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76 Cards in this Set
- Front
- Back
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A newborn at 5 hours old, wakes from a sound sleep and becomes very active and begins to cry. WHich of the following signs if exhibited by this newborn would indicated expected adaptation to extrauterine life?
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Increased mucus production, passage of meconium, HR of 160 bpm.
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When assessing a newborn boy at 12 hours of age, the nurse notes a rash on his abdomen and thighs. The rash appears as irregular reddish blotches with pale centers: The nurse would:
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Document the finding as erythema toxicum.
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A breasfed full term newborn girl is 12 hours old and is being prepared for early discharge. Which of the following assessment findings, if present could delay discharge?
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Yellowish tinge in sclera and on face, periodic apneic episodes lasting 20-24 seconds.
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As part of a thorough assessment of a newborn, the nurse should check for hip dislocation and dysplasia with which technique?
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Ortolani's manuever
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When assessing a newborn after birth, the nurse notes flat, irregular, pinkish marks on the bridge of the nose, nape of neck and over the eyelids. The areas blanch when pressed with a finger. THe nurse would document findings as:
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Telangiectatic nevi.
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After completing an initial assessment of a full term baby boy, the nurse records the following measurements. Which measurements would be a cause of concern and require further evaluation of the newborn?
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Head circumference: 31 cm
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A newborn male is estimated to be at 40 weeks of gestation following an assessment using the New ballard scale. Which of the following would be a ballard scale finding consistent with this newborn's full term status?
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Thinning of lanugo with some bald areas, testes descended into the scrotum, elbow does not pass midline when arm is pulled across the chest.
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The nurse evaluates lab test results of a newborn who is 4 hrs old. Which of the following results would require notification of the pediatrician?
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Glucose 34 mg/dl
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A newborn male has been designated as large for gestational age. His mother was diagnosed with gestational diabetes late in her pregnancy. The nurse should be alert for signs of hypoglycemia when she assesses:
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Jitteriness
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A radiant warmer will be used to help a newborn girl to stabilize her temperature. The nurse implementing this care measure should do which of the following?
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Undress and dry the infant before placing her under the warmer.
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A newborn male has been scheduled for circumcision. Essential nursing care measuras following this surgical procedure would include:
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Apply PJ or A&D ointment to the site with every diaper change until site is healed.
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The doctor has ordered that a newborn receive a hep b vaccine prior to discharge. In fulfilling order, the nurse should do which of the following?
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Obtain parental consent prior to vaccine, inform parents that the next vaccine in series needs to be given in 1 month, administer the injection into the vastus lateralis muscle.
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THe nurse is preparing to admin erythromycin ointment to a newborn after birth, which of the following nursing actions would be appropriate?
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Wear gloves, cleanse eyes if secretions are present, wipe away excess ointment after 1 minute, apply the ointment from inner to outer canthus
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During a home visit, the mother of a 1 week old infant son tells the nurse that she is very concerned about whether her baby is getting enough breast milk. THe nurse would tell this mom that at 1 week of age a well nourish newborn should exhibit which of the following?
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A minimum of 3 bms a day
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A woman is trying to calm her fussy baby in prep for feeding. She exhibits a need for further instruction if she does which of the following:
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Removes all clothing from infant except the diaper
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THe nurse should teach breastfeeding mothers about breast care measures to preserve the integrity of the nipples and areola. WHich of the following should the nurse include in the instructions?
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Apply modified lanolin to both dry and sore nipples.
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A breastfeeding woman asks the nurse about what birth control she should use during the postpartum period. Which is the best recommendation for the first 6 weeks after birth?
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Barrier method using a combo of a condom and spermicide foam.
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A woman has determined that bottle feeding is the best feeding method for her. Instruction the woman should receive regarding this feeding include:
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Expect a 1 week old newborn to drink approx 30-60 ml of formula at each feeding.
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A nurse is evaluating a woman's breastfeeding technique. Which of the following actions would indicate further instruction?
