NCLEX Practice Questions — Set 43
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks’ gestation is placed in an oxygenated isolette. The neonate’s mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate?
Show answer and rationale
Correct answer: C. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.
Many intensive care units that care for high-risk neonates recommend that the mother pump her breasts, store the milk, and bring it to the unit so the neonate can be fed with it, even if the neonate is being fed by gavage. As soon as the neonate has developed a coordinated suck-and-swallow reflex, breast-feeding can begin. Secretory immunoglobulin A, found in breast milk, is an important immunoglobulin that can provide immunity to the mucosal surfaces of the gastrointestinal tract. It can protect the neonate from enteric infections, such as those caused by Escherichia coli and Shigella species. Some studies have also shown that breast-fed preterm neonates maintain transcutaneous oxygen pressure and body temperature better than bottle-fed neonates. There is some evidence that breast milk can decrease the incidence of necrotizing enterocolitis. The preterm neonate does not need additional fat in the diet. However, some neonates may need an increased caloric intake. In such cases, breast milk can be fortified with an additive to provide additional calories. Neonates who are receiving oxygen can breast-feed. During feedings, supplemental oxygen can be delivered by nasal cannula.
Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks’ gestation for retinopathy of prematurity (ROP)?
Show answer and rationale
Correct answer: B. The neonate is at risk because of multiple factors.
ROP, previously called retrolental fibroplasia, is associated with multiple risk factors, including high arterial blood oxygen levels, prematurity, and very low birth weight (less than 1,500 g). In the early acute stages of ROP, the neonate’s immature retinal vessels constrict. If vasoconstriction is sustained, vascular closure follows, and irreversible capillary endothelial damage occurs. Normal room air is at 21%. Acidosis, not alkalosis, is commonly seen in preterm neonates, but this is not related to the development of ROP. Phototherapy is not related to the development of ROP. However, during phototherapy, the neonate’s eyes should be constantly covered to prevent damage from the lights.
Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications?
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Correct answer: D. Laser therapy.
Because the retina may become detached with ROP, laser therapy has been used successfully in some medical centers to treat ROP. Cromolyn sodium is used to treat seasonal allergies. ROP is not associated with glaucoma, so frequent testing is not necessary. Because the vessels of the eye are affected, not the corneas, corneal transplantation is not used.
Three days after admission of a neonate born at 30 weeks’ gestation, the neonatologist plans to assess the neonate for intraventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following?
Show answer and rationale
Correct answer: A. Cranial ultrasonography.
Neonates who weigh less than 1,500 g or are born at less than 34 weeks’ gestation are susceptible to IVH. Cranial ultrasound scanning can confirm the diagnosis. The spinal fluid will show an increased number of red blood cells. Arterial blood gas specimen collection is done to evaluate the neonate’s oxygen saturation level. Skull radiographs are not commonly used because of the danger of radiation. Additionally, computed tomography scans have replaced the use of skull x-ray films because they can provide more definitive results. Complete blood count specimen collection is usually performed to determine the hemoglobin, hematocrit, and white blood cell count. The results are not specific for PIVH.
Which of the following would the nurse most expect to assess in a neonate born at 28 weeks’ gestation who is diagnosed with intraventricular hemorrhage (IVH)?
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Correct answer: D. Bulging fontanels.
A common finding of IVH is a bulging fontanel. The most common site of hemorrhage is the periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile. Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development of IVH. Other common manifestations include neurologic signs such as hypotonia, lethargy, temperature instability, nystagmus, apnea, bradycardia, decreased hematocrit, and increasing hypoxia. Seizures also may occur. Hyperbilirubinemia refers to an increase in bilirubin in the blood and may be seen if bleeding was severe.
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant’s mouth during these feedings. The nurse replies that the pacifier helps in what ways?
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Correct answer: D. All of the above
Nonnutritive sucking has been seen in infants as early as 28 weeks and ultrasound examinations have shown thumb sucking in utero even earlier. Nonnutritive sucking provides oral stimulation and allows the baby to maintain the sucking reflex needed for breast- or bottle-feedings later. It does not teach the infant how to suck and swallow. Sucking is thought to help with gastric emptying by stimulating secretions of GI peptides. Moisture of the mucous membranes is an indication of adequate hydration, and nonnutritive sucking will not have an effect.
While caring for a neonate born at 32 weeks’ gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist?
Show answer and rationale
Correct answer: A. Abdominal distention.
Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate’s immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis.
Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?
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Correct answer: C. "My baby may require long-term respiratory support."
BPD is a chronic illness that may require prolonged hospitalization and permanent assisted ventilation. The disease typically occurs in compromised very-low-birth-weight neonates who require oxygen therapy and assisted ventilation for treatment of respiratory distress syndrome. The cause is multifactorial, and the disease has four stages. The neonate’s activities may be limited by the disease. Antibiotics may be prescribed, and bronchodilators may be used, but these medications will not cure the chronic disease state. Seizure activity is associated with periventricular-intraventricular hemorrhage, not BPD.
A preterm infant born 2 hours ago at 34 weeks’ gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
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Correct answer: B. Insertion of a chest tube into the neonate.
The client data support the diagnosis of pneumothorax, which would be confirmed with a chest x-ray. Pneumothorax is an accumulation of air in the thoracic cavity between the parietal and visceral pleurae and requires immediate removal of the accumulated air. Resolution is initiated with insertion of a chest tube connected to continuous negative pressure. The neonate does not need to be placed on a ventilator unless there is evidence of severe respiratory distress. The goal of treatment is to re-inflate the collapsed lung. Administering bronchodilators through the nares or suctioning the neonate’s nares would do nothing to aid in lung re-inflation.
Which of the following would alert the nurse to suspect that a neonate born at 34 weeks’ gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
Show answer and rationale
Correct answer: A. Hypoproteinemia.
Decreased protein or hypoproteinemia is a sign of overhydration, which can lead to patent ductus arteriosus or congestive heart failure. Bulging fontanels, decreased serum sodium, decreased urine specific gravity, and decreased hematocrit are other signs of overhydration. Hypernatremia (increased serum sodium concentration) or increased urine specific gravity would suggest dehydration, not overhydration. Polycythemia evidenced by an elevated hematocrit would suggest hypoxia or congenital heart disorder.
A neonate born by cesarean at 42 weeks’ gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following is the priority problem?
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Correct answer: C. Hypoglycemia.
Increased respiratory rate and tremors are indicative of hypoglycemia, which commonly affects the postterm neonate because of depleted glycogen stores. There is no indication that the neonate has ineffective airway clearance, which would be evidenced by excessive amounts of mucus or visualization of meconium on the vocal cords. Lethargy, not tremors, would suggest infection or hyperthermia. Furthermore, the postterm neonate typically has difficulty maintaining temperature, resulting in hypothermia, not hyperthermia. Decreased cardiac output is not indicated, particularly because the neonate was born by cesarean section, which is not considered a difficult birth.
At a home visit, the nurse assesses a neonate born vaginally at 41 weeks’ gestation 5 days ago. Which of these findings warrants further assessment?
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Correct answer: A. Loose, watery stool in diaper.
