Unit 2 & 3 Review Questions

The nurse is reviewing the lab reports on a 17-year-old new patient. The gonadotropin-releasing hormone levels are extremely low. The nurse can anticipate that the patient will
a. have primary, but not secondary, sexual characteristics.
b. look older than her years.
c. have adequate levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
d. not have primary or secondary sexual characteristics.
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The nurse is reviewing the lab reports on a 17-year-old new patient. The gonadotropin-releasing hormone levels are extremely low. The nurse can anticipate that the patient will
a. have primary, but not secondary, sexual characteristics.
b. look older than her years.
c. have adequate levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
d. not have primary or secondary sexual characteristics.
d. not have primary or secondary sexual characteristics.
Gonadotropin-releasing hormone begins increasing as a boy enters puberty, stimulating secretion of LH and FSH from the anterior pituitary. LH and FSH then stimulate secretion of testosterone. With low levels of GNRH, she will look younger, because she has not started to develop primary or secondary sexual characteristics. The level of GNRH increases slowly until it is adequate to stimulate the anterior pituitary to increase its production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
A 23-year-old postpartum woman is having trouble breastfeeding. Upon assessment, the nurse discovers that the woman does not have a let-down reflex. One reason for this may be that she is lacking the hormone
a. oxytocin
b. progesterone
c. prolactin
d. estrogen
a. oxytocin
One purpose of oxytocin is to stimulate contractions in the breast muscles that will push the breast milk down toward the nipple. This is called the let-down reflex. Progesterone will cause a relaxation of the breast muscles if present but will not affect them if the hormone is lacking. Estrogen stimulates the growth of breast tissue in preparation for breastfeeding but does not stimulate the let-down reflex. Prolactin is important for breast milk production but not the let-down reflex.
When comparing the endometrial cycle with the ovarian cycle on day 22,
a. the progesterone level is low, but the FSH level is at its peak.
b. the estrogen level is low, but the LH level is at its peak.
c. both the estrogen level and the LH level are at the peak.
d. the progesterone level is at its peak, but the LH level is low.
d. the progesterone level is at its peak, but the LH level is low.
In the endometrial cycle on day 22, the progesterone level has reached its peak and will start decreasing in 1 to 2 days. In the ovarian cycle at the same time, the LH levels have already dropped and will remain low until about day 10 on the next cycle. On day 22, the progesterone level should about be at its peak, and the FSH level should be low. On day 22, the estrogen level is high, and the LH level is low.
Which is a secondary sexual characteristic?
a. Production of sperm
b. Maturation of ova
c. Secretion of gonadotropin-releasing hormone
d. Female breast development
d. Female breast development
A secondary sexual characteristic is one not directly related to reproduction, such as development of the characteristic female body form. Sperm production, maturation of ova, and secretion of gonadotropin-releasing hormone are directly related to reproduction and therefore are not secondary sexual characteristics.
Fertilization of the ovum takes place in which part of the fallopian tube?
a. Interstitial portion
b. Isthmus
c. Infundibulum
d. Ampulla
d. Ampulla
The ampulla is the wider middle part of the tube lateral to the isthmus and is where fertilization occurs. The interstitial portion runs into the uterine cavity and lie within the uterine wall. The isthmus is the narrow part of the tube adjacent to the uterus. If fertilization occurs in these sections, it is too close to the site of implantation, and the fertilized ovum would not have time to properly develop prior to implantation. The infundibulum is the wide, funnel-shaped terminal end of the tube toward the ovaries. If fertilization occurred in this section, the fertilized ovum could travel out into the abdominal cavity.
A woman who is 6 weeks' pregnant is in for her prenatal appointment and asks the nurse when the sex of the baby can been determined by ultrasound. The nurse bases her answer on the knowledge that
a. the sex cannot be determined by ultrasound; an amniocentesis must be done.
b. the external genitalia look similar in both males and females until about 9 weeks of gestation.
c. the sex of the baby can be determined now by ultrasound.
d. the external genitalia will look different at 6 weeks, so an ultrasound can be done at that time.
b. the external genitalia look similar in both males and females until about 9 weeks of gestation.
The external genitalia starts to change at about 9 weeks of gestation. Prior to that time, males and females look similar and it is not possible to determine the sex from ultrasound. Sex of a fetus can be determined by ultrasound after the 9th week.
