1. a. b. c. d. 2.

The nurse is caring for the mother of a newborn. The nurse recognizes that keeps the cord exposed to the air. washes her hands before sponge bathing her baby. washes the cord and surrounding area well with water at each diaper checks it daily for bleeding and drainage. A client telephones the clinic to ask about a home pregnancy test she used

the mother needs more teaching regarding cord care because she

change.

this morning. The nurse understands that the presence of which hormone strongly suggests a woman is pregnant? a. b. c. d. 3. a. b. c. d. 4. a. b. c. d. 5. Estrogen HCG Alpha-fetoprotein Progesterone The nurse is assessing a six-month-old child. Which developmental skills are Speaks in short sentences. Sits alone. Can feed self with a spoon. Pulling up to a standing position. While teaching a 10 year-old child about their impending heart surgery, the Provide a verbal explanation just prior to the surgery Provide the child with a booklet to read about the surgery Introduce the child to another child who had heart surgery three days ago Explain the surgery using a model of the heart When caring for an elderly client it is important to keep in mind the changes

normal and should be expected?

nurse should

in color vision that may occur. What colors are apt to be most difficult for the elderly to distinguish? a. b. Red and blue. Blue and gold.

c. d. 6. a. b. c. d. 7.

Red and green. Blue and green. While giving nursing care to a hospitalized adolescent, the nurse should be Pain management Restricted physical activity Altered body image Separation from family A woman who is 32 years old and 35 weeks pregnant has had rupture of

aware that the MAJOR threat felt by the hospitalized adolescent is

membranes for eight hours and is 4 cm dilated. Since she is a candidate for infection, the nurse should include which of the following in the care plan? a. b. c. d. 8. Universal precautions. Oxytocin administration. Frequent temperature monitoring. More frequent vaginal examinations. The nurse prepares for a Denver Screening test with a 3 year-old child in the

clinic. The mother asks the nurse to explain the purpose of the test. The BEST response is to tell her that the test a. b. c. d. 9. Measures potential intelligence Assesses a childs development Evaluates psychological responses Diagnoses specific problems A 27-year-old woman has Type I diabetes mellitus. She and her husband

want to have a child so they consulted her diabetologist, who gave her information on pregnancy and diabetes. Of primary importance for the diabetic woman who is considering pregnancy should be a. b. c. d. 10. a review of the dietary modifications that will be necessary. early prenatal medical care. adoption instead of conception. understanding that this is a major health risk to the mother. The nurse is planning care for an 18 month-old child. Which of the following

should be included the in the childs care?

a. b. c. d. 11.

Hold and cuddle the child often Encourage the child to feed himself finger food Allow the child to walk independently on the nursing unit Engage the child in games with other children The nurse in an infertility clinic is discussing the treatment routine. The

nurse advises the couple that the major stressor for couples being treated for infertility is usually a. b. c. d. 12. a. b. c. d. 13. having to tell their families. the cost of the interventions. the inconvenience of multiple tests. the right scheduling of sexual intercourse. The nurse is assessing a four month-old infant. The nurse would anticipate Hold a rattle Bang two blocks Drink from a cup Wave bye-bye The nurse is evaluating a new mother feeding her newborn. Which

finding that the infant would be able to

observation indicates the mother understands proper feeding methods for her newborn? a. b. c. d. 14. Holding the bottle so the nipple is always filled with formula. Allowing her seven pound baby to sleep after taking 1 ounces from the Burping the baby every ten minutes during the feeding. Warming the formula bottle in the microwave for 15 seconds and giving it The nurse is caring for a pregnant client. The client asks how the doctor

bottle.

directly to the baby. could tell she was pregnant just by looking inside. The nurse tells her the most likely explanation is that she had a positive Chadwicks sign, which is a a. b. Bluish coloration of the cervix and vaginal walls Pronounced softening of the cervix

c. d. 15.

Clot of very thick mucous that obstructs the cervical canal Slight rotation of the uterus to the right When caring for an elderly client it is important to keep in mind the changes

in color vision that may occur. What colors are apt to be most difficult for the elderly to distinguish? a. b. c. d. 16. a. b. c. d. 17. Red and blue. Blue and gold. Red and green. Blue and green. The nurses FIRST step in nutritional counseling/teaching for a pregnant Teach her how to meet the needs of self and her family Explain the changes in diet necessary for pregnant women Question her understanding and use of the food pyramid Conduct a diet history to determine her normal eating routines A woman who is six months pregnant is seen in antepartal clinic. She

woman is to

states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to a. b. c. d. 18. a. b. c. d. 19. increase her fluid intake to three liters/day. request a prescription for a laxative from her physician. stop taking iron supplements. take two tablespoons of mineral oil daily. The nurse is observing children playing in the hospital playroom. She would Competitive board games with older children With their own toys along side with other children Alone with hand held computer games Cooperatively with other preschoolers The nurse is caring for residents in a long term care setting for the elderly.

expect to see 4 year-old children playing

Which of the following activities will be MOST effective in meeting the growth and development needs for persons in this age group? a. Aerobic exercise classes

b. c. d. 20.