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Washes her breasts and nipples thru out the day with soap and water, Lines her bra with a thick plastic lined pad to absorb leakage, positions baby supporting back and shoulders securely and then brings her breast toward the baby putting the nipple in the baby's mouth.
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A new breastfeeding mother asks the nurse how to prevent nipple soreness. The nurse tells this woman that the key to preventing sore nipples is to:
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Correct breastfeeding technique.
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Categorizing growth and behavior into approximate age stages:
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Provides a convenient means to describe the majority of children.
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Which of the following is an example of a cephalocaudal directional trend in development?
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Infants stand after they are able to hold the back erect.
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Which of the following is considered fixed and precise in the development of children?
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The order of development
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The directional trend that predicts orderly and continuous development is known as:
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Sequential
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Sensitive periods in dev't are those times when the child:
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More likely to respond to beneficial stimulation
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If a newborn measures 19 inches at birth, the expected height at 4 years would be:
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38 inches
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An important prereq for all other mental activity is the child's awareness that an object exists even when no longer visible. According to Piaget, this is:
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Object permanence
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Predominate characteristic of Piaget's preoperational period is egocentricity which means?
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Inability to see another's perspective
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If an infant weighs 9 kg at 12 months, how many kg was the infant's probably birthweight?
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1.5 kg
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If an infant's head circumference is 46 cm at 6 months, how many cm would you expect the head circumference to be at 8 months?
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46.5
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The infant's posterior fontanel usually closes by:
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12-18 months.
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Which of the following characteristcs of vision begins to develop by 6 weeks of age and should be well established by 4 months?
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Strabismus
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Which of the following assessment findings would be considered most abnormal?
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The infant who begins to roll from front to back at 6 months
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The nurse should withhold the vaccine if the child:
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Has a moderately acute illness without fever.
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Colic is more common in the infant who:
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Has signs of failure to thrive
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Which of the following techniques has been demo'd by research to be most successful when 2 or more immunizations are given in one visit?
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Inject the less painful first.
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Which of the following types of injuries is a leading cause of death in infants?
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Asphyxiation
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If the chest circumference of a toddler is 50 cm, what would you expect the head circum to be?
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50 cm
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Which of the following skills is not necessary for the toddler to acquire before separation and individuation can be achieved?
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Lack of anxiety during separation from parents
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THe usual number of words acquired by the age of 2 is about:
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300
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Which of the following types of play increases in freq as child moves through toddler period?
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Parallel play
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The best approach for extinguishing a toddler's attention seeking behavior of a tantrum with head banging is:
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Protect the child from injury
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Children should be placed in convertible car restraints until:
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they weigh 40 lbs, they reach 40 inches in height, the midpoint of the child's head is higher than the vehicle back seat.
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Which of the following best describes the formal operational thinking that occurs between the ages of 11 and 14?
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Thought process includes thinking in abstract terms, possibilities and hypotheses.
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According to Erikson, a key to identity achievement in adolescence is best described as:
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Related to the adolescent's interactions with others, serving as a mirror and reflecting information back to the adolescent.
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Most respiratory infections in children are caused by:
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Viruses
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THe most likely reason that the respiratory infection rate increases drastically in the age range from 3-6 months is that the:
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Maternal antibodies have decreased and the infant's own antibody production is immature.
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GABHS infection is usually a:
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Brief illness that places the child at risk for serious sequelae.
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In the post op period following a tonsillectomy, the child should be:
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Placed on bed rest for the day of surgery
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Which of the following signs is an early indication of hemorrhage in a child who has had a tonsillectomy?
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Continuous swallowing
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The nurse should suspect epiglottis if the child has:
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Absence of cough in the presence of drooling and agitation
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In the child who is suspected of having epiglottis, the nurse should:
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Have intubation equipment available.
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Which of the following children is most likely to be hospitalized for treatment of croup?
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The 2 year old using accