Answer: 3 Show
Explanation: 1. Trust versus mistrust (birth to 1 year)—The task of the first year of life is to establish trust in the people providing care. Trust is fostered by provision of food, clean clothing, touch, and comfort. If basic needs are not met, the infant will eventually learn to mistrust others. Answer: 4, 2, 3, 1 Developmental assessment Answer: 1/B, 2/C, 3/A, 4/C, 5/A, 6/B 1. Despair One that returns to baseline after a contraction ends A return of the FHR to baseline after a contraction ends is called a late deceleration; it begins after the contraction has started, the lowest point of the deceleration occurs after the peak of the contraction, and the deceleration usually does not return to baseline until after the contraction ends (late recovery). Late decelerations, which are caused by uteroplacental insufficiency, are a sign of a compromised fetus. The FHR does not always drop with a contraction. Beat-to-beat variability indicates a fetus with a healthy nervous system and does not warrant concern. A decrease in fetal heart rate to 110 beats/min during a contraction, known as an early deceleration, is the result of fetal head compression during a contraction; the FHR returns to baseline at the same time that the contraction ends. 1, 2 Toddlers who consume more than 24 ounces of milk daily in place of other foods may develop milk anemia, because milk is a poor source of iron. A toddler needs more protein than fats in the diet. Certain foods, such as nuts, grapes, and raw vegetables, as well as hot dogs, candy, and popcorn, have been implicated in choking deaths and should be avoided. Calcium and phosphorus are important for healthy bone growth. Small frequent meals consisting of breakfast, lunch, and dinner with three interspersed high nutrient-dense snacks help improve nutritional intake. 2. The liver is palpated 3 cm below the costal margin. A 15-month-old child's liver should be palpable 1 to 2 cm below the right costal margin. The anterior fontanel closes completely around 18 months of age. Abdominal or diaphragmatic breathing is expected in children younger than 7 years. A pulse rate of 104 beats/min is within the expected range (100 to 110 beats/min) for a 15-month-old child. A nurse in the pediatric
clinic is performing a physical assessment of a 15-month-old toddler. What finding indicates that a disorder may be present? 1 A 2-month-old infant The nurse measures head circumference during the growth and development assessment until 36-months of age. The 2-month-old infant, the 3-year-old preschooler, and the 18-month-old toddler would all require as head circumference to assess growth. The adolescent and school-age child would not require a head circumference measurement to assess growth. For which clients should the nurse measure head circumference during the growth and development assessment? Select all that apply. 1 4. Infants' cartilaginous hip joints promote molding of the acetabulum. The cartilaginous hip joints are the basis for the use of abduction devices (e.g., Pavlik harness) and spica casts when the infant is very young. Congenital hip dysplasia does not limit ambulation for the young child, although the gait will be affected. Traction is not used to correct developmental dysplasia of the hip. Although casted infants are easier to manage than casted toddlers, this is not the reason for early treatment. Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures? 1 1. Practice using the nonmedicated insulin pen first. The child's confidence, readiness, and skill for giving self-injections are essential in the long-term management of diabetes, and the child should be taught to practice using the nonmedicated insulin pen. Learning responsibility for injections should be a gradual process that takes place with continuous support and guidance. The sites must be rotated. The recommended procedure is to draw up the regular insulin first and then the intermediate-acting insulin to prevent contamination of the multidose vial of regular insulin with the intermediate-acting insulin. A nurse plans to teach a school-aged child with type 1 diabetes who is receiving both intermediate-acting insulin (Novolin N) and regular insulin (Novolin R) daily how to self-administer the insulin before discharge. What should the nurse teach the child? 1 3. Intake and output over the past 24 hours The infant is exhibiting signs of severe dehydration. The monitoring parameter that will be most helpful for evaluating these findings is intake and output, because checking this will help the nurse determine whether intake is adequate or fluid loss is excessive. Serum electrolytes, respiratory rate and rhythm changes, and certain changes in heart sounds are more likely to be the result of, rather than cause of, dehydration. Deteriorating cardiac function is more likely to lead to fluid retention than to fluid loss or dehydration. During the assessment of a hospitalized infant, the nurse notes dry mucous membranes, absence of tears when the infant cries, and poor skin turgor. Which parameter will help the nurse further evaluate these findings? 1 2, 3, 4, 5 Poison prevention teaching points supported by evidence that the nurse should include in a session for parents of toddlers include correct medication administration, safe storage of toxic substances, strategies for effective discipline, and the importance of being out of view of the toddler while taking prescribed medications. Strategies for effective discipline are important for safely regulating the toddler's behavior to further reduce the risk of poisoning. The use of plants for teas or medicine should be avoided because this is known to increase the risk for poisoning. Which poison prevention points, supported by current evidence, should the nurse include in a teaching session to parents of toddlers? Select all that apply. 1 2. Development of a sense of initiative According to Erikson, the chief psychosocial task of preschoolers is acquiring a sense of initiative. Control over bodily functions, toleration of separation from parents, and ability to interact with others in a less egocentric manner are the psychosocial tasks of toddlers. A nurse is studying Erikson's theory of psychosocial development in preschoolers. Which task does the nurse identify as the chief psychosocial task of this age group? 1 3. The teeth may become stained. Liquid oral iron supplements may stain the teeth; brushing the teeth after administration may limit the discoloration. There should be no change in the color of the urine. Yellowing of the skin is a sign of jaundice; it is not a side effect of an iron supplement. The stools will become black-green; clay-colored stools are a sign of biliary obstruction. An 11-month-old infant with iron-deficiency anemia is started on an oral iron supplement. What information should the nurse include when teaching the parents about the side effects of iron supplements? 1 2. Burp frequently during a feeding Because of the cleft (opening) in the lip, infants with this condition tend to suck in excessive air; burping helps prevent regurgitation of formula. Thickened formula is given to infants with reflux problems, such as vomiting after each feeding. The semi-Fowler position may be used for infants with reflux problems; this infant should be held during feedings. The bottle should never be propped, because aspiration may occur. An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation? 1 2. "I have no problems with any of my other children." Identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt suspicions of physical abuse and warrant further investigation. Taking a walk is helpful for both the mother and the child and does not indicate abuse. Sending a child to his or her room alone is an acceptable punishment for misbehavior. Although making a child stand in the corner is demeaning, it is not physical abuse. Child maltreatment is suspected in a 3-year-old girl admitted to the hospital with many poorly explained injuries. Which statement by the mother further supports this suspicion? 1 2, 3 The nurse should tell the parent that by 3 years of age a child is able to draw simple stick people and usually able to stack a tower of small blocks. Toddlers can easily turn doorknobs. They are able to manage drinking from a cup without spilling. Children of this age also hold crayons with their fingers. A parent asks the nurse about physical changes to expect in the 3-year-old child. What physical changes should the nurse explain? Select all that apply. 1 1, 3, 4 While performing a health assessment of adolescents, the nurse should treat adolescents as adults and maintain the adolescents' rights to confidentiality. The nurse should also conduct the examination in a nonthreatening area. While performing the assessment of an adolescent, a nurse should call him or her by his or her first name. The nurse should gather all the history of infants and small children from their parents or guardians. Which of these measures should the nurse adopt while performing the health assessment of an adolescent? Select all that apply. 1 1, 3 Fine motor skills expected at 4 years of age include using scissors and being able to tie shoe laces; therefore, these questions are appropriate during the health history interview. Riding a tricycle is a gross motor behavior that is expected by 3 years of age. Climbing steps using alternate feet is a gross, not fine, motor skill that is expected by 4 years of age. Building a tower using 9 or 10 blocks is a fine motor skill expected by age 3, not age 4. Which questions should the nurse include when conducting a health history interview with the parents of a 4-year-old client to assess fine motor skills? Select all that apply. 1 2. Contemplation An adolescent who acknowledges a problem but is not yet ready or sure of wanting to change belongs to the contemplation stage of change model. The maintenance stage is characterized by maintaining a behavior change. In the precontemplation stage, the adolescent does not yet acknowledge there is a problem behavior that needs to be changed. In the preparation stage, the adolescent gets ready to change. During a nutritional counseling session, an adolescent says to a nurse, "I am not following my diet properly, but I know I should do it." Which stage of change model does the adolescent belong? 1 1. Holds a crayon The ability to hold a crayon is a fine motor skill that the nurse should expect when conducting a developmental assessment for an infant between 10 to 12 months of age. Walking with assistance, standing alone, and sitting from a standing position are all gross motor skills the nurse would anticipate for this infant. Which fine motor skill should the nurse expect when assessing the development of an infant between 10 and 12 months of age? 1 1. "Please describe your child's feeding pattern." It is important to determine the infant's feeding pattern, because drinking formula from a bottle while in a recumbent position may lead to pooling of fluid in the pharyngeal cavity, which hinders eustachian tube drainage. Although knowing the frequency of ear infections is important, the factor that precipitated the otitis media is more significant. Although it is important to determine what medication has been given for otitis media, it is more important to determine the cause of this infection. Asking about the other family members is irrelevant, because otitis media is an inflammatory response, not a hereditary disease. A nurse is obtaining the health history of a 7-month-old who has had repeated episodes of otitis media. What question is most important for the nurse to include in the interview with the mother? 1 2. Uncoordinated suck and swallow Most cases of poor growth and FTT in the first two months of life occur due to an uncoordinated suck and swallow during feedings (formula or breast); therefore, this is the priority nursing assessment. Assessing for financial difficulties, neglect and abuse, and a knowledge deficit are appropriate but not the priority in this situation. The nurse is providing care to a 6-week-old infant who is hospitalized for poor growth. The infant is currently being breastfed and is diagnosed with failure to thrive (FTT). Which is the priority nursing assessment for this infant? 1 3. Recent viral infection There is a strong relationship between Reye syndrome and an antecedent viral infection, especially one treated with aspirin. Rash, tonsillitis, and high fever are not specifically related to Reye syndrome. An 8-year-old child is admitted to the emergency department with signs and symptoms of Reye syndrome. What information from the child's history is most important for the nurse to obtain in light of the child's tentative diagnosis? 2, 3, 4 Rectal temperatures are considered invasive by the preschool-age child; however, it is not the only reason to avoid taking this child's temperature rectally. Oral temperatures are accurate, as long as the child can hold the thermometer in the mouth correctly. Chemotherapy causes alterations in mucous membranes; a rectal thermometer could damage delicate rectal tissue. A skin sensor is accurate as long as the instructions provided by the product are followed. Tympanic temperatures are accurate as long as proper technique is used. A nurse is caring for a preschool-age child with leukemia who is undergoing chemotherapy and may have a fever. What factors should the nurse consider before taking this child's temperature? Select all that apply. 1 1. A positive body image Children with nephrotic syndrome are treated with immunosuppressive agents, including steroids. During exacerbations they may have a characteristic pale, overweight appearance as a result of edema. Steroid side effects include growth retardation, cataracts, obesity, and hirsutism. Children may become very sensitive about these changes as they grow older. Although the ability to test the urine may be indicated, body image poses a greater concern. Engaging in usual childhood activities between attacks should promote the development of fine muscle coordination. Sterility is not associated with nephrotic syndrome. A 4-year-old child with nephrotic syndrome has repeated relapses. As the child gets older, what is the most important attribute for the child to develop? 1 1. Assessing the infant's status Assessment, the first step of the nursing process, is the priority because it influences all future interventions. The infant's respiratory status and vital signs should be assessed before a sedative is administered. Although it is important to attach the nasogastric tube to a suction device, this may be done after the infant's status has been assessed. Although it is important to connect the intravenous line to a pump, this may also be done after the infant's status has been assessed. After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action? 1 4. Daily head circumference measurements Hydrocephalus, which typically occurs after surgical correction, is a major complication of myelomeningocele. Measuring the head circumference daily provides an accurate basis for day-to-day comparisons. Although important, daily weights are not specific to monitoring for a developing hydrocephalus. An infant's output is unrelated to hydrocephalus. Vital signs should be taken every 2 to 4 hours after surgery. A nurse is caring for an infant who has undergone surgery to correct a myelomeningocele. What assessment provides data about a potential major complication for this infant? 1
4. Inability to understand that others have a different perspective Which toddler behavior should the nurse identify as egocentrism, a characteristic of preoperational thought? 1
2. Dark, frothy urine Dark, frothy urine is characteristic of a child with nephrotic syndrome; large amounts of protein in the urine cause it to take this appearance. The child may be somewhat, not severely, lethargic. Blood pressure is normal or decreased; hypertension is associated with glomerulonephritis. Children with nephrotic syndrome usually have a pale complexion and are not flushed and ruddy in appearance. A 4-year-old child with nephrotic syndrome is admitted to the pediatric unit. What clinical finding does the nurse expect when assessing this child? 1 3. Injury prevention and dental health Preschoolers are at risk for injury because of their increasing independence, and dentition issues are important because of the need to preserve the primary teeth until it is time for permanent teeth to erupt. Nutrition and bullying are more appropriate topics for school-aged children. Most preschoolers are not developmentally ready for organized sports, and immunizations should be up to date if in daycare. Toilet training is an appropriate topic for toddlers. Children are expected to be toilet trained by the time they reach preschool age. A nurse who volunteers in a daycare for preschoolers has been asked to give a presentation to parents about health promotion. Which topics should the nurse include? 1 1. Trust Trust is developed if the infant's needs are being met by the caregivers. The task of industry should be successfully completed during the childhood years (6 to 12 years of age). The task of initiative should be successfully completed between 3 and 6 years of age. The stage of autonomy is successfully completed during the toddler years (1 to 3 years of age). A 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson's theory of development, what task does the nurse determine that the infant is in the process of achieving? 1 Which growth and developmental assessment with the nurse include when conducting a health maintenance visit for a 15Growth and developmental assessments that the nurse should perform for a 15-month-old toddler include length, weight, and head circumference. Body mass index is not assessed until 24-months of age. A developmental surveillance, not screening, is appropriate for a 15-month-old toddler.
Which growth and developmental changes indicate increased maturity during the school age stage of development?Which growth and developmental change indicates increased maturity during the school-aged stage of development? 1 The school-aged child experiences an increase in leg length in relation to height. 2 The school-aged child does not experience a decrease in head circumference in relation to standing height.
For which client would the nurse conduct a developmental surveillance during a scheduled health maintenance visit?The nurse would conduct a developmental screening for the 9-month-old infant during a scheduled health maintenance visit. The 2-week-old newborn, the 15-month-old toddler, and the 4-year-old preschooler would all require developmental surveillance during a health maintenance visit.
In which stage of Piaget's theory of growth and development does an infant develop an action pattern to deal with the environment?During the sensorimotor stage, infants develop an action pattern for dealing with their environment.
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For which clients should the nurse measure head circumference during the growth and development assessment select all that apply quizlet?
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