of expected reference range)
Expected Reparatory Range for a Preschool Age Child Depending on activity, 21 to 25 respirations/min
A nurse in a pediatric clinic is talking with the mother of a preschool age child. The mother tells the nurse that her son is a "pinky eater". Which of the following responses should the nurse make? "Preschool-age children eat slightly more than toddlers." (Eat about half the amount of an adult, and only slightly more than a toddler)
Why should Fruit juice consumption be limited for Pre-school age children? It has been associated with dental caries, obesity, and metabolic syndrome
A nurse is reviewing routine screenings for adolescents. Which of the following screenings should the nurse expected to be included? Scoliosis (Essential during preadolescence and adolescence period. Scoliosis screen should be implemented at ages 10 to 12 for females and 13 to 14 for males)
A nurse is reinforcing instruction about immunizations with a client who is at 12 weeks of gestation. Which of the following vaccines is safe for the nurse to administer? Tetanus and diphtheria (Td) and Inactivated influenza (TIV)
A nurse is reinforcing teaching with the parents of an 8 month old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching? "You should bring the infant's favorite blanket to the hospital." (Transitional object brings comfort)
A nurse is reinforcing teaching with a parent of a toddler about dealing with temper tantrums. Which of the following statements by the parents indicates an understanding of the teaching? "I should ignore the tantrum behavior."
A nurse is collecting data from an infant at a well-child visit. The nurse should expect the infant to double his birth weight by which of the following ages? 6 months (Birth weight typically doubles between the ages of 5 and 6 months)
A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names? Whooping cough (Common name for pertussis)
A nurse is caring for a 6 month old child. The child's provider has ordered diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine? Temp of 40.5 C (104.9 F) after last DTaP (High fever is a serious side effect)
A nurse is reinforcing teaching about immunizations with the parents of a newborn. Which of the following statements should the nurse make? "Your newborn is scheduled to have Hepatitis B vaccine prior to discharge." (Infant should receive 3 doses of the Hep B vaccine following birth; Prior to discharge, at 1 to 2 months and during the 6th month of age)
A nurse is caring for a 17 year old client who has a terminal illness and refuses treatment. The client's mother wants to proceed with treatment. Which of the following actions should the nurse take? Notify the charge nurse of the situation (Although a parent or legal guardian can give the consent for a minor, the nurse should facilitate a discussion between the parent and adolescent to resolve their differences)
A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a 15 month old child. Which of the following findings should the nurse identify as a contraindication for this immunization? The child has a congenital immunodeficiency (Severe illness that is contraindicated for receiving the MMR)
Can you receive antibiotics and also receive the MMR vaccine? YES, receiving antibiotics for a mild illness is not a contraindication for receiving the MMR vaccine
A nurse is assisting with the care of a 3 month old infant following a surgical procedure. Which of the following pain scales should the nurse use to determine the infant's pain level? FLACC (Appropriate for infants and children up to 7 years of age)
When is it appropriate to use the Word-Graphic Rating Scale for a pain scale? Appropriate for children between the ages of 4 and 17 years
A nurse is caring for a 4 year old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths? "Let's play a game of blowing cotton balls across your table."
A nurse is collecting data from a 7 month old infant. Which of the following findings should indicate to the nurse a need for further evaluation? Babbles one-syllable sounds (Should babble in sounds that contain MULTIPLE syllables)
Expected findings for a 7 month old infant Uses a unidexterous grasp, Has a fear of strangers, Sits leaning forward on both hands
A nurse is assessing the psychosocial development of an 18 month old toddler. The nurse should recognize that this stage is characterized by which of the following behaviors? Offering negative responses due to the need for autonomy
TRUE/FALSE: A 2 1/2 year old child Creates imaginary playmates TRUE: Children usually create imaginary playmates at around the age of 2 1/2 years
A nurse is reinforcing teaching with a parent of a 15 month old toddler about safety. Which of the following information should the nurse include? Avoid marshmallow and popcorn, Position furniture away from windows
Order of Erikson's stages of Psychosocial Development from Birth through 18 years of age Trust vs. Mistrust << Autonomy vs. Shame and Doubt << Initiative vs. Guilt << Industry vs. Inferiority << Identity vs. Role Confusion (TA - GIR)
A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks? Defining a sense of self
A nurse is administering analgesia to a 6 month old male following inguinal hernia repair. Which of the following findings should the nurse identify as effective pain relief? Closed mouth (An open, square-shaped mouth is an indicator of pain in infants)
A nurse is preparing to administer an oral elixir to a 3 month old infants using an oral medication syringe. Which of the following actions should the nurse plan to take? Position the syringe to the side of the infant's tongue (Prevents aspiration when dispensed in small amounts)
A nurse is planning care for a 4 year old child who has been admitted to the hospital. Which of the following toys should the nurse plan to provide the child? Modeling clay (Preschool age children enjoy molding clay with their fingers, and provides an opportunity for creativity and entertainment as well as developing fine motor skills)
A nurse is collecting data from a 9 month old infant. Which of the following findings requires a nursing intervention? Positive Moro Reflex (This reflex disappears at approximately 3 to 4 months of age)
During a routine well child visit, a nurse is reinforcing teach with the parents of a preschool age child whom they have difficulty getting to sleep. Which of the following statements by the parents indicates an understanding of the teaching? "I will encourage my child to fall asleep with his favorite toy."
A nurse is collecting data from a 3 month old infant. Which of the following findings should the nurse report to the provider? The infant is unable to raise his head when in a prone position (Should be able to raise her head to a 45 or 90 degree angle from the prone position)
When will an infant be able to use the Pincer grasp? An 8 month old infant should be able to use a Pincer grasp
A nurse is preparing to administer vaccines to a 4 month old infant. Which of the following vaccines should the nurse plan to administer? Rotavirus (Should receive either a two dose series (2 months and another at 4 months) or a three dose series (2 months, 4 months, and 6 months)
A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations? Influenza (TIV) [Severe anaphylactic reactions can occur]
A nurse is talking with a 13 year old female client who is having her annual health screening visit. Which of the following comments by the client should concern the nurse? "None of the kids at my school like me, and I don't like them either." (Developing a peer group is critical to adolescents development and self-esteem)
A nurse is collecting data from a 3 year old child. Which of the following findings should the nurse expect? Goes up stairs using alternate feet
At what age should a child be able to follow Three Commands in Succession? A 5 year old child can follow three commands in succession.
A nurse is reinforcing health promotion teaching with the parents of a toddler. Which of the following should the nurse include as the leading cause of death among this age group? Unintentional Injuries
A nurse is reinforcing teaching about nutrition with a parent of an infant. Which of the following statements by the parent indicates an understanding of the teaching? "I should wait to give my baby fruit juice until 6 months of age (Fruits provide minimal nutritional value to an infant's diet, therefor the parent should limit the infant's fruit juice intake and NOT offer until 6 months of age)
A nurse is selecting a toy for a 7 month old infant. Which of the following toys should the nurse choose? A soft toy that squeaks or crackles when squeezed (Toy should be soft, lift, and easy to handle for a 7 month old, Toys should respond to manipulation)
A nurse is caring for a 4 year old child who refused to take his medication because of the bad taste. Which of the following strategies should the nurse use to elicit the child's cooperation? Offer the child an ice pop prior to administering the medication (Will help numb the tongue, Alleviates the bad taste)
A nurse is preparing to administer scheduled immunizations to a 5 year old child. Which of the following vaccines should the nurse plan to administer? Varicella (VAR) [First dose is given at 12 to 15 months, second dose given at 4 to 7 years of age)
When is the Meningococcal (MCV4) vaccine given? Since Neisseria meningitidis is the leading cause of bacterial meningitis in the US, the MCV4 vaccine is given to children who are 11 to 12 years old AND those who will be living in college dormitories IF NOT PREVIOUSLY VACCINATED)
A nurse is reinforcing teaching to parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching? "Temper tantrums are the toddler's attempt to gain control of a situation."
A parent states, "I leave the room while my child is throwing a temper tantrum." How should the nurse respond? The nurse should inform the parent that, although they should ignore the behavior's, it is important to remain present to provide the toddler with a feeling of security)
A nurse is collecting data regarding the pain level of a 3 year old child on the second postoperative day following an appendectomy. Which of the following actions should the nurse take? Use the FACES scale to assess the child's pain level (Appropriate tool for a 3 year old child)
ORDER (according to age) of FACES, Color tool, Numeric scale, and Visual Analog Scale to assess a child's pain level? FACES (3 years), Color Tool (4 years or older), Visual Analog Scale (4 1/2 years and older), and Numeric Scale (5 years or older)
A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. This behavior is developmentally appropriate at which of the following ages? 3 years (Can typically go up stairs using alternating feet BUT will descend by placing both feet on each step)
A nurse is collecting data from a 6 year old child at a well child visit. Which of the following statements by the child's parent should the nurse report to the provider? "The teacher says my child has to squint to see the board." (Manifestation of strabismus (Vision disorder, not aligned together) which MUST be diagnosed early in order to prevent vision loss)
A nurse is reinforcing health promotion teaching to the parents of an infant. Which of the following conditions should the nurse include as the leading cause of death among age group? Congenital anomalies, Respiratory distress Unintentional injury, SIDs Congenital anomalies
A nurse is reinforcing teaching about car seat safety with a parent of an infant who weighs 4.5 kg (10 lb). Which of the following actions by the parent indicates an understanding of the teaching? Place a small towel to the side of the infant's head to minimize head movement (Rolling small towel or blanket and placing it to the side of the infant's head is recommended)
A nurse is collecting data from a 10 month old infant. Which of the following findings should the nurse report to the provider? The infant does not sit steadily without support (Gross moto skill should be attained by 8 months of age)
A nurse is reinforcing teaching with the parents of an adolescent about expected development. Which of the following developmental tasks should the nurse instruct the parents to expect the adolescent to achieve? Trust, Initiative, Identify, or Autonomy Identify (Should achieve the developmental task of establishing an identity)
Expected findings for a 6 month old infant. HR 130/min, Respiratory rate 18/min, Temp 100.8 degress, SpO2 92% HR 130/min (Expected if 109-169/min for infant)
Varicella incubation period 2 to 3 weeks (14 to 16 days)
A nurse is collecting data from a 4 year old child. Which of the following findings should the nurse expect? HR 110/min (Should range between 73-137/min for 4 year old)
A nurse is collecting data from a 10 year old child during a well child visit. Which of the following statements by the child indicates he is meeting the psychosocial development expectations of a school age child? "I really want to do well in school." (Erikson's stage of psychosocial development for a 10 year old client is Industry vs Inferiority. Want to develop a sense of accomplishment)
A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching? Clean secretions from the tube using hydrogen peroxide
At what pressure should a nurse use a suctioning device on a CHILD? Set the vacuum pressure at 60 to 100 mm Hg when suctioning a child
Created by: AdrianMtz42
 

 



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