MCN QUIZZES

PRELIMS:

1. Assessment is very important to determine if the couple are at risk to have a child with genetic.
What are the things to be noted or recorded by the nurse during assessment? Select all that apply.
 Age of the mother (<35 years old)
 Age of the father (>55 years old)
 Relationship of the couple by blood
 Ethnic background
 Prenatal history

2. One of the genetic disorders has a code of 46XY23q. what is this disorder?
 Down syndrome
 Cri-du-chat syndrome
 Fragile x syndrome
 Klinefelter syndrome

3. Trisomy 13 is also known as Patau syndrome. What are the characteristics of this disorder? Select
all that apply.
 Cleft lip and palate
 Small jaw
 Small eyes
 Most do not survive beyond early childhood
 Long face

4. The following characteristics are TRUE about Turner’s syndrome, EXCEPT. Select all that apply.
 It has a code of 45X0
 Common among males
 Low set hairline
 Small testes
 Webbed neck

5. This is a diagnostic test that is being done between 14 th-16th week of pregnancy. This is called
 Amniocentesis

6. This refers to the study of surface markings on the skin

 Dermatoglyphics

7. This is a disorder in which the child exhibit a rag doll appearance, with brushfield spots, large
tongue and with small mouth cavity. This is
 Trisomy 18
 Trisomy 13
 Trisomy 21
 Trisomy 28

8. A diagnostic procedure wherein a sample of peripheral venous blood or a scraping of cells from the
buccal membrane is taken.
 Karyotyping

9. What do we need to remember about klineflter syndrome? Select all that apply.
 It has a code of 46XXY
 Common among females
 With an extra X chromosome
 Nonfunctional ovaries
 Small testes
10. What is the normal genome?
 46XXY/ 46XY

11. This refers to actual gene composition.

 Genotype

1. A rheumatic heart disease is a beta hemolytic streptococcal infection which particularly involves the
 Atrium
 Ventricles
 Aorta
 Valves

2. When assessing a pregnant woman’s risk for complications, which of the following would lead the
nurse to suspect that the woman is considered high risk? Select all that apply.
 BMI between 18.5 and 30
 History of intimate partner abuse
 Previous pregnancy with twins
 Two previous miscarriages
 30 years of age

3. Angelique Abaga is 22 years old who developed deep vein thrombosis during her stay in the
hospital. On bed rest and is prescribed low molecular weight heparin subcutaneous. What education
will she need in relation to this?
 Her infant will be born with scattered petechiae on his trunk.
 Heparin can cause darkened or non flexible skin in newborns.
 Heparin does not cross the placenta and she does not affect the fetus
 Some infants will be born with allergic symptoms to heparin

4. During an assessment of Angela Parong, a perinatal client with a history of left-sided heart failure.
Nurse Acosta notes that Angela Parong is experiencing unusual episodes of non-productive cough on
minimal exertion. Nurse Acosta interprets that this finding may be the first initial indicator of which
important cardiac problem?
 Orthopnea
 Pulmonary edema
 Right sided heart failure
 Decreased blood volume

5. As oxygen saturation of Lailanie decreases, chemoreceptors stimulate the respiratory center to

 Increase heart rate
 Increase respiratory rate
 Decrease respiratory rate
 Increase systemic blood pressure

6. When planning care for pregnant woman with heart disease, the nurse should do which of the
following?
 Plan an exercise schedule to prevent thrombus formation during labor.
 Assess complaints of fatigue and note as desired to promote maximum fetal and maternal
nutrition.
 Instruct the client to eat as much food as desire to promote maximum fetal and maternal
nutrition.
 Discourage the mother from taking any medications during pregnancy since it will affect the
baby.

7. Almost all women are screened for gestational diabetes by a 50 gram glucose challenge test. For
this test, you would instruct a woman that
 She will have to fast for 12 hours prior to the test.
 The test takes up to 12 hours prior to the test
 She will need to collect a 24 hour urine following test
 If serum glucose is above 140mg/dl, more testing will be required.

8. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational
diabetes. Which statement if made by the client indicates for further education?
 I need to stay on the diabetic diet
 I will perform glucose monitoring at home
 I need to avoid exercise because negative effects on insulin production.
 I need to be aware of the infections.

9. Which statement is INCORRECT regarding the oral glucose challenge test on mothers being
screened for gestational diabetes?
 This is usually done during the 24th-28th week of pregnancy
 After 50g oral glucose is ingested, venous sample is taken for glucose determination after 60
minutes
 If the serum glucose at 1 hour is 140 mg/dl, the woman is scheduled are above 120 mg/dl, a 3
hour fasting glucose
 If two or more blood samples collected for fasting glucose are above 120 mg/dl, a diagnosis of
diabetes is made

10. Marie is suffering from cardiovascular disease and therefore needs a team approach during
pregnancy. She should visit her obstetrician before conception so her health care team can be familiar
with her health state and evaluate her heart function. A pregnant client with cardiac classification III is

 A woman who has moderate to marked limitation of physical activity her less than ordinary
activities are enough for her to experience excessive fatigue, palpitations and dyspnea.

11. Patricia’s cousin develops diabetes during pregnancy. What are the possible complications? Select
all that apply.
 Hydramnios
 LGA
 Hyperbilirubinemia
 Difficult labor
 Congenital anomalies

12. Absence of lower extremities for the baby as a result of having of having diabetic mother. This
refers to

 Caudal regression syndrome

13. It is the accumulation of fluid in the peritoneal area

 Ascites

14. The mother has history of seizure and she’s pregnant. The following are effects EXCEPT;

 Cerebral palsy

15. This is atest that is being done on the 4th - 6th week of pregnancy detecting hyperglycemia

 Glycosylated hemoglobin

16. What are the signs and symptoms of left sided heart disease EXCEPT. Select all that apply
 Peripheral edema
 Jugular distention

17. If polyuria Is for excessive urination, what about for excessive thirst?
 Polydipsia

18. Oral hypoglycemic drugs are recommended for pregnant clients with diabetes.
 FALSE

19. Babies with diabetic mothers are hypoglycemic while still inside the uteru and hyperglycemic after
birth
 FALSE

20. The normal fasting blood glucose

 95

21. At 16 weeks gestation, no fetal heart rate was detected during assessment of a pregnant patient.
An ultrasound confirmed a hydratidiform molar pregnancy. Which of the action should the nurse tell,
the patient expect during her one year follow-up?
 Multiple serum chorionic gonadotrophin levels will be drawn

22. In taking care of patients with placenta previa, the health personnel should do the following.
EXCEPT.
 Internal examination

23. While observing Cara’s signs and symptoms, the nurse understands that abruption placenta is

 Premature separation of a normally implanted placenta.

24. The following are signs and symptoms of placenta previa. Select all that apply.
 Bright red vaginal bleeding
 Soft, relaxed nontender uterus

25. A client who’s 3 months pregnant with her first child reports that she has had increasing morning
sickness for the past month. Nursing assessment reveals a fundal height of 20 cm and no audible fetal
heart tones. The nurse should suspect which complication of pregnancy.
 Gestational trophoblastic disease

26. A pregnant client is diagnosed with partial placental previa. In explaining the diagnosis, the nurse
tells the client that the usual treatment for placenta previa is which of the following?
 Activity limited to bed rest

27. A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows
that the placenta is located at the edge of the cervical opening. As the nurse you know that which
statement is FALSE about this finding>
 The patient will need to have a c-section and cannot deliver vaginally.

28. Your patient who is 34 weeks pregnant is diagnosed with total placenta previa. The patient is A
positive. What nursing interventions below will you include in the patients care? Select all that apply.
 Monitoring vital signs
 Placing patient on side lying position
 Monitoring pad count’
 Monitoring CBC and clotting levels

29. Select all the signs and symptoms associated with placenta previa.
 Painless bright red bleeding
 Normal fetal heart rate
 Abnormal fetal position
30. A patient who is 25 weeks pregnant has a partial placenta previa. As the nurse, you’re educating
the patient about the condition and self care. Which statement by the patient requires you to re-
educate the patient?
 “I may start to experience dark red bleeding with pain.”

31. After an Rh (-) mother has delivered her Rh (+) baby, the mother is given Rhogam. This is done in
order to

 Prevent the mother from producing antibodies against the Rh (+) antigen that she may have
gotten when she delivered to her Rh (+) baby.

32. Because of a rapidly rising bilirubin level, exchange transfusion was performed on the newborn.
The nurse understands that the blood to be transfused to the newborn should be

 Type O, Rh negative

33. A nurse provides instructions to a malnourished client regarding iron supplementation during
pregnancy. Which statement when made by the client would indicate an understanding of the
instructions?

 The iron is best taken on full stomach.

34. Marina with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy.
Aggressive management of a sickle cell crisis includes which of the following measures? Select all that
apply.

 Hospitalization
 Intravenous fluids
 Blood transfusion

35. Clients with megaloblastic anemia should be encouraged to do which of the following?

 Take the prescribed folic acid supplements

1. A 34-year-old female is currently 16 weeks pregnant. You’re collecting the patient’s health history.
She has the following health history: gravida 5, para 4, BMI 28, hypertension, depression, and family
history of type 2 diabetes. Select below all the risk factors in this scenario that increases the patient’s
risk for developing gestational diabetes.

 34 years old
 Gravida 5, para 4
 BMI 28
 Family history of type 2 diabetes

2. The best technique to determine if the client has ectopic pregnancy that is done initially is

 Ultrasound

3. There are three common classifications of anemia. What classification does not require the client to
have iron supplement?

 Sickle cell anemia

4. The student nurse was asked to enumerate the s/s of left sided heart failure. She’s correct if

 Pulmonary edema
 Weight gain
 Cough

5. This refers to the elevated amount of glucose

 Hyperglycemia

6. Rh (D) immune globulin is being given when? Select all that apply.
 28 weeks of gestation
 40 weeks gestation
 Within 72 hours after delivery

7. You’re providing an educational class for pregnant women about gestational diabetes. You discuss
the role of insulin in the body. Select all the correct statement about the role and function of insulin
 “insulin is a hormone secreted by the beta cells of the pancreas.”
 “insulin influences cells by causing them to uptake glucose from the blood.”

8. You’re teaching a pregnant mother with gestational diabetes about the signs and symptoms of
hyperglycemia. What are the signs and symptoms you will include in your education to the patient?
Select all that apply.

 Frequent hunger
 Polydipsia
 Frequent urination

9. When are most pregnant patients tested for gestational diabetes?

 24-28 weeks gestation

10. A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient
experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms
can present with abruptio placentae? Select all that apply.

 Hard abdomen
 Tender uterus
 Fetal distress

11. Select all the signs and symptoms associated with placenta previa

 Painless bright red bleeding

 Normal fetal heart rate
 Abnormal fetal position

12. A patient who is 25 weeks pregnant has partial placenta previa. As the nurse, you’re educating the
patient about the condition and self-care. Which statement by

 “i may start to experience dark red bleeding with pain.”

13. The 36th week pregnant client went to the hospital for prenatal check-up. She was diagnosed
before to have placenta previa. Which of the following interventions should not be observed during
the check-up of the client?

 Monitor vital signs

 Checking cervical dilatation
 Monitoring the position of the baby via ultrasound
 Checking FHT via doppler

14. Which of the following statement is TRUE regarding abruptio placenta?

 It needs fibrinogen via IV

15. The student nurse is correct when she states that the type of bleeding for a client with placenta
previa is

 Bright red

16. What do you need to observe when the client has H-mole? Select all that apply.
 Persistent nausea and vomiting
 HCG level is between 1-2 million

17. Which statement is correct about gestational trophoblastic disease? Select all that apply.
 Mole is detected via ultrasound
 Risk for choriocarcinoma
 Risk to have preeclampsia

18. What are the signs and symptoms that may suggest ectopic pregnancy? Select all that apply.
 Shoulder pain
 Cervical motion tenderness
 Cullen’s sign

19. The drug of choice for unruptured ectopic pregnancy is

 Methotrexate

20. A client is said to be Rh sensitized if, select all that apply

 History of miscarriage
 Had ectopic pregnancy
 Had amniocentesis

MIDTERMS:

1. The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 cm. A repeat IE done at 10 AM
showed that cervical dilation was 7 cm. The correct interpretation of this result is

 Protracted active phase

2. A nurse monitoring the client who is in the active stage of labor. The client has been experiencing
contractions that are short, irregular and weak. The nurse documents that the client is experiencing
which type of labor dystocia?

 Hypotonic

3. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not
strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

 Obtaining an order to begin IV oxytocin infusion

4. The client is in active labor. She is on oxytocin per IV infusion drip. Which of the following situations
would require that the infusion be stopped?

 Contractions occur at less than 2 minute intervals or at last for longer than 90 seconds.

5. When uterine rupture occurs, which of the following would be the priority?

 Limiting hypovolemic shock

6. Which of the following would be a sign that uterine rupture has occured?
 Sharp abdominal pain in between contractions

7. A woman develops a pathologic retraction ring during labor. On assessment, you would expect to
find its appearance as

 A line of indention over the lower abdomen

8. In terms of planning care, why is the development of a pathologic retraction ring important?

 It precedes surrounding rupture

9. If the labor period lasts only for 3 hours, the nurse should suspect that the following conditions may
occur. Select all that apply.

 Fetal anoxia
 Laceration of the cervix
 Laceration of perineum
 Cranial hematoma in the fetus

10. Which of the following best describes preterm labor?

 Labor that begins after 20 weeks gestation and before 37 weeks gestation

11. To prevent preterm labor from progressing, drugs are usually prescribed to halt labor. The drugs
commonly given are? Select all that apply.

 Magnesium sulfate
 Terbutaline

12. Mrs. Madrid has prolonged labor. What is the most common cause for arrest of descent during
the second stage of labor?

 Cephaloperlvic disproportion

13. A woman you care for during labor is having contractions 2 minutes apart but rarely over 50
mmHg in strength; the resting tone is high, 20-25 mmHg. She asks what she can do to make
contractions more effective. Your best response would be that

 She needs to rest because her contractions are hypertonic

14. A gravid 7, para 6 woman is in the hospital only 15 minutes when she begins to deliver
precipitously. The fetal head begins to deliver as you walk into the labor room. Your best action would
be to

 Place a gloved hand gently on the fetal head to guide delivery

15. The following are common causes of dysfunctional labor. Which of these can a nurse, on her
manage?

 Full bladder

16. The danger of a resting tone that is too high is that

 Lack of relaxation

17. Which of the following describes why hypertonic contractions tend to become very painful?
 The myometrium becomes sensitive from the lack of relaxation and anoxia of uterne cells

18. Formation of a pathologic contraction ring is a danger sign of labor. To assess for this, you would

 Palpate the lower segment of the uterus.

19. Which of the following indicates that Ritodrine is effective in a woman with preterm labor?

 Uterine contraction stops

20. Labor is said to be precipitous if select all that apply

 The total length of labor is under 3 hours

 Sudden cervical dilatation and effacement
 Sudden expulsion of the baby
 Sudden descent of the baby

1. If a fetus is determined to be in face presentation. What would be most important to observe in the
newborn after birth?

 Signs of dehydration

2. Shoulder dystocia is a birth problem that occurs when the fetal head is born but the shoulders are
to broad to enter and be born through the pelvic outlet. This happens during

 The second stage of labor

3. A student nurse is studying the different types of breech presentation. She came across an
illustration in which the hips of the fetus are flexed and the knees are flexed, the elbows are flexed,
the buttocks alone present to the cervix. She is correct if she identified this as

 Complete breech

4. Mc Robert’s maneuver may widen the pelvic outlet and help in letting the anterior shoulder be
delivered. This maneuver is described as

 Asking the woman to flex her thighs sharply on her abdomen

5. You assess that a fetus is in a breech presentation. Where would you auscultate for fetal heart
sounds?

 High in the abdomen

6. If the fetus is large, which means the baby is at risk for shoulder dystocia. Which finding in the
newborn would be most important to assess for the following shoulder dystocia in labor?

 Uncoordinated respirations

7. Situation: Mrs. Favour, gravida 2 para 0010, is admitted to the labor and delivery area. Initial
assessment reveals cervical dilatation of 4cm; cervical effacement, 100 % station 0, contractions
moderately intense and occurring every 5-6 minutes and lasting 45-60 seconds. Fetal heart tones are
loudest in the left upper quadrant. When performing Leopold’s maneuver, nurse Tina detects a hard,
round object at the level of the fundus. Assessment findings for Mrs. Favour indicate that the fetus

 Breech presentation
8. The arc of rotation of the fetal head in a posterior position is longer than in the anterior position.
The fetal head rotation against sacrum causes the intense pressure and pain in the lower back of the
woman. All of the following measures will alleviate the pain EXCEPT

 Maintaining a dorsal recumbent position

9. The nurse understands that the fetal head is in which of the following positions with a face
presentation?

 Completely extended

10. As a delivery room nurse, you would expect that the nurse will do which of the following
interventions to relieve the impacted fetal shoulders quickly?

 Suprapubic pressure

11. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate
would be most audible in which of the following areas?

 Above the maternal umbilicus and to the right of midline

12. Mc Robert’s maneuver may widen the pelvic outlet and help in letting the anterior shoulder be
delivered. This maneuver is described as

 Asking the woman to flex her thighs sharply on her abdomen

13. When the bag of water ruptures spontaneously, the nurse should inspect the vaginal for possible
cord prolapsed. If here is part of the cord that has prolapsed into the vaginal of the correct nursing
intervention is to

 Cover the prolapsed cord with strike gauze wet with sterile saline

14. Which of the following statements is true regarding asynclitism?

 Face and brow presentation are examples of this

15. If a fetus is in breech position, it can be turned to a cephalic position by external cephalic version
just before or during labor. An important assessment to make immediately following this would be

 Fetal heart rate

16. A laboring client has been dilated 9-10 cm for 2 hours. The fetal head ha remained at zero station
for 45 minutes despite adequate pushing efforts by the client. A sterile vaginal exam reveals a position
of occiput posterior. Which of the following actions by the nurse would be most appropriate?

 Assist the client to a hands and knees position

17. The client’s history reveals that a condition preventing the fetus to pass through maternal pelvis is
interpreted as

 Maternal disproportion

18. The student states the following for breech presentation. She needs further instruction if she
includes which of the following cause of breech presentation?

 Oligohydramnios allowing free fetal movement

19. Which of the following statements is true regarding asynclitism?

 Face and brow presentation are examples of this

20. The woman is in active labor. The presentation of the fetus left occiput posterior. Which of the
following measures should be included when caring for the client?

 Provide back massage

FINAL QUIZZES IN MCN LEC

QUIZ 1
1. A nurse in the nursery is caring for a neonate. On assessment the infant is exhibiting
grunting, tachypnea, nasal flaring and grunting. Respiratory distress syndrome is diagnosed
and the physician prescribes surfactant replacement therapy. The nurse would prepare to
administer this therapy by
- Instillation of the preparation into the lungs through an endotracheal tube.
2. Which of the following is the most important concept associated with the high-risk new-
born?
- Support the high risk newborn’s cardiopulmonary adaptation by maintaining adequate
airway.
3. A nurse is assessing a new-born who was born at 32 weeks gestation. Which of the
following would the nurse most likely find? Select all that apply
- Ruddy skin
- Abundant Lanugo
- Copious vernix caseosa
4. Small for gestational age newborns are at risk for difficulty of maintaining body
temperature due to
- They do not have as much fat stores as do other infants.
5. Hypothermia is common in newborn because of their inability to control heat. The
following would be an appropriate nursing intervention to prevent heat loss EXCEPT
- Place the crib beside the wall
6. Andrea has no spontaneous respirations at birth. Suppose her amniotic fluid is heavily
stained with meconium. Which would be your best action?
- Keep her warm until a laryngoscope can be passed.
7. Heat regulation is the most critical factor for a newborn's survival next to establishing
respiration. Which of the following characteristics of newborns predispose them to poor
heat regulation?
- Newborns cannot shiver yet.
8. Which of the following nursing diagnoses would be given priority in then care of a newborn
one hour of age?
- Ineffective thermoregulation
9. The reason nurse May keeps the neonate in a neutral thermal environment is that when a
newborn becomes too cool, the neonate requires
- More oxygen, and the newborn’s metabolic rate increases.
10. Heat regulation is the most critical factor for a newborn's survival next to establishing
respiration. Which of the following characteristics of newborns predispose them to poor
heat regulation?
- Newborns cannot shiver yet
11. An insulin dependent diabetic delivered a 10-pound male. When the baby is brought to the
nursery, the priority care is to
- Check the baby’s serum glucose level and administer glucose if <40mg/dl
12. Therese has just given birth at 42 weeks gestation. When the nurse assesses the neonate,
which physical finding is expected
- Desquamation of the epidermis
13. The physical finding you would expected to be seen in ljezie because of prematurity is
- Lack of sole creases on her feet.
 14. After therapeutic interventions, a newborn demonstrates adequate lung expansion. The
amount of pressure that would enable her to continue to reinflate the alveoli of her lungs
would be.
- 15-20 cm H2o
15. Which of the following manifestations in a six-month-old infant who was born prematurely
would lead a nurse to suspect that the infant has apnea?
- Episodes of breath-holding during periods of stress.

Quiz 2 finals

1. Baby Nicks has surfactant administered at birth. The purpose of surfactant is to

- Prevent alveoli from collapsing on expiration
2. When developing the initial plan of care for a neonate who was born at 41 weeks '
gestation was diagnosed with meconium aspiration syndrome (MAS), and requires
mechanical ventilation, which of the following should the nurse include
- Care of an umbilical arterial line
3. Which of the following are typical signs and symptoms of pneumonia? Select - all - that
-appl
- Coarse crackles
- Oxygen saturation 90%
- Elevated WBC
- Tachypnea
4. A nurse in the nursery caring for a neonate. On assessment the infant is exhibiting
grunting, tachypnea, nasal flaring and grunting Respiratory distress syndrome is diagnosed
and the physician prescribes surfactant replacement therapy. The nurse would prepare to
administer this therapy by
- Installation of the preparation into the lungs through an endotracheal tube
5. The GI system plays a major role in maintaining fluid, electrolyte, and acid - base balance.
The GI system often is involved with two severe acid base imbalances which is
- Metabolic acidosis and metabolic alkalosis
6. A two -month - old is showing signs and symptoms of heart failure. An echocardiogram is
ordered. The test shows the infant has a ventricular septal defect (VSD). Which statement
below best describes the blood flow in the heart due to this congenital heart defect?
- The blood in the heart is shunting from the left ventricle to the right ventricle, which is
increasing pulmonary blood flow.
7. While assessing a newborn's heart sounds you note a loud murmur at the left upper sternal
border. You report this to the physician who suspects the infant may have patent ductus
arteriosus. The physician asks you to obtain a pulse pressure. If patent ductus arteriosus is
present the pulse pressure would be
- wide
8. Atrial septal defects can lead to a decrease in lung blood flow.
- False (increase)
9. In Hypertonic Dehydration water is lost in a greater proportion than electrolytes and it
occurs when fluid intake decreases in conjunction with a fluid loss increase. It occurs in a
child with Select that apply
- Nausea (preventing fluid intake)
- Fever (increase fluid loss through perspiration)
- Profuse diarrhea- where there is a greater loss of fluid than salt
- Renal disease- associated with polyuria such as nephrosis with diuresis.
10. An echocardiogram shows that your patient has an atrial septal defect located at the
bottom of the septum near the tricuspid and mitral valves. As, the nurse you know this is
what type of atrial septal defect (ASD)?
- Ostium primum
11. Interpret the ABG's. pH=7.36; PaCO2=55; HCO3; =28
- Respiratory acidosis fully compensated
12. Overhydration is serious as dehydration because the ECF overload can lead to
cardiovascular overload and cardiac failure. All of the following are true about
overhydration except
- The excess fluid in these instances is usually intravascular and interstitial
13. All of the following are included in the Assessment in Metabolic alkalosis. Select all the
apply.
- The child will breathe slowly and shallowly
14. The level of bicarbonate (HCO3) in arterial blood is normally
- 22-26 mEq/L
15. MAS can be prevented by
- Tracheal suctioning once baby is delivered.
16. The family is caring for their youngest child Justin who is suffering from Tetralogy of fallot.
Which of the following are defects associated with this congenital heart condition?
- Ventricular septal defect, overriding aorta, pulmonic stenosis and right ventricular
hypertrophy.
17. Hypotonic Dehydration occurs when there is a disproportionately high loss of electrolytes
relative to fluid lost. The plasma concentration of sodium and chloride will be low. This
could result from all of the following except?
- Excessive intake of salt associated with great gain through intake
18. When diarrhea occurs, or when a child becomes diaphoretic because of fever, the fluid
output can be markedly decreased
- False (increase)
19. Select all the correct options that represent the pathophysiology of an asthma attack
- The mucosa lining experiences severe inflammation
- The goblet cells within the mucosa lining produce excessive amounts of mucous.
20. Metabolic acidosis may result from diarrhea When diarrhea occurs, a great deal of sodium
is lost with stool. This excessive loss of Na, in turn, causes the body to conserve Hions in an
attempt to keep the total number of positive and negative ions in serum balanced. As a
result, all of the following will occur except
- Arterial blood gas analysis will reveal a increased pH
21. Isotonic Dehydration is when a child's body loses more water than it absorbs (as with
diarrhea) or absorbs less fluid than it excretes (as with nausea and vomiting). As a result,
all of the following will occur. Select all that apply
- There will be a decrease in the volume of blood plasma
- The body compensates for this rapidly by shifting interstitial fluid into the blood vessels
22. You're caring for a 2-year-old patient who has a large atrial septal defect that needs repair.
This defect is causing complications. These complications are arising from an abnormal
shunting of blood throughout the heart. As the nurse, you know that a shunt is occurring in
the heart due to the defect.
- Left-right
23. Fluid shifts from the blood stream to interstitial and intracellular spaces (from areas of
great osmotic pressure to areas of lesser pressure).
- False (lesser to great)
24. You're working on a unit that provides specialized cardiac care to the pediatric population.
Which patient below would be the best candidate for Indomethacin from the treatment of
patent ductus arteriosus?
- A premature infant
25. What is the interpretation of the ABG if the pH = 7.60; PaCO2=33^ prime HCO3=16?
- Metabolic alkalosis, partially compensated
26. A nurse in the nursery is monitoring a preterm infant for respiratory distress syndrome.
Which assessment signs if noted in the newborn would alert the nurse to the possibility of
this syndrome
- Tachypnea and retractions
27. You're caring for a 2-day- old infant with a large patent ductus arteriosus. The mother of
the infant is anxious and asks you to explain her child's condition to her again. Which
statement below BEST describes this condition?
 - The vessel connecting the aorta and pulmonary artery has failed to close at birth, which
is leading to a left to right shunt of blood.

Quiz 3 finals
1. The nurse is caring for an infant following a cleft lip repair. What are the post-operative
Intervention to be observe Select all that apply.
- Maintain patent airway
- Cleanse the suture line
- Prevent the child from crying
- Place the infant in supine position
2. A nurse visits a child with Mono and provides care instructions to the parents Which
Instruction should the nurse give the parents?
- Notify HCP if child develops abdominal pain left shoulder pain.
3. While assessing a newborn with cleft lip, the nurse would be alert that which of the
following will most likely be compromised?
- Sucking ability
4. The nurse is reviewing the laboratory report of a client who underwent a bone marrow
biopsy. The finding that would most strongly support a diagnosis of acute leukemia is the
existence of a large number of immature
- leukocytes
5. For a child with infectious mononucleosis, why must abdominal palpation be performed
gently?
- The enlarged spleen can rupture
6. A child is diagnosed with Wilm's tumor. In planning teaching interventions, what key
points should the nurse emphasize for the parents
- Do not put pressure on the abdomen.
7. A 5-year-old is admitted to the hospital with complaints of leg pain and fever. On physical
examination, the child is pale and has bruising over various areas of the body. The
physician suspects that the child has ALL The informs the parent that the diagnosis will be
confirmed by which of the following?
- Bone marrow aspirate
8. Which of the following interventions should NOT be included in the care plan for a three
month old Infant who has just undergone cleft palate repair?
- Place the infant in supine position
9. A child is diagnosed with intussusceptions. The nurse performs an assessment on a child
knowing that which of the following is a characteristic of this disorder?
- Invagination of a section of the intestine into the distal bowel.
10. A parent tells a nurse "My three month old infant has passed several stools that resembled
clumpy red jelly ". The nurse should suspect that the infant has developed
- intussuspection
11. Willy is being assessed by Nurse Detdet for possible intussusception; which of the
following would be least likely to provide valuable information?
- Family history
12. The following are signs and symptoms of intussusceptions EXCEPT
- Slow rr
Dapat na answer ay: distended abdomen, dance’s sign, hematochezia (s&s of intussusceptions)
13. Parents are often unaware that their child is developing leukemia. What are the first signs
commonly seen a child with acute lymphocytic leukemia (ALL)?
- Fatigue and bruising
14. David age 15 months is recovering from surgery to remove Wilm's tumor. Which findings
best indicates that the child is free from pain?
- Increased interest in play
15. A child with leukemia is being discharged after beginning chemotherapy. What instructions
will the nurse include in the teaching plan for the parents of this child?
- Avoid fresh vegetables that are not cooked.
 16. When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most
Important to avoid which of the following?
- Palpating the child’s abdomen
17. A nurse preparing to care for a child with a diagnosis of intussusceptions. The nurse
reviews the child's record and expects to note which symptom of this disorder
documented?
- Bright red blood and mucus in the stools
18. Baby RR is a 4 month old infant with a tentative diagnosis of intussusceptions. Which
procedure will likely be ordered for the infant?
- Barium enema
19. A child is diagnosed with Wilm's tumor. During assessment, the nurse in charge expects to
find
- An abdominal mass.
20. Which of the following is a priority nursing intervention for the infant with cleft lip?
- Monitoring for adequate nutritional intake
21. A nurse caring for a patient with acute lymphoblastic leukemia (ALL). Which of the
following is the most likely age range of the patient?
- 3-10 years old
22. Julius is scheduled for surgical repair of his cleft palate. A priority in the post -op plan of
care for Julius would include teaching the mother
- To use cup or wide bowl spoon for feeding
23. The mode of trandmission of infectious mononucleosis is select all that apply
- Kissing
- Sexual intercourse
- Saliva
- Direct contact (not sure)
24. Situation: Cathy, 3 months old had cleftlip on the left side of the mouth. She is scheduled
for surgical correction of the defect. All of the following nursing interventions are included
in the care plan for Cathy who has just undergone cleft lip repair. Which of the following
actions by the mother should NOT be allowed by the nurse?
- Position the infant in prone position.

MIDTERM EXAM
1. A nurse in labor room is monitoring a client with dysfunctional labor for signs of fetal or
maternal compromise. Which of the following assessment findings would alert the nurse to
a compromise?
- Persistent nonreassuring fetal heart tone.
2. The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6cm. A repeat IE done at 10
AM showed that cervical dilation was 7 cm. The correct interpretation of this result is?
- The active phase stage is protracted.
3. A nurse is monitoring the client who is in the active stage of labor. The client has been
experiencing contractions that are short, irregular and weak. The nurse documents that
the client is experiencing which type of labor dystocia?
- Hypotonic
4. A multigravida at 38 weeks ' gestation is admitted with painless, bright red bleeding and
mild contractions every 7 to 10 minutes. Which of the following assessments should be
avoided?
- Cervical dilation
5. A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a
slowing labor. The nurse is reviewing the physician's order and would expect to note which
of the following prescribed treatments for this condition?
- Oxytocin infusion
6. After 4 hours of active labor, the nurse notes that the contractions point of a primigravida
client are not strong enough to dilate the cervix. Which of the following would the nurse
anticipate doing?
- Obtaining an order to begin IV Pitocin infusion.
7. Nurse Igube is aware that one of the following is the most serious adverse effect
associated with oxytocin (Pitocin) administration during labor.
- Water intoxication.
8. Mrs. Maine Corpuz is in active labor. She is on oxytocin per IV infusion drip. Which of the
following situations would require that the infusion be stopped?
- Contractions occur at less than 2 minutes interval or last longer than 90 seconds.
9. If contractions are hypertonic, the resting tone will be above average. A usual resting tone
is
- 15 mmhg
10. Nurse Soria is in labor room preparing to care for a client with hypertonic uterine
dysfunction. Nurse Soria told that the client that she's experiencing uncoordinated
contractions that are erratic in their frequency, duration and intensity. The priority nursing
intervention in caring for the client is to
- Provide pain relief measures.
11. Situation Mrs. Hernandez gravida 2 para 0010, is admitted to the labor and delivery area.
Initial assessment reveals cervical dilataion of 4 cm; cervical effacement, 100% station 0;
contractions, moderately intense and occurring every 5-6 minutes and lasting 45-60
seconds. Fetal heart tones are loudest in the left upper quadrant When performing
Leopold’s manoeuvre nurse Katerina detects a hard, round object at the level of the
fundus.

Assessment findings for Mrs. Fernandez indicate that the fetus is in a.

- Breech presentation
12. If a fetus is in a breech position, it can be turned to a cephalic position by external cephalic
version just before or during labor. An important assessment to make immediately
following this would be
- Fetal heart rate
13. You assess that a fetus is in a breech presentation Where wo you auscultate for fetal heart
sounds?
- High in the abdomen
14. Mr. Meyer, a student nurse is studying the different types of breech presentation, He came
across an illustration in which the hips of the fetus are flexed and the knees are flexed, the
elbows are flexed, the buttocks alone present to the cervix. He is correct if she identified
this as
- Footling breech
15. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal
heart rate would be most audible in which of the following areas?
- Above the maternal umbilicus and to the left midline.
16. Ms. Patacsil a student nurse states the following reasons for breech presentation. She is
CORRECT if she includes which of the following causes breech presentation? Select all that
apply.
- Multiple gestation
- Pendulous abdomen
- Any space occupying mass in the uterus.
17. Breech presentation is more hazardous to a fetus than a cephalic presentation because
there is a higher risk of the following complications. The student nurse needs further
instruction if she states which of the following as a complication.
- Brachial Fracture
18. The arc of rotation of the fetal head in a posterior position is longer than in the anterior
position. The fetal head rotation against the sacrum causes the intense pressure and pain
in the lower back of the woman. All of the following measures will alleviate the pain
EXCEPT
- Maintaining a dorsal recumbent position
19. If a fetus is determined to be in a face presentation, what would be most important to
observe for in the new born after birth?
- Signs of dehydration
20. The nurse understands that the fetal head is in which of the following positions with a chin
presentation?
- Completely extended
21. If the fetus is large which means the baby is at risk for shoulder dystocia. Which finding in
the new born would be most important to assess for following shoulder dystocia in labor?
- Uncoordinated breathing
22. The rarest presentation which occurs in multipara with a relaxed abdominal muscle is
- Brow presentation
23. Which of the following statements is true regarding asynclitism?
- face and brow presentation are examples of this
24. Shoulder dystocia is a birth problem that occurs when the fetal head is but the shoulders
are too broad to enter and be born through the pelvic outlet. This happens during
- Second stage of labor
25. A laboring client is admitted and assessment reveals that the fetus is in a footling breech
position. The nurse should be aware that EXCEPT
- The length of labor is shortened with the fetus in this position.
26. Mrs. Angela Parong, a laboring client has been dilated 9-10 cm for 2 hours. The fetal head
has remained at zero station for 45 minutes despite adequate pushing effects by the client.
A sterile vaginal exam reveals a position of occiput posterior. Which of the following
actions by the nurse would be most appropriate?
- Assist the client to a hands and knees position
27. The client's past history reveals that a condition preventing the fetus to pass through the
maternal pelvis is interpreted by the nurse as
- Cephalopelvic disproportion
28. a primigravida, the nurse would suspect cephalopelvic disproportion when
- the cervix remains unchanged for 3 hours with regular contractions and prior cervical
dilation.
29. A client has a midpelvic contracture from a previous pelvic injury due to motor vehicle
accident as a teenager. The nurse is aware that this could prevent a fetus from passing
through or around which structure during childbirth?
- Ischial spines
30. Mc Robert's maneuver may widen the pelvic outlet and help in letting the anterior
shoulder be delivered. This maneuver is described as
- Asking the woman to flex her thighs sharply on her abdomen.
31. A nurse has developed a plan of care for a client experiencing dystocia and includes several
nursing interventions in the plan of care. Which of the following interventions will be
included in the plan of care to a client experiencing dystocia? Select all that apply
- Monitor fetal heart rate
- Provide comfort measures
- Changing the client’s position frequently
- Keeping the significant others informed of the progress of labor
32. As a delivery room nurse, you would expect that the nurse midwife will do which of the
following interventions to relieve the impacted fetal shoulders (dystocia) quickly?
- Suprapubic pressure
33. The nurse establishes an IV. line, then connects Mrs. Hernandez to an electronic fetal
monitor. The fetal monitoring strip shows an FHR deceleration occurring about 30 seconds
after each contraction begins, the FHR returns to the baseline after the contraction is over.
This type of deceleration is caused by
- Uteroplacental insufficiency
34. if the has uteroplacental Insufficiency, the nurse's first action should be to
- position the client on her left side
35. Mr. Cawis is monitoring the fetal heart rate of a client who is in labor. He is correct if he
will report to his clinical instructor that fetal heart rate is said to be in distress if select all
that apply
- FHT is 160 bpm, weak and irregular
- FHT is less than 120 bpm or over 160 bpm
- FHT decreased during a contraction and persists even after the uterine contraction ends.
36. Situation: Mrs. Erin Magtanggol gravid 2 para 1001 comes to the labor and delivery area
and reports ruptured amniotic membranes and contractions that occur every 3 minutes
and last 50 to 60 seconds. The fetus is in left occiput anterior (LOA) position.
- Check the FHR
37. The woman is in active labor. The presentation of the fetus is left occiput posterior. Which
of the following measures should be included when caring for the client?
- Provide back massage
38. Late in the first stage of labor Mrs Estal receives a spinal block to relieve discomfort. A
short time later, her husband tells the nurse that his wife feels dizzy and is complaining of
numbness around her lips. What do the client's symptoms suggest?
- Anaesthesia overdose
39. Mrs. Ramos has prolonged labor. What is the most common cause for the arrest of descent
during the second stage of labor?
- Cephalopelvic disproportion
40. When giving narcotic analgesics to mother in labor, the special consideration to follow is
- Uterine contractions are strong and the baby will not be delivered yet within the next 3
hours.
41. A woman you care for during labor is having contractions 2 minutes apart but rarely over
5ommHg in strength; the resting tone is high, 20-25 mmHg. She asks what she can do to
make contractions more effective. Your best response would be that
- She needs to rest because her contractions are hypertonic
42. A gravid 7 para 6 woman is in the hospital only 15 minutes when she begins to deliver
precipitously. The fetal head begins to deliver as you walk into the labor room. Your best
action would be to
- place a glove hand gently on the fetal head to guide delivery.
43. When PROM occurs, which of the following provides evidence of the nurse's understanding
of the client's immediate needs?
- PROM removes the fetus most effective defense against infection
44. It is essential for a nurse to take which of the following actions immediately after artificial
rupture of membranes?
- Assess the fetal heart rate
45. When uterine rupture occurs, which of the following would be the priority?
- Limiting hypovolemic shock
46. A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse
would monitor the client closely for the risk of uterine rupture if which of the following
occurred?
- Forcep delivery
47. Which of the following would be a sign that uterine rupture has occurred?
- Sharp abdominal pain in between contractions
48. A nurse in labor room is performing a vaginal assessment on a pregnant client in labor. The
nurse notes the presence of umbilical cord protruding from the vagina. Which of the
following would be the initial nursing action?
- Place the client in Trendelenburg position
49. When the bag of waters ruptures spontaneously, the nurse should inspect the vaginal
introitus for possible cord prolapsed. If there is part of the cord that has prolapsed into the
vaginal opening, the correct nursing intervention is to
- Cover the prolapsed cord with sterile gauze wet in sterile NSS
50. A nurse is providing emergency measures to a client in labor who has been diagnosed with
a prolapsed cord. The mother becomes anxious and frightened and says to the nurse,
"Why are all of these people in here? Is my baby going to be alright? Which of the
following nursing diagnoses would be most appropriate for this client at this time?
- fear
51. Suppose a woman experiences a uterine inversion and the placenta is still attached. What
would be your best action?
- Increase the woman’s intravenous fluid to help restore blood loss.
52. Which of the following techniques during labor and delivery can lead to uterine inversion?
 - Strongly tugging on the umbilical cord to deliver the placenta and hasten placental
separation.
53. A woman develops a pathologic retraction ring during labor. On assessment, you would
expect to find its appearance as
- a line of indentation over the lower abdomen.
54. In terms of planning care, why is the development of a pathologic retraction ring
important?
- It precedes surrounding rupture
55. A nurse is monitoring a client who is experiencing a precipitous birth. The nurse is waiting
for the physician to arrive. When the infant's head crowns, the nurse would instruct the
client to
- breath rapidly (pant)
56. If the labor period lasts only for 3 hours, the nurse should suspect that the following
conditions may occur Select all that apply
- Fetal anoxia
- Laceration of the cervix
- Laceration of perineum
- Cranial hematoma in the fetus
57. After a precipitous delivery, a nurse notes that the new mother is passive and only touches
her new born infant briefly with her fingertips. The nurse would do which of the following
to help the woman process what has happened?
- Support the mother in her reaction the newborn infant
58. Which of the following best describes preterm labor?
- Labor that begins after 20 weeks gestation and before 37 weeks gestation.
59. To prevent preterm labor from progressing, drugs are usually prescribed to halt labor. The
drugs commonly given are. Select all that apply
- Magnesium sulfate
- Terbutaline
- ritodrine
60. A woman is one hour postpartum after vaginal delivery is experiencing heavy vaginal
bleeding. Which of the following actions would a nurse take first?
- Massage the uterine fundus
61. A nurse is monitoring a new mother in the postpartum period for signs of hemorrhage.
Which of the following signs, if noted in the mother, would be an early sign of excessive
blood loss?
- An increase in the PR from 88 bpm to 102 bpm
62. A nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm
but that bleeding is excessive. The initial nursing action would be which of the following?
- Notify the physician
63. Nurse Xianel assess a client for evidence of postpartum point hemorrhage during the third
stage of labor. Early signs of this postpartum complication include
- Increased pulse rate
- Increase respiratory rate
- Decrease BP
64. Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated
with blood within 2 hours post-partum PR= 80 bpm. fundus soft and boundaries not well
defined. The appropriate nursing diagnosis is
- Hemorraghe secondary to uterine atony.
65. The nurse should anticipate that hemorrhage related to uterine atony may occur
postpartally if this condition was present during the delivery
- Excessive analgesia was given to the mother
66. A new mother received epidural anaesthesia during labor and had a forceps delivery after
pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20
points, her diastolic BP has dropped 10 points, and her pulse is 120bpm. The client is
anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying
the health care provider the nurse immediately plans to
- Prepare the client for surgery
67. After surgical evacuation and repair of a paravaginal hematoma, the mother is discharged
3 days postpartum. A nurse knows that the new mother needs further discharge
instructions when the new mother states
- “the only medications I will take are prenatal vitamins and stool softener
68. Cynthia has a perineal hematoma. A common cause of this is
- Bleeding from the placing of perineal episiotomy sutures
69. A nurse in a postpartum unit checks the temperature of a client who delivered a healthy
new born 4 hours ago. The mother's temperature is 100.8F. The nurse provides oral
hydration to the mother and encourages fluids. Four hours later the nurse rechecks the
temperature and notes that it is still the same. Which of the following is the most
appropriate intervention?
- Continue hydration and recheck the temperature after 4 hours.
70. Which temperature best signals postpartum infection?
- 101.2 F on the third postpartal day
71. A postpartum client has a nursing diagnosis of High Risk for infection. The goal formulated
is: " The client will not develop an infection during her hospital stay." Which of the
following assessment data would support the conclusion that the goal has been met?
- Absence of fever
72. Helen has a WBC of 25, mm3. For a postpartal woman, you would assess this as
- A normal count
73. A nurse is developing a plan of care for a post-partum client who was diagnosed with
superficial venous thrombosis. Which of the following interventions would be a
component of the plan of care?
- Elevation of the affected extremity
74. Situation: Aiko, a 37 years old multipara, is admitted with a tentative diagnosis of femoral
thrombophlebitis. The nurse assesses the patient with
- Leg pain
75. Which of the following best describes thrombophlebitis?
- Inflammation of the vascular endothelium with clot formation on the vessel wall.
76. While the postpartum client is receiving heparin for thrombophlebitis, which of the
following drugs would the nurse Mica expect to administer if the client develops
complications related to heparin therapy?
- Protamine sulfate
77. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours.
For which of the following would the nurse be alert?
- Endometritis
78. The physician confirms the diagnosis of femoral thrombophlebitis and orders 5,000 units
heparin subcutaneously every 12 hours. The physician has prescribed heparin for Mrs.
Cariaga to
- Prevent additional thrombus formation
79. Fe develops endometritis. What would be the best activity for her?
- Walking in her room listening to music
80. It is essential that a nurse take which of the following measures prior to discharging a
woman who is at risk for postpartum depression?
- Arrange a visit to the woman’s home within the next 48 hours
81. Which statement by Ms. Nabua is most suggestive of a woman developing postpartal
psychosis?
- My baby has the devil’s eyes.
82. The Manganti couple will undergo testing for subfertility. Subfertility is said to exist when
- a couple has been trying to conceive for 1 year
83. Cely and her husband have been trying for a year and a half to conceive a third child. What
is the average time span it takes a couple to conceive?
- Pregnancy usually occurs within 1 year of unprotected coitus.
84. Situation: Hero and Celine have been married for almost 18 months already. They came to
the clinic because they have been trying to get pregnant during the entire duration of their
marriage without success. When assessing the inadequacy of sperm for conception to
occur, which of the following is the most useful criterion?
 - Sperm count
85. Situation: Hero and Celine have been married for almost 18 months already. They came to
the clinic because they have been trying to get pregnant during the entire duration of their
marriage without success. Celine is instructed by the nurse to record signs and symptoms
of her ovulation. Which is NOT included?
- irritability
86. After thorough evaluation, the doctor confirmed that all findings are normal Celine asked
the nurse, "What does it mean to be diagnosed with primary infertility? " The nurse
appropriate reply is that
- The diagnosis means that she and her husband are normal but they just could not get
pregnant yet.
87. The physician schedules Celine for hysterosalpingogram (HSG). The nurse should explain to
her that this procedure will be performed
- 2-6 days after next menses
88. Hero asks you what is therapeutic insemination by donor entails. Which would be your
best answer?
- Donor sperm are introduced vaginally into the uterus or cervix.
89. Mr. Hero asks his nurse. "What can I do to make sure that the analysis of my semen sample
is as accurate as possible?" The nurse is incorrect if she includes which of the following as
health teaching.
- use lubricant when you collect the specimen.
90. Carol has been told she has blocked fallopian tubes. Which of the following options should
the nurse help her explore?
- In vitro fertilization
91. When discussing the benefits associated with childless living with a couple who is
subfertile, which of the following should the nurse include? Select all that apply
- Career growth,
- pursuit of hobbies,
- personal contributions to society,
- continuance of education
92. Which of the following would be most appropriate to include when teaching a man to
increase his sperm count?
- Wear clothing that does not restrict or over hear the scrotum
- Avoid frequent use of saunas
- Limit alcohol intake
- Increase frequency of coitus

93. The physician confirms the diagnosis of femoral thrombophlebitis and orders 5,000 units
heparin subcutaneously every 12 hours. The physician has prescribed heparin for Mrs.
Cariaga to
- Prevent additional thrombus formation
94. A nurse is caring for a client who has developed postpartum endometritis Based on the
nurse's knowledge of this condition, which symptoms would the nurse expect to see?
- Pelvic pain and fever
95. Suppose Marites has a retained placental fragment that is causing extensive postpartal
bleeding. What hormone test would you anticipate being ordered?
- Human chorionic gonadotropin hormone
96. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which
of the following statements if made by the mother indicates a need for further education?
- “I need to stop breastfeeding until the condition resolves”
97. A nurse determines that a G3P3 client is beginning to go into shock and is hemorrhaging as
a result of a partial inversion of the uterus. The nurse pages the obstetrician STAT and calls
for assistance. The client asks in an apprehensive voice. "what is happening to me? I feel so
funny and I know I am bleeding. Am I dying? The nurse responds to the client, knowing
that the client is feeling
- Panic secondary to shock
98. The nurse is assessing a patient, who has many risk factors for the development of a DVT,
for signs and symptoms of a deep vein thrombosis. What signs and symptoms below would
possibly indicate a deep vein thrombosis is present? Select all that apply’
- Redness
- Pain
- Warm extremity
- Swelling
99. Which option below is considered a positive Homan's Sign for the assessment of a deep
vein thrombosis (DVT)?
- The patient reports pain when the foot is manually dorsiflexed.
 MCN REVIEW GUIDE ANSWER: A BASE OF
QUESTIONS SPONTANEOUS
BREATHING FOR 20
1. A baby girl is born 8 weeks SECONDS OR MORE
premature. At birth, she has
no spontaneous respirations
but is successfully 4. Heat regulation is the most
resuscitated. Within several critical factor for a newborn’s
hours she develops survival next to establishing
respiratory grunting, respiration. Which of the
cyanosis, tachypnea, nasal following characteristics of
flaring, and retractions. She’s newborns predispose them to
diagnosed with respiratory poor heat regulation?
distress syndrome, intubated ANSWER: NEWBORNS
and placed on a ventilator.
CANNOT SHIVER YET
Which nursing action should
be included in the baby’s
plan of care to prevent 5. Hypothermia is common in
retinopathy of prematurity? newborn because of their
ANSWER: PARTIAL inability to control heat. The
PRESSURE OF OXYGEN following would be an
appropriate nursing
(Pao2) LEVELS
intervention to prevent heat
loss EXCEPT:
2. Andrea has no spontaneous ANSWER: PLACE THE CRIB
respiration at birth. Suppose BESIDE THE WALL
her amniotic fluid is heavily
stained with meconium.
Which would be your best 6. Which of the following is the
action? most important concept
ANSWER: KEEP HER associated with the high-risk
newborn?
WARM UNTIL A
LARYNGOSCOPE CAN BE ANSWER: SUPPORT THE
PASSED HIGH-RISK NEWBORN’S
CARDIOPULMONARY
ADAPTATION BY
3. Which of the following
MAINTAINING ADEQUATE
manifestations in a six month
AIRWAY
old infant who was born
prematurely would lead a
nurse to suspect that the
infant has apnea?
7. Which of the following becomes too cool, the
nursing diagnoses would be neonate requires:
given priority in the care of a
ANSWER: MORE OXYGEN,
newborn one hour of age?
AND THE NEWBORN’S
ANSWER: ACTIVE METABOLIC RATE
THERMOREGULATION INCREASES

8. After therapeutic 11. The most common

interventions, a newborn adaptation of a child with
demonstrates adequate lung Tetralogy of Fallot
expansion. The amount of
pressure that would enable ANSWER: CLUBBING
her to continue to re-inflate FINGERS
the alveoli of her lungs would
be:
12. Usually PDA closes as
ANSWER: 15-20 CM H20 the oxygen level increases
and the prostaglandin levels
fall. If it does not close, which
9. A nurse in the nursery is of the following drugs given?
caring for a neonate. On
assessment, the infant is ANSWER: INDOMETHACIN
exhibiting grunting,
tachypnea, nasal flaring and
13. During assessment of a
grunting. Respiratory distress
newborn diagnosed with a
syndrome is diagnosed and
cardiac anomaly, you
the physician prescribed
detected that the infant’s
surfactant replacement
femoral pulses are absent.
therapy by:
Which of the following
ANSWER: INSTILLATION diseases is most likely
OF THE PREPARATION presented by the symptom?
INTO THE LUNGS ANSWER: COARACTATION
THROUGH AN OF THE AORTA
ENDOTREACHEAL TUBE

14. The family is caring for

10. The reason nurse May their youngest child Justin
keeps the neonate in a who is suffering from
neutral thermal environment Tetralogy of Fallot. Which of
is that when a newborn the following are defects
 associated with this JUST AFTER THE HEAD IS
congenital heart condition? DELIVERED
ANSWER: VENTRICULAR
SEPTAL DEFECT, 18. Myer, 2 months is
OVERRIDING AORTA, suspected of having
PULMONIC STENOSIS AND coarctation of the aorta. The
RIGHT VENTRICULAR cardinal sign of this defect is:
HYPERTROPHY
ANSWER: UPPER
EXTREMITY
15. A parent of an infant HYPERTENSION
who has a small atrial septal
defect makes all of the
following comments. Which 19. A 10-year old boy who
one indicates an accurate is suspected of having
understanding of the infant’s coarctation of the aorta is
condition? hospitalized. It is essential
that the nurse performs
ANSWER: MY BABY NEEDS which of the following during
TO HAVE A HEART the initial physical
SURGERY IMMEDIATELY examination?
ANSWER: MONITORING BP
16. A 4-year-old with IN ALL FOUR EXTREMITIES
Tetralogy of Fallot is seen in a
squatting position near his
20. When assessing a
bed. The nurse should:
newly delivered neonate, the
ANSWER: TAKE NO nurse notes the following
ACTION IF HE LOOKS findings: Arms and legs
COMFORTABLE BUT slightly flexed; skin smooth
CONTINUE TO OBSERVE and transparent; abundant
HIM lanugo on the back; slow
recoil of pinna; and few sole
creases. In light of these
17. Meconium aspiration findings, the care plan for
syndrome (MAS) can be this neonate should include
prevented by: nursing orders to monitor for:
ANSWER: SUNCTIONING ANSWER: RESPIRATORY
MOUTH, NOSE AND DISTRESS SYNDROME
POSTERIOR PHARYNX
21. Which independent
nursing intervention are
appropriate for a client who is 24. You are conducting a
experiencing alteration in preoperative teaching to the
oxygenation? SATA. parents of a child who is to
undergo a cardiac surgery for
ANSWERS: correction of septal defect.
Which of the following should
 Assisting with
you include in the health
positioning,
teaching?
 Monitoring activity
ANSWER: CONCEPT OF
intolerance,
PAIN MANAGEMENT
 Encouraging deep
breathing exercises
25. When developing the
 Provide suctioning initial plan of care for a
neonate who was born at 41
weeks’ gestation, was
22. Five days after diagnosed with Meconium
admission, you have noted Aspiration Syndrome (MAS),
on assessment the presence and requires mechanical
of machinery like murmur ventilation, which of the
during heart auscultation, following should the nurse
wide pulse pressure and include
decreased diastolic blood
ANSWER: CARE OF AN
pressure. Which congenital
UMBILICAL ARTERIAL LINE
cardiac anomaly is most
likely to be present?
ANSWER: PATENT DUCTUS 26. Which data supports
ARTERIUSUS the Nurse’s assessment that
a newborn with acute
respiratory distress syndrome
23. During assessment of a is improving?
newborn diagnosed with a
ANSWER: OXYGEN
cardiac anomaly, you
SATURATION OF 92%
detected that the infant’s
femoral pulses are absent.
Which of the following 27. The Nurse admits in
diseases is most likely the pediatric ward an infant
presented by the symptom? with respiratory distress.
ANSWER: COARACTATION Expected assessment would
OF THE AORTA be:
 ANSWER: NASAL FLARING  Ruddy skin,
 Copious vernix
28. Baby Elmo has caseosa,
surfactant administered at  Scant lanugo
birth. The purpose of
surfactant is to:  High pitched cry

ANSWER: PREVENT
ALVEOLI FROM
32. An insulin dependent
COLLAPSING ON
diabetic delivered a 10-pound
EXPIRATION male. When the baby is
brought to the nursery, the
priority care is to
29. Baby Jenny who is
small-for-gestation is at ANSWER: CHECK THE
increased risk during the BABY’S SERUM GLUCOSE
transitional period for which LEVEL AND ADMINISTER
complication? GLUCOSE IF <40MG/DL
ANSWER: POLYCYTHEMIA
PROBABLY DUE TO
33. The physical finding
CHRONIC FETAL HYPOXIA
you would expect to be seen
in Jezie because of
30. Small for gestation age prematurity is:
newborns are at risk for ANSWER: LACK OF SOLE
difficulty of maintaining body CREASES ON HER FEET
temperature due to:
ANSWER: THE DO NOT
34. Which of the following
HAVE AS MUCH FAT
would the nurse need to
STORES AS DO OTHER incorporate in the plan of
INFANTS care for a newborn who is
large for gestational age
(LGA)? SATA
31. A Nurse is assessing a
newborn who was born at 32 ANSWER:
weeks gestation. Which of
the following would the Nurse  Observe closely for
most likely find? SATA signs of
hyperbilirubinemia

ANSWERS:  Decrease stimulation

such as holding and
 talking to prevent 38. Baby Jeorge develops
seizure hyperbilirubinemia. What is a
method used to treat
 Be alert for
hyperbilirubinemia in a
respiratory problems
newborn?
due to increased
intracranial pressure ANSWER: EARLY FEEDING
TO SPEED PASSAGE OF
 Assess for possible
MECONIUM
impaired parenting
due to newborn’s
high-risk status 39. The following are signs
and symptoms of
Intussusception. SATA
35. Baby girl Andrea born
vaginally was determined to ANSWERS:
be large for gestational age.  Abdominal pain
The nurse would assess this
newborn carefully for:  Currant Jelly Stool

ANSWER: INCREASED  Sausage Shaped

INTRACRANIAL PRESSURE Mass
 Draw legs towards
the chest
36. Which of the following
newborn characteristics
would suggest that there was
nutritional deprivation during 40. All of the following are
fetal growth? included in the Assessment in
Metabolic Alkalosis. SATA
ANSWER: WIDELY
SEPARATED SUTURES ANSWERS:

 The child will breath

37. Therese has just given slowly and hallowly
birth at 42 weeks’ gestation.  pH will be elevated
When the nurse assesses the (near or above 7.45)
neonate, which physical
finding is expected?  Hc03 level will be
near or above 28
ANSWER: DESQUAMATION mEq/L
OF EPIDERMIS
41. Metabolic acidosis may electrolytes and it occurs
result from diarrhea. When when fluid intake decreases
diarrhea occurs, a great deal in conjunction with a fluid
of sodium is lost with stool. loss increase. It occurs in a
This excessive loss of Na, in child with: SATA
turn, causes the body to
ANSWERS:
conserve Ions in an attempt
to keep the total number of  Nausea
positive and negative ions in
serum balanced. As a result,  Fever
all of the following will occur  Profuse diarrhea
except:
 Renal disease
ANSWER: ARTERIAL
BLOOD GAS ANALYSIS
WILL REVEAL AN
45. Signs and symptoms of
INCREASED pH hypnotic dehydration
includes all the following
42. A Nurse is preparing to except:
care for a child with a ANSWER: INCREASED
diagnosis of URINE OUTPUT
Intussusceptions. The Nurse
reviews the child’s record
and expects to note which 46. Hypotonic dehydration
symptom of this disorder occurs when there is a
documented? disproportionately high loss
of electrolytes relative to
ANSWER: BRIGHT RED
fluid lost. The plasma
AND MUCUS STOOL concentration of sodium and
chloride will be low. This
43. For a child with could result from all of the
diagnosis of Hirschsprung’s following except:
disease, you expect the ANSWER: EXCESSIVE
child’s stool to be INTAKE OF SALT
ANSWER: RIBBON LIKE ASSOCIATED WITH GREAT
STOOL GAIN THROUGH INTAKE

44. In Hypertonic 47. The child has cleft lift.

Dehydration water is lost in a Chieloplasty was done. What
greater proportion than is the post operativce nursing
care to be observe? SATA
 ANSWERS:

 Place the infant in 52. Infants do not

supine position concentrate urine as well as
adults because their kidneys
 Maintain patent
are immature.
airway
ANSWER: TRUE
 Clean the suture line
using water
53. Isotonic dehydration is
when a child’s body loses
48. The most common more water than it absorbs
diagnostic procedure used for (as with diarrhea) or absorbs
Hirschsprung’s disease and less fluid than it excretes (as
Intussusception is Barium with nausea and vomiting).
Enema: As a result, all of the
following will occur. SATA
ANSWER: TRUE
ANSWERS:

49. What is the most  There will be a

common complication if the decrease in the
child has cleft palate? volume of blood
plasma
ANSWER: OTITIS MEDIA
 The body
50. The following are signs compensates for this
and symptoms of rapidly by shifting
Intussusception: SATA interstitial fluid in
the volume of blood
ANSWER:
plasma
 Distended abdomen 54. Overhydration is
 Dance’s sign serious as dehydration
because the ECF overload
 Hematochezia can lead to cardiovascular
overload and cardiac failure.
All of the following are true
51. When diarrhea occurs, about overhydration except:
or when a child becomes
ANSWER: THE EXCESS
diaphoretic because of fever,
the fluid output can be FLUID IN THESE
markedly decreased. INSTANCES IS USUALLY

ANSWER: FALSE
 INTRAVASCULAR AND  Echocardiography
INTERSTITIAL Colored doppler
 MRI
 ECG
55. Postoperative nursing
care to an infant with cleft 60. It is a type of
palate includes positioning congenital heart disease
into: which is an abnormal
communication between the
ANSWER: PRONE two atria, allowing blood to
TRENDELENBURG shift from left to the right
POSITION atrium Causing an increase in
the volume in the right side
of the heart and generally
56. Postoperative nursing results in ventricular
care to an infant with cleft lift hypertrophy and increased
pulmonary artery blood flow
includes positioning into:
ANSWER: ATRIAL SEPTAL
ANSWER: SUPINE DEFECT
POSITION
61. It is a type of Atrial
Septal Defect wherein the
57. It is the most common opening is at the lower end of
type of congenital heart the septum
disease wherein the pressure ANSWER: OSTIUM
in the left ventricle is greater PREMIUM (ASD1)
than in the right ventricles
ANSWER: VENTRAL 62. It is a type of Atrial
SEPTAL DEFECT Septal Defect wherein the
opening is near the center of
58. It Indicates the the septum
presence of a defect that ANSWER: OSTIUM
permits the passage of blood SECUNDUM (ASD2)
from the higher pressure, left
sided cardiac chamber to a 63. What are the
lower pressure, right sided manifestations of a patient
cardiac chamber. with Atrial Septal Defect?
ANSWER: ACYANOTIC SATA
HEART DISEASE/ ANSWER:
INCREASED PULMONARY  Harsh systolic
BLOOD FLOW murmur over the 2nd
or 3rd interspace
59. How Ventral septal (pulmonic area)
defect diagnose. SATA  Enlarged right side
ANSWERS: of the heart
  Increased pulmonary 68. It occurs when blood is
circulation shunted from the venous to
 Separation in the the arterial system as a
atrial septum result of abnormal
 Increased oxygen communication between the
saturation in the two system (deoxygenated
right atrium blood to oxygenated blood)
or RIGHT-LEFT shunts.
64. What are the most ANSWER: CYANOTIC
common diagnostic HEART DISEASE/
procedure for Atrial Septal DECREASED PULMONARY
defect? BLOOD FLOW
ANSWER:
 Echocardiography 69. What will happen when
 Cardiac there is a decreased
catheterization pulmonary blood flow that
 Doppler involves obstruction in the
pulmonary artery? SATA
65. What to observe in ANSWER:
postoperative client with  Increases pressure
Atrial Septal defect? in the right side of
ANSWER: OBSERVE FOR the heart
ARRHYTHMIAS  Deoxygenated blood
shunts from right to
66. A Nurse is assessing a left RESULTING in
newborn who was diagnose deoxygenated blood
with PDA. Which of the invading the
following would the Nurse systemic circulation
most likely find? SATA
ANSWERS: 70. It is an extremely
 Wide pulse pressure serious disorder because the
 Low diastolic tricuspid valve is completely
pressure closed allowing no blood to
 Machinery murmur flow from the right atrium to
 ECG is normal – but the right ventricle.
may show ventricle ANSWER: TRICUSPID
enlargement if the ATRESIA
shunt is large
71. Tricuspid Atresia causes
67. The most common blood to cross through the
diagnostic procedure used for patent foramen ovale into
PDA is: the left atrium, bypassing the
ANSWER: lungs. What will be develop
ECHOCARDIOGRAPHY into an infant if the shunts
are close? SATA
ANSWER:
  Extreme Cyanosis presented by these
 Tachycardia symptoms?
 Dyspnea ANSWER: TETRALOGY OF
FALLOT
72. Which nursing
management should be 75. It is a procedure in
included in the baby’s plan of treating Tetralogy of Fallot
care in treating Tricuspid wherein it relieves pulmonary
Atresia? stenosis, VSD and overriding
ANSWER: aorta.
 IV infusion of PGE1 ANSWER: BROCK
 Surgery PROCEDURE

73. What are the four (4) 76. It is a procedure in

anomalies present in treating Tetralogy of Fallot
Tetralogy of Fallot? SATA wherein it creates a shunt
ANSWER: between the aorta and the
 VSD pulmonary artery (creating a
 Dextroposition ductus arteriosus to allow
(overriding) of the blood to leave the aorta and
aorta enter the pulmonary artery,
 Hypertrophy of the oxygenate the lungs and
right ventricle return to the left side of the
 Pulmonary stenosis heart, the aorta and the
body.
74. During assessment of a ANSWER: BLALOCK-
newborn diagnosed with a TAUSSIG PROCEDURE
cardiac anomaly, you
detected that the infant’s 77. What are the
Skin is cyanotic/bluish, there therapeutic management
is a presence of should be included in the
polycythemia, severe baby’s plan of care in
dyspnea, growth restriction, treating Tetralogy of Fallot?
clubbing of the fingers, ANSWER:
squatting/knee chest position  Surgery- to connect
when resting, Syncope the heart defects
(fainting), Hyper cyanotic  Place the baby in a
episodes (spells), Cognitive knee chest
challenge, Loud, harsh,  Administer oxygen
widely transmitted murmur  Administer morphine
or a soft, scratchy localized sulfate
systolic murmur in the left  Administer Oral
second, as well as third or Propanolol
fourth parasternal interspace
may be present. Which 78. It is the narrowing of
disease is most likely the pulmonary valve or the
 pulmonary artery jut distal to
the valve and Inability of the 82. What are the 2
right ventricle to evacuate locations of coarctation of the
blood by way of the aorta? SATA
pulmonary artery because of ANSWER:
the obstruction leads to right  Preductal
ventricular hypertrophy.  Postductal
ANSWER: PULMONARY
STENOSIS 83. During assessment of a
newborn diagnosed with a
79. A Nurse is assessing a cardiac anomaly, you
newborn who was diagnose detected that the infant’s
with Pulmonary Stenosis. brachial pulses are absent.
Which of the following would Which of the following
the Nurse most likely find?
diseases is most likely
SATA
presented by the symptom?
ANSWERS:
 Symptomatic, ANSWER: COARCTATION
Cyanosis, Thrill OF THE AORTA
 Systolic ejection
murmur 84. What are the signs and
 signs of mild (right- symptoms of lower BP in the
sided) heart failure lower extremities? SATA
 Widely split of the ANSWERS:
2nd heart sound  Leg pain on exertion
 Cold feet
80. It is the most common  Muscle spasms
therapeutic management of  Pulse is weak,
Pulmonary Stenosis wherein delayed or even
a catheter with an uninflated absent
balloon at its tip is inserted
and passed through the heart 85. What are the signs and
into the stenosed valve. symptoms of higher BP in
ANSWER: BALLOON upper extremities? SATA
ANGIOPLASTY ANSWERS:
 Headache
81. It is the leading cause  Epistaxis
of congestive heart failure in  Pulse in the upper
the first few months of life extremities will be
wherein there is narrowing of rapid and bounding
the lumen of the aorta due to
constricting band and occurs 86. It is a surgery
most frequently in boys than procedure done to a patient
in girls with Coarctation of the Aorta
ANSWER: COARCTATION where in the narrowed
OF THE AORTA portion of the aorta is
 removed and the new ends of maintain the entire heart
aorta are anastomosed. Also, action.
a graft of transplanted ANSWER: HYPOPLASTIC
subclavian artery may be LEFT HEART SYNDROME
necessary if the narrowed
section is so extensive than 90. What are the
an anastomosis cannot be therapeutic management
accomplished readily. should be included in the
ANSWER: baby’s plan of care in
INTERVENTIONAL treating Hypoplastic Left
ANGIOGRAPHY (BALLOON Heart syndrome?
CATHETER) ANSWER:
 Ultrasound –
87. A Nurse is assessing a prenatally
newborn who was diagnose  Echocardiography
with Transposition of the  Prostaglandin
Great Arteries. Which of the therapy- to maintain
following would the Nurse a PDA---to increase
most likely find? SATA blood supply to the
ANSWERS: aorta
 Cyanotic from birth  Heart
 Enlarged heart transplantation- to
 Heart changes prolonged the child’s
 Low oxygen life
saturation
91. A system that plays a
88. A Nurse is assessing a major role in maintaining
newborn who was diagnose fluid, electrolyte, acid–base
with Total Anomalous balance and serves as the
Pulmonary Venous Return. main route by which
Which of the following would substances are taken into the
the Nurse most likely find? body and can be a major
SATA source of loss if vomiting or
ANSWERS: diarrhea occurs.
 Absent spleen ANSWER:
 Mildly cyanotic GASTROINTESTINAL
 Easily gets tired TRACT

89. It is a type of cardiac 92. Fluid is normally

anomaly wherein the left obtained by the body through
ventricle is nonfunctional. oral ingestion of fluid and by
There is a Lack of adequate
the water formed in the
strength to pump blood into
the systemic circulation metabolic breakdown of food.
causes the right ventricle to
ANSWER: TRUE
hypertrophy as it tries to
93. In infants, the relatively  the osmotic
greater surface area to body pressure in
mass also causes a greater extracellular spaces
insensible loss. decreases.
 The kidneys begin
ANSWER: TRUE
to excrete more
94. Fluid intake is altered fluid to decrease
when a child is nauseated ECF volume and
and unable to ingest fluid or bring the proportion
is vomiting and losing fluid of electrolytes and
ingested. fluid back into line.
ANSWER: TRUE  This may lead to a
secondary
extracellular
95. It occurs when water dehydration
and salt are lost in proportion
to each other 100. It is as serious as
ANSWER: ISOTONIC
dehydration because the ECF
DEHYDRATION
overload can lead to
96. It occurs when water is cardiovascular overload and
lost out of proportion to salt cardiac failure.
or water depletion. ANSWER:
ANSWER: HYPERTONIC OVERHYDRATION
DEHYDRATION
101. What are the
97. Fluid shifts from the
interstitial and intracellular manifestations that body
spaces into the bloodstream serum is becoming acidotic?
(from areas of less osmotic SATA
pressure to areas of greater ANSWERS:
pressure).  The pH of blood is
ANSWER: TRUE normally slightly
10alkaline, ranging
98. Dehydration occurs in
the interstitial and from 7.35 to 7.45.
intracellular compartments.  PCO2 (the amount of
ANSWER: TRUE dissolved carbon
dioxide in arterial
99. What will happen when blood) is normally 35
low levels of electrolytes to 45 mm Hg.
occur? SATA
 The level of
ANSWERS:
bicarbonate (HCO3)
 in arterial blood is alkalosis results from
normally 22 to 26 vomiting?
mEq/L.
ANSWER: HYPOKALEMIA

102. What will happen when

105. DOES THE WHOLE
there is an excessive loss of
SECTION OF LYDIA HALL WILL
Sodium?
BE ABLE TO PASS THE FINAL
ANSWER:
EXAMINATION?
 A child becomes
ANSWER: ABSOLUTELY
acidotic as the YES!
number of Ions in
the blood increases
106. A nurse in the nursery
proportionately over
is monitoring a preterm infant
the number of oh for respiratory distress
ions present. syndrome. Which assessment
 Arterial blood gas signs if noted in the newborn
analysis will reveal a would alert the nurse to the
decreased pH (under possibility of this syndrome?
7.35) ANSWER: TACHYPNEA AND
 low hco3 value (near RETRACTIONS
or below 22 mEq/L).
107. For Hirschsprung’s disease, there is
103. In assessing Metabolic no stool in the rectum.
Alkalosis. Which of the
ANSWER: TRUE
following would the Nurse
most likely find?
ANSWERS: 108. A child diagnosed with
intussusceptions. The nurse performs
 The child will
an assessment on a child knowing
breathe slowly and that which of the following is a
shallowly characteristic of this disorder?
 pH will be elevated ANSWER: INVAGINATION OF A
(near or above 7.45) SECTION OF THE INTESTINE
 HCO3 level will be INTO THE DISTAL BOWEL
near or above 28
mEq/L 109. The GI system play a major
role in maintaining fluid, electrolyte,
and acid-base balance. The GI
104. Barry has frequent system often is involved with two
bouts of vomiting. What severe acid-base imbalances which is
secondary electrolyte problem ANSWER: METABOLIC ACIDOSIS
often occurs when metabolic AND METABOLIC ALKALOSIS
110. The following are signs and
symptoms of intussusceptions
except

ANSWER: SLOW PR
109 FINAL

NURSING CARE OF HIGH-RISK NEWBORN Top Benefits of Breastfeeding for Mothers and Babies
 Supports Baby’s Growth and Development
 High risk newborn can be defined as a newborn,  Boosts Immune System
regardless of birth weight, size or gestational age who has  Greater IQ
a greater than average chance of morbidity especially  Aids Mom’s Weight Loss
within the first 28 days of life  Reduces Cancer Risk
 Lower SIDS (Sudden Infant Death Syndrome) Risk
ASSESSMENT Breastfeeding
 Initial assessment  Enhanced natural immunity
o apgar scoring  Reduced allergy risk
 The Apgar score rates:  Bonding
o Respiration, crying  Weight normalization (mom)
o Reflexes, irritability Formula Feeding
o Pulse, heart rate  High sugar exposure
o Skin color of body and extremities  High GMO exposure
o Muscle tone  Increased allergy risk
 Synthetic vitamins
CLINICAL ASSESSMENT  Increased risk fat deficiency
General Anthropometric, shape, size, signs of distress,
apparent deformity, posture Intravenous Lines and Tubes
Skin Mottling, erythma toxixum, cyanosis,
birthmark, meningioma, hematoma etc.
Head/Eyes/Ea Red reflex, hemorrhage, micorphthelmia,
rs/Nose/Throa conjunctivitis, patent nare, intact palate
t
Respiratory Shape and symmetry of chest, use of
accessory muscles, respiratory rate,
auscultate breath sound, oxygen saturation Procedures and Equipment
Cardiovascula Heart rate, sound, murmur, pulse, blood
r pressure, capillary refill
Abdomen Abdominal distension, sign of regurgitation,
characteristics of emesis and stool, liver
margine, bowel sound
Genitourinary Abnormality of genitalia, characteristics of
urine, weight of the body
Rectum Tone, anus abnormality, meconium passage
Neuromuscul Movement of joints, position, flexion,
ar extension, reflex actions, level of PROBLEMS RELATED TO MATURITY
consciousness, body size changes, pupillary I. PREMATURITY
response, hip alignment  Prematurity is a term for the broad category of neonates
Temperature Regulation born at less than 37 weeks' gestation.
Mechanism of Heat Loss  Lack of surfactant makes them vulnerable to RDS.
Risk Factors
 History of premature birth, miscarriage, abortion
 Multiple pregnancies
 Closely spaced pregnancies
 Obstetric complications
 Smoking cigarettes or using illicit drugs
 Stressful life events, such as the death of a loved one or
Four ways a newborn may lose heat to the environment domestic violence
 Physical injury or trauma
NUTRITION AND FLUID MAINTENANCE  Lack of prenatal care
Enteral Feeding Characteristics of Premature Infant
A. Immature Respiratory System
 Insufficient surfactant allows alveoli to collapse with
each expiration
 Skeletal muscles are weak so may not be able to
reposition head and body to maintain patent airway
 Respiratory failure if most common cause of death in
preterm infants within the 1st 72 hours
 109 FINAL

B. Temperature Regulation Assessment

 Lack of subcutaneous fat to insulate body  Reduced subcutaneous tissue-loose skin, especially of
 Small muscle mass buttocks and thighs
 Absent sweat or shiver mechanisms  Long, curved fingernails and toenails
C. Immature immune system  Reduced amount of vernix caseosa
 Lack of immunoglobulins from mother (cross to the  Abundant scalp hair
placenta in the 3rd trimester)  Wrinkled, macerated skin; possibly pale, cracked,
 Difficulty localizing infection and poor WBC parchment-like skin
response  Having the alert appearance of a 2- to 3-week old neonate
 Increased risk of infection after delivery
D. Immature Liver  Greenish-yellow staining of skin, fingernails or cord
 Increased risk of hyperbilirubinemia indicating fetal distress
 Immature production of clotting factors Nursing Care Management
 Increased risk of hypoglycemia  Assessment: APGAR, BALLARD
E. Gastrointestinal  Be alert for meconium aspiration
 Weak suck/swallow reflex until 33-34 weeks  Check complications: Tachypnea, increasing signs of
gestation and poor gag/cough reflexes cyanosis, difficulty breathing, Inspiratory nasal flaring
 Increased risk of Necrotizing Enterocolitis (NEC)--- and retraction of chest, Expiratory grunting, Concomitant
a neonatal disorder related to immature GI system cerebral irritation-jitteriness, hypotonia, seizures
and hypoxia  Additional signs: metabolic acidosis, hypotension,
F. Renal hypoglycemia, hypocalcemia
 Unable to concentrate urine effectively increasing the  Adequate oxygenation and PPV
risk of dehydration  Adequate administration of calories and fluid
 Prolonged drug excretion time related to immature  Administration of antibiotics prophylactically
kidneys
G. Neuromuscular Problems Related to Gestational Weight
 Increased risk of apnea
 Poor muscle tone
 Weak or absent reflexes
 Weak, feeble cry
Priority Nursing Diagnoses
 Impaired gas exchange
 Ineffective thermoregulation
 Imbalanced nutrition: less than body requirements A. SMALL FOR GESTATIONAL AGE (SGA)
 Risk for infection  smaller in size than normal for the gestational age, most
Nursing Interventions commonly defined as a weight below the 10 th percentile
 Admitted in NICU for the gestational age
 Assess physical characteristics  SGA infants are small for their age because they
 Obtain accurate body measurements experienced IUGR
 Assist with laboratory testing as indicated Causes
 Monitor closely for complications  Mother’s malnutrition
 Neonatal resuscitation as necessary  Placental damage
 Mothers who smoke heavily or use narcotics
II. POST MATURITY  Infants with intrauterine infections – rubella,
 Post maturity is a word used to describe babies born after toxoplasmosis
42 weeks.  Babies with chromosomal abnormalities
 At risk because the placenta appears to function Assessment
effectively for only 40 weeks. After this time, it seems to  Prenatal Assessment
lose its ability to carry nutrients effectively to the fetus. o Fundal Height during pregnancy becomes
Develop Post-term Syndrome progressively less than expected
 weight loss o A sonogram can demonstrate decrease in size.
 amount of amniotic fluid may be less at birth than o A biophysical profile, non-stress test, placental
normal, may be meconium stained grading and UTZ can provide additional information.
 overgrown fingernails Appearance
Cause: Unknown  have lower weight and body mass
Maternal factors  look thin and pale, and have loose, dry skin
 Primigravida  umbilical cord is often thin and dull-looking rather than
 High parity mother at any age shiny and fat
 Post-mature infant appears to have suffered from Other Findings
intrauterine malnutrition and hypoxia  High hematocrit level
109 FINAL

 Polycythemia- due to state anoxia during intrauterine life. CONDITIONS ASSOCIATED WITH ALTERATIONS IN
 Acrocyanosis- blueness of hands and feet INFECTIOUS, INFLAMMATORY, AND
o HYPOGLYCEMIA - one of the most common IMMUNOLOGIC RESPONSE
problem in SGA infants because of decreased
glycogen stores Inflammation and the Immune System
o Birth Asphyxia - common problem for SGA infants  Inflammation is the body's normal response to injuries or
because they have underdeveloped chest muscles and infections.
because of risk of developing meconium aspiration  Inflammation is a complex process involving various
syndrome due to anoxia during labor. types of immune cells, clotting proteins and signaling
Priority Nursing Diagnoses molecules, all of which change over time.
 Hypothermia
 Risk for Injury Inflammation vs Infection
 Imbalanced nutrition: less than body requirements  Infection refers to the invasion and multiplication of a
Nursing care management pathogen within the body
 Assess for the presence of meconium during labor and  Inflammation is the body's protective response against
 Assess temperature and provide neutral thermal infection.
environment
 Assess for signs of hypoglycemia Tools of our immune system
 Weigh daily and assess changes in weight  Cells of immune system travel to the site of injury and
B. LARGE FOR GESTATIONAL AGE cause inflammation.
 fetus or infant who is larger than expected for their age  Results in widening of local blood vessels in response to
and gender an outflow of fluid and immune cells into surrounding
 It can also include infants with a birth weight above the tissues.
90th percentile.  This process often causes the cardinal signs of
Etiology inflammation:
 Primary cause: infant of diabetic mother (IDM) o warmth
 If preterm, at risk for RDS o redness
 If posterm, at risk for meconium aspiration o swelling
Increased risk of o pain
 Hyperbilirubinemia related to increase o Loss of function
 bilirubin released from damaged RBC secondary to
traumatic delivery White blood cells (leukocytes)
 Birth injury: fractured clavicle, Erb-Duchenne paralysis  help fight infection by attacking invaders and consuming
secondary to shoulder dystocia infected or dead cells
Assessment a. Lymphocytes- responsible for producing antibodies
 Macrosomia (large body size and high birthweight)  Antibodies help the immune system recognize foreign
 Signs of birth trauma related to cephalopelvic proteins that do not belong to the body. In doing so, they
disproportion (CPD) initiate an inflammatory response and clear the body of
 Hypoglycemia, especially with an IDM the invader.
Priority Nursing Diagnoses
 Risk for injury Neutrophils
Nursing Interventions  White blood cells that arrive first at the site of injury.
 Assess for signs of birth injury They release chemical signals that attract other immune
 Assess for signs of hypoglycemia cells in an effort to help protect the body.

Monocytes
 are special white blood cells that mature into cells called
macrophages
 capable of eating and destroying potential pathogenic
invaders in a process called phagocytosis

Eosinophils Basophils
 responds in parasite infections

Elements of Disease Causation

 This model explains that disease results from the
interaction between the agent and the susceptible host in
an environment that supports the transmission of the agent
from a source to that host.
109 FINAL

The Epidemiologic Triad o Personal protective equipment

o Personal hygiene
o First aid
o Removal of catheters and tubes

Susceptible host
 Any person, especially those receiving healthcare
Break the Chain!
o Immunizations
o Treatment of underlying disease
Break the Chain of Infection o Health insurance
Infectious Agent o Patient education
 Bacteria
 Viruses MEASLES (RUBEOLA)
 Fungi  Measles, or rubeola, is a highly contagious viral infection
 Parasites that starts in the respiratory system. It still remains a
Break the Chain! significant cause of death worldwide, despite the
o Diagnosis and treatment availability of a safe, effective vaccine.
o Antimicrobial stewardship Causative Agent: Paramyxovirus/ Measles virus
Mode of Transmission: Droplet
Reservoir Clinical Features: Incubation Period- 10-12 days
 Dirty surfaces and equipment 1. Pre-eruptive/ Prodromal
 People o Fever (3-4 days)
 Water o 3Cs: coryza, cough, conjunctivitis
 Animals/insects 2. Eruptive Stage- appearance ofmaculopapular rashes,
 Soil (earth) begins on face and upper neck
Break the Chain!  Koplik’s Spot- pathognomonic sign ( greyish white dots
o Cleaning, disinfection, sterilization with reddish areola located on the buccal mucosa)
o Infection prevention policies 3. Post-eruptive/ Desquamation- rashes starts to
o Pest control disappear (fades in order of appearance)

Portal of exit
 Open wounds/skin
 Splatter of body fluids
 Aerosols
Break the Chain!
o Hand hygiene
o Personal protective equipment Complications
o Control of aerosols and splatter  Pneumonia
o Respiratory etiquette  Severe diarrhea
o Waste disposals  Encephalitis
 Blindness
Mode of transmission  Ear infection
 Contact (direct or indirect) Diagnosis
 Ingestion  Symptoms evaluation
 Inhalation  Blood tests
Break the Chain!  Throat and/or nose swab
o Hand hygiene  Urine sample
o Personal protective equipment
o Food safety Measles Infection Timeline
o Cleaning, disinfection, sterilization
o Isolation

Portal of entry
 Broken skin/incisions
 Respiratory tracts
 Mucous membranes
 Catheters and tubes
Break the Chain!
o Hand hygiene
109 FINAL

Who are at Risk?  Up to 85% of infants affected if infected during first

 Unvaccinated child trimester
 Unvaccinated due to medical reasons Complications
 Missed booster shot  Arthralgia or arthritis
 Vitamin A deficiency o Children rare
Prevention o Adult female up to 70%
Health Advisory: measles  Thrombocytopenic 1/3000 cases
 Measles spreads easily and can cause serious illness purpura
 Get vaccinated to prevent measles  Encephalitis 1/500+ cases
 Protect yourself from measles  Neutritis rare
Nursing Responsibility  Orchitis rare
 Strict isolation Treatment and Prevention:
 Skin care  Symptomatic and supportive treatment
 Eye care  For exposed pregnant women-serum immune globulin
 Nasal and oral care  Immunization
 Adequate rest and nutrition Prevention
 Increase OFI  Immunization- MMR vaccine
 Keep patient dry  Avoid MOT
 Vit A supplement
CHICKEN POX (VARICELLA)
GERMAN MEASLES (RUBELLA)  highly contagious infection that usually affects children
 a contagious viral infection best known by its distinctive  The telltale sign of chickenpox is a super-itchy skin rash
red rash with red blisters.
 “three-day measles”  Over the course of several days, the blisters pop and start
 While this infection may cause mild symptoms or even no to leak. Then they crust and scab over before finally
symptoms, it can cause serious problems for unborn healing.
babies whose mothers become infected during pregnancy. CA: Varicella zoster virus
CA: Rubella virus MOT: Droplet
MOT: Airborne/Droplet Clinical Manifestations
Period of Communicability: entire course of the disease  Symptoms appear within 10 to 21 days after exposure
Clinical Manifestation 1. Pre-eruptive-fever, body malaise, headache, fatigue
1. Pre-eruptive 2. Eruptive-appearance of vesiculopustular rash that is
o fever (1-2 days), mild cough and colds itchy and with generalized distribution
2. Eruptive stage o appears first on the covered part (scalp and trunk)
o appearance of maculopapular rash then on the exposed parts
o Appears within 24hrs and covers the entire body; 3. Post-eruptive- rashes starts to dry, crust, and scab
pinkish and discreet then fall off
 Forscheimer’s spot- pathognomonic sign (fine red spot on
the soft palate)
3. Post-eruptive-takes place on the third day of illness

 You can spread the virus to other people until all the spots
crust over.
Risk of Rubella Infection during Pregnancy Diagnostic Exam: Clinical observation
Preconception Minimal risk Medical Management: Soverax (Acyclovir)- will decrease
0-12weeks 100% risk of fetus being congenitally the number of rashes
infected resulting in major congenital Nursing Care
1. Skin care- don’t scratch
abnormalities
2. Increase resistance
Spontaneous abortion occurs in 20% of cases
3. Hydration
13-16 weeks Deafness & retinopathy 15 \% cases
4. Analgesic
After 16 Normal development, slight risk of deafness
Prevention
weeks & retinopathy I. Immunization- zoster vaccine
Congenital Rubella Syndrome 1. 1st dose- 1y/o, 2nd dose-4-5 y/o
 Infection may affect all organs 2. Avoid MOT
 May lead to fetal death or premature delivery
 Severity of damage to fetus depends on gestational age
109 FINAL

HERPES ZOSTER (SHINGLES)  Mumps is highly contagious for about nine days after
 caused by the reactivation of the VZV symptoms appear.
 Primary infection with VZV causes varicella. Once the
illness resolves, the virus remains latent in the dorsal root
ganglia. VZV can reactive later in a person’s life and
cause a painful, maculopapular rash called herpes zoster.
CA: Herpes Zoster virus/ Dormant VZV
Clinical Manifestations
1. Pre-eruptive: fever, headache, photophobia, malaise
2. Eruptive: appearance of vesiculo-pustular rash
o commonly appears on the trunk and does not usually
cross the body’s midline CA: Paramyxovirus
o rash is usually painful, itchy, or tingly MOT: Droplet
o rash develops into clusters of vesicles Symptoms
3. Post –eruptive: New vesicles continue to form over  Fever
three to five days and progressively dry and crust  Loss appetite
over in about 2-4 weeks  Headache
 Muscle pain
 When eating pains
 Pain ear, jaw, chin
Complications
 Encephalitis
 Pancreatitis
 Hearing loss
 Meningitis
Potential Complications  Oophoritis
Neurologic  Orchitis
 Post herpetic neuralgia Management
 Cranial and motor neuron palsies  Follow good hand washing practices
o Ramsey Hunt Syndrome  Conservative, supportive, medical care
o Bell’s palsy  Use of analgesics
 Encephalitis  Warm or cold packs to the swollen parotid area
 Stroke  A light diet with plenty fluid intake
 Hearing loss  Acidic foods and liquids should be avoided
Ophthalmic Prevention Tips
 Visual loss 1. Make sure you are up to date on your vaccines
 Pain  The MMR vaccine is the BEST protection against
 Facial scarring mumps!
 Keratitis 2. Be aware of the signs and symptoms of Mumps
Cutaneous o Loss of appetite
 Bacterial super infection o Fever
 Scarring o Tiredness
Visceral (rare) o Headache
 Myocarditis o Muscle aches
 Pericarditis
 Arthritis MONONUCLEOSIS “KISSING DISEASE”
 Hepatitis  refers to a group of symptoms usually caused by the
Management and Prevention Epstein-Barr virus (EBV)
 Antivirals: Acyclovir  infection is typically not serious and usually goes away on
 Prednisone its own in 1 to 2 months
 Analgesics; narcotics, pregabalin
 Vaccine: Recombinant zoster vaccine (RZV)
Nursing Care
 Skin care
 Pain control measures

MUMPS (ENDEMIC PAROTITIS)

 a viral infection that primarily affects saliva-producing
(salivary) glands that are located near your ears. Mumps
can cause swelling in one or both of these glands.
CA: Epstein–Barr virus
109 FINAL

What is this? Prevention

 It is a common illness that can leave you feeling tired and Precautions to take when you have Mono
weak for weeks or months  Avoid sharing utensils
 Also known as  Avoid sharing drinks or drinking straws
o Mono  Wash your hands often
o The “kissing disease”  Cover any coughs or sneezes
 It is most often seen in teens and young adults  Avoid kissing
 Children can get the virus, but it often goes unnoticed
because their symptoms are mild
 Older adults usually do not get mono, because they have
immunity to the virus
Risk Factors
 Kissing infected person
 Sharing utensils
 Contact with other bodily fluids
 Teens and kids
Symptoms
 Mononucleosis, or mono, is a viral infection that can
cause flu-like symptoms that usually show up 4 to 6
weeks after you get it
Entire Body - - - - - Specific Areas
 Headache
 Mild fever
 Fatigue
 Swollen tonsils
 Sore throat
 Enlarged
 Lymph nodes
 Skin rash
 Body aches
Diagnosis
 Symptoms evaluation
 Physical exam
 Complete blood count
 Antibody test
Treatment
 Rest for one to two weeks
 Take fever reducing medication
 Use ice packs or heating pads for body aches
 Use lozenges and spray medications for a sore throat
 Gargle with arm salt water for swollen tonsils
Complications
 Enlarged spleen
 Inflammation of the liver
 Rare complications
o anemia, which is a decrease in your red blood cell
count
o thrombocytopenia, which is a decrease in platelets,
the part of your blood that begins the clotting process
o inflammation of the heart
o complications that involve the nervous system, such
as meningitis or Guillain-Barré syndrome
o swollen tonsils that can obstruct breathing
Mono Flare-up
 Mono symptoms like fatigue, fever, and a sore throat
usually last for a few weeks. In rare cases, the symptoms
can flare up months or even years later.
 EBV, which usually is what causes a mono infection,
remains in your body for the rest of your life. It’s usually
in a dormant state, but the virus can be reactivated.
109 FINAL

NEONATAL RDS & MAS o In utero growth restriction (IUGR)

o Maternal hypertension, diabetes, pre-eclampsia or
Respiratory Distress Syndrome eclampsia, smoking and drug abuse
Hyaline membrane disease
MAS Manifestations
Pathophysiology  The classical signs and symptoms of patients with MAS
 Inappropriate respiratory adaptation to extrauterine life. are:
Result of primary absence, deficiency, or alteration in the o Greenish yellow staining
production of pulmonary surfactant o Tachypnea
o Nasal flaring & chest retractions
RDS Risk factors o cyanosis/yellow-green tinged umbilical cord, nail
 Prematurity beds, or skin
Surfactant Deficiency Disease
o Oligohydramnios or structural lung abnormalities MAS Complication
o Prenatal ultrasonographic findings  Pneumonia - inflammation/infection of the lung
 Pneumothorax - lung rupture/collapse
RDS Manifestations  Surfactant Inactivation
 Tachypnea  Blocked airways
 Grunting - “ugh” sound with each breath
 Changes in color of the fingers, toes and lips. Management of MAS
 Nasal flaring - widening of the nostrils with each breath  Oxygen therapy
 Chest retractions A facemask with oxygen can help inflate the baby’s
lungs.
Management of RDS  Fetal monitor detect stress. Observe severity of MAS, and
 Temperature control clear away as much meconium by suctioning the mouth,
 NGT/Parenteral feeding nose, and throat.
 Minimal handling  Antibiotics to treat infection
 Antibiotics  ABG analysis
 Prone position  Suctioning
 Having a ventilator breathe
 Continuous positive airway pressure (CPAP).
 Artificial surfactant.

Meconium Aspiration Syndrome

 Meconium Aspiration Syndrome (MAS) is the term used
to describe a spectrum of disorders, marked by various
degrees of respiratory distress in the newborn infant.
o Meconium - dark green, sticky and lumpy fecal
material produced during pregnancy.
o Meconium passed in-utero leads to aspiration of
meconium stained amniotic fluid (MSAF) and
develop MAS

Meconium Severity Grading

 Grade 1
o Thin, slightly yellow or green meconium. No
indication of fetal distress
 Grade 2
o Moderately thick meconium (green or brownish).
Could be an indication of some fetal distress
 Grade 3
o Thick, pea-soup meconium (brown or black ). There
is an increased risk of featl distress.

Risk Factors
 Post maturity
o Fetal distress (tachycardia / bradycardia)
o Intrapartum hypoxia secondary to placental
insufficiency
o Oligohydramnios
 109 FINAL

PEDIATRIC

 Asthma is a chronic lung disease (no cure) that causes

narrowing and inflammation of the airways (bronchi and
bronchioles) that leads to difficulty breathing.

Nursing Interventions for Asthma

A. Presenting with an asthma attack:
 Baseline vital signs
 Keep patient calm and comfort the patient
 Position in high Fowler’s to help with ease of breathing
 Administer bronchodilators as ordered by MD
 Administer oxygen (oxygen saturation 95-99%)
Key Players of an Asthma Attack:  Auscultate lung sounds throughout: (decrease in
1. What surrounds these structures? wheezing?….patient breathing easier? respiratory rate
 Smooth muscles that wrap around the airway. This normal?)
muscle helps with dilating and constricting the airway.  Monitor skin color and for any retractions of the chest,
2. What is inside these structures? can they talk to you with ease now or is it still difficult for
 Goblet cells produce mucous, which helps trap the them to talk?)
irritants and bacteria we breathe in.
Medications
What can trigger asthma?  RELIEVERS
 Environment: smoke, pollen, pollution, perfumes, dander, o Rescue inhalers
dust mites, pests (cockroaches), cold and dry air, mold o Works in minutes
 Body Issue: respiratory infection, GERD, hormonal shifts, o Relax muscles
exercise-induced  CONTROLLERS:
 Intake of Certain Substances: drugs, food additives o decreases swelling and mucus production
o Use everyday
Early warning signs: o Overtime, makes lungs healthier
 starting to become short of breath easily  INHALERS
 easily fatigued with physical activity o Use spacer for children to help get the medication
 frequent coughing (mainly at night) and trouble sleeping deep into the lungs
at night  NEBULIZER
 symptoms similar to a cold: sneezing, scratchy throat, o for young kids and babies
tired, headache o turns liquid into fine mist
 irritable
 wheezing with activity

Signs and Symptoms of Asthma Attack

 Chest Tightness
 Wheezing (auscultate…expiratory wheezing and can
program to inspiration in severe cases)
 Coughing
 Difficulty Breathing (***especially exhaling)
 Increased respiratory rate

Can progress to: The general principles of the zone monitoring system are as
 where rescue inhaler won’t work follows:
 can’t talk easily ZONE CONDITION READING (% OF BEST)
 chest retractions (stomach sucked- in, chest sticking out GREEN GO 80%-100%
along with collarbone with each breath Situation: Your medication is working. Go ahead with your
 cyanosis of the lips and skin, normal activities.
 diaphoresis YELLOW CAUTION 50%-80%
 Need medical intervention fast!! Situation: Use caution in your activities. Refer to your
treatment plan for actions to be taken.
RED STOP Less than 50%
Situation: Medical alert. You should get immediate medical
attention.
109 FINAL

Arterial Blood Gas ANALYSIS o HCO3 , pH : Metabolic alkalosis

 Arterial blood gases (ABG) test measures the acidity (pH) LET’S PLAY!
and the levels of oxygen and carbon dioxide in the blood. SAMPLE PROBLEM:
 This test is used to find out how well your lungs are able pH 7.29 PaCO2 50 HCO3 25
to move oxygen into the blood and remove carbon ACID Normal BASE
dioxide from the blood. pH
 An ABG test requires that a small volume of blood be PaCO2 HCO3-
drawn from an artery.
pH 7.51 PaCO2 47 HCO3 32
PURPOSE o METABOLIC ALKALOSIS
 It helps us identify a potential acid-base imbalance in the
body. The following acid-base imbalances can occur in PARTIALLY, FULLY OR UNCOMPENSATED
the body:  Either the respiratory or metabolic system will always try
o Respiratory acidosis or Respiratory alkalosis to increase or decrease itself to help achieve a normal
o Metabolic acidosis or Metabolic alkalosis blood pH.
 For example, if the blood pH is acidic due to respiratory
Normal ABG Values acidosis (a high PaCO2), the metabolic system will try to
pH 7.35-7.45 compensate by keeping bicarbonate (hence increasing the
CO2 35-45 HCO3 level…therefore making itself “alkaline”) and this
pO2 80-100 will help increase the blood pH.
HCO3 22-26
O2 Sat. 95-100% Is it Uncompensated, Partially, or Fully compensated?
 Look at the pH: is it normal or abnormal?
ANALYZING ABG RESULTS If the pH is ABNORMAL: it is either uncompensated or
Goals of ABG Analysis partially compensated…it will NEVER be fully
 With the given lab values, we need to determine if the compensated
interpretation is:  If the pH is NORMAL: it is fully compensated because
1. Acidosis the body has corrected the problem
Alkalosis
2. Metabolic FULLY COMPENSATED
Respiratory
3. Fully Compensated
Partially Compensated
Uncompensated

Acid Base Mnemonic (ROME)

Respiratory
Opposite
pH PCO2 Alkalosis
pH PCO2 Acidosis Problem 1:
Metabolic ABGs: pH 7.43 PaCO2 28 HCO3 18
Equal ACID Normal BASE
pH HCO3 Alkalosis HCO3- pH PaCO2
pH HCO3 Acidosis
 pH: 7.43 (falls within 7.35-7.45) = NORMAL but is on
What does “Respiratory Opposite” mean? the alkalotic side
 The CO2 (remember carbon dioxide represents the  PaCO2: 28 (less than 35) = ALKALOTIC
respiratory system) and pH will be OPPOSITE of each  HCO3: 18 (less than 22) = ACIDOTIC
other…one will be elevated while the other will be  To determine the type of compensation look at the pH…is
decreased…this means it’s a respiratory disorder. it normal or abnormal? It’s NORMAL! Therefore, we
o CO2 , pH : Respiratory acidosis have full compensation.
o CO2 , pH : Respiratory alkalosis  Respiratory alkalosis, fully compensated

What does “Metabolic Equal” mean? Problem 2:

 The HCO3 (remember bicarb represents the metabolic A patient has the following arterial blood gas results: blood
system) and pH will be EQUAL…either both will be pH 7.37, PaCO2 33 mmHg, and HCO3 17 mEq/L. This is
elevated or decreased….this means it’s a metabolic known as:
disorder. A. Partially compensated respiratory alkalosis
o HCO3 , pH : Metabolic acidosis B. Fully compensated metabolic acidosis
109 FINAL

C. Partially compensated respiratory acidosis o Palpate the radial, brachial or femoral artery
D. Fully compensated respiratory alkalosis o Palpate for maximum pulsation at 45-60 degree angle
o Once the artery is punctured, arterial pressure will
 pH: 7.37 (falls within 7.35-7.45) = NORMAL but it’s on push up the piston of the syringe and a pulsating flow
the acidotic side of blood will fill the syringe
 PaCO2: 33 (less than 35) = ALKALOTIC o Apply firm pressure for 5 minutes
 HCO3: 17 (less than 22) = ACIDIC o Air is removed and cap the syringe needle and keep it
 Metabolic acidosis, fully compensated in a container of ice

Problem 3: Perform Allen’s Test

A patient has the following arterial blood gas results: blood  The modified Allen's test is a test to determine the
pH 7.50, PaCO2 49, and HCO3 30 mEq/L. This is known as: patency of the collateral arterial blood supply to the hand
A. Fully compensated respiratory acidosis - it is performed especially before drawing arterial blood
B. Partially compensated metabolic alkalosis from the radial artery.
C. Partially compensated metabolic acidosis
D. Fully compensated metabolic alkalosis

ABGs: pH 7.50 PaCO2 49 HCO3 30

ACID Normal BASE
PaCO2 pH
HCO3
o Partially compensated, metabolic alkalosis

 Now you may be asking yourself what if the PaCO2 was

normal? Then it would be Uncompensated because the
respiratory system isn’t attempting to correct the
metabolic alkalosis.

A child was brought to the emergency department of a

hospital after she fell into the ground and hurt her left leg. She
is noted to be tachycardic and tachypneic. Measurement of
arterial blood gas reveals pH 7.6, PaCO2 31 mm Hg, and
HCǑ3 25 mmol/L. What does this mean?
pH 7.6 ALKALOSIS
PaCO2 31 ALKALOSIS
HCǑ3 25 NORMAL
o RESPIRATORY ALKALOSIS, UNCOMPENSATED

Baby boy Carl was rushed to the hospital due to vomiting and
a decreased level of consciousness. The patient displays slow
and deep and he is lethargic and irritable in response to
stimulation. Measurement of arterial blood gas shows pH 7.56,
paCo2 20, HCO3 20. What is your assessment?
o Respiratory Alkalosis, Partially compensated

Baby Angela was rushed to the Emergency Room following

her mother's complaint that the infant has been irritable,
difficult to breastfeed and has had diarrhea for the past 3 days.
The infant's respiratory rate is elevated and the fontanels are
sunken. The Emergency Room physician orders ABGs after
assessing the ABCs. The results from the ABG results show
pH 7.39, PaCÓ2 27 mmHg and HCǑ3 19 mEq/L.
o Metabolic Acidosis, Fully Compensated

NURSING RESPONSIBILITIES
 Procedure
o Identify patient by name and explain procedure
o Temperature
o Heparinize 2 ml syringe
o Wash hands wear gloves
109 FINAL

INTUSSUSCEPTION
ALSO KNOWN AS“TELESCOPING” DIAGNOSIS & TEST
1. Physical examination
 a condition where the bowel "invaginates" or "telescopes" 2. ultrasonography-- able to identify the mass with 100%
into itself accuracy,
 This telescoping action often blocks food or fluid from 3. other radiologic tests — barium enema and air contrast
passing through. And cuts off the blood supply to the part enema
of the intestine that's affected.
 This can lead to infection, death of bowel tissue or a tear
in the bowel, called perforation.

TREATMENT & MANAGEMENT

 Once intussusception is diagnosed, the next step is to
attempt reduction (to push the intestine back) using a
liquid contrast enema or air contrast enema
 The liquid contrast enema and air contrast enema
CAUSES
procedures have a 60% to 70% success rate, with a 6% to
 The exact cause of intussusception is unknown.
10% rate of intussusception recurrence. They also have a
 In most cases, it is preceded by a virus that produces
low risk of complications.
swelling of the lining of the intestine, which then slips
into the intestine below.
 In some children, it is caused by a condition that the child During the surgery After the surgery
is born with, such as Meckel’s diverticulum. Your child is fully sedated by Your child is given pain
a pediatric anesthesiologist. medication to keep him or her
RISK FACTORS If laparoscopy will be comfortable after the surgery.
 Age (6-18mos) performed, small instruments The child will require
 Sex (male) and a camera will be inserted intravenous fluids for several
 Abnormal intestinal formation at birth (anatomical factor) through small incisions into days because the intestines
 Certain conditions the abdominal cavity. are temporarily slowed.
o Cystic fibrosis Alternatively, a small incision Feedings aren’t given during
o Intestinal polyps is made on the right side of this period. Most children are
the abdomen, and the able to eat again in one to
SYMPTOMS intestine is pushed back into three days.
 The first sign of intussusception in an otherwise healthy its normal position.
infant may be sudden, loud crying caused by belly pain. If the intussusception can’t be
Infants who have belly pain may pull their knees to their reduced, then the surgeon
chests when they cry. will remove the involved
 The pain of intussusception comes and goes, usually segment of bowel.
every 15 to 20 minutes at first. These painful episodes last
longer and happen more often as time passes. Eating, Diet, & Nutrition
Other possible symptoms include:  After surgery for intussusception, eat a regular diet with a
 Stool mixed with blood and mucus — sometimes referred variety of healthy foods.
to as currant jelly stool because of its appearance. o Whole-grain breads
 Right upper quadrant mass (sausage shaped) o Low-fat dairy products
 N/V o Beans
 diarrhea o Fruits
These symptoms begin suddenly, usually one week after a o Vegetables
non-specific viral illness. o Lean meats
o Fish
COMPLICATIONS
 Intussusception can cut off the blood supply to the
affected portion of the intestine. If left untreated, lack of
blood causes tissue of the intestinal wall to die. Tissue
death can lead to a tear in the intestinal wall, called a
perforation.
 This can cause an infection of the lining of the abdominal
cavity, known as peritonitis.
109 FINAL

Hirschsprung’s Disease o Anorectal manometry

ALSO KNOWN AS “Congenital Aganglionic Megacolon”

 disease is a condition that affects the large intestine TREATMENT & MANAGEMENT
(colon) and causes problems with passing stool  Pull-through surgery
 The condition is present at birth (congenital) as a result of o In this procedure, the lining of the diseased part of
missing nerve cells (ganglion cells) in the muscles of the the colon is stripped away. Then, the normal section
baby's colon. Without these nerve cells stimulating gut is pulled through the colon from the inside and
muscles to help move contents through the colon, the attached to the anus. This is usually done using
contents can back up and cause blockages in the bowel. minimally invasive (laparoscopic) methods, operating
through the anus.

CAUSES
 Scientists aren’t sure why the ganglion cells don’t migrate
down to the end of the rectum completely.
 However, genetic factors may be involved, especially
when longer lengths of intestine are involved or when
someone else in the family also has the condition.

RISK FACTORS
 Having a sibling who has Hirschsprung's disease
 Being male
 Having other inherited conditions

SYMPTOMS
 The most obvious sign is a newborn's failure to have a
bowel movement within 24-48 hours after birth.
Other signs and symptoms in newborns may include:
o Swollen belly
o Vomiting, including vomiting a green or brown
substance
o Constipation or gas, which might make a newborn
fussy
o Diarrhea
In older children, signs and symptoms can include:
o Swollen belly
o Chronic constipation
o Gas
o Failure to thrive
o Fatigue

COMPLICATIONS
 Children with Hirschsprung disease are at increased risk
for infections that can cause serious and even life-
threatening problems.---Enterocolitis

DIAGNOSIS & TEST

 Doctors diagnose Hirschsprung disease by taking a
medical and family history, performing a physical exam,
and ordering tests. Tests may include :
o Abdominal x-ray
o Contrast enema
o Rectal biopsy
109 FINAL

OSTOMY SURGERY CONGENITAL HEART DISEASES/DEFECTS

 abnormal portion of the colon is removed and the top,  Congenital heart defects are structural abnormalities of
healthy portion of the colon is connected to an opening the heart and/or great vessels occurring during fetal
the surgeon creates in the child's abdomen. development.
 Stool then leaves the body through the opening into a bag  They are also referred to as congenital heart diseases, or
that attaches to the end of the intestine that protrudes CHD.
through the hole in the abdomen (stoma). This allows  CHD can be subdivided into 2 main types: Cyanotic and
time for the lower part of the colon to heal. Acyanotic.

RISK FACTORS
 Genetics
 Infections e.g. Rubella
 Drug use/alcohol

 Here is a simplified overview of the normal blood flow

through the heart:

Results of surgery
 Diarrhea
 Constipation
 Leaking stool (fecal incontinence)
 Delays in toilet training

1. Deoxygenated blood enters the right atrium of the heart

from the body through two large veins: the superior vena
cava (which returns blood from the upper body) and the
inferior vena cava (which returns blood from the lower
body).
2. The right atrium contracts, pushing the blood into the
right ventricle through the tricuspid valve.
3. The right ventricle contracts, pumping the deoxygenated
blood out of the heart through the pulmonary valve and
into the pulmonary artery.
4. The pulmonary artery carries the deoxygenated blood to
the lungs, where it picks up oxygen and releases carbon
dioxide through the process of respiration.
5. Oxygenated blood returns from the lungs to the left
atrium of the heart through the pulmonary veins.
6. The left atrium contracts, pushing the oxygenated blood
into the left ventricle through the mitral valve (also
known as the bicuspid valve).
7. The left ventricle contracts, pumping the oxygenated
blood out of the heart through the aortic valve and into the
aorta.
8. The aorta, the largest artery in the body, distributes the
oxygenated blood to the rest of the body's tissues and
organs through a network of arteries and arterioles.
9. In the capillaries, oxygen and nutrients are exchanged
with the surrounding tissues, while carbon dioxide and
waste products are collected.
10. Deoxygenated blood returns to the heart through venules
and veins, starting the cycle again by entering the right
atrium.
 This continuous circulation ensures that oxygenated blood
is supplied to all organs and tissues, while deoxygenated
blood is efficiently transported to the lungs for
oxygenation. The coordinated contraction and relaxation
109 FINAL

of the heart's chambers, along with the opening and  Truncus arteriosus is when one blood vessel leaves the
closing of valves, help maintain this normal blood flow. heart instead of 2.
o The main pulmonary artery leaves the right side of
Cyanotic Congenital Heart Defects the heart and delivers deoxygenated blood to the
 cardiac defects in which the blood pumped to the rest of lungs.
the body contains less than normal amounts of oxygen o The aorta leaves the left side of the heart and delivers
 In other words, the heart pumps mixed oxygen-poor and oxygenated blood to the rest of the body.
oxygen-rich blood to the body. o In the case of truncus arteriosus, the great vessel
 This can lead to cyanosis which is a bluish discoloration coming out of the heart fails to divide during
of the skin. development.
 Cyanotic heart defects typically contain right-to-left o This leaves a connection between the aorta and
shunts, meaning deoxygenated blood from the right heart pulmonary artery.
is shunted to the left heart. o As a result, oxygen-poor blood from the right heart
 As a result, oxygen-poor blood is delivered to the body and oxygen-rich blood from the left heart are
and can cause cyanosis. delivered to the rest of the body----CYANOSIS!

Acyanotic Congenital Heart Defects Transportation of Great Arteries

 Cardiac defects that can affect the normal flow of blood,  Two great arteries leaving the heart are reversed
but blood oxygen levels delivered to the body typically
remain normal.
 left-to-right shunts in which oxygenated blood from the
left heart is shunted to the right heart.
 The blood in the left heart still remains oxygen-rich, and
that is why there is no cyanosis as oxygen-rich blood is
delivered to the rest of the body.
 Two great arteries leaving the heart are transposed
Congenital Heart Defects  Transposition of great arteries is when the 2 main arteries
 Structural abnormalities of the heart and/or great vessels leaving the heart (main pulmonary artery and aorta) are
accuring during fetal development transposed or reversed.
Right-to-Left Shunt Left-to- Right Shunt  Therefore, the main pulmonary artery arises from the left
CYANOTIC ACYANOTIC ventricle instead of the right, and the aorta arises from the
Heart defect in which less than Heart defect in which right ventricle instead of the left.
normal oxygen levels are oxygen levels delivered to
delivered to the body the body typically remain Tricuspid Atresia
normal  Tricuspid valve fails to form “Tri=3

Cyanotic Heart Defects

Truncus Arteriosus
o One great vessel leaving heart
Transportation of Great Arteries
o Two great vessels (pulmonary artery and aorta) are
transposed
Tricuspid Atresia  As a result, blood from the right atrium cannot enter the
o Tricuspid valve fails to form right ventricle.
Tetralogy of Fallot  Instead, an atrial septal defect is present (a hole in the
o Tetrad of cardiac defects (pulmonary stenosis, RVH, wall between the right and left atrium).
overriding aorta, VSD)  This allows for deoxygenated blood in the right atrium to
Total Anomalous Pulmonary Venous Return flow into the left atrium.
o 5 words; Pulmonary do not connect to left atrium  As a result, oxygen-poor blood from the right heart mixes
with the oxygen-rich blood in the left heart.
Truncus Arteriosus  This can lead to decreased oxygen levels in the blood
 One of great vessel leving the heart, instead of 2 delivered to the rest of the body, which can cause
cyanosis.

Tetralogy of Fallot
 Tetrad of 4 cardiac defects
1. Pulmonary Stenosis
2. Right Ventricular Hypertrophy (RVH)
3. Overriding Aorta
4. Ventricular Septal Defect (VSD)
109 FINAL

o cyanosis
o poor feeding and poor weight gain
o clubbing fingers
o Dyspnea/tachypnea
o Murmur
o Polycythemia

MANAGEMENT
*TET SPELLS—cyanosis when baby cries  Surgery!
--”hypercyanotic spells”---assume knee-chest, squatting  POST-OP:
position (bigger kids)
1. Monitor for heart failure
o Provide calm environment
o weight gain
o Small-frequent feeding
o periorbital edema
 Pulmonary stenosis is narrowing of the pulmonary valve
o pale cool extremities
and main pulmonary artery. o decreased wet diapers
 Right ventricular hypertrophy is thickening of the right o poor feeding
ventricular wall.
2. Elevate the head to reduce respiratory effort
 Overriding aorta refers to the enlarged aortic valve that
3. Monitor signs of infection/bleeding
seems to open from both ventricles and sits on top of the
ventricular septal defect.
ACYANOTIC HEART DEFECTS
 Finally, the ventricular septal defect is a hole in the wall  Left to right blood flow= increased pulmonary flow
between the right and left ventricle. (increased lung flow) –PULMONARY
 The pulmonary stenosis, RVH, and VSD can alter
 ASD
pressure gradients and create a right-to-left shunt,
 VSD
allowing oxygen-poor blood in the right heart to flow to
 PDA
the left heart----CYANOSIS  AVSD
Total Anomalous Pulmonary Venous Return (TAPVR) ASSESSEMENT
 5 words = TAPVR
 Diaphoresis during feeding
 Pulmonary veins connect to systematic venous system
 Heart murmur
rather than left atrium
 Signs of fluid overload
 Increased risk for heart failure and pulmonary
hypertension
 Hole between ATRIA
 Murmur is expected
 Closes on its own---if not, surgery
 Hole between VENTRICLES
 Grunting during feeding
 TAPVR is when the pulmonary veins connect to the
 Systolic heart murmur (left sternal border)
systemic venous system rather than the left atrium.
 Closes naturally—if not surgery
 Normally the 4 pulmonary veins deliver oxygenated
 Opening that connects aorta to pulmonary artery
blood from the lungs to the left atrium.
 Loud machine like murmur
 In the case of TAPVR, the pulmonary veins do not
 Closes naturally by 48hrs--Surgery
connect to the left atrium.
 Premature: Indomethacin (NSAID)
 They connect to the systemic venous system instead.
 Both ASD and VSD
 As a result, the oxygenated blood from the lungs mixes
 Seen in babies with Down Syndrome
with the deoxygenated venous blood from the body, and
the mixed blood flows back to the right atrium.---
MANAGEMENT
CYANOSIS
 Medications
o Blood pressure drugs.
TESTS/DIAGNOSIS
o Water pills (diuretics).
1. Pulse oximetry
o Heart rhythm drugs.
o ECG
 Surgery--valvotomy
o 2D echo
All Cyanotic Heart Defects are TRouBLe!
o Chest x-ray
o Cardiac catheterization
o Heart MRI

ASSESSMENT
1. Hypoxia
109 FINAL

CEREBRAL PALSY 3. Surgery

o Orthopedic surgery may be used to relieve pain and
 Cerebral palsy is a disorder of movement, muscle tone improve mobility. It may also be needed to release
and coordination that is caused by damage that occurs to tight muscles or correct bone irregularities caused by
the immature, developing brain, most often before birth. spasticity.
4. Other treatment
CAUSES o Speech therapy
 Cerebral palsy is caused by an abnormality or disruption o Occupational therapy
in brain https://nurseslabs.com/cerebral- o Physical therapy
palsy/development, usually before a child is born. Factors o Recreational therapy
that may lead to problems with brain development o Counseling or psychotherapy
include: o Social services consultations
o Mutations in genes that lead to abnormal brain COMPLICATIONS
development  Muscle weakness, muscle spasticity and coordination
o Maternal infections that affect the developing fetus problems can contribute to a number of complications
o Lack of oxygen to the brain (asphyxia) related to either during childhood or later during adulthood,
difficult labor or delivery including:
o Infant illness o Contracture. Contracture is muscle tissue shortening
due to severe muscle tightening (spasticity).
TYPES OF CEREBRAL PALSY Contracture can inhibit bone growth, cause bones to
 Spastic Cerebral Palsy bend, and result in joint deformities, dislocation or
o It causes weak or stiff muscles and exaggerated partial dislocation.
reflexes, making it difficult to walk. Abnormalities o Malnutrition. Swallowing or feeding problems can
include unintentionally crossing their knees or make it difficult for someone who has cerebral palsy,
making scissor-like movements with their legs. particularly an infant, to get enough nutrition. This
 Dyskinetic Cerebral Palsy may cause impaired growth and weaker bones. Some
o Have trouble controlling their body movements. The children may need a feeding tube for adequate
condition causes involuntary, unusual movements in nutrition.
the arms, legs, and hands. It also affects the face and o Mental health conditions. People with cerebral palsy
tongue. It is difficult for the affected person to sit, may have mental health (psychiatric) conditions, such
walk, swallow, or talk. as depression. Social isolation and the challenges of
 Ataxic Cerebral Palsy coping with disabilities can contribute to depression.
o It is characterized by voluntary muscle movements o Lung disease. People with cerebral palsy may
that often appear disorganized, clumsy, or jerky. develop lung disease and breathing disorders.
They may have difficulty walking and performing o Neurological conditions. People with cerebral palsy
fine motor functions, such as grasping objects and may be more likely to develop movement disorders
writing. or worsened neurological symptoms over time.
 Hypotonic Cerebral Palsy o Osteoarthritis. Pressure on joints or abnormal
o Causes diminished muscle tone and overly relaxed alignment of joints from muscle spasticity may lead
muscles. The arms and legs move very easily and to the early onset of painful degenerative bone
appear floppy, like those of a rag doll. As they grow disease (osteoarthritis).
older, they may struggle to sit up straight as a result o Osteopenia. Fractures due to low bone density
of their weakened muscles. (osteopenia) can stem from several common factors
such as lack of mobility, nutritional shortcomings and
MANAGEMENT antiepileptic drug use.
1. Assistive aids include: o Eye muscle imbalance. This can affect visual fixation
o Eyeglasses and tracking; an eye specialist should evaluate
o Hearing aids suspected imbalances.
o Walking aids
o Body braces PREVENTION
o Wheelchairs  Most cases of cerebral palsy can't be prevented, but you
2. Medications can lessen risks. If you're pregnant or planning to become
o Muscle relaxants are commonly used to treat the pregnant, you can take these steps to keep healthy and
symptoms of spasticity. Relaxing the muscles helps minimize pregnancy complications:
reduce pain from muscle spasms. o Make sure you're vaccinated. Vaccination against
o Your doctor might prescribe: diseases such as rubella may prevent an infection that
⁻ Baclofen could cause fetal brain damage.
⁻ Dantrolene (Dantrium) o Take care of yourself. The healthier you are heading
⁻ Diazepam (Valium) into a pregnancy, the less likely you'll be to develop
⁻ Tizanidine (Zanaflex) an infection that may result in cerebral palsy.
109 FINAL

o Seek early and continuous prenatal care. Regular AUTISM

visits to your doctor during your pregnancy are a
good way to reduce health risks to you and your  Autism, also known as autism spectrum or ASD, is a
unborn baby. Seeing your doctor regularly can help developmental condition that leads to communication,
prevent premature birth, low birth weight and social, and behavioral challenges.
infections.
o Practice good child safety. Prevent head injuries by CAUSES/RISK FACTORS
providing your child with a car seat, bicycle helmet,  Genetics
safety rails on beds and appropriate supervision.  Experiencing complications at birth
 Environmental Factors
 No link between vaccines and autism spectrum disorder

ASSESSMENT
Autism Top Early Signs
 Delayed speech development
 Spin objects
 Referred to play alone
 Rejecting cuddles
 Sleep problem
 Hyperactivity
Autism Early Signs in Infants
1. Unusual visual fixations
o Unusually strong and persistent examination of
objects
2. Abnormal repetitive behaviors
o Spending unusually long periods of time repeating an
action, such as looking at their hands or rolling an
object
3. Lack of appropriate sound development
o Delayed development of vowel sounds, suchs as “ma
ma, da da, ta ta”
4. Delayed intentional communications
o Neutral facial tones and decreased efforts to gesture
and gain parent attention
5. Decreased interest in interaction
o Greater interest in objects than people and difficult to
sustain face to face interactions

OTHER SOCIAL CHARACTERISTICS

 Avoids or does not keep eye contact
 Does not respond to name by 9 months of age
 Does not show facial expressions like happy, sad, angry,
and surprised by 9 months of age
 Does not play simple interactive games like pat-a-cake by
12 months of age
 Uses few or no gestures by 12 months of age (for
example, does not wave goodbye)
 Does not notice when others are hurt or upset by 24
months of age
 Does not notice other children and join them in play by 36
months of age
 Does not pretend to be something else, like a teacher or
superhero, during play by 48 months of age
 Does not sing, dance, or act for you by 60 months of age

DIAGNOSIS
 Diagnosing ASD can be difficult since there is no medical
test, like a blood test, to diagnose the disorder.
 Developmental screening
o 9 months, 18 mnths, 24 months, 30 months of age
109 FINAL

o Common = 18 and 24 months ADHD

 Restricted or Repetitive ATTENTION DEFICIT HYPERACTIVITY DISORDER
 Behaviors or Interests
 A chronic condition that affects millions of children and
 People with ASD have behaviors or interests that can often continues into adulthood. Marked by an ongoing
seem unusual. pattern of inattention and/or hyperactivity-impulsivity that
o Lines up toys or other objects and gets upset when interferes with functioning or development.
order is changed
o Repeats words or phrases over and over (called TYPES OF ADHD
echolalia)  INATTENTIVE
o Plays with toys the same way every time o Fails to give close attention to details or makes
o Is focused on parts of objects (for example, wheels) careless mistakes
o Must follow certain routines o Has difficulty sustaining attention
o Flaps hands, rocks body, or spins self in circles o Does not appear to listen
o Struggles to follow instructions
COMPLICATIONS o Has difficulty with organization
 Problems with social interactions, communication and o Avoids or dislikes tasks requiring sustained mental
behavior can lead to: effort
o Problems in school and with successful learning o Loses things
o Employment problems o Is easily distracted
o Inability to live independently o Is forgetful in daily activities
o Social isolation  Hyperactive-Impulsive
o Stress within the family o Fidgets with hands or feet or squirms in chair
o Victimization and being bullied o Has difficulty remaining seated
o Runs about or climbs excessively, extreme
TREATMENT restlessness in adults
 While there is no "cure" for autism, there are several o Difficulty engaging in activities quietly
effective interventions that can improve a child's o Acts as if driven by a motor, adults will often feel
functioning: inside as if they are driven by a motor
o Behavior Programs o Talk excessively
o Medications o Blurts out answers
o Education and Learning Programs  Combined
o Other Treatments and Therapies o Meets the criteria for both inattention and
hyperactive-impulsive presentations
INTERVENTIONS
 Give advance notice before a transition is going to occur. CAUSE
 Use visual supports.  Genetics
 Use structure and consistency.  Environment
 Provide light praise for good transitions.  Significant head injuries
 Consistency  Problems with the central nervous system at key moments
 Have Clear Expectations. Set clear, attainable in development.
expectations for your child and your family.
RISK FACTORS
 Maternal factors, such as:
o Smoking during pregnancy
o Preterm labor
o Mental health conditions
o Exposure to certain environmental toxins
o High blood pressure
o Prematurity
o Gender
o Hereditary
o Age

CLINICAL MANIFESTATIONS
 Impulsiveness
 Disorganization and problems prioritizing
 Poor time management skills
 Problems focusing on a task
 Trouble multitasking
109 FINAL

 Excessive activity or restlessness o preferential seating

 Poor planning o extended time for test taking
 Low frustration tolerance o a written list of due dates and assignments
 Frequent mood swings o note-taking support
 Problems following through and completing tasks 3. MEDICATION
 Hot temper o Medication management is a proven treatment for
 Trouble coping with stress many individuals with ADHD, but not all children
and teens with ADHD need to take medication.
COMPLICATIONS Those with milder forms may be successful with a
 Often struggle in the classroom, which can lead to structured environment and firm, but fair types of
academic failure and judgment by other children and discipline and reward.
adults o Stimulants work by stimulating dopamine receptors
 Tend to have more accidents and injuries of all kinds than so there is more regular nerve transmission, which
do children who don't have ADHD results in increased attention span.
 Tend to have poor self-esteem ⁻ short- intermediate, and long-acting formula
 Are more likely to have trouble interacting with and being ⁻ methylphenidate transdermal (Daytrana) in a
accepted by peers and adults patch form.
 Are at increased risk of alcohol and drug abuse and other ⁻ Stimulant medications
delinquent behavior ⁻ amphetamines
4. Other medications that may be used for ADHD include:
DIAGNOSIS o nonstimulant medications,
 IQ testing-used to document intelligence. o atomoxetine (Strattera)
 The Wechsler Intelligence Scale for Children (WISC) the o SNRIs, and centrally acting adrenergic agents
test most often chosen, consists of two portions: a verbal o guanfacine (Intuniv, Tenex) and clonidine
scale and a performance scale. Atomoxetine
 A child is given three final scores: verbal IQ, performance
IQ, and a combination or full-scale IQ. HOW TEACHERS AND PARENTS CAN HELP?
 Children with ADHD show a "scatter" pattern on both  Teachers can provide accommodations in the classroom
performance and verbal portions, doing on some portions o Preferential seating
and poorly on others. o Shorter assignments
o Closer supervision and Clearer instructions
 Initial history o Help in getting started on assignments
 Physical assessment o Closer supervision of homework
 Completion of evidence-based rating scales o Frequent communication with parents/doctors
o Allow time for movement
 For this reason, test results are more accurate if they take o Environment with fewer distractions during tests
IQ tests individually in rooms free of distractions such as
attractive toys for this same reason. NURSING MANAGEMENT
 Accept the child or individual as what he is.
THERAPEUTIC MANAGEMENT  Consider his condition and communicate with him as an
IT IS IMPORTANT TO: equal.
 Encourage parents to be fair but firm and to set consistent  Approach the child at his current level of functioning. Do
limits to reduce arguments. not use baby talk nor direct him as to his chronological
 Teach parents to give instructions slowly and to make age; encourage him to express his thoughts or emotions
certain they have their child's attention before giving and respond to him therapeutically
instructions  Use simple and direct instructions
 Consequences need to be established and discussed ahead  Implement scheduled routine every day. Make his routine
of time and delivered immediately. If a child has predictable and something like ritualistic so that it will
difficulty making decisions because of easy distractibility, only be easy for him to grasp for his independent
a question such as "Do you want to wear your red or your functioning.
blue shirt today? is less effective than a statement such as  Avoid stimulating or distracting settings
"Here is your blue shirt to wear today."  Give positive reinforcements
 Urge parents to make sure their child recognizes their  Encourage physical activity
anger is at the behavior, not the child

1. ENVIRONMENTAL MODIFICATION
o Construction of a stable learning environment is
crucial for children with ADHD so instruction can be
free from the distractions of an entire class
2. EDUCATIONAL MODIFICATION
109 FINAL

QUIZZES 12. Necrotizing enterocolitis (NEC) is an acute inflammatory

disease of the gastrointestinal mucosa that can progress to
1. A pregnant woman was admitted for induction of labor at perforation of the bowel. Approximately 2% to 5% of
43 weeks of gestation with sure dates. A nonstress test premature infants succumb to this fatal disease. Care is
(NST) in the obstetrician's office revealed a nonreactive supportive, however, known interventions may decrease
tracing. On artificial rupture of membranes, thick, the risk of NEC. To develop an optimal plan of care for
meconium-stained fluid was noted. The nurse caring for this infant, the nurse must understand which intervention
the infant after birth should anticipate: has the greatest effect on lowering the risk of NEC: Early
 Meconium aspiration, hypoglycemia, and dry, enteral feedings
cracked skin  Breastfeeding
2. A client with group AB blood whose husband has group 13. A newborn was admitted to the neonatal intensive care
O has just given birth. The major sign of ABO blood unit after being delivered at 29 weeks of gestation to a 28-
incompatibility in the neonate is which complication or year-old multiparous, married, Caucasian woman whose
test result? pregnancy was uncomplicated until premature rupture of
 Jaundice within the first 24 hours of life membranes and preterm birth. The newborn's parents
3. A nurse in a delivery room is assisting with the delivery arrive for their first visit after the birth. The parents walk
of a newborn infant. After the delivery, the nurse prepares toward the bedside but remain approximately 5 feet away
to prevent heat loss in the newborn resulting from from the bed. The nurse's most appropriate action would
evaporation by: be to:
 Drying the infant in a warm blanket  Go to the parents, introduce himself or herself, and
4. A primigravida has just delivered a healthy infant girl. gently encourage the parents to come meet their
The nurse is about to administer erythromycin ointment in infant, explain the equipment first, and then focus on
the infant's eyes when the mother asks, "What is that the newborn.
medicine for?" The nurse responds: 14. A nurse in a newborn nursery is performing an
 "Erythromycin is given prophylactically to prevent a assessment of a newborn infant. The nurse is preparing to
gonorrheal infection." measure the head circumference of the infant. The nurse
5. Necrotizing enterocolitis (NEC) is an inflammatory would most appropriately: Wrap the tape measure around
disease of the gastrointestinal mucosa. The signs of NEC the infant's head and measure just above the eyebrows.
are nonspecific. Some generalized signs include:  Place the tape measure under the infant's head, wrap
 Abdominal distention, temperature instability, and around the occiput, and measure just above the
grossly bloody stools eyebrows
6. The nurse is aware that a neonate of a mother with 15. The most important nursing action in preventing neonatal
diabetes is at point risk for what complication? infection is:
 Hypoglycemia  Good handwashing.
7. Because of the premature infant's decreased immune 16. When assessing the preterm infant the nurse understands
functioning, what nursing diagnosis should the nurse that compared with the term infant, the preterm infant
include in a plan of care for a premature infant? has: Few blood vessels visible through the skin. More
 Risk for infection subcutaneous fat Well-developed flexor muscles.
8. For clinical purposes, preterm and post-term infants are  Greater surface area in proportion to weight
defined as: 17. Which action best explains the main role of surfactant in
 Preterm before 37 weeks, and post-term beyond 42 the neonate?
weeks, no matter the size for gestational age at birth  Helps the lungs to be expanded after the initiation of
9. A macrosomic infant is born after a difficult forceps- breathing
assisted delivery. After stabilization the infant is weighed, 18. A nurse in the newborn nursery is monitoring a preterm
and the birth weight is 4550 g (9 pounds, 6 ounces). The newborn infant for respiratory distress syndrome. Which
nurse's most appropriate action is to: assessment signs if noted in the newborn infant would
 Monitor blood glucose levels frequently and observe alert the nurse to the possibility of this syndrome?
closely for signs of hypoglycemia.  Tachypnea and retractions
10. While assessing a 2-hour old neonate, the nurse observes 19. On day 3 of life, a newborn continues to require 100%
the neonate to have acrocyanosis. Which of the following oxygen by nasal cannula. The parents ask whether they
nursing actions should be performed initially? can hold their infant during his next gavage feeding.
 Do nothing because acrocyanosis is normal in the Given that this newborn is physiologically stable, what
neonate response would the nurse give?
11. A nurse in a newborn nursery receives a phone call to  "You may hold your baby during the feeding."
prepare for the admission of a 43-week-gestation newborn 20. A premature infant with respiratory distress syndrome
with Apgar scores of 1 and 4. In planning for the receives artificial surfactant. How would the nurse explain
admission of this infant, the nurse's highest priority surfactant therapy to the parents?
should be to:  "Surfactant improves the ability of your baby's lungs
 Connect the resuscitation bag to the oxygen outlet to exchange oxygen and oxygen and carbon dioxide."
109 FINAL

21. A postpartum nurse is providing instructions to the 30. Carl, an elementary student, was rushed to the hospital
mother of a newborn infant with hyperbilirubinemia who due to vomiting and a decreased level of consciousness.
is being breastfed. The nurse provides which most The patient displays slow and deep (Kussmaul breathing),
appropriate instructions to the mother? and he is lethargic and irritable in response to stimulation.
 Continue to breast-fed every 2-4 hours He appears to be dehydrated-his eyes are sunken and
22. An infant at 26 weeks of gestation arrives intubated from mucous membranes are dry-and he has a two-week
the delivery room. The nurse weighs the infant, places history of polydipsia, polyuria, and weight loss.
him under the radiant warmer, and attaches him to the Measurement of arterial blood gas shows pH 7.0, PaO2
ventilator at the prescribed settings. A pulse oximeter and 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L,
cardiorespiratory monitor are placed. The pulse oximeter other results are Na+ 126 mmol/L, K+ 5 mmol/L. and Cl-
is recording oxygen saturations of 80%. The prescribed 95 mmol/L. What is your assessment?
saturations are 92%. The nurse's most appropriate action  Metabolic Acidosis. Partially Compensated
would be to: 31. Select all the following that can trigger an asthma
 Listen to breath sounds and ensure the patency of the  Smoke
endotracheal tube, increase oxygen, and notify a  Caffeine
physician.  Cold, windy weather
23. When providing play therapy for a child with a 32. Which of the following statements from a patient with
communicable disease who is in an isolation room, what environmental allergies indicates the need for further
would be one priority principle or rationale for toy education?
selection?  "carpet helps reduce allergens"
 The toy should be washable 33. Acyclovir (Zovirax) is given to children with chickenpox
24. Which of the following best describes why children have to:
fewer respiratory tract infections as they grow older?  decrease the number of lesions/rashes.
 Repeated exposure to organisms causes increased 34. A child is diagnosed with chicken pox. The nurse collects
immunity data regarding the child. Which finding is characteristic of
25. What should the nurse expect to observe in the the rashes chicken pox?
of a patient with rubeola?  Vesiculopustular rash that starts on the trunk and
 Rashes begins on the face and neck scalp
 Koplik's spot is located on the buccal mucosa 35. Baby Elmo has surfactant administered at birth. The
 Rashes fades in cephalocaudal pattern purpose
26. You're teaching a class on critical care concepts to a  prevent atelectasis of alveoli from collapsing on
group of new nurses. You're discussing the topic of acute expiration
respiratory distress syndrome (ARDS). At the beginning 36. A 42-week-gestation baby has been admitted to the
of the lecture, you assess the new nurses' understanding neonatal intensive care unit. At delivery, thick green
about this condition. Which statement by a new nurse amniotic fluid was noted. Which of the following actions
demonstrates he understands the condition? by the nurse is critical at this time?
 This condition develops because the premature baby  Respiratory evaluation and clear the airway due to
has insufficient amount of surfactant needed to have meconium aspiration
effective gas exchange. 37. A four year-old child is recovering from chicken pox
27. What is the single most effective method by which the (varicella). The parents would like to have the child return
nurse can break the chain of infection? to day care as soon as possible. In order to ensure that the
 Wash hands between procedures and clients. illness is no longer communicable, the nurse would assess
28. A nurse is caring for a patient who have Shingles; after for?
the health teaching, the nurse is aware that the patient  All lesions crusted and dried off
understood the disease process if she states which of the 38. The nurse is caring for a hospitalized child with a
ff? diagnosis of rubella (German measles). The nurse reviews
 “My condition was caused by reactivation of the the primary health care provider's progress notes and
organisms that caused my Measles when I was reads that the child has developed Forchheimer sign.
younger" Based on this documentation, which should the nurse
 “I will only observe rashes in a particular part of my expect to note in the child?
body"  Petechiae spots located on the palate
 “Common complication Includes post herpetic 39. Which newborn would the nurse recognize as being most
neuralgia where I can feel pain even after my rashes at risk for developing respiratory distress syndrome?
dry”  A 34-week-gestation male baby born by cesarean
29. The nurse is teaching nursing students about childhood delivery to a mother with insulin-dependent diabetes
skin lesions. Which is an elevated, circumscribed skin 40. The nurse assigned to care for a child with mumps is
lesion that is less than 1 cm in diameter and filled with monitoring the child for the signs and symptoms
serous fluid? associated with the common complication of mumps. The
 Vesicle nurse monitors for which sign/symptom that is indicative
of this common complication?
109 FINAL

 A red, swollen testicle 50. A patient is on mechanical ventilation with PEEP

41. Which statement MOST accurately describes the (positive end-expiratory pressure). Which finding below
pharmacodynamics of vaccines? indicates the patient is developing a complication related
 Vaccines work by stimulating the immune system to to their therapy and requires immediate treatment?
form antibodies against their specific antigen,  Blood pressure 70/45
providing active immunity. 51. You are caring for a patient with acute respiratory distress
42. An adolescent is diagnosed with infectious syndrome. As the nurse you know that prone positioning
mononucleosis. The nurse reinforces home care can be beneficial for some patients with this condition.
instructions to the parents about the care of the patient. Which findings below indicate this type of positioning
Which instructions should the nurse provide to the was beneficial for your patient with ARDS?
parents?  Improvement in lung sounds
 Maintain the patient on bed rest for 1-2 weeks  PaO2 increased from 59 mmHg to 82 mmHg
 Use lozenges for sore throat 52. A patient is experiencing respiratory failure due to
 Use salt water gargle to sooth sore throat pulmonary edema. The physician suspects ARDS but
43. You're providing care to a patient who is being treated for wants to rule out a cardiac cause. A pulmonary artery
aspiration pneumonia. The patient is on a 100% non- wedge pressure is obtained. As the nurse you know that
rebreather mask. Which finding below is a HALLMARK what measurement reading obtained indicates that this
sign and symptom that the patient is developing acute type of respiratory failure is NOT cardiac related?
respiratory distress syndrome (ARDS)?  <18 mmHg
 The patient's PaO2 remains at 45 mmHg. 53. You’re precepting a nursing student who is assisting you
44. You're teaching a class on critical care concepts to a care for a patient on mechanical ventilation with PEEP for
group of new nurses. You're discussing the topic of acute treatment of ARDS. The student asks you why the PEEP
respiratory distress syndrome (ARDS). At the beginning setting is at 10 mmHg. Your response is:
of the lecture, you assess the new nurses understanding  "This pressure setting helps open the alveoli sacs that
about this condition. Which statement by a new nurse are collapsed during exhalation."
demonstrates he understands the condition? 54. What priority nursing diagnosis should be included for
 "This condition develops because alveolar capillary patients with acute lymphocytic leukemia?
membrane permeability has changed leading to fluid  Potential for injury
collecting in the alveoli sacs."  Risk of infection
45. During the exudative phase of acute respiratory distress  Activity intolerance
syndrome (ARDS), the patient's lung cells that produce 55. A child with cancer has the following lab result: WBC
surfactant have become damaged. As the nurse you know 10,000, RBC 5, and plts of 20,000. When planning this
this will lead to? child's care, which risk should the nurse consider most
 Atelectasis significant?
46. A patient has been hospitalized in the ICU for a near  Hemorrage
drowning event. The patient's respiratory function has 56. A nurse analyzes the lab values of a child with leukemia
been deteriorating over the last 24 hours. The physician who is receiving chemotherapy. The nurse notices that the
suspects acute respiratory distress syndrome. A STAT platelet count is 19,500 cell/mm3. Based on this lab value
chest x-ray is ordered. What finding on the chest x-ray is which intervention would the nurse document in her plan
indicative of ARDS? of care.
 white-out infiltrates bilaterally  Use a small toothbrush for mouth care
47. You're providing care to a patient who was just 57. What are the needs of the patient with acute lymphocytic
transferred to your unit for the treatment of ARDS. The leukemia and thrombocytopenia?
patient is in the exudative phase. The patient is ordered  to a private room so she will not be infected by other
arterial blood gases. The results are back. Which results patients and health care workers
are expected during this early phase of acute respiratory 58. The most common signs and symptoms of leukemia
distress syndrome that correlates with this diagnosis? related to bone marrow involvement are which of the
 PaO2 40, pH 7.59, PaCO2 30, HCO3 23 following?
48. Which patient below is at MOST risk for developing  Petechiae, fever, fatigue
ARDS and has the worst prognosis? 59. David, age 15 months, is recovering from surgery to
 A 69-year-old female with sepsis caused by a gram- remove Wilms' tumor. Which findings best indicates that
negative bacterial infection. the child is free from pain?
49. As the nurse you know that acute respiratory distress  Increased interest in play
syndrome (ARDS) can be caused by direct or indirect 60. A child is diagnosed with Wilms' tumor. In planning
lung injury. Select below all the INDIRECT causes of teaching interventions, what key point should the nurse
ARDS: emphasize to the parents?
 Sepsis  Do not put pressure on the abdomen.
 Blood transfusion  Avoid contact or physical sorts
 Pancreatitis 61. A child is diagnosed with Wilms' tumor. During
assessment, the nurse in charge expects to detect:
109 FINAL

 An abdominal mass  Limiting visitors who have colds and infections.

62. When assessing a child with Wilm's tumor, the nurse  Ensuring meticulous handwashing by all persons
should keep in mind that it is most important to avoid coming in contact with the client.
which of the following? 76. A baby has hirschsprung disease which of the following is
 Palpating the child's abdomen the most consistent finding:
63. The mother of a 4 year old child brings the child to the  Delayed passing of meconium
clinic and tells the pediatric nurse specialist that the 77. The nurse is caring for an infant newly diagnosed with
child's abdomen seems to be swollen. During further Hirschsprung disease. Which of the following does the
assessment of the subjective data, the mother tells the nurse understand about this infant's condition?
nurse that the child has been eating well and that the  There is a lack of peristalsis in the large intestine and
activity level of the child is unchanged. The nurse, an accumulation of bowel contents, leading to
suspecting the possibility of a Wilm's tumor, would avoid abdominal distention.
which of the following during the physical assessment? 78. The nurse is assessing an infant with Hirschsprung’s
 Palpating the abdomen for a mass. disease. The nurse can expect the infant to:
64. A 10 year old child with hemophilia A has slipped on the  Have a scaphoid-shaped abdomen.
ice and bumped his knee. The nurse should prepare to 79. Dustin who was diagnosed with Hirschsprung’s disease
administer an: has a fever and watery explosive diarrhea. Which of the
 intravenous infusion of factor VIII following would Nurse Joyce do first?
65. A nurse is discussing childhood cancer with the parents of  Notify the physician immediately
a child in an oncology unit. Which statement by the nurse 80. Parents bring their infant to the clinic, seeking treatment
would be the most accurate? for vomiting and diarrhea that has lasted for 2 days.
 "The most common site for children's cancer is the On assessment, the nurse in charge detects dry mucous
bone marrow."" membranes and lethargy. What other findings suggest a
66. A 4-year-old has a right nephrectomy to remove a Wilms fluid volume deficit?
tumor. The nurse knows that it is essential to:  A sunken fontanel
 Prevent urinary tract infections 81. A newborn’s failure to pass meconium within the first 24
67. Which condition assessed by the nurse would be an early hours after birth may indicate which of the following?
warning sign of childhood cancer?  Hirschsprung disease
 swelling, lumps, masses on body 82. Which of the following electrolytes are lost as a result of
68. A child is admitted to the hospital with a diagnosis of vomiting?
Wilm's tumor, Stage II. Which of the following  hydrogen and potassium
statements most accurately describes this stage? 83. What signs and symptoms would alert the nurse to the
 The tumor extended beyond the kidney but was possibility of intussusception?
completely resected.  Currant jelly stools
69. Which of the following is most likely indicated in  Kicking and drawing of legs
hirschsprung disease? 84. A client with acute leukemia is admitted to the oncology
 Surgical resection/pull through procedure unit. Which of the following would be most important for
70. Which of the following would the nurse identify as the the nurse to inquire?
initial priority for a child with acute lymphocytic  “Have you had a respiratory infection in the last 6
leukemia? months?”
 Instituting infection control precautions. 85. Sandro, a sophomore student is educating group of
71. Which of the following complications are three main parents about Juvenile Diabetes Mellitus. He is correct if
consequences of leukemia? he states which of the following?
 Anemia, infection, and bleeding tendencies.  "Also known as Type 1 diabetes, it is a condition in
72. A client with leukemia has neutropenia. Which of the which your child's body no longer produces an
following functions must be frequently assessed? important hormone insulin."
 Breath sounds  "There's no cure for type 1 diabetes in children, but it
73. A child is seen in the pediatrician’s office for complaints can be managed."
of bone and joint pain. Which of the following other  "If your child has Type 1 DM, he needs to learn how
assessment findings may suggest leukemia? to give injections, count carbohydrates and monitor
 Petechiae his blood sugar because that will be a part of his daily
74. What are the three most important prognostic factors in routine".
determining long-term survival for children with acute 86. A child with type1 diabetes has ball practice. Nurse
leukemia? teaching to prevent hypoglycemia during practice tells the
 Histologic type of disease, initial WBC count, and child:
client’s age at diagnosis  Have juice before practice
75. In formulating a nursing diagnosis of risk for infection for 87. A patient with diabetes has a morning glucose of 50. The
a client with chronic lymphoid leukemia (CLL), nursing patient is sweaty, cold, and clammy. Which of the
measures should include: following nursing interventions is the MOST important?
 Placing the client in protective isolation.  Give the patient ½ cup (4 oz) of fruit juice
109 FINAL

88. A patient who has diabetes is nothing by mouth as prep 100. A group of student nurses are reviewing nursing
for surgery. The patient's parent states they feel like their diagnoses for cleft lip and cleft palate. The students
child's blood sugar is low. You check the glucose and find recognize which of the following as priority nursing
it to be 52. The next nursing intervention would be to: diagnosis for children with cleft lip and cleft palate?
 Administer Dextrose 50% IV per protocol  Altered nutrition: less than body requirements related
89. A 15 year old, who is type 1 diabetic, reports that she to excessive feeding time and child fatigue
almost "passes out" during gym class. What information 101. The Foley Family is caring for their youngest child,
would you assess from the teenager? Justin, who is suffering from tetralogy of Fallot. Which of
 Her eating habits prior to gym class. the following are defects associated with this congenital
90. While assessing a newborn with cleft lip, the nurse would heart condition?
be alert that which of the following will most likely be  Ventricular septal defect, overriding aorta, pulmonic
compromised? stenosis (PS), and right ventricular hypertrophy
 Sucking ability. 102. Which of the following disorders leads to cyanosis from
91. When providing health teaching to parents on how to care deoxygenated blood entering the systemic arterial
for the child with a cleft lip and palate, the nurse should circulation?
emphasize the following EXCEPT?  Truncus arteriosus
 Breast-feeding is the only recommended feeding for  Tetralogy of Fallot
these babies, bottle-feeding for babies with cleft lip  Transposition of great vessels
and cleft palate is not allowed. 103. You’re providing an in-service to a group of new nurses
92. A home care nurse provides instructions to the mother of who will be caring for patients who have Congestive heart
an infant with cleft palate regarding feeding. Which defects. Which statement below is INCORRECT
statement if made by the mother indicates a need for concerning how the blood normally flows through the
further instructions? heart?
 “I will use the regular type of nipple for bottle  Unoxygenated blood enters through the superior and
feeding.” inferior vena cava and travels to the left atrium.
93. You are going over insulin administration education with 104. As the nurse you know which statements are TRUE about
a patient's mother. Which statement by her raises Tetralogy of Fallot?
concern?  “Tetralogy of Fallot is a cyanotic heart defect.”
 "I should consider teaching my child how to report  “In this condition the heart has to work harder to
symptoms in case i am not around". pump blood to the lungs due to narrowing of
94. The labor and delivery nurse knows that many infants pulmonary valves, which cause the right ventricle to
with a cleft lip also have a cleft palate. Which assessment work harder and enlarge.”
technique will determine if the infant has a cleft palate?  “Many patients with this condition will experience
 Insert a gloved finger and palpate the top of the clubbing of the nails.”
infant's mouth. 105. A newborn is diagnosed with truncus arteriosus. You’re
95. Due to Blanca's limited prenatal care, she and her husband educating the parents about this heart defect. Which
are unprepared to have an infant born with an statement by the mother demonstrates she understood the
abnormality. Which prenatal screening could have education provided about this condition?
detected the presence of a cleft lip at 13 to 14 weeks'  “My baby’s heart shares one instead of two artery
gestation? that connects the right and left ventricles.”
 Ultrasound screening. 106. A 1-day-old infant is ordered an echocardiogram due to
96. According to Maslow's hierarchy of needs, which nursing abnormal signs and symptoms related to a congenital
diagnosis for the pediatric patient with cleft palate needs heart defect. The echo confirms that truncus arteriosus is
to be addressed first? present. What signs and symptoms may present in this
 Alterated nutrition, less than body requirements. congenital heart defect?
97. The nurse is caring for the child with cleft lip and palate.  Cyanosis
Which of the following does the nurse understand as a  Poor feeding
complication of this disorder?  Inability to gain weight
 Otitis media 107. An ACE inhibitor is ordered by the physician for an infant
 Altered dentation with truncus arteriosus. This medication will decrease
 Speech impediments afterload and help with the management of heart failure.
98. When planning care for the infant diagnosed with cleft lip Which medication below is an ACE inhibitor?
and palate, which action would the nurse take in relation  Catopril
to the priority nursing diagnosis for this child? 108. You’re caring for a 2-year-old patient who has Total
 Burp the baby well throughout feedings Anomalous Pulmonary Venous Return. You know that
99. You are taking care of an infant who has come back from this condition can cause complications. These
having cleft palate repair. The nurse would include all of complications are arising from an abnormal shunting of
the following in the plan of care except: blood throughout the heart. As the nurse, you know that a
 Placing the patient in their abdomen __________________ shunt is occurring in the heart due
to the defect.
109 FINAL

 Left-to-right 120. The labor and delivery nurse knows that many infants
109. After admitting a child with an atrial septal defect, you with a cleft lip also have a cleft palate. Which assessment
start developing a nursing care plan. What nursing technique will determine if the infant has a cleft palate?
diagnoses can you include in the patient’s plan of care  Insert a gloved finger and palpate the top of the
based on the complications that arise from this condition? infant's mouth.
 Risk of Infection 121. Based on the newborn assessment that the NICU nurse
 Decrease Cardiac Output records in the EMR, which areas need to be addressed?
 Excess Fluid Volume  Sucking reflex.
 Activity Intolerance  Palates intact.
110. A newborn baby is born with transposition of the great  Nares patent.
arteries (TGA). You’re explaining the condition to the 122. Which therapeutic response is appropriate for the NICU
parents. Which statement by the father demonstrates he nurse to give to Jose?
understood the education provided about this condition?  "I understand this can be upsetting. This deformity
 “The aorta and pulmonary artery are switched, which occurs early in the pregnancy, often before a woman
causes the aorta to arise from the right ventricle and knows she is pregnant."
the pulmonary artery to arise from the left ventricle.” 123. Which causative factors should a pregnant woman
111. A two-month-old is showing signs and symptoms of heart eliminate or avoid to prevent cleft lip and/or palate in her
failure. An echocardiogram is ordered. The test shows the unborn child?
infant has a ventricular septal defect (VSD). Which  Use of retinoids.
statement below best describes the blood flow in the heart  Consumption of alcohol.
due to this congenital heart defect?  Smoking/secondhand smoke.
 “The blood in the heart is shunting from the left 124. Which nursing action would best help facilitate the
ventricle to the right ventricle, which is increasing bonding process and ease Blanca's hesitation to hold her
pulmonary blood flow.” daughter?
112. You’re working in the NICU providing care to a neonate  The nurse should comment on Maria's beautiful hair
who has a large patent ductus arteriosus. Which heart while holding Maria.
sound would require you to immediately notify the 125. The nurse observes Blanca and Jose identifying the
physician? likeness of Maria to themselves and other family
 Loud, machine-like murmur members. Based on this response, which action is the best
113. The blood enters on the left side of the heart through the approach for the nurse to implement next?
______________ and enters the left atrium. It then passes  The nurse should allow Jose and Blanca time to bond
through the _____________to enter the left ventricle. with Maria.
 pulmonary vein, bicuspid valve 126. Which are the best responses by the nurse?
114. When assessing a child with a cleft palate, the nurse is  "Your breast milk is the best option and is
aware that the child is at risk for more frequent episodes customized to meet Maria's physiological needs."
of otitis media due to which of the following?  "The breast milk production is physically beneficial
 Ineffective functioning of the Eustachian tubes. to you and Maria".
115. While assessing a newborn with cleft lip, the nurse would 127. Jose asks the nurse if that will be enough milk for Maria,
be alert that which of the following will most likely be or if they should add formula to the breast milk. Which
compromised? responses by the nurse are the best instructions to give
 Sucking ability. Jose and Blanca about breastfeeding Maria?
116. When providing postoperative care for the child with a  "The breast milk does not need formula
cleft palate, the nurse should position the child in which supplementation."
of the following positions?  "The sucking of the neonate stimulates the production
 Prone. of milk."
117. An 18-month-old is scheduled for a cleft palate repair. 128. The nurse prepares Blanca's colostrum using the
The usual type of restraints for the child with a cleft Haberman nipple and attempts to feed Maria. Which
palate repair are: action is the most appropriate for the nurse to take?
 Elbow restraints.  Utilize Universal Precautions during the procedure.
118. A home care nurse provides instructions to the mother of 129. How should the nurse respond to Jose's reaction?
an infant with cleft palate regarding feeding. Which  Acknowledge his concerns and explain that all
statement if made by the mother indicates a need for infants will leak a little bit of their feedings.
further instructions?  Acknowledge his concerns and educate him that the
 “I will stimulate sucking by rubbing the nipple on the open cleft cannot muffle the sounds of suckling and
lower lip.” swallowing.
119. Which action should the labor and delivery nurse take? 130. The nurse explains to Blanca and Jose that Maria will
 Answer Blanca's questions and allow her to see her swallow excessive air as she suckles. She explains that it
daughter. is important for Maria to be burped at least 2 to 3 times
during each feeding. Jose asks the nurse why is it
important to burp Maria.hich facts should the nurse
109 FINAL

include in her explanation to Jose, on the importance of 143. Which intervention should be included when addressing
burping Maria at least 2 to 3 times during each feeding? this nursing diagnosis?
 Prevent gastric distress.  Obtain referrals for language-based learning
 Encourage adequate intake. development.
131. The client asks the nurse why her baby must suffer 144. When discussing the long-term requirements for Maria's
punishment for her discretions. Which response by the health maintenance, the nurse emphasizes the need for
nurse is likely to be most helpful? Maria to have frequent hearing tests. Which rationale
 Allow Blanca to cry and verbalize her feelings of supports this nursing intervention?
grief and guilt.  An altered eustachian tube contributes to recurrent
132. Later in the day, the nurse joins Blanca and Maria in their otitis media.
room to discusses possible outcomes of Maria's disorder. 145. What is the best initial response by the nurse?
Blanca asks the nurse, "Will Maria ever look normal?" To  "Maria may have improper positioning of her teeth."
prepare the client for surgical repair of Maria's cleft lip, 146. Which interventions should the nurse implement?
which outcome explanation by the nurse is the most  Feed soft, bland baby food mixed with water.
important?  Sit the child in an upright position when feeding.
 Show Blanca pictures of infants who have undergone 147. The nurse discusses with Blanca how to provide care of
cosmetic surgery. Maria's mouth until her palate repair heals. Which
133. Based on Maria's behavior, how should the nurse instruction should the nurse include in the teaching?
respond?  Encourage Maria to drink water after each feeding.
 Document this behavior in the chart as a normal 148. What should be the nurse's first response?
Moro reflex.  "That is difficult. There are no easy answers when
134. What action should the nurse take? others are ridiculing your child."
 Ask Blanca why she does not want to take a sitz bath. 149. You're providing an in-service to a group of new nurses
135. Which goal must be met before discharging Blanca and who will be caring for patients who have Tetralogy of
Maria from the hospital? Fallot. Which statement below is INCORRECT
 Both parents will feed Maria to demonstrate the concerning how the blood normally flows through the
proper feeding method. heart?
136. What is the appropriate nursing action?  Unoxygenated blood enters through the superior and
 The nurse needs to document the weight loss in the inferior vena cava and travels to the left atrium.
EMR. 150. A 4-month-old is diagnosed with Tetralogy of Fallot.
137. How should the nurse respond? You're providing an illustration to the parent to help him
 The cleft palate repair is delayed to allow normal understand the pathophysiology of this condition. What
palatal changes. defects must be present in the illustration to help the
138. In preparation for the future surgical repair of the cleft lip, parent understand their child's condition?
the nurse discusses Maria's needs during the early  Ventricular septal defect
postoperative period and tells Jose and Blanca about  Right ventricular hypertrophy
actions they can begin now to help prepare Maria for that  Displacement of the aorta
time. Which intervention should the nurse discuss with  Pulmonic stenosis
Maria's parents? 151. While feeding a 3-month-old infant, who has Tetralogy of
 Place Maria in elbow restraints for 15 minutes 5 Fallot, you notice the infant's skin begins to have a bluish
times a day so she will be less resistant to the tint and the breathing rate has increased. Your immediate
restraints after surgery. nursing action is to?
139. Which assessment provides the best indication to the  Stop feeding the infant and place the infant in the
nurse that knee-to-chest position and administer oxygen.
 Maria's current weight is 7 lbs 10 oz (3.45 kgs). 152. You are assessing the heart sounds of a patient with a
140. Which interventions should the nurse implement? severe case of Tetralogy of Fallot. You would expect to
 Feed Maria with a Breck feeder and then rinse her hear a __________ murmur at the _______ of the sternal
mouth. border?
 Report bleeding from the suture site to the primary  systolic; left
HCP. 153. As the registered nurse you are developing a plan of care
141. Jose calls the nurse's station and tells the nurse that Maria for a patient with Tetralogy of Fallot. Select all the
is crying, and he thinks she is in pain. What action should appropriate nursing diagnoses below that would be
the nurse take first? specific to this patient:
 Assess the infant's breathing pattern and her incision  Activity Intolerance
site.  Failure to thrive
142. The nurse teaches Jose and Blanca how to care for Maria's 154. A family member, who is caring for a 2-year-old with
incision site after discharge from the hospital. Which Tetralogy of Fallot, asks you why the child will
instruction will the nurse discuss with Maria's parents? periodically squat when playing with other children. Your
 Apply a thin line of antibiotic ointment to the suture response is:
line.
109 FINAL

 “Squatting helps to increase systemic vascular tricuspid and mitral valves. As the nurse you know this is
resistance, which will decrease the right to left shunt what type of atrial septal defect (ASD)?
that is occurring in the ventricles and this helps  Ostium Primum
increase oxygen levels.” 165. You’re assessing the heart sounds of a child with an atrial
155. You're caring for a newborn who has Tetralogy of Fallot septal defect. You note a heart murmur at the 2nd
with severe cyanosis. You anticipate the newborn will be intercostal space at the left upper sternal border. Heart
started on ___________? murmurs noted in patients with an atrial septal defect are
 Alprostadil called?
156. A newborn baby with transposition of the great arteries  Midsystolic murmurs
has an echocardiogram performed to detect if any other 166. Select the structure below that allows blood to flow from
defects are present in the heart. As the nurse, you know the right to left atrium in utero and that should close after
that what other defects can most commonly occur with birth:
TGA?  Formen Ovale
 Ventricular septal defect 167. Atrial septal defects can lead to a decrease in lung blood
 Patent ductus arteriosus flow.
 Tetralogy of fallot  False
157. A newborn baby, who is diagnosed with transposition of 168. You're caring for a 2-day-old infant with a large patent
the great arteries, is ordered by the physician to be started ductus arteriosus. The mother of the infant is anxious and
on an infusion of prostaglandin E (alprostadil). The asks you to explain her child's condition to her again.
purpose of this medication is to: Which statement below BEST describes this condition?
 Allow a continued connection between the aorta and  "The vessel connecting the aorta and pulmonary
pulmonary artery via the ductus arteriosus. artery has failed to close at birth, which is leading to
158. You're educating the parents of a patient with a left-to-right shunt of blood."
transposition of the great arteries about the treatment 169. As the nurse you know which statements below are
options. Which treatment option below provides a correct about the ductus arteriosus?
permanent solution and is performed within the first few  "The ductus arteriosus is a structure that should be
weeks of life? present in all babies in utero."
 Arterial switch procedure  "The ductus arteriosus normally closes about 3 days
159. In a normal heart without any type of congenital heart after birth or sooner."
defect, the pulmonary vein carries oxygenated blood away 170. While assessing a newborn’s heart sounds you note a
from the lungs to the left side of the heart. loud murmur at the left upper sternal border. You report
 True this to the physician who suspects the infant may have
160. Your newborn patient has a severe case of transposition patent ductus arteriosus. The physician asks you to obtain
of the great arteries. The baby does not have any other a pulse pressure. If patent ductus arteriosus is present, the
defects and is therefore experiencing severe cyanosis and pulse pressure would be ___________.
needs medical intervention immediately. The newborn is  Wide
started on prostaglandin E and is scheduled for a balloon 171. As noted in the previous question, a loud murmur was
atrial septostomy. noted during assessment of a newborn with patent ductus
 During this procedure a hole in the atrial septum is arteriosus. As the nurse you know that what type of
enlarged, which will be temporary. murmur is a hallmark sign of this condition?
161. Select all the signs and symptoms of how a newborn with  systolic and diastolic machinery-like murmur
transposition of the great arteries may present after birth: 172. You’re working on a unit that provides specialized
 Cyanosis cardiac care to the pediatric population. Which patient
 Low oxygen levels below would be the best candidate for Indomethacin from
 Increased respiratory rate the treatment of patent ductus arteriosus?
 Increased heart rate  A premature infant
162. Atrial septal defects are characterized by a hole in the 173. You’re working in the NICU providing care to a neonate
interatrial septum that allows blood to mix in the right and who has a large patent ductus arteriosus. Which finding
left atria, which are the lower chambers of the heart. during your head-to-toe assessment would require you to
 False immediately notify the physician?
163. A patient is diagnosed with a large atrial septal defect.  Crackles
You’re providing information for the patient on the 174. You’re providing education to the parents of a child who
complications related to this condition. What topics will has a patent ductus arteriosus. The parents want to know
you include in the patient's education? the complications of this condition. In your education,
 Heart failure you will include which of the following complications of
 Stroke PDA?
 Pulmonary Hypertension  Heart failure
164. An echocardiogram shows that your patient has an atrial  Pulmonary hypertension
septal defect located at the bottom of the septum near the  Recurrent lung infections
 Endocarditis
109 FINAL

175. A newborn is diagnosed with truncus arteriosus. You're  Diuretics

educating the parents about this heart defect. Which 185. An infant has a large ventricular septal defect (VSD). The
statement by the mother demonstrates she understood the defect is located in the upper section of the ventricular
education provided about this condition? septum and is near the tricuspid and aortic valve. Based
 "My baby's heart shares one artery that connects the on this description, what type of ventricular septal defect
right and left ventricles." is this?
176. What other congenital heart defect is most commonly  Membranous
present in truncus arteriosus? 186. A small muscular ventricular septal defect has a high
 Ventricular septal defect probability of self-closure, and these types of VSDs are
177. Which of the following genetic disorders increases a found in the lower portion of the ventricular septum.
patient risk of developing truncus arteriosus?  True
 DiGeorge syndrome 187. The signs and symptoms of a ventricular septal defect are
178. A 3-day-old infant is diagnosed with truncus arteriosus. most commonly detected in a baby following birth.
As the nurse, you know to monitor the infant for what  False
complications? 188. A concerned mother brings her 3-month-old to the clinic.
 Heart failure The mother states the infant seems to be small for its age.
 Pulmonary hypertension In addition, she states the infant fatigues very easily while
179. A 1-day-old infant is ordered an echocardiogram due to feeding and rarely finishes a feeding. While collecting a
abnormal signs and symptoms related to a congenital thorough health history, what other signs and symptoms
heart defect. The echo confirms that truncus arteriosus is described by the mother may indicate the child has a
present. What signs and symptoms may present in this congenital heart defect, such as a ventricular septal
congenital heart defect? defect?
 Cyanosis  Frequent treatment for lung infections
 Poor feeding  Diaphoresis when nursing
 Inability to gain weight  Swelling in the hands and feet
180. You're teaching a class to a group of parents about 189. After speaking with the mother of the infant in the
congenital heart defects. During the class discussion, you previous question, who may have a ventricular septal
ask the group to describe the surgical repair for truncus defect, you auscultate heart sounds. If a ventricular septal
arteriosus. Select all the TRUE statements by the group defect was present, you may hear a harsh murmur that is
members about this surgical repair: _______________________.
 "During the surgery the pulmonary arteries are  Located at the lower left sternal border and starts at
separated from the truncus arteriosus and connected S1 and extends into S2.
to the right ventricle using a valved conduit." 190. A 4-month-old is scheduled to take Digoxin for treatment
 "Some patients may need another surgical repair later of a ventricular septal defect. The patient’s apical pulse is
on because of narrowing of the conduit that may 89 beats per minute. As the nurse you will?
occur or they may outgrow it."  Hold the dose
181. A newborn is taking Digoxin prior to surgical repair of a  Notify the physician
truncus arteriosus. You’re assessing morning labs and the 191. As the nurse you know that if a patient has a large
patient’s Digoxin level is 1.8 ng/mL. The next dose of ventricular septal defect and does not receive treatment,
Digoxin is due at 1000. As the nurse you will? the patient may develop Eisenmenger Syndrome. This
 Administer the dose as ordered syndrome causes?
 Check apical pulse prior to administration of the  A reversal of blood shunting in the heart from right to
scheduled dose at 1000 left and will cause cyanosis.
182. An ACE inhibitor is ordered by the physician for an infant 192. Which of the following symptoms do NOT present in
with truncus arteriosus. This medication will decrease hyperglycemia?
afterload and help with the management of heart failure.  Blood glucose <60 mg/dL
Which medication below is an ACE inhibitor? 193. Type 1 diabetics typically have the following clinical
 Catopril characteristics:
183. You’re developing a care plan for an infant with truncus  Thin, young with ketones present in the urine
arteriosus. When analyzing the pathophysiology for this 194. A patient with diabetes has a morning glucose of 50. The
condition, what nursing diagnosis can be included in this patient is sweaty, cold, and clammy. Which of the
patient’s plan of care? following nursing interventions is the MOST important?
 Imbalance Nutrition  Give the patient ½ cup (4 oz) of fruit juice
 Activity intolerance 195. Which of the following patients is at most risk for Type 2
 Ineffective breathing pattern diabetes?
184. Prior to surgery for truncus arteriosus, what medications  A 28 year old male with a BMI of 49.
may be ordered to help with heart function and 196. The _____ ______ secrete insulin which are located in the
complications related to heart failure? _______.
 Digoxin  Beta cells, pancreas
 ACE Inhibitors
109 FINAL

197. A 36-year-old male is newly diagnosed with Type 2 nurse provide to the parents? Note: More than one answer
diabetes. Which of the following treatments do you may be correct.
expect the patient to be started on initially?  Regular developmental screening is important to
 Diet and exercise regime avoid secondary developmental delays.
198. Which of the following statements are true regarding  Cerebral palsy is caused by injury to the upper
Type 2 diabetes treatment? motor neurons and results in motor dysfunction, as
 Insulin may be needed during times of surgery or well as possible ocular and speech difficulties.
illness.  Parent support groups are helpful for sharing
199. What statement or statements are INCORRECT regarding strategies and managing health care issues.
Diabetic Ketoacidosis? 214. The nurse is caring for a 4-year-old with cerebral palsy.
 Cheyne-stokes breathing will always present in DKA. Which nursing intervention will help ready the child for
 Severe hypoglycemia is a hallmark sign in DKA. rehabilitative services?
200. A Type 2 diabetic may have all the following signs or  Providing suckers and pinwheels to help strengthen
symptoms EXCEPT: tongue movement.
 Ketones present in the urine 215. The nurse answers a call bell and finds a frightened
201. An ear infection usually begins with a cold. mother whose child, the patient, is having a seizure.
 True. Which of these actions should the nurse take?
202. Otitis media is more common in children.  The nurse should clear the area and position the client
 True. safely.
203. The ear's eustachian tube is the main part of the ear 216. When assessing the development of a 15month old child
affected in otitis media. with cerebral palsy, which of the following milestones
 True. would the nurse expect a toddler of this age to have
204. The adenoids may also play a role in otitis media. achieved?
 True.  Putting a block in cup.
205. Earache and fever are 2 symptoms of otitis media. 217. Nurse Irish is aware that Ritalin is the drug of choice for a
 True. child with ADHD. The side effects of the following may
206. Children who live in homes where there is cigarette be noted by the nurse:
smoke are more likely to get otitis media.  increased attention span and concentration.
 True. 218. Methylphenidate (Ritalin) is prescribed to an 8-year-old
207. Which of the following instructions should Nurse child for the treatment of attention deficit hyperactivity
Cheryl include in her teaching plan for the parents of disorder (ADHD). The nurse will most likely monitor
Reggie with otitis media? which of the following during the medication therapy?
 Avoiding contact with people who have upper  Height and weight.
respiratory tract infections. 219. The parents of Suzanne, a child with attention deficit
208. Nurse Veronica is teaching a group of parents about otitis hyperactivity disorder, tell the nurse they have tried
media. When discussing why children are predisposed to everything to calm their child and nothing has worked.
this disorder, the nurse should mention the significance of Which action by the nurse is most appropriate initially?
which anatomical feature?  Actively listens to the parents’ concern before
 Eustachian tubes planning interventions.
209. When assessing a child with a cleft palate, the nurse is 220. The school nurse assesses Brook, a child newly diagnosed
aware that the child is at risk for more frequent episodes with attention deficit hyperactivity disorder (ADHD).
of otitis media due to which of the following? Which of the following symptoms are characteristic of the
 Ineffective functioning of the Eustachian tubes. disorder?
210. Chad, a 5-year-old preschooler, is brought to the clinic  Constant fidgeting and squirming.
due to an ear problem. Which assessment data would  Difficulty paying attention to details.
cause the nurse to suspect serous otitis media?  Easily distracted.
 Plugged feeling in the ear and reverberation of the  Talking constantly, even when inappropriate.
client’s own voice. 221. Which of the following statements about ADHD in
211. A toddler with otitis media has just completed antibiotic children is false?
therapy. A recheck appointment should be made to:  The Multimodal Treatment Study of Children with
 Document that the infection has completely cleared. ADHD suggests that pharmacological treatment of
212. Mrs. Cooper is concerned about her 4-month-old son’s ADHD is as effective as behavioral therapy alone.
unusual condition; which of the following statements 222. A nurse is caring for a toddler who has acute otitis media.
made by her would indicate that the child may have Which of the following is the priority action for the nurse
cerebral palsy? to take?
 “My baby won’t lift his head up and look at me; he’s  Administer analgesics.
so floppy.” 223. An infant who has clinical manifestations of AOM is
213. A toddler has recently been diagnosed with cerebral brought to an outpatient facility by his parent. The nurse
palsy. Which of the following information should the should recognize that which of the following factors
places the infant at risk for otitis media
109 FINAL

 History of cleft palate disorder (ASD). Which statement by the parents indicates
224. A nurse is assessing an infant. Which of the following that further teaching is necessary?
findings are clinical manifestations of acute otitis media?  "We will use more complete sentences in talking with
 Fussiness our child."
 Crying 236. A preschool-age patient was recently diagnosed with
 Pulling at an ear autism spectrum disorder (ASD). The nurse should
225. A nurse is caring for a 2-year-old child who has had three consider which observation of the patient to be supportive
ear infections in the past 5 months. The nurse should of the diagnosis?
know that the child is at risk for developing which of the  Rocking on the exam table
following as a long-term complication? 237. Which assessment finding should the nurse expect in a
 Recurrent respiratory infections child with autism spectrum disorder (ASD)?
226. The mother of an 18-month-old child is concerned about  Reiteration of questions as opposed to answering
the child not meeting developmental milestones and them
wants the child tested for cerebral palsy. Which  Head banging
diagnostic approach should the nurse explain to this  Echolalia
mother?  Enchantment with rhythmic repetition of verse or
 Observation of symptoms and ruling out other song
disorders 238. An adolescent diagnosed with attention-
227. The nurse is giving an overview of cerebral palsy (CP) to deficit/hyperactivity disorder (ADHD) is having difficulty
a group of new nurses. Which statement should the nurse maintaining concentration in the inpatient milieu. Which
include in the teaching? nursing intervention would help improve the client's task
 "Not all patients with CP have an intellectual performance?
disability."  Encourage dividing tasks into smaller, attainable
228. The parent of a child with cerebral palsy (CP) ask the steps and reward successful completion.
nurse, "What is the purpose of these braces?" Which 239. Which is considered a hyperactive/impulsive behavior
response by the nurse is correct? seen in attention deficit hyperactivity disorder (ADHD)?
 "Braces help with mobility and provide stabilization."  Inability to play quietly
229. A 9-month-old child is diagnosed with spastic cerebral 240. The nurse is evaluating an 8-year-old child who
palsy (CP). Which clinical manifestation should the nurse demonstrates the following behaviors: daydreaming, poor
expect to assess in this patient? school performance, constant fidgeting, interrupting
 Hypertonia and rigidity others, and mood swings. The child's speech development
230. A 22-year-old patient with cerebral palsy (CP) is is age-appropriate. Which disorder would the nurse
experiencing chronic pain. Which reason should the nurse suspect?
identify that explains the most common cause of chronic  Attention deficit hyperactivity disorder (ADHD)
pain in adults with this health problem? 241. The nurse is instructing a group of pregnant mothers. One
 Muscle contractions client asks if there are any risk factors for her baby
231. During a routine exam, the nurse notices that a 2-year-old developing attention deficit hyperactivity disorder
child shows signs of inadequate coordination and muscle (ADHD). The nurse responds with which of the
stiffness. Which developmental disorder should the nurse following?
suspect in this patient?  Mother smokes while pregnant
 Cerebral palsy  Mother drinks alcohol during pregnancy
232. The nurse is discussing the need for early diagnosis and 242. The parent of a 3-year-old who seems to be overactive
treatment of autism spectrum disorder (ASD) with parents asks the nurse how a diagnosis of attention deficit
of children suspected of having the condition. Which hyperactivity disorder would be made for the child. The
statement should the nurse include? nurse tells the parent that a diagnosis is made by which of
 "Early diagnosis and treatment gives your child the the following methods?
best chance of becoming a fully functioning adult."  History and physical assessment
233. The nurse is assessing a 3-year-old child for symptoms of 243. The family of a child who is experiencing attention deficit
autism spectrum disorder (ASD). Which assessment hyperactivity disorder tells the nurse that they are having
finding should lead the nurse to confirm the diagnosis? difficulty dealing with the child's behavior at home. The
 Engages in repetitive behaviors nurse teaches the family which of the following
 Comprehends language well beyond the complexity techniques to help manage the child at home?
of age  Have routines for eating, sleeping, and recreation.
234. The nurse is presenting to a group of parents whose 244. The home health nurse is planning care for a child with
children are suspected of having autism spectrum disorder attention deficit hyperactivity disorder (ADHD). Which
(ASD). Which statement by the nurse should be included? of the following behaviors by the child would indicate
 "The features of autism are typically apparent by the progress toward the goal of increased self-esteem?
time a child is 2-3 years of age."  The child is able to control impulse behavior.
235. The nurse is teaching parents how to communicate with 245. Which activity is best suited to the 12-year-old with
their child who is diagnosed with autism spectrum juvenile rheumatoid arthritis?
109 FINAL

 Swimming
246. A nurse is caring for a school‐age child who has juvenile
rheumatoid arthritis. Which of the following home care
instructions should the nurse include in the teaching?
 using a warm compresses or moist packs can provide
comfort and relieve stiffness.
 ibuprofen should be taken with food to prevent GI
distress.
 Perform range‐of‐motion exercises.
247. Which would the nurse teach an adolescent is a
complication of corticosteroids used in the treatment of
juvenile idiopathic arthritis (JIA)?
 Immune suppression.
248. The nurse is teaching the parent of a child newly
diagnosed with juvenile idiopathic arthritis (JIA). The
nurse would evaluate the teaching as successful when the
parent is able to say that the disorder is caused by the:
 Immune-stimulated inflammatory response in the
joint.
249. Which would the nurse teach a patient when NSAIDs are
prescribed for treating juvenile idiopathic arthritis (JIA)?
 Take with food.
250. One nursing diagnosis for juvenile idiopathic arthritis
(JIA) is impaired physical mobility.
 Give pain medication prior to ambulation.
 Assist with range-of-motion activities.
 Use nonpharmacological methods, such as heat.
251. The mother of a 4-year-old child with juvenile idiopathic
arthritis (JIA) is worried that her child will have to stop
attending preschool because of the illness. Which of the
following responses by the nurse would be most
appropriate?
252. "Your child should be encouraged to attend school, but
he'll need extra time to work out early morning stiffness."