Transportation for shopping trips Reminiscence groups Regularly scheduled social activities A pregnant woman is advised to alter her diet during pregnancy by

increasing her protein and Vitamin C to meet the needs of the growing fetus. Which diet BEST meets the clients needs? a. b. c. d. Scrambled egg, hash browned potatoes, half-glass of buttermilk, large 3oz. chicken, C. corn, lettuce salad, small banana 1 C. macaroni, C. peas, glass whole milk, medium pear Beef, C. lima beans, glass of skim milk, C. strawberries nectarine

answers 1. Answer C. Exposure to air helps dry the cord. Good hand washing is the prime mechanism for preventing infection. Washing the surrounding area is fine but wetting the cord keeps it moist and predisposes it to infection. It is important to check for complications of bleeding and drainage that might occur. 2. Answer B. Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not positively confirm pregnancy. 3. Answer B. The child develops language skills between the ages of one and three. A six-month-old child is learning to sit alone. The child begins to use a spoon at 12-15 months of age. The baby pulls himself to a standing position about ten months of age. 4. Answer D. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using something concrete, like a model will help the child understand the explanation of the heart surgery. 5. Answer D. The elderly are better able to distinguish between red and blue because of the difference in wavelengths. The elderly are better able to distinguish between blue and gold because of the difference in wavelengths. The elderly are better able to distinguish between red and green because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age. The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age. 6. Answer C. The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance. 7. Answer C. Universal precautions are necessary for all clients but a specific

assessment of the clients temperature will give an indication the client is becoming infected. Oxytocin may be needed to induce labor if it is not progressing, but it is not done initially.Temperature elevation will indicate beginning infection. This is the most important measure to help assess the client for infections, since the lost mucous plug and the ruptured membranes increase the potential for ascending bacteria from the reproductive tract. This will infect the fetus, membranes, and uterine cavity. More frequent vaginal examinations are not recommended, as frequent vaginal exams can increase chances of infection. 8. Answer B. The Denver Developmental Test II is a screening test to assess children from birth through 6 years in personal/social, fine motor adaptive, language and gross motor development. A child experiences the fun of play during the test. 9. Answer B. A review of dietary modifications is important once the woman is pregnant. However, it is not of primary importance when considering pregnancy. Pregnancy makes metabolic control of diabetes more difficult. It is essential that the client start prenatal care early so that potential complications can be controlled or minimized by the efforts of the client and health care team. The alternative of adoption is not necessary just because the client is a diabetic. Many diabetic women have pregnancies with successful outcomes if they receive good care. While there is some risk to the pregnant diabetic woman, it is not considered a major health risk. The greater risk is to the fetus. 10. Answer B. According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living. 11. Answer D. Having to tell families may also be a factor contributing to stress but is not the major stressor. Cost may also be a contributing factor to stress but is not usually the major factor. The inconvenience of multiple tests may also be a factor contributing to stress but is not usually the major factor. Sexual activity "on demand is the major cause of stress for most infertile couples. 12. Answer A. The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months. 13. Answer A. Holding the bottle so the nipple is always filled with formula prevents the baby from sucking air. Sucking air can cause gastric distention and intestinal gas pains. A seven-pound baby should be getting 50 calories per pound: 350 calories per day. Standardized formulas have 20 calories per ounce. This seven-pound baby needs 17.5 ounces per day. 17.5 ounces per day divided by 6-8 feedings equals 2-3 ounces per feeding. A normal newborn without feeding problems could be burped halfway through the feeding and again at the end. If burping needs to be at intervals, it should be done by ounces or half ounces, not minutes. Microwaving is not recommended as a method of warming due to the uneven heating of the formula. If used, the formula should be shaken after warming and the temperature then checked with a drop on the wrist. The recommended method of warming is to place the bottle in a pan of hot water to warm, and then check the temperature on the wrist before feeding. 14. Answer A. Chadwicks sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by

vasocongestion. 15. Answer D. The elderly are better able to distinguish between red and blue because of the difference in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to age. The elderly have poor blue-green discrimination. The effects of age are greatest on short wavelengths. These changes are related to the yellowing of the lens with age. 16. Answer D. Assessment is always the first step in planning teaching for any client. 17. Answer A. In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy, as ordered, and should not be discontinued. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near mealtimes. 18. Answer D. Cooperative play is typical of the preschool period. 19. Answer C. According to Eriksons theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry, and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. 20. Answer D. Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good source of Vitamin C.