When teaching a group of mothers of preteen girls, the nurse explains that the earliest outward sign of puberty starting is
a. skeletal growth.
b. body contours.
c. breast changes.
d. body hair.
c. breast changes.
Breast changes, such as nipple enlargement and protrusion, are the earliest outward changes of puberty. Body contours and hair develop as puberty progresses. The growth spurt begins about 1 year after initial breast development.
A 16-year-old is being seen for the first time by the nurse practitioner. The young woman states that she has not had the onset of menstruation yet. Her breasts are developing and her pelvis has widened. The term used to describe this list of signs and symptoms is
a. latent amenorrhea
b. secondary amenorrhea
c. primary amenorrhea.
d. absent amenorrhea
c. primary amenorrhea.
Primary amenorrhea is when a girl has not started menstruation by the time she is 16 years old. Secondary amenorrhea is the absence of menstruation for at least three cycles after regular cycles have been established.
During a childbirth class a woman asks the nurse, "I'm just 8 weeks pregnant. I know the placenta is not fully developed yet, so what is producing all the hormones I need?" The nurse will development her answer on the knowledge that
a. the corpus luteum secretes the extra hormones necessary until the placenta develops.
b. the pituitary is working to secrete the extra hormones that are necessary until the placenta develops.
c. extra hormones are not necessary for this stage of the pregnancy.
d. the placenta is big enough at this point to produce the hormones necessary.
a. the corpus luteum secretes the extra hormones necessary until the placenta develops.
LH causes the follicle to persist as a corpus luteum for about 12 days after ovulation. If conception occurs, the fertilized ovum secretes human chorionic gonadotropin that causes the corpus luteum to persist. The corpus luteum produces the extra estrogen and progesterone necessary to support the pregnancy. The placenta is not mature enough to produce the estrogen and progesterone necessary to support the pregnancy. The corpus luteum will do this until the placenta is mature. Extra estrogen and progesterone are necessary to support the pregnancy. The pituitary will secrete the LH necessary to keep the corpus luteum until conception occurs. After conception, the fertilized ovum will secrete human chorionic gonadotropin to keep the corpus luteum going. The corpus luteum secretes the extra hormones necessary for the pregnancy.
The average man is taller than the average woman at maturity because of
a. earlier development of secondary sexual characteristics.
b. starting puberty at an earlier age.
c. earlier onset of the growth spurt.
d. a longer period of skeletal growth.
d. a longer period of skeletal growth.
The man's greater height at maturity is the combined result of beginning the growth spurt at a later age and continuing it for a longer period of time. Males start puberty 6 months to 1 year later than females.
During the first 2 weeks after conception, the fertilized ovum is called a a. fetus. b. neonate. c. zygote. d. embryo.c. zygote. During the preembryonic stage, the cell formed by the union of an ovum and sperm is called the zygote. This stage lasts 2 weeks. The embryonic stage is from week 3 to week 8 after conception. The fetal stage lasts from week 9 until birth. After the fetus is born, it is called a neonate.To maintain the corpus luteum and the continuing supply of estrogen and progesterone, the zygote secretes which hormone? a. Oxytocin b. Prolactin c. Human chorionic gonadotropin d. Luteinizing hormonec. Human chorionic gonadotropin The cells of the zygote secrete human chorionic gonadotropin. The hCG feeds back into the ovum to prolong the corpus luteum. Prolactin is produced in the pituitary glands and is necessary for breast milk production. Luteinizing hormone is produced in the pituitary glands and is necessary for the release of the mature ovum at ovulation. Oxytocin is produced in the pituitary glands and is necessary for contractions during labor and the let-down reflex with breastfeeding.Implantation of the zygote should occur in the upper portion of the uterus. This is the best area for the growing fetus and placenta for all of these reasons except a. the muscle fibers of the upper uterus prevent blood loss post-delivery. b. the upper uterus lining is thick. c. the upper uterus is richly supplied with blood. d. the upper uterus is supplied with the beginnings of the umbilical cord.d. the upper uterus is supplied with the beginnings of the umbilical cord. The umbilical cord develops from the zygote. The upper uterus is rich with blood. This is optimal for fetal gas exchange and nutrition. The uterine lining is thicker in the upper portion. This prevents the placenta from attaching so deeply that it does not easily detach after birth. The muscle fibers of the upper portion of the uterus are strong interlacing fibers that will clamp down over the site of placental separation, preventing excessive bleeding.Basic structures of all major body organs are completed during which period of development? a. Zygote b. Fetus c. Embryoc. Embryo The embryonic period is from week 3 until week 8. During this time, the basic structures of the major body organs are formed. During the zygote period, cell division begins and implantation occurs. During the fetal period, major body organs mature.A woman who is 12 weeks' pregnant comes to the clinic for counseling concerning an abortion. The nurse is aware that the woman needs further teaching when she says a. You can tell if the baby is a girl or boy." b. "I think you can hear the baby's heartbeat now." c. "I know that this pregnancy is just a group of round cells at this point." d. "The baby's intestines are inside the abdomen."c. "I know that this pregnancy is just a group of round cells at this point." Early in the zygote stage of development, the fertilized ovum divides into cells. They resemble a ball at that point. By 12 weeks, the fetus has arms, legs, a head, and major organs. The heartbeat can be detected as early as 8 weeks with ultrasound. Male and female external genitalia can be distinguished by appearance during the 12th week. The intestines are originally contained within the umbilical cord because the liver and kidneys occupy most of the abdominal cavity. By the 10th week, the intestines are contained within the abdominal cavity.A woman told the nurse the doctor had written down that she had experienced quickening. When explaining this to the woman, the nurse uses the knowledge that quickening is a. an excessive amount of amniotic fluid. b. the first sensation of fetal movement. c. the cheese-like secretions that cover the fetus. d. the production of a surface-active lipid necessary for the neonate to breathe.b. the first sensation of fetal movement. The first sensation of fetal movement detected by the woman is called quickening. The cheese-like covering over the fetus is called vernix caseosa. The surface-active lipid that is produced by a fetus is called surfactant. An excessive amount of amniotic fluid is called hydramnios.Dizygotic twins develop from a. two fertilized ova and may be the same sex or different sexes. b. a single fertilized ovum and are always of the same sex. c. two fertilized ova and are the same sex. d. a single fertilized ovum and may be the same sex or different sexes.a. two fertilized ova and may be the same sex or different sexes. Dizygotic twins are two different zygotes, each conceived from a single ovum and a single sperm. They may be both male, both female, or one male and one female. Monozygotic twins are from a single fertilized ovum and are always the same sex. Dizygotic twins come from two fertilized ovum and may be the same sex, but they may also be different sexes.Which part of the mature sperm contains the male chromosomes? a. X-bearing sperm b. The middle portion of the sperm c. The head of the sperm d. The tail of the spermc. The head of the sperm The head of the sperm contains the male chromosomes that will join the chromosomes of the ovum. The middle portion of the sperm supplies energy for the tail's whip-like action.If an X-bearing sperm fertilizes the ovum, the baby will be female. The tail of the sperm helps propel the sperm toward the ovum.One of the assessments performed in the delivery room is checking the umbilical cord for blood vessels. Which finding is considered to be within normal limits? a. Two arteries and two veins b. One artery and one vein c. Two arteries and one vein d. Two veins and one arteryc. Two arteries and one vein The umbilical cord contains two arteries and one vein to transport blood between the fetus and the placenta. Two arteries and two veins are abnormal and may indicate other anomalies. Two veins and one artery are abnormal and may indicate other anomalies. One artery and one vein are abnormal and may indicate other anomalies.The nurse understands that prenatal growth and development proceed in a cephalocaudal pattern, meaning that a. the brain will develop first. b. the brain will develop last. c. the heart develops last. d. the liver and spleen will develop first.a. the brain will develop first. Cephalocaudal development means it occurs in a head-to-toe manner. Therefore, the brain will develop first, not last. Cephalocaudal development means it occurs in a head-to-toe manner. Therefore, the liver and spleen would not be the first organs to develop. Cephalocaudal development means it occurs in a head-to-toe manner. Therefore, the heart will be one of the first organs to develop.A woman tells the nurse she is 16 weeks' pregnant. During the assessment, the nurse measures the fundus of the uterus to be at the umbilicus. The nurse correctly interprets the comparison of the dates with the measurements to be a. incongruent. b. congruent. c. irrelevant. d. not comparable.a. incongruent. The fundus should be at the umbilicus by 20 weeks. At 16 weeks, it is normally midway between the symphysis pubis and the umbilicus. The two sets of data do not match, and more assessment is necessary. From 16 to 18 weeks until 36 weeks, the fundal height, measured in centimeters, is approximately equal to the gestational age of the fetus in weeks.While the vital signs of a pregnant woman in her third trimester are being assessed, the woman, who is lying supine, complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate? a. Have the patient turn to her left side; recheck her blood pressure in 5 minutes. b. Have the patient sit down and hold her arm in a dependent position. c. Have the patient lie supine for 5 minutes; recheck her blood pressure on both arms. d. Have the patient stand up; retake her blood pressure.a. Have the patient turn to her left side; recheck her blood pressure in 5 minutes. Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Having the patient stand up would cause an increase in systolic and diastolic pressures. Having the patient hold her arm in a dependent position will cause a false reading.During her first prenatal visit to the clinic, a woman gives the following obstetric history: a boy born 9 years ago at full term, twin girls born 5 years ago at 36 weeks, a miscarriage at 9 weeks 2 years ago. The nurse correctly records her obstetric history as a. gravida 4, para 2, aborta 1. b. gravida 4, para 3, aborta 1. c. gravida 3, para 3, aborta 1. d. gravida 3, para 2, aborta 1.a. gravida 4, para 2, aborta 1. The woman is currently pregnant and has been pregnant 3 more times; that makes her a gravida 4. She has delivered two pregnancies after 20 weeks of gestation; that makes her a para 2. The twin girls count as one pregnancy. She delivered one pregnancy prior to 20 weeks; that makes her an aborta 1.A woman is expecting her second child. She expressed concern to the nurse about how her 4-year-old will adapt to the new baby. The following are some suggestions the nurse should include in her teaching. (Select all that apply.) a. Decide which of your toys you would like to give to the new baby. b. Come in and listen to the baby's heartbeat. c. Spend more time with grandmother to prepare him for being away from mother during the birth. d. Take a sibling class offered by the hospital.b, c, d A 4-year-old is curious about the changes in mother's body and the baby. By being included in the process, the child will not feel left out. It will also give the child an opportunity to ask questions. Children need to prepare for being away from mother during the birth and hospitalization. Starting early in the pregnancy to spend more time with the individual who will care for them will assist in the transition. Sibling classes provide an opportunity for children to discuss what newborns are like and what changes the new baby will bring to the family. Children need to be reassured that they are still maintaining an important role in the family. When they are asked to give up their possessions for the new baby, they may feel resentment.A woman is 35 weeks' pregnant during her clinic visit. She complains of numerous vaginal infections during the pregnancy. She tells the nurse, "I'm afraid I have diabetes, because I have some infections." The best response by the nurse would be a. "Diabetes is a possibility. I will set you up for testing." b. "A vaginal infection is a symptom of diabetes, but it also is a problem with normal pregnancies due to the changes in your vaginal area." c. "This seems to be a concern with all of our patients today." d. "Itching is a problem with pregnancies and it makes you think you have an infection. The physician can order you some cream to help with the itching and pain."b. "A vaginal infection is a symptom of diabetes, but it also is a problem with normal pregnancies due to the changes in your vaginal area." During pregnancy, the glycogen levels of the vaginal area increase. This favors the growth of yeast-causing infections. Diabetes is a possibility, but there are other considerations that need to be assessed first. Vulva itching is not a common problem with pregnancy. These symptoms should be investigated for the cause and treated.The nurse notes that the hemoglobin level of a woman at 35 weeks of gestation is 11.5 g/dL. The nurse's next action should be to a. recall that the RBC count increases slightly during pregnancy. b. call the physician; this shows mild anemia. c. note that this is within the normal range for an average adult. d. note that this is within the normal range for pregnancy.d. note that this is within the normal range for pregnancy. The normal range of hemoglobin for pregnancy is greater than 11 g/dL in the first and third trimesters and greater than 10.5 g/dL in the second trimester. The normal range of hemoglobin for an average female is 12 to 16 g/dL. With pregnancy the levels are lower due to the increased iron requirements of the fetus. The RBC count decreases slightly because of hemodilution.A woman is concerned that she has developed numerous nosebleeds during this pregnancy. She feels this is a sign of leukemia and wants to be screened. The nurse's response to the woman should be based on the fact that a. leukemia is a major concern during pregnancy. b. nosebleeds are rare in pregnancy; therefore further assessment is necessary. c. platelet count decreases significantly during pregnancy. d. nosebleeds are a common occurrence during pregnancy.d. nosebleeds are a common occurrence during pregnancy. With the higher levels of estrogen causing increased vascularity in the upper respiratory tract, epistaxis is a common occurrence. Leukemia rates do not increase during pregnancy. There is a slight decrease in the platelet count but within normal range.During a prenatal visit at 36 weeks of gestation, the nurse tested a woman's urine for glucose and protein. The results indicated a trace amount of glucose. The nurse's next action should be to a. consider this as a normal result for this stage of pregnancy. b. retest the urine for accuracy. c. have the woman give another sample for retesting. d. report the results immediately to the physician so further testing can be preformed.a. consider this as a normal result for this stage of pregnancy. Small amounts of glucose in the urine may indicate physiologic spilling that occurs during normal pregnancy, and further testing is not necessary. Larger amounts of glucose in the urine require further testing.During prenatal teaching it is important for the nurse to inform the patient about danger signs in pregnancy. Which sign need to be reported immediately to the health care provider? a. Frequent urination b. Clear mucous vaginal discharge c. Backache that occurs after standing for a long period d. Vaginal bleedingd. Vaginal bleeding Vaginal bleeding during pregnancy needs to be reported immediately. It may be an indication of several complications of pregnancy, such as placenta previa or abruptio placenta. Mucous discharge may increase during pregnancy and is considered normal. Frequent urination is common during the first trimester and later in the third trimester. Backaches are the most common complaint during the third trimester.A woman is expecting her first baby in 7 months. During the nurse's assessment Anna continues to ask questions about changes in her body. The nurse can recommend which type of class to assist the woman with her questions? a. Childbirth preparation class b. Parenting class c. Early pregnancy class d. Preconception classc. Early pregnancy class An early pregnancy class focuses on the first two trimesters. They cover information on adapting to pregnancy, dealing with discomforts, and understanding what to expect. Preconception class is for couples thinking about having a baby. They are designed to help them prepare to have a healthy pregnancy. Childbirth preparation class focuses on preparation for labor and delivery. Parenting classes focus on care of the newborn.A mother asks the pediatric office nurse why her toddler son needs to be seen by an eye specialist. Which explanation by the nurse to the mother states the importance of detecting and following up strabismus in young children? a. Epicanthal folds may develop in the affected eye. b. Corneal light reflexes may occur symmetrically. c. Muscle imbalance can cause loss of vision. d. Color vision deficit may result.c. Muscle imbalance can cause loss of vision. Loss of vision may develop if the eyes do not work together. The brain may ignore the visual cues from one eye, resulting in blindness. Color vision is dependent on rods and cones in the retina, not on muscle coordination. Epicanthic folds are present at birth. Symmetric corneal light reflexes are normal and tests alignment of the eyes. It doesn't explain why strabismus testing is important.A cooperative 6-year-old child is being evaluated for a sore throat. Which method should the nurse use to view the tonsils and oropharynx of this child? a. Examine the mouth when the child is crying to prevent the need for a tongue blade. b. Ask the child to open her mouth wide and say, "Ahh." c. Pinch the nostrils closed until the child opens her mouth, and then insert the tongue blade. d. Ask the child to open her mouth wide, and then place the tongue blade on the center back area of the tongue.b. Ask the child to open her mouth wide and say, "Ahh." If the child is cooperative, the child can open her mouth and move the tongue around for the examiner. During crying there is insufficient opportunity to accurately visualize the mouth. Placing the tongue blade in the back of the throat can cause gagging. The child is being evaluated for a sore throat, not a neurologic issue. It would be traumatic and a safety risk to pinch the nostrils closed, forcing the child to open her mouth, and then insert the tongue blade. No reason would warrant such measures, especially with cooperative children.The nurse is assessing a 6-month-old infant who smiles, coos, and has a strong head lag. What assessment should the nurse make about this infant's development? a. These are normal findings for an infant this age. b. The parent needs to work with the infant to stop the head lag. c. A developmental/neurologic follow-up evaluation is needed. d. The infant could have some cognitive impairment.c. A developmental/neurologic follow-up evaluation is needed. The head lag should be almost gone by 4 months of age. This child requires evaluation by a specialist. A 6-month-old infant should have social interaction beyond smiling and cooing and should no longer have head lag. The assumption that the child is cognitively impaired is unwarranted. The child requires evaluation before appropriate interventions can be determined.The anterior fontanel appears slightly bulging when a 4-month-old cries. What action by the nurse is indicated? a. Document the findings b. Notify the pediatrician c. Check the Moro reflex d. Time how long the infant criesa. Document the findings The finding is normal. Crying causes the fontanel to bulge slightly. There's no need to notify the pediatrician since this is normal. There is no need to check the Moro reflex. The length of time the infant cries has nothing to do with the fontanel bulging.The nurse is preparing to assess the lung sounds of a 3-month-old sleeping infant who is being held on her belly by her mother against the mother's upper chest. Which techniques should the nurse use to obtain an accurate assessment? (Select all that apply.) a. Identify the hyperresonance heard as normal because of the thin chest wall. b. Warm the stethoscope head before placing it on the infant's shirt. c. Auscultate the lung sounds through her back. d. Place the infant flat while listening to the lungs. e. Assess the lungs from the apex to the base bilaterally. f. Gently turn the infant on her back prior to beginning the assessment.a, c, e The lungs should be assessed from the apex to the base bilaterally Hyperresonance is normal because of the thin chest wall in infants and young children. Auscultation of the lung sounds through the back can provide accurate data. The infant can remain in the current position for an accurate assessment. She is quiet and her head is elevated against the mother's upper chest. Warm the stethoscope head before placing it directly on the infant's skin, not over the shirt. The infant should be in an elevated position, which she already is in, while listening to the lungs.The nurse is ready to begin a physical examination of an 8-month-old infant who is sitting contentedly on her mother's lap, chewing on a toy. Which assessment should the nurse do first? a. The reflexes b. The head, including the fontanel c. Heart and lungs d. Eyes, ears, and mouthc. Heart and lungs While the child is quiet, auscultation should be performed. Because this is the least intrusive of the options given, it affords the best opportunity to hear the required sounds. Eliciting reflexes might disturb the child, making auscultation afterward difficult. Examining the eyes, ears, and mouth might disturb the child, making auscultation of the heart and lungs afterward difficult. Although examining the head is often the starting point, the nurse should perform the assessments that require quiet and cooperation of the infant first.When the nurse lifts the skin on the abdomen and releases it quickly to check skin turgor, the tissue remains suspended for a few seconds, then slowly falls back on the abdomen. Which evaluation can the nurse correctly determine from the findings? a. The child is dehydrated. b. The child is overly hydrated. c. The tissue shows normal elasticity. d. The child is properly hydrated.a. The child is dehydrated. Skin remaining suspended, or "tented," when released is seen when poor skin turgor is related to dehydration. In normal elasticity, the skin would return immediately to its original position. If the child was overly hydrated, the skin would not remain suspended or tented. If the child was properly hydrated, the skin would spring back quickly when released.The nurse is assessing a preschooler's chest as part of a well-child exam. What normal findings would the nurse expect to document? a. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing. b. Respiratory movements are primarily thoracic. c. Retraction of the muscles between the ribs on respiratory movement. d. Anteroposterior diameter to be equal to the transverse diameter.a. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing. The preschooler has a coordinated breathing pattern. For a preschooler, breathing is a coordinated function that uses abdominal breathing as well as a little chest movement. It is incorrect for the anteroposterior diameter to be equal to the transverse diameter. Retraction of the muscles between the ribs on respiratory movement is indicative of respiratory distress.Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? a. Palpate another area simultaneously. b. Ask the child not to laugh or move if it tickles. c. Begin with deeper palpation and gradually progress to superficial palpation. d. Have the child "help" with palpation by placing his or her hand over the palpating hand.d. Have the child "help" with palpation by placing his or her hand over the palpating hand.It allows the nurse to perform the assessment while including the child to have the child "help" with palpation by placing his or her hand over the palpating hand. It would not promote relaxation and would make it more difficult to perform the assessment to palpate another area simultaneously. It might only contribute to the child's laughter to ask the child not to laugh or move if it tickles. It would not promote relaxation and would make it more difficult to perform the assessment to begin with deeper palpation and gradually progress to superficial palpation.The nurse is doing a neurologic assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hours ago. Which is the most essential part in this assessment? a. Checking the reactivity of pupils. b. Performing a doll's head maneuver. c. Obtaining an oculovestibular response. d. Performing a fundoscopic examination to identify papilledema.a. Checking the reactivity of pupils. Pupil reactivity is an important indication of neurologic health. The pupils should be assessed for presence o reactivity, whether the reactivity is equal, and the rate of reactivity. A doll's head maneuver should not be performed if there is a cervical spine injury. Oculovestibular response is a painful test that should not be done on a child who is having variable levels of consciousness. Papilledema does not develop until 24 to 48 hours into the course of unconsciousness. This is also not within a pediatric nurse's scope of practice unless there is advanced training and education.The nurse is working with children with inflammatory bowel disease (IBD). What should the nurse include as essential in the dietary regimen? a. Eating a high-protein, low-calorie diet. b. Taking daily vitamin supplements. c. Including a low-protein but high-caloric intake. d. Ingesting a high-fiber diet.b. Taking daily vitamin supplements. Multivitamins, iron, and folic acid supplementation are recommended. A high-protein, high-calorie diet is needed to help correct nutritional deficits. A high-fiber diet is not recommended for IBD. Even small amounts of bran have been associated with a worsening of the child's condition.Management of a peptic ulcer in a child often includes which component? a. Coping with the stress of a chronic illness b. Drinking milk at frequent intervals c. Taking an antacid an hour before meals and at bedtime d. Taking proton pump inhibitorsd. Taking proton pump inhibitors Proton pump inhibitors block the production of acid. They are well tolerated and have infrequent side effects. Milk is not beneficial in the management of peptic ulcer disease. Coping with stress is beneficial, but peptic ulcer disease is treatable. Proton pump inhibitors are more effective than antacids.The nurse is caring for an infant immediately after returning from having a pyloromyotomy. What actions would the nurse to expecting to perform in the immediate postoperative period? (Select all that apply.) a. Assure bowel sounds are present before feeding the infant. b. Keep the infant on his left side with the head slight elevated. c. Irrigate the nasogastric tube with sterile water. d. Weigh diapers after oral feedings have been started. e. Maintain the infant's head in an elevated position. f. Provide oral care frequently until the infant begins drinking.a, e, f Provide oral care frequently until the infant begins drinking. The infant's head must be maintained in an elevated position for prevent reflux or aspiration. Oral care should be done frequently until the infant begins drinking because. Mucous membranes are more susceptible to breakdown in their dehydrated state. Bowel sounds must be present before feeding the infant. Keeping the infant on his left side with the head slightly elevated is not appropriate postoperatively. The nasogastric tube is usually removed immediately after surgery; if it were to be irrigated, normal saline would be used. Diapers should be weighed whether the infant is eating or only on intravenous infusions.The mother of an infant with suspected Hirschsprung disease asks the nurse about the disease because she was too upset to ask the physician. Which explanation by the nurse is best? a. It results in frequent evacuation of solids, liquid, and gas. b. The colon has an aganglionic segment. c. There is a part of the colon that doesn't have the nerves to function. d. It results in excessive peristaltic movements within the gastrointestinal tract.c. There is a part of the colon that doesn't have the nerves to function. The mother needs clear, easy to understand words to understand her infant's condition. There is a lack of peristalsis in the affected segment, which interferes with the evacuation of solid waste. Hirschsprung disease is a mechanical obstruction caused by a lack of motility of a segment of the intestine resulting from the lack of innervation by ganglion cells. This is too technical to use as an explanation to the mother. There is a lack of peristalsis in the affected segment, which interferes with the evacuation of solid waste.The mother of a child with a nasogastric tube (NG) after surgery for acute appendicitis asks about the purpose of the tube. Which explanation by the nurse is most appropriate? a. The tube helps to maintain electrolyte balance. b. The tube helps empty the stomach until bowel activity resumes. c. The tube prevents the spread of infection. d. The tube maintains an accurate record of output.b. The tube helps empty the stomach until bowel activity resumes. The nasogastric tube is used to maintain gastric decompression until the return of intestinal activity. Nasogastric drainage is one part of the child's output. The nurse would need to incorporate the drainage with other output. The nasogastric tube may adversely affect electrolyte balance by removing stomach secretions. There is no relationship to the spread of infection.An adolescent has just been diagnosed with Crohn disease and is receiving extensive patient education. Nursing care has been appropriate if which topic is explored with the patient? a. Coping with stress and adjusting to chronic illness b. Adjusting to chronic illness and preventing spread of illness to others c. Preventing spread of illness to others and nutritional guidance d. Nutritional guidance and preventing constipationa. Coping with stress and adjusting to chronic illness Crohn' disease is a chronic disease with life-threatening/life-altering complications. The nursing interventions include helping the child cope with stress and learn how to adjust to the illness. Nutritional guidance is necessary, but constipation is not an issue. Adjustment to chronic illness is necessary, but Crohn' disease is inflammatory, not infectious. Nutritional guidance is necessary, but Crohn' disease is not infectious.The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What should the nurse include in the teaching plan? a. Give reassurance that hepatitis A cannot be transmitted to other family members. b. The child should not return to school until 3 weeks after the icteric phase. c. Teach infection control measures to family members. d. Bed rest is important until 1 week after the icteric phase.c. Teach infection control measures to family members. Hepatitis A is a contagious disease, transmitted through the fecal-oral route. The nurse should teach infection control measures to family. The disease does not usually have an icteric phase and often is subclinical. The period of communicability is from the latter half of the incubation period, 1 week after the onset of clinical illness. Hepatitis A infection is spread through the fecal-oral route.A neonate has been just diagnosed with biliary atresia. What should the nurse consider when providing support to a family whose infant has just been diagnosed? a. Children with surgical correction live normal lives. b. Prognosis for full recovery is excellent. c. Liver transplantation may be needed eventually. d. Death usually occurs by 6 months of age.c. Liver transplantation may be needed eventually. Approximately 80-90% of children with biliary atresia will require liver transplantation. Even with surgical intervention, most children experience liver failure and require transplantation. If untreated, death will usually occur by 2 years of age. Long-term survival is possible with surgical intervention. Liver transplantation is usually required.The nurse assesses a neonate immediately after birth and suspects a tracheoesophageal fistula. Which assessment data would cause the nurse to suspect this defect? a. Flat anterior and posterior fontanels b. An excessive amount of frothy saliva in the mouth c. Sneezing clear fluid d. Absence of sucking and swallowingb. An excessive amount of frothy saliva in the mouth Excessive salivation and drooling is indicative of tracheoesophageal fistulas. With a fistula, the child has difficulty managing the secretions causing choking, coughing, and cyanosis. Sneezing is normally seen in neonates as they clear out their nasal passages. Flat fontanels are normally seen in neonates. The infant is able to suck but cannot manage the secretions or oral intake.The nurse is caring for a child with probable intussusception. The child had diarrhea before admission, but while waiting for administration of air pressure to reduce the intussusception, the child passes a normal brown stool. What is the priority nursing action? a. Auscultate for bowel sounds. b. Notify the physician. c. Check vital signs, including blood pressure. d. Measure the abdominal girth.b. Notify the physician. Passage of a normal stool indicates that the intussusception has resolved. Notification of the physician is essential to determine whether a change in treatment plan is indicated. Measuring abdominal girth is indicated, but the physician must be notified of the change in status. Auscultating for bowel sounds is indicated, but the physician must be notified of the change in status. Vital signs, including blood pressure, may be indicated, but the physician must be notified of the change in status.A young child is diagnosed with vesicoureteral reflux. What would the nurse expect to read in the medical history that the child had been experiencing? a. Hypotension b. Incontinence c. Increased renal arterial perfusion d. Recurrent kidney infectionsd. Recurrent kidney infections Reflux allows urine flow to be forced back to the kidneys. When the urine is infected, this contributes to kidney infections. Pyelonephritis occurs as a result of reflux. Scarring occurs because of inflammation from pyelonephritis, which then causes decreased renal arterial perfusion. Incontinence may be associated with urinary tract infections, but it is not a direct result of reflux. Hypertension results from the cycle of infection/inflammation/scarring/decreased perfusion. Renin-angiotensin is released, which ultimately elevates blood pressure.A 7-year-old girl born with a myelomeningocele has a neurogenic bladder. Her parents have been performing clean intermittent catheterization. Based on the knowledge of child development and chronic disability, what action should the nurse implement? a. Teach the child appropriate bladder control. b.