A loose, watery stool in the diaper is indicative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the neonate, compared with the adult. Frequent hiccups are considered normal in a neonate and do not warrant additional investigation. Pink papular vesicles (erythema toxicum) on the face are considered normal in a neonate and disappear without treatment. Dry, peeling skin is normal in a postterm neonate.
When performing an initial assessment of a postterm male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani’s sign. Which of the following actions should the nurse do next?
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Correct answer: B. Notify the primary health care provider immediately.
Ortolani maneuver involves flexing the neonate’s knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani sign, suggesting a possible hip dislocation. The nurse should notify the primary health care provider promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. It should be noted that many institutions now limit performing the Ortolani’s maneuver to APNs or physicians. Determining the length of the mother’s labor provides no useful information related to the nurse’s finding. Keeping the infant under the radiant warmer is necessary only if the neonate’s temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness.
When developing the initial plan of care for a neonate who was born at 41 weeks’ gestation with meconium aspiration syndrome (MAS) requiring mechanical ventilation, which of the following should the nurse include?
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Correct answer: B. Care of an umbilical arterial line.
Care of an umbilical arterial line would be included in the neonate’s plan of care because an umbilical arterial line is commonly inserted to monitor arterial blood pressures, blood pH, blood gases, and infusion of intravenous fluids, blood, or medications. Frequent ultrasound scans are not indicated at this time. However, chest radiographs may be used to detect lung densities, because pneumonia is a major complication of this disorder. Orogastric feeding may not be feasible while the health care team focuses on interventions to establish adequate oxygenation. The neonate with MAS commonly experiences hypoglycemia, not hyperglycemia. Hypoglycemia occurs because of depletion of glucose stores related to hypothermia.
The neonate in the nurse’s care has a pneumothorax. The nurse knows the signs of early decompensation and to carefully assess which of the following?
Show answer and rationale
Correct answer: C. All of the above
The pneumothorax may affect cardiac output, thus affecting perfusion causing a decrease in B/P and color. As the neonate attempts to compensate, bradycardia or tachycardia may be exhibited. A change in temperature and urinary output are very late signs of decompensation.
A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do?
Show answer and rationale
Correct answer: D. Use constant, gentle touch.
Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands.
A neonate born at 40 weeks’ gestation admitted to the nursery is found to be hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is reading 75%. The nurse should:
Show answer and rationale
Correct answer: B. Provide supplemental oxygen.
Recommended pulse oximetry reading in a full-term neonate is 95% to 100%. The saturation reading of only 75% is an indication that the neonate is not adequately oxygenating in room air. Providing supplemental oxygen will increase the neonate’s oxygen saturation. Increasing the IV rate will not improve the oxygen saturation. Documenting the finding and taking no action is not appropriate with a saturation of 75%. Wrapping and increasing the body temperature of the neonate may increase the saturation reading only if it is inaccurate due to cold extremities. Caution must be used because overheating a neonate can be harmful.
A neonate with heart failure is being discharged home. In teaching the parents about the neonate’s nutritional needs, the nurse should explain that:
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Correct answer: B. The neonate may need a more calorie-dense formula.
Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fluid intake will decrease calories needed for growth. These neonates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growth and development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the primary health care provider.
During an assessment of a neonate born at 33 weeks’ gestation, a nurse finds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indomethacin. An expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosis is:
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Correct answer: B. Closure of a patent ductus arteriosus.
The indication for the use of indomethacin is to close a patent ductus arteriosus. Adverse effects include decreased renal blood flow, platelet dysfunction with coagulation defects, decreased GI motility, and an increase in necrotizing enterocolitis. Thus, increased bleeding time, decreased gastrointestinal function, and decreased renal output would be expected outcomes after the administration of indomethacin.
A preterm neonate is unable to breast- or bottle-feed. The primary health care provider writes a prescription to feed the neonate via nasogastric (NG) tube. When choosing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate’s:
Show answer and rationale
Correct answer: B. Weight.
The size of the NG feeding tube is based on the neonate’s weight. A larger feeding tube can be inserted into a heavier neonate. The disease process plays no role in the size of the feeding tube used. The neonate’s weight and size can vary widely; thus, there is no standard tube size for any gestational age. Length will determine the depth at which the NG tube is placed in the stomach, not the size of the tube.
A nurse is reviewing a client’s maternal prenatal record and notes that the mother used narcotics during her pregnancy. A primary nursing intervention when caring for a drug-exposed neonate is to:
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Correct answer: A. Minimize environmental stimuli.
A quiet environment with decreased stimulation is the best treatment for a drug-exposed neonate. The drug-exposed neonate has limited ability to deal with stress and cope with stimuli. Assessing vital signs with blood pressure every hour will disturb the neonate’s rest periods and cause increased physical and psychological demands. Placement in a well-lighted or stimulating environment is overwhelming for the neonate and will increase the neonate’s stress level.
The nurse is receiving over the telephone a laboratory results report of a neonate’s blood glucose level. The nurse should:
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Correct answer: D. Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results.
To ensure client safety, the nurse should first write the results on the chart, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client’s electronic record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues.
A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: A. "Antibodies are not usually formed until after exposure to an antigen."
Hemolytic disease of the newborn is associated with Rh problems. Hemolytic disease of the newborn occurs most commonly when the mother is Rh-negative the infant is Rh-negative. About 13% of Caucasians, 7% to 8% of people of African descent, and 1% of people of Asian descent are Rh-negative. Rh-positive cells enter the mother’s Rh-negative bloodstream, and antibodies to the Rh-positive cells are produced. In a subsequent pregnancy, the antibodies cross the placenta to the Rh-positive fetus and begin the destruction of Rh-positive cells through hemolysis. This results in severe fetal anemia.
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following?
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Correct answer: C. "Antibodies are not usually formed until after exposure to an antigen."
The problem of Rh sensitivity arises when the mother’s blood develops antibodies after fetal red blood cells enter the maternal circulation. In cases of Rh sensitivity, this usually does not occur until after the first pregnancy. Hence, hemolytic disease of the newborn is rare in a primiparous client. A mismatched blood transfusion in the past or an unrecognized spontaneous abortion could also result in hemolytic disease because the transfusion or abortion would have the same effects on the client. The statement about the other baby having a different father may be true. However, if both fathers were Rh-positive, then sensitization could occur. Most women do not have immunity against the antibodies formed when Rh-positive cells enter the mother’s bloodstream. Antibodies are not neutralized by the mother’s system.
After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at birth, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following?
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Correct answer: B. Polycythemia.
The Rh-sensitized neonate generally does not have problems related to polycythemia. Therefore, the client needs additional teaching. In general, moderate to severe Rh sensitization can cause anemia, enlarged spleen, and cardiac decompensation. Cardiac decompensation (as in heart failure) occurs because of severe anemia. Anemia is caused by the destruction of red blood cells by antibodies as the severity of hemolytic disease of the neonate increases. Splenic enlargement is caused by the excessive destruction of fetal red blood cells.
After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which of the following?
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Correct answer: A. Antibodies coating the neonate’s red blood cells.
A direct Coombs test is done on umbilical cord blood to detect antibodies coating the neonate’s red blood cells. Hematocrit is used to detect anemia. Sodium, potassium, and chloride are used to detect electrolyte imbalances. Antigens on the neonate’s red blood cells are proteins that help determine the neonate’s blood type.
