Test Bank Maternity and Pediatric Nursing Chapter 44 By Susan Ricci, Terri Kyle, and Susan Carman
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Course
Maternity and Pediatric Nursing
Institution
Maternity And Pediatric Nursing
Test Bank Maternity and Pediatric Nursing Chapter 44 By Susan Ricci, Terri Kyle, and Susan Carman
1. The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which of the following responses from his mother indicates a need for furt...
Test Bank Maternity and Pediatric Nursing Chapter 44
By Susan Ricci, Terri Kyle, and Susan Carman
1. The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele
who has developed a sensitivity to latex. Which of the following responses from his
mother indicates a need for further teaching?
A) "He needs to get a medical alert identification."
B) "I will need to discuss this with his caregivers."
C) "A product's label indicates whether it is latex-free."
D) "He must avoid all contact with latex." - CORRECT ANSWERS-Ans: C
Feedback:
The Food and Drug Administration (FDA) requires that all medical supplies be
labeled if they contain latex, but this is not the case with consumer products. The
mother must be familiar with products that contain latex. The Spina Bifida
Association of America maintains an updated list of latex-containing products.
Getting a medical alert identification, talking with his caregivers, and avoiding all
contact with latex are correct.
2. The nurse is caring for an 8-year-old boy with myasthenia gravis and is teaching
his parents about the signs of cholinergic crisis. Which of the following responses by
the parents indicates a need for further teaching?
A) "Low blood pressure is a sign of crisis."
B) "He might have difficulty swallowing."
C) "He may start to sweat a lot."
D) "More saliva in the mouth is a common sign." - CORRECT ANSWERS-Ans: B
Feedback:
Dysphagia is a sign of myasthenic crisis. Increased salivation, hypotension, and
increased sweating are signs and symptoms of cholinergic crisis.
3. The nurse is providing postoperative care for a 14-month-old girl who has
undergone a myelomeningocele repair. The girl's mother is extremely anxious and
tells the nurse she is afraid she will never learn how to care for her daughter at
home. Which response by the nurse would be most appropriate?
A) "I will help you become comfortable in caring for your daughter."
B) "You must learn how to care for your daughter at home."
C) "You will need to learn to collaborate with all the caregivers."
D) "There is a lot to learn, and you need a positive attitude." - CORRECT
ANSWERS-Ans: A
Feedback:
The nurse needs to empower families to become the experts on their child's needs
and conditions via education and participation in care. The most positive approach is
to let the mother know the nurse will support her and help her become an expert on
her daughter's care. Telling the mother that she must learn how to care for her
daughter or that she must have a positive attitude is not helpful. Telling her that she
needs to collaborate with the caregivers is true, but does not address her fears.
,4. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part
of the plan of care, the nurse focuses on maintaining his cardiopulmonary function.
Which intervention would the nurse implement to best promote maximum chest
expansion?
A) Deep-breathing exercises
B) Upright positioning
C) Coughing
D) Chest percussion
. - CORRECT ANSWERS-Ans: B
Feedback:
The nurse should emphasize that the child's position should be arranged to promote
maximum chest expansion. This is usually in the upright position. Deep-breathing
exercises are for strengthening/maintaining respiratory muscles. Coughing helps
clear the airways. Chest percussion helps loosen secretions in lungs
5. A 6-year-old boy with cerebral palsy has been admitted to the hospital for some
tests. His condition is stable. The boy's mother remains with her son, but she is
obviously exhausted and stressed. Which response by the nurse would be most
appropriate?
A) "Would you like me to bring you a blanket and pillow?"
B) "You are doing such a wonderful job with your son."
C) "He's in good hands; consider going home to get some sleep."
D) "Are you planning to spend the night or to go home?" - CORRECT ANSWERS-
Ans: C
Feedback:
Providing daily, intense care can be quite demanding and tiring. When a child with
cerebral palsy is admitted to the hospital, this may serve as a time of respite for
family and primary caregivers. The nurse should remind the mother that her son is in
good hands and urge her to go home. Asking her whether she is planning to stay
might make the mother feel obligated to stay. Asking if she wants a blanket or pillow
does not encourage the mother to leave the hospital. Telling the mother she is doing
a good job is nice, but does not encourage her to take a break.
6. A nurse is caring for a 14-year-old girl following myelography. Which of the
following would be the priority nursing action?
A) Monitoring for a decrease in spasticity
B) Observing for signs of meningeal irritation
C) Assessing motor function
D) Observing for mental confusion or hallucinations - CORRECT ANSWERS-Ans: B
Feedback:
Following myelography, the nurse should carefully observe for signs of meningeal
irritation because of what is involved in this procedure. Monitoring for a decrease in
muscle spasticity, assessing motor function, and observing for mental confusion or
hallucinations is appropriate following an intrathecal test dose of baclofen.
7. The nurse has developed a plan of care for a 6-year-old with muscular dystrophy.
He was recently injured when he fell out of bed at home. Which intervention would
the nurse suggest to prevent further injury?
A) Recommend the bed's side rails be raised throughout the day and night.
B) Suggest a caregiver be present continuously to prevent falls from bed.
, C) Encourage a loose restraint to be used when he is in bed.
D) Recommend raising the bed's side rails when a caregiver is not present. -
CORRECT ANSWERS-Ans: D
Feedback:
The nurse should recommend that side rails on the bed be elevated when a
caregiver is not present. The use of restraints should be avoided if at all possible.
Suggesting that a caregiver be present at all times places undue stress on the
family. Close observation is more appropriate. Recommending side rails be elevated
at all times may be upsetting to the child and make him feel like a "baby."
8. The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and
flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. Which
of the following would the nurse use when documenting these observations?
A) Spastic
B) Athetoid
C) Ataxic
D) Mixed - CORRECT ANSWERS-Ans: B
Feedback:
Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It
affects all four extremities with possible involvement of the face, neck, and tongue.
The movements increase in periods of stress. Dysarthria and drooling may be
present as well. Spastic cerebral palsy is characterized by poor control of posture,
balance, and movement; exaggeration of deep tendon reflexes; and hypertonicity of
affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and
wide-based gait.
9. The nurse is caring for a child with a spinal cord injury and providing instruction to
the parents on promoting skin integrity. Which response from the mother indicates a
need for further teaching?
A) "I need to monitor his skin at least twice a week."
B) "I must monitor skin affected by his adaptive equipment."
C) "He must change positions frequently."
D) "We must avoid harsh cleaning products." - CORRECT ANSWERS-Ans: A
Feedback:
The nurse needs to emphasize to the mother that she must monitor the condition of
the entire surface of the skin several times daily to provide a baseline and allow for
early identification of areas at risk. Monitoring the skin affected by adaptive
equipment, changing positions frequently, and avoiding harsh cleaning products are
appropriate.
10. The nurse is teaching a group of students about myelinization in a child. Which
statement by the students indicates that the teaching was successful?
A) Myelinization is completed by 4 years of age.
B) The process occurs in a head-to-toe fashion.
C) The speed of nerve impulses slows as myelinization occurs.
D) Nerve impulses become less specific in focus with myelinization. - CORRECT
ANSWERS-Ans: B
Feedback:
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