After teaching the mother of a neonate with erythroblastosis fetalis who is to receive an exchange transfusion, which of the following, if stated by the mother as the purpose of the transfusion, indicates effective teaching?
Show answer and rationale
Correct answer: B. To correct the neonate’s anemia.
An exchange transfusion is done to reduce the blood concentration of bilirubin and correct the anemia. The exchange transfusion does not replenish the white blood cells or restore the fluid and electrolyte balance. The neonate’s Rh-positive blood is replaced by Rh-negative blood.
The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate?
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Correct answer: C. Brain.
The organ most susceptible to damage from uncontrolled hemolytic disease is the brain. Bilirubin levels increase as the red blood cells are destroyed. Bilirubin crosses the blood-brain barrier and damages the cells of the central nervous system. This condition, called kernicterus, is potentially fatal. Although the kidneys, lungs, and liver may be affected by increased bilirubin levels, the brain will sustain the most life-threatening injury.
The nurse determines that a newborn is hypoglycemic based on which of the following findings?
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Correct answer: D. Both of the above
A blood glucose reading at or below 30 mg/dL (1.7 mmol/L) within 2 hours of birth and irregular respirations, tremors, and hypothermia are indicative of hypoglycemia. Blood glucose should be 45 mg/dL (2.5 mmol/L) by 24 hours of age. Internal fetal monitors detect the strength of contractions and the fetal heart rate. An infant of an insulin-dependent mother and a large-for-gestational-age infant are at greater risk of developing hypoglycemia and need to be observed carefully but these findings are not definitive for the diagnosis of hypoglycemia.
The nurse is caring for an infant of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which of the following?
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Correct answer: A. Interrupted supply of maternal glucose and continued high neonatal insulin production.
Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most neonates do not develop hypoglycemia if their mothers are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.
When caring for a neonate weighing 4,564?g (10 lb, 1 oz) born vaginally to a of a mother with diabetes, the nurse should assess the neonate for fracture of the:
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Correct answer: C. Clavicle.
Infants born to mothers with diabetes tend to be larger than average, and this neonate weighs 10 lb, 1 oz (4,564 g). The most common fractures are those of the clavicle and long bones, such as the femur. In a neonate, the skull bones are not fused and move to allow for vaginal birth, so skull fracture is rarely seen. Wrist and rib cages are rarely fractured.
While caring for a neonate of a woman with diabetes soon after birth, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate’s blood glucose level and it is 60 mg/dL (3.3 mmol/L), but the neonate continues to exhibit jitteriness and tremors. The nurse should first:
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Correct answer: C. Request a prescription for a blood calcium level.
This neonate has a mother with diabetes who tends to have higher calcium levels, which can cause secondary hypoparathyroidism in their neonates. This lack of calcium may be the cause of the tremors and jitteriness of this neonate and a serum calcium level should be obtained. Other factors contributing to hypocalcemia in neonates include hypophosphatemia from tissue metabolism, vitamin D antagonism from increased cortisol levels, and decreased serum magnesium levels. Beginning a glucose IV based on a normal infant glucose level would have no benefit. Rechecking the neonate’s temperature is a precaution that can be taken to assure that it is within normal limits but is not the action to take first. Refeeding the infant who has a normal newborn blood glucose level is not appropriate.
The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean section 1 hour ago. The mother is a class B primipara with insulin-dependent diabetes. She asks the nurse, "Why is my baby in the neonatal intensive care unit?" The nurse bases a response on the understanding that neonates of mothers with class B diabetes commonly develop which of the following conditions?
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Correct answer: D. Hypocalcemia.
Hypoglycemia is caused by the rapid depletion of glucose stores. In addition, neonates born to class B diabetic women are about seven times more likely to suffer from respiratory distress syndrome than neonates born to nondiabetic women. This neonate should be closely monitored for symptoms of hypoglycemia and respiratory distress. Neonates of diabetic mothers commonly have polycythemia, not anemia. Anemia and hemolytic disease are associated with erythroblastosis fetalis. Persistent pulmonary hypertension is associated with meconium aspiration syndrome.
After teaching a primiparous client who used opiates during pregnancy about possible gastrointestinal signs and symptoms in her neonate, which of the following, if stated by the mother as common, indicates effective teaching?
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Correct answer: B. Vomiting.
Neonates experiencing opiate withdrawal have gastrointestinal problems similar to those of adults withdrawing from opiates. The neonates exhibit poor sucking, vomiting, drooling, diarrhea, regurgitation, and anorexia. In addition, they are difficult to console and difficult to feed. Because of these problems, the neonate withdrawing from opiates needs to be monitored carefully to prevent dehydration. Neonates with opiate exposure experience hypertonia, not hypotonia, due to increased central nervous system irritability. Diarrhea, not constipation, is seen in these neonates. Abdominal distention is associated with necrotizing enterocolitis, not opiate withdrawal.
When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to:
Show answer and rationale
Correct answer: C. Tightly swaddle the neonate.
A neonate undergoing cocaine withdrawal is irritable, often restless, difficult to console, and often in need of increased activity. It is commonly helpful to swaddle the neonate tightly with a blanket, offer a pacifier, and cuddle and rock the neonate. Offering extra nourishment is not advised because overfeeding tends to increase gastrointestinal problems such as vomiting, regurgitation, and diarrhea. Environmental stimuli such as bright lights and loud noises should be kept to a minimum to decrease agitation. Minimizing touching of the neonate to only when he or she is crying will not aid the bonding process between mother and neonate. Frequent holding and touching are permissible.
A neonate born at 38 weeks’ gestation is admitted to the neonatal nursery for observation. The neonate’s mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following?
Show answer and rationale
Correct answer: D. "We will test your baby at 2 weeks of age because testing for HIV now may give a false-positive result."
Although most neonates are asymptomatic, they do test positive for HIV at birth because of the mother’s antibodies. It may take several months before an accurate diagnosis can be made. New guidelines suggest that infants should be tested at 2 to 3 weeks, 1 to 2 months, and again 4 to 6 months. It is estimated that 15% to 30% of all HIV-positive mothers without treatment will give birth to HIV-positive infants. With appropriate drug intervention to the mother during pregnancy, 95% of these neonates can be born unaffected. An enlarged liver at birth is associated with erythroblastosis fetalis, not HIV infection. Virologic testing, such as deoxyribonucleic acid polymerase chain reaction, viral culture, or ribonucleic acid plasma assay, can diagnose HIV infection by 6 months of age and commonly in the first month.
When caring for a multiparous client who is human immunodeficiency virus (HIV)-positive and asking to breast-feed her neonate as soon as possible, which of the following instructions about breast milk should the nurse include in the teaching plan?
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Correct answer: C. It has been found to contain the retrovirus HIV.
Breast milk has been found to contain the retrovirus HIV. In general, mothers are discouraged from breast-feeding if they are HIV positive because of the risk of possible transmission of the virus if the neonate is HIV negative. Breast milk does contain some immunoglobulins, but it does not protect the neonate from HIV infection.
While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which of the following actions should the nurse do first?
Show answer and rationale
Correct answer: A. Bathe the neonate.
Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive mothers to decrease blood exposure. Placing the neonate under the radiant warmer for the vitamin K injection is not necessary unless the neonate’s temperature is subnormal. Washing the injection site with povidone-iodine before giving the injection is not necessary because of the risk for possible allergy to iodine preparations. The first dose of zidovudine is given when the newborn is 6 to 12 hours old, but vitamin K is recommended to be given within an hour of birth to be most effective. Therefore the vitamin K should not be delayed.
A male neonate born at 38 weeks’ gestation by cesarean section after prolonged rupture of the membranes and a maternal oral temperature of 102�F (38.8�C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the primary health care provider?
Show answer and rationale
Correct answer: B. Behavioral changes.
Symptoms of infection in a neonate include subtle behavioral changes, such as lethargy and irritability, and color changes such as pallor or cyanosis. Other symptoms include temperature instability, poor feeding, gastrointestinal disorders, hyperbilirubinemia, and apnea. Leukocytosis, an elevated white blood cell count possibly as high as 30,000 cells/mm3 (30 � 109/L) or more, may be normal during the first 24 hours. An apical heart rate of 132 bpm is normal. Warm, moist skin is not a typical sign of infection in neonates. Typically, temperature instability is common. The neonate’s temperature is low and the skin is cool and dry.
The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following will the nurse need to instruct the parents to do because of the neonate’s infection?
Show answer and rationale
Correct answer: D. Wash their hands thoroughly before touching the neonate.
The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. The parents must be careful around medical equipment to ensure proper function and around the intravenous site so that it is not dislodged, but being careful with the equipment is not sufficient to prevent transmission of microbes to the neonate. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate’s psychological development. Normally, the neonate does not need to be isolated. It is not necessary for the parents to wear a mask while holding the neonate. The neonate is not contagious and is receiving treatment for the infection.
A female neonate born vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the first time that the parents visit the neonate in the nursery?
Show answer and rationale
Correct answer: D. Emphasize the neonate’s normal characteristics.
On the initial visit, the parents may be shocked, fearful, and anxious. Nursing care should include spending time with the parents to allow them to express their emotions. The nurse should initially emphasize the neonate’s normal characteristics. After the parents have had sufficient time to adjust to the neonate’s special needs, surgical interventions can be discussed. Telling the parents that this is not a life-threatening defect or that everything will be all right after the surgery is not helpful. Doing so discounts their feelings. Reassuring the parents about the success rate of the surgery can be done once the parents have had time to adjust to the neonate and express their emotions.
After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?
Show answer and rationale
Correct answer: D. "I should clean her mouth with soapy water after feeding."
After feeding, the mouth should be cleaned with sterile water, not soapy water, to reduce the risk for aspiration. The cleft lip should be cleaned with sterile water to prevent crusting before surgical repair. The neonate needs to be fed in an upright position to prevent aspiration. The neonate with a cleft lip and palate commonly swallows large amounts of air during feeding. Therefore, the neonate needs to be burped frequently to help eliminate the air and decrease the risk for regurgitation. The neonate with a cleft lip and palate should be fed with a special soft nipple that fills the cleft and facilitates sucking.
When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
Show answer and rationale
Correct answer: A. Drug-induced hemolytic anemia.
Drug-induced hemolytic anemia is acquired, antibody-mediated, RBC destruction precipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa, procainamide, quinidine, and thiazides. Purpura is a condition with various manifestations characterized by hemorrhages into the skin, mucous membranes, internal organs, and other tissues. Infectious emboli are clumps of bacteria present in blood or lymph. Ecchymoses are skin discolorations due to extravasations of blood into the skin or mucous membranes.
A client is to have a Schilling test. The nurse should:
Show answer and rationale
Correct answer: C. Start a 24- to 48-hour urine specimen collection.
Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24- to 48-hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorptive state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Methylcellulose is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not a part of the Schilling test. If stool contaminates the urine collection, the results will be altered.
Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)?
Show answer and rationale
Correct answer: C. Hyperactivity and speech disorders are common.
Central nervous system disorders are common in neonates with FAS. Speech and language disorders and hyperactivity are common manifestations of central nervous system dysfunction. Mild to severe mental retardation and feeding problems also are common. Delayed growth and development is expected. These neonates feed poorly and commonly have persistent vomiting until age 6 to 7 months. These neonates do not have a 70% mortality rate, and there is no treatment for FAS.
While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which of the following stages of grief?
Show answer and rationale
Correct answer: D. Shock.
The physical appearance of the anomaly and the life-threatening nature of the disorder may result in shock to the parents. The parents may hesitate to form a bond with the neonate because of the guarded prognosis. Denial would be evidenced if the parents acted as if nothing were wrong. Bargaining would be evidenced by parental statements involving "if-then" phrasing, such as, "If the surgery is successful, I will go to church every Sunday." Anger would be evidenced if the parents attempted to blame someone, such as health care personnel, for the neonate’s condition.
Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?
Show answer and rationale
Correct answer: C. Keep the neonate’s eyes completely covered.
To prevent eye damage from phototherapy, the eyes must remain covered at all times while under the lights. The eye patches can be removed when the neonate is held out of the lights by the parents for feeding. Instead of a regular diaper, a "string" diaper or disposable face mask may be used to help contain loose stools, while allowing maximum skin exposure. Feeding formula or breast milk every 2 to 3 hours is recommended to prevent hypoglycemia and to encourage gastrointestinal motility. Because the phototherapy lights can overheat the neonate, the temperature should be checked by the axillary route every 2 to 4 hours.
While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?
Show answer and rationale
Correct answer: A. Absent Moro reflex.
An absent Moro reflex, lethargy, opisthotonos, and seizures are symptoms of bilirubin encephalopathy, which, although rare, can be life-threatening. Bronze discoloration of the skin and maculopapular chest rash are normal and are caused by the phototherapy. They will disappear once the phototherapy is discontinued. A urine specific gravity of 1.001 to 1.020 is normal in term neonates.
The nurse is caring for a neonate at 38 weeks’ gestation when the nurse observes marked peristaltic waves on the neonate’s abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the primary health care provider because these signs are indicative of which of the following?
Show answer and rationale
Correct answer: A. Pyloric stenosis.
Marked visible peristaltic waves in the abdomen and projectile vomiting are signs of pyloric stenosis. If the condition progresses without surgical intervention, the neonate will become dehydrated and develop metabolic alkalosis. Signs of esophageal atresia include coughing and regurgitation with feedings. Diaphragmatic hernia, a life-threatening event in which the abdominal contents herniate into the thoracic cavity, may be evidenced by breath sounds being heard over the abdomen and significant respiratory distress with cyanosis. Signs of hiatal hernia include vomiting, failure to thrive, and short periods of apnea.
The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following?
Show answer and rationale
Correct answer: B. Loud cardiac murmurs through systole and diastole.
With a patent ductus arteriosus, a cardiac defect marked by a failure of the patent ductus arteriosus to close completely at birth, blood from the aorta flows into the pulmonary arteries to be reoxygenated in the lungs and returned to the left atrium and ventricle. The effect of this altered circulation includes increased workload on the left side of the heart and increased pulmonary vascular congestion. Term infants are commonly asymptomatic, but a loud, machinery-like murmur may be heard throughout systole and diastole. This murmur may be accompanied by a suprasternal thrill, and the heart may be enlarged. Decreased cardiac output with faint peripheral pulses, poor peripheral perfusion, feeding difficulties, and severe congestive heart failure are symptoms associated with severe aortic stenosis. With this defect, the aortic valve is thickened and rigid, leading to decreased cardiac output and reduced myocardial blood flow. Profound cyanosis over most of the body, fatigue on exertion, feeding difficulties, and chronic hypoxemia are associated with tetralogy of Fallot. With this defect, malalignment of the ventricular system results in nonrestricted ventral septal defects, pulmonic stenosis, overriding of the aorta, and hypertrophy of the left ventricle. The heart appears boot shaped. A harsh systolic murmur with a palpable thrill is associated with truncus arteriosus. It is marked by incomplete division of the great vessel. This is caused by a ventral septal defect. Bounding pulses and a widening pulse pressure may also be present.
Assessment of a term neonate at 8 hours after birth reveals tachypnea, dyspnea, sternal retractions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifies the primary health care provider based on the interpretation that these symptoms are associated with which of the following?
Show answer and rationale
Correct answer: C. Coarctation of the aorta.
Coarctation of the aorta accounts for 5% to 7% of congenital heart disease. There is localized constriction of the aorta, at or near the insertion site of the ductus arteriosus, that increases afterload and decreases cardiac output. The infant with coarctation of the aorta presents with symptoms of poor lower body perfusion, metabolic acidosis, and congestive heart failure. Cyanosis is present in the lower part of the body because of decreased cardiac output. The child with a partial atrioventricular septal defect may be asymptomatic at birth. The symptoms in a child with a complete defect depend on the pulmonary artery pressure. If the pressure is high, the child will experience cyanosis on exertion; if it is low, congestive heart failure, manifested by tachypnea, dyspnea, and sternal retractions, may be present. The child with pulmonary atresia has profound (complete) cyanosis. On auscultation, the second heart sound is heard as a single sound. This is caused by failure of the pulmonary valve to develop and is accompanied by hypoplastic development of the pulmonary artery and right ventricle. Transposition of the great arteries is associated with complete cyanosis during the first few hours of life. These infants demonstrate hypoxemia with a minimal response to oxygen. In this defect, the pulmonary and systemic systems exist in parallel. Systemic blood (unoxygenated) travels to the right atrium and right ventricle, then into the aorta. Pulmonary venous blood (oxygenated) recirculates through the left side of the heart and through the lungs.
The nurse is caring for a 2-day-old neonate in the recovery room 30 minutes after surgical correction for the cardiac defect, transposition of the great vessels. Which of the following would alert the nurse to notify the primary health care provider?
Show answer and rationale
Correct answer: B. Warm, dry skin.
The normal pulse rate in a neonate is 120 to 160 bpm. Therefore, a femoral pulse rate of 90 bpm is too low. Diminished peripheral pulses, coolness and mottling of the extremities, delayed capillary refill, hypotension, and decreased urine output are indicative of low cardiac output and poor perfusion. The neonate may be experiencing a complication of the surgery, such as blood loss or leaking of fluid into the interstitial space. The surgeon should be notified immediately to correct the diminished pulse, through either medications or transfusions. An oxygen saturation between 85% and 100% is considered normal. The surgeon does not need to be notified unless the oxygen saturation falls below 85%. Pale pink extremities are considered a normal finding. If mottling or cyanosis develops, the surgeon should be notified immediately. Warm, dry skin is also a normal finding. If the skin becomes cool or appears cyanotic, the surgeon should be notified.
The nurse is performing an admission assessment on a neonate and finds the femoral pulses to be weaker than the brachial and radial pulses. The next nursing action should be to:
Show answer and rationale
Correct answer: C. Take the neonate’s blood pressure in all four extremities.
The next nursing action in this situation would be to assess the B/P in all four extremities and compare the findings. A difference of 15 mm Hg in the systolic blood pressure between the arms and legs is an indication of a narrowed aorta. This could be an emergency and the physician needs to be notified as soon as the B/P data has been collected. Generally, prescribing a physician consult is not a nursing function. Placing the neonate in reverse Trendelenburg will only decrease the perfusion to the lower extremities.
A neonate is 4 hours of age. The nursing assessment reveals a heart murmur. The nurse should:
Show answer and rationale
Correct answer: B. Further assess for signs of distress.
Further assessment for signs of distress is necessary. At 4 hours of age a transient murmur may be heard as the fetal shunts are closing. This is a normal finding. If no other distress is noted, the physician doesn’t need to be called. Result can be noted on the chart. Further assessment is needed to know if continuing routine care and feeding are appropriate and safe for the neonate.
The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine follow-up. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?
Show answer and rationale
Correct answer: D. Ask the primary staff nurses to take their babies back to the sleeping mothers’ rooms.
The nurse should manage this situation by asking the staff nurses to take at least one baby back to a room with a sleeping mother. This would allow the babies who are in need of care in the nursery to remain there. To maintain safety, the SCN cannot admit a client until they are prepared and have the staffing for this infant to be transferred. Social services can be called to determine if either of the newborns who have been referred to them can be discharged, but releasing these infants from the nursery will take several hours. It is unsafe to keep the infant with a respiratory rate of 80s waiting for a bed.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
Show answer and rationale
Correct answer: D. All of the above
A hospital-specific security system is the standard of care to prevent neonatal abduction. The bulb syringe should be visible and easily accessible to both the mother and the nurse in case of choking. Someone should remain in the room who is able to safely care for the infant. This may be the mother or a family member if the mother is physically not able to care for the infant. The infant should be lying on the back or side, rather than the abdomen to prevent Sudden Infant Death Syndrome ("back to sleep"). Infant falls from a mother’s bed are a serious safety problem. The infant should be in the mother’s arms or in the crib rather than lying on a bed, even with the side rails up, as an infant can slip through the rails. A sleeping mother is not aware of the status of the infant who can easily fall out of her arms; the infant can be in the mother’s arms only if she is awake.
After receiving change of shift report in the normal newborn nursery, which neonate should the nurse see first?
Show answer and rationale
Correct answer: C. Neonate B, 4 hours of age with a blood glucose of 30 (1.7 mmol/L).
The blood glucose of 30 (1.7 mmol/L) is the most critical. Glucose is the only fuel that the brain can use. It is important to protect the central nervous system and levels less than 40?(2.2?mmol/L) in a neonate indicate hypoglycemia. Grunting at � hour of age may be normal transitioning to extrauterine life. A temperature of 97.4 (36.4 �C) is only slightly low for a neonate at this age. Ninety five percent of all neonates will void at least once in the first 24 hours. This is not unusual at this age.
The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their Moms, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the RN assign to the UAP?
Show answer and rationale
Correct answer: A. All of the above
The role of the UAP allows this member of the health care team to take vital signs on patients, record feedings, and voids and stools of infants according to hospital guidelines. The newborn assessment is completed by a licensed care provider as is the tube feeding. Bathing of the newborn is within the scope of practice for the nursing assistant but the initial assessment of patency of the gastrointestinal tract, which is initiated by the first feeding, is within the scope of licensed care providers. If there is a trachea esophageal fistula, this is the time when it may become evident.
After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent:
Show answer and rationale
Correct answer: C. "What personal beliefs or safety concerns do you have about vaccinations?"
By trying to determine the source of parents’ concerns, the nurse is able to acknowledge their feelings and provide the most appropriate information. This approach increases the likelihood parents will listen to the health care provider’s views. Exemptions for vaccines vary by state, province, or territory, and many parents feel legal requirements for vaccinations take away parental rights. The number of vaccinations given at one time may not be the issue. Waivers are used only if clients refuse vaccination after a discussion of risks and benefits.
Which of the following is appropriate language development for an 8-month-old? The child should be:
Show answer and rationale
Correct answer: B. Saying "dada" and "mama" nonspecifically.
It is important for the nurse to assist parents in assessing speech development in their child so that developmental delays can be identified early. According to the Denver Developmental Screening Examination, at 8 months of age, the child should say "mama" and "dada" nonspecifically and imitate speech sounds. Children cannot say "dada" or "mama" specifically or use more than three words until they are about 12 months of age. A?child cannot respond to specific commands or point to objects when requested until about 17 months of age.
The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to:
Show answer and rationale
Correct answer: C. The infant’s diet can be changed from formula to whole milk when the infant is 12 months old.
According to the Denver Developmental Screening Examination, a child of 8 months should sit without support for long periods of time. An 8-month-old child does not have the ability to stand without hanging on to a stationary object for support. His muscles are not developed enough to support all his weight without assistance. His balance has not developed to the point that he can stand and stoop over to reach an object.
The nurse is teaching the parents of an 8-month-old about what the child should eat. The nurse should include which of the following points in the teaching plan?
Show answer and rationale
Correct answer: B. The infant’s diet can be changed from formula to whole milk when the infant is 12 months old.
Infants should be kept on formula or breast milk until 1 year of age. The protein in cow’s milk is harder to digest than that found in formula. The infant cannot digest fats well, so some foods from the four food groups are not necessary in his diet during infancy. Solids are introduced into the infant’s diet around 4 to 6 months, after the extrusion reflex has diminished and when the child will accept new textures. Iron deficiency develops in term infants between 4 to 6 months when the prenatal iron stores are depleted. Fortified cereals can be added to the infant’s diet at 4 to 6 months to prevent iron deficiency anemia.
A 10-month-old looks for objects that have been removed from his view. The nurse should instruct the parents that:
Show answer and rationale
Correct answer: D. The child understands the permanence of objects even though the child cannot see them.
Understanding object permanence means that the child is aware of the existence of objects that are covered or displaced. Neuromuscular development, curiosity, and the ability to transfer objects are not associated with the principle of object permanence. Although, at 10 months, neuromuscular development is sufficient to grasp objects and a child’s curiosity has increased, neither are related to the thought process involved in object permanence.
Which statement by a parent reflects the need for further teaching regarding car seat safety?
Show answer and rationale
Correct answer: B. "My baby should stay in a rear-facing car seat until he is 1 year old."
New guidelines from the American Academy of Pediatrics and Canadian Pediatric Society recommend that parents keep their toddlers in a rear-facing car seat until 2?years of age. Car seats are marked with an expiration date because the integrity of the plastic may deteriorate with age. Booster seats are recommended for older children until they are 4 feet 9 inches (144.8 cm). This typically occurs between the ages 8 and 12 years. Children should ride in the back seat until they are 13 years of age to minimize injury should airbags be deployed.
The parents of a 3-week-old healthy newborn ask the nurse why their daughter is intermittently cross-eyed. The nurse’s best response is:
Show answer and rationale
Correct answer: B. "An eye patch may be necessary for 6 weeks to correct her vision."
During the first few months of life, an infant’s eyes may wander and appear to be crossing. As the eye muscles mature, between 2 and 3 months of age, both eyes will focus on the same thing. No intervention is necessary, as crossing of the eyes is normal in the first few months of life.
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening?
Show answer and rationale
Correct answer: C. Does not babble.
By the end of 3 months, infants should babble. Lack of babbling suggests a language delay and warrants further investigation. Infants typically would begin playing peek-a-boo around 7 months. The ability to roll front to back typically occurs at 5?months. Head lag is expected to resolve by 5 months.
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
Show answer and rationale
Correct answer: D. An acute bilateral ear infection.
Vaccination in the presence of a moderate to severe infection, with or without fever, increases the risk of injury and decreases the chance of mounting good immunity. There is currently no evidence to suggest vaccines raise the risk of SIDS. A mild temperature may be expected with the DTaP. A fever of >40.5�C within 48 hours of vaccination would warrant caution. The DTaP is not a live vaccine. No special precautions are needed regarding immunosuppressed family members.
The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which vaccine order would the nurse question?
Show answer and rationale
Correct answer: C. Measles, mumps, and rubella (MMR).
The MMR is a live vaccine. Neither the American Academy of Pediatrics nor the Public Health Agency of Canada recommends routine vaccination with the MMR (either alone or combined with the varicella vaccine) to children younger than 12 months. The DTaP, Hib, and Hep B are all indicated.
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:
Show answer and rationale
Correct answer: C. Hepatitis B (Hep B).
A 1-month-old infant is usually able to lift the head and turn it from side-to-side from a prone position. The full-term infant with no complications has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old.
The nurse notes that an infant stares at an object placed in his/her hand and takes it to his/her mouth, coos and gurgles when talked to, and sustains part of his/her own weight when held in a standing position. The nurse correctly interprets these findings as characteristic of an infant at which of the following ages?
Show answer and rationale
Correct answer: C. 4 months.
Holding the head erect when sitting, staring at an object placed in the hand, taking the object to the mouth, cooing and gurgling, and sustaining part of her body weight when in a standing position are behaviors characteristic of a 4-month-old infant. A 2-month-old typically vocalizes, follows objects to the midline, and smiles. A 7-month-old typically is able to sit without support, turns toward the voice, and transfers objects from hand to hand. Usually, a 9-month-old can crawl, stand while holding on, and initiate speech sounds.
An 8-month-old infant is seen in the well-child clinic for a routine checkup. The nurse should expect the infant to be able to do which of the following?
Show answer and rationale
Correct answer: D. Both of the above
Typical abilities demonstrated by 8-month-old infants include playing peek-a-boo and transferring objects from one hand to another. The ability to say "dada" and "mama" is more typical of 10-month-old infants. Infants usually are at least 12 months old when they achieve the ability to walk independently. Infants who are 15 months old commonly can feed themselves with a spoon and stack two blocks.
The parent of a 9-month-old infant is concerned that the infant’s front soft spot is still open. The nurse should tell the parent:
Show answer and rationale
Correct answer: A. "This is normal because this soft spot usually closes between 12 and 18 months."
The anterior fontanel, commonly known as the soft spot, closes between 12 to 18 months in most infants. The nurse normally measures an infant’s occipital frontal circumference at each well-child visit. This action alone does not relieve the parent’s concerns. Referrals would be indicated for premature or delayed closures of the fontanel especially if there were other abnormal findings. Closure of the anterior fontanel by 12 months can only be expected to occur in approximately a third of all infants.
A mother states that she thinks her 9-month-old "is developing slowly." When assessing the infant’s development, the nurse is also concerned because the infant should be demonstrating which of the following characteristics?
Show answer and rationale
Correct answer: B. Vocalizing single syllables.
Normally, a 9-month-old infant should have been voicing single syllables since 6 months of age. Absence of this finding would be a cause for concern. An infant usually is able to stand alone at about 10 months of age. An infant usually is able to build a tower of two cubes at about 15 months of age. An infant usually is able to drink from a cup with little spilling at about 15 months of age.
Which infant most needs a developmental referral for a gross motor delay?
Show answer and rationale
Correct answer: C. The 9-month-old who does not stand holding on.
More than 90% of 9-month-olds are able to stand holding on to objects. Rolling over is expected at 4 to 6 months, and sitting without support is expected at 6 months. Creeping is expected at 9?months.
Which intervention should the nurse employ to reduce trauma caused by vaccine administration to an infant?
Show answer and rationale
Correct answer: C. Simultaneously administer vaccines at separate sites.
Simultaneous injection reduces the anxiety from anticipation of the next injection. Needle length must be long enough to deposit the vaccine into the muscle. A 5/8-inch (1.6-cm) needle is appropriate for newborns, but is not long enough for infants older than 1 month or other children. Aspirating for blood return does not confirm needle placement and is no longer recommended by the American Council on Immunization Practices for vaccine administration. The Public Health Agency of Canada does not recommend aspiration to confirm needle placement. Breast-feeding during vaccinations, not before, has been found to reduce pain.
An uncle is shopping for a toy to give his niece. He has no children of his own and asks his neighbor, a nurse, what would be the most appropriate toy to give a 15-month-old child. Which toy should the nurse recommend to facilitate learning and development?
Show answer and rationale
Correct answer: B. A push-pull toy.
push-pull toy will aid in development of gross motor skills and muscle development. A stuffed animal is age appropriate for a toddler but is not the best toy to promote development. A music box is most appropriate to stimulate development for an infant. A nursery mobile is most appropriate to stimulate development for an infant.
A 2-year-old tells his mother he is afraid to go to sleep because "the monsters will get him." The nurse should tell his mother to:
Show answer and rationale
Correct answer: C. Read a story to him before bedtime and allow him to have a cuddly animal or a blanket.
Behavior problems related to sleep and rest are common in young children. Consistent rituals around bedtime help to create an easier transition from waking to sleep. Allowing a child to sleep with his parents commonly creates more problems for the family and child and does not alleviate the problem or foster autonomy. Increasing activity before bedtime does not alleviate the separation anxiety in the toddler and causes further anxiety. Allowing him to stay up later than his normal time for bed will increase his anxiety, make it more difficult for him to fall asleep, and do nothing to lessen his fear.
A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to:
Show answer and rationale
Correct answer: D. Establish a sense of security.
Toddlers establish ritualistic patterns to feel secure, despite inconsistencies in their environment. Establishing a sense of identity is the developmental task of the adolescent. The toddler’s developmental task is to use rituals and routines to help in making autonomy easier to accomplish. Ritualistic patterns do involve patterns of behavior, but they are not utilized to develop learning behaviors.
A mother of a toilet-trained 3-year-old expresses concern over her child’s bed-wetting while hospitalized. The nurse should tell the mother:
Show answer and rationale
Correct answer: C. "It’s very common for children to regress when they’re in the hospital."
A child will regress to a behavior used in an earlier stage of development in order to cope with a perceived threatening situation. Readiness for toilet training should be based on neurological, physical, and psychological development, not the age of the child. Children are afraid of hospitalization but the bed-wetting is a compensatory mechanism done to regress to a previous stage of development that is more comfortable and secure for the child. Telling the mother that bed-wetting is related to fluid intake does not provide an adequate explanation for the underlying regression to an earlier stage of development.
A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?
Show answer and rationale
Correct answer: D. Identify strategies to prevent difficulties in parenting.
Identifying ways to prevent difficulties in parenting would be helpful in reducing the incidence of child abuse and reducing the stress of child rearing. However, it would not help to develop positive attachment behaviors. Providing opportunities for the mother to hold and examine the newborn and help with care helps establish a positive emotional bond between the mother and newborn. Providing time for the mother to be alone with the infant further allows the mother and newborn to bond.
A mother brings her 18-month-old to the clinic because the child "eats ashes, crayons, and paper." Which of the following information about the toddler should the nurse assess first?
Show answer and rationale
Correct answer: B. Any changes in the home environment.
A craving to eat nonfood substances is known as pica. Toddlers use oral gratification as a means to cope with anxiety. Therefore, the nurse should first assess whether the child is experiencing any change in the home environment that could cause anxiety. Teething or the eruption of large teeth and the amount of attention from the mother are unlikely causes of pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica, but research has not substantiated this theory. A soft, low-roughage diet is an unlikely cause.
When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup, which of the following should the nurse expect the child to be able to do?
Show answer and rationale
Correct answer: C. Kick a ball forward.
A 2-year-old child usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child.
A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. Which of the following should the nurse try first?
Show answer and rationale
Correct answer: A. Allow a parent to assist.
Parents can be asked to assist when their child becomes uncooperative during a procedure. Most commonly, the child’s difficulty in cooperating is caused by fear. In most situations, the child will feel more secure with a parent present. Other methods, such as asking another nurse to assist or waiting until the child calms down, may be necessary, but obtaining a parent’s assistance is the recommended first action. Restraints should be used only as a last resort, after all other attempts have been made to encourage cooperation.
When observing the parent instilling prescribed ear drops prescribed twice a day for a toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops is effective when the parent pulls the toddler’s pinna in which of the following directions?
Show answer and rationale
Correct answer: C. Down and backward.
In a child younger than 3 years of age, the pinna is pulled back and down, because the auditory canals are almost straight in children. In an adult, the pinna is pulled up and backward because the auditory canals are directed inward, forward, and down.
The mother asks the nurse for advice about discipline for her 18-month-old. Which of the following should the nurse suggest that the mother use?
Show answer and rationale
Correct answer: B. Time-out.
Time-out is the most appropriate discipline for toddlers. It helps to remove them from the situation and allows them to regain control. Structuring interactions with 3-year-olds helps minimize unacceptable behavior. This approach involves setting clear and reasonable rules and calling attention to unacceptable behavior as soon as it occurs. Physical punishment, such as spanking, does cause a dramatic decrease in a behavior but has serious negative effects. However, slapping a child’s hand is effective when the child refuses to listen to verbal commands. Reasoning is more appropriate for older children, such as preschoolers and those older, especially when moral issues are involved. Unfortunately, reasoning combined with scolding often takes the form of shame or criticism and children take such remarks seriously, believing that they are "bad."
When planning a 15-month-old toddler’s daily diet with the parents, which of the following amounts of milk should the nurse include?
Show answer and rationale
Correct answer: D. 2 to 3 cups (500 to 750 mL).
Toddlers around the age of 15 months need 2 to 3 cups (500 to 750 mL) of milk per day to supply necessary nutrients such as calcium. A daily intake of more than 3 cups (750 mL) of milk may interfere with the ingestion of other necessary nutrients.
To encourage autonomy in a 4-year-old, the nurse should instruct the mother to:
Show answer and rationale
Correct answer: D. Tell the child when the combination of clothes is not appropriate.
At age 4, the child should be learning to dress without supervision. A child will feel more autonomous if allowed to try to take on tasks herself. Such attempts should be encouraged to increase self-esteem. Allowing choices encourages the child’s capacity to control her behavior. Continued dependency may cause the child to doubt her own abilities. Telling the child that a combination of clothes is not appropriate may cause the child to doubt her abilities. Feelings of guilt can develop from not being able to accomplish what the child feels the adult expects of her.
The mother of a 4-year-old expresses concern that her child may be hyperactive. She describes the child as always in motion, constantly dropping and spilling things. Which of the following actions would be appropriate at this time?
Show answer and rationale
Correct answer: D. Explain that this is not unusual behavior.
Preschool-age children have been described as powerhouses of gross motor activity who seem to have endless energy. A limitation of their motor ability is that in moving as quickly as they do, they are not always able to judge distances, nor are they able to estimate the amount of strength and balance needed for activities. As a result, they have frequent mishaps. This level of activity typically is not associated with changes at home. However, if the behavior intensifies, a referral to a pediatric neurologist would be appropriate. Children who have been abused usually demonstrate withdrawn behaviors, not endless energy.
The mother of a preschooler reports that her child creates a scene every night at bedtime. The nurse and the mother decide that the best course of action would be to do which of the following?
Show answer and rationale
Correct answer: B. Establish a set bedtime and follow a routine.
Bedtime is often a problem with preschoolers. Recommendations for reducing conflicts at bedtime include establishing a set bedtime; having a dependable routine, such as story reading; and conveying the expectation that the child will comply. Allowing the child to stay up late one or two nights interferes with establishing the needed bedtime rituals. Excitement, such as active play, just before bedtime should be avoided because it stimulates the child, making it difficult for the child to calm down and prepare for sleep. Using food such as a cookie as a reward if bedtime is pleasant should be avoided because it places too much importance on food. Other rewards, such as stickers, could be used as an alternative.
The parents of a preschooler ask the nurse how to handle their child’s temper tantrums. Which of the following should the nurse include in the teaching plan?
Show answer and rationale
Correct answer: D. Both of the above
Some parents find that putting the child in time-out until control is regained is very effective. Others find that ignoring the behaviors works just as well with their child. Both suggestions are appropriate to include in the teaching plan. Sending the child to his bedroom means the child is being punished for having a tantrum. Spanking the child is never an option. Attempting to reason with a child having a temper tantrum does not work because the child is out of control. A more appropriate time to discuss it with the child is when the child regains control.
After teaching a group of parents of preschoolers attending a well-child clinic about oral hygiene and tooth brushing, the nurse determines that the teaching has been successful when the parents state that children can begin to brush their teeth without help at which of the following ages?
Show answer and rationale
Correct answer: A. 7 years.
Children younger than 7 years of age do not have the manual dexterity needed for tooth brushing. Therefore, parents need to help with this task until that time.
After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:
Show answer and rationale
Correct answer: A. Does not understand body integrity.
The preschool-age child does not have an accurate concept of skin integrity and can view medical and surgical treatments as hostile invasions that can destroy or damage the body. The child does not understand that exsanguinations will not occur from the injection site. Here, the child is verbalizing a fear consistent with the developmental age. The child would most likely verbalize concerns of not wanting another procedure or exhibit other symptoms associated with pain if those were the underlying issues. If control was the main issue, the child would try to control more than just the bandage removal.
The family of a 5-year-old, only child has just moved to a rural setting. At the well-child visit, the father expresses concern that his child seems prone to minor accidents such as skinning his elbow and knees or falling off his scooter. The nurse tells the father:
Show answer and rationale
Correct answer: A. "Children frequently have more accidents when families experience change."
Family changes and stresses (e.g., moving, having company, taking a vacation, adding a new member) can distract parents and contribute to accidents. Only children typically receive more attention than those with siblings. Thus, the risk would be less. Families who live in the suburbs frequently are more affluent and, therefore, better able to maintain a home less conducive to accidents. A parent’s formal education is unrelated to accidents.
When developing the teaching plan about illness for the mother of a preschooler, which of the following should the nurse include about how a preschooler perceives illness?
Show answer and rationale
Correct answer: C. A punishment for wrongdoing.
Preschool-age children may view illness as punishment for their fantasies. At this age children do not have the cognitive ability to separate fantasies from reality and may expect to be punished for their "evil thoughts." Viewing illness as a necessary part of life requires a higher level of cognition than preschoolers possess. This view is seen in children of middle school age and older. Perceiving illness as a test of self-worth or as the will of God is more characteristic of adults.
To determine if a blood pressure reading is normal, the nurse must know which information about the child?
Show answer and rationale
Correct answer: C. All of the above
Blood pressures percentiles for children are referenced by the age, sex, and height. Measurements at or above the 95th percentile are considered indicative of hypertension. Weight and elevated BMI contribute to hypertension but are not used to define it. The OFC is not routinely measured in children over 2 years of age.
A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child?
Show answer and rationale
Correct answer: A. Has a strong sense of justice and fair play.
School-age children are concerned about justice and fair play. They become upset when they think someone is not playing fair. Physical affection makes them embarrassed and uncomfortable. They are concerned about others and are cooperative in play and school.
To assess a 9-year-old’s social development, the nurse asks the parent if the child:
Show answer and rationale
Correct answer: C. Has a best friend.
During the school-age years children learn to socialize with children of the same age. The "best friend" stage, which occurs around 9 or 10 years of age, is important in providing a foundation for self-esteem and later relationships. Thinking independently, organizing, and planning are cognitive skills. Active play relates to motor skills.
A 10-year-old child proudly tells the nurse that brushing and flossing her teeth is her responsibility. The nurse interprets this statement as indicating which of the following about the child?
Show answer and rationale
Correct answer: A. She is most likely capable of this responsibility.
School-age children delight in riddles and jokes. Mastery of the ambiguities of language and of sentence structure allows the school-age child to manipulate words, and telling riddles and jokes is a way of practicing this skill. Children who suffer from inadequate attention from parents tend to demonstrate abnormal behavior. Peer influence is less important to school-age children, and while the child may learn the joke from a friend, he is telling the joke to master language. Watching television does not influence the extent of joke telling.
The mother tells the nurse that her 8-year-old child is continually telling jokes and riddles to the point of driving the other family members crazy. The nurse should explain this behavior is a sign of:
Show answer and rationale
Correct answer: A. Inappropriate peer influence.
Snacks are necessary for school-age children because of their high energy level. School-age children are in a stage of cognitive development in which they can learn to categorize or classify and can also learn cause and effect. By preparing their own snacks, children can learn the basics of nutrition (such as what carbohydrates are and what happens when they are eaten). The mother and child should make the decision about appropriate foods together. School-age children learn to make decisions based on information, not instinct. Some knowledge of nutrition is needed to make appropriate choices.
The mother asks the nurse about her 9-year-old child’s apparent need for between-meal snacks, especially after school. When developing a sound nutritional plan for the child with the mother, the nurse should advise the mother:
Show answer and rationale
Correct answer: A. The child does not need to eat between-meal snacks.
The values of height and weight percentiles are usually similar for an individual child. Measurements between the 5th and 95th percentiles are considered normal. Marked discrepancies identify overweight or underweight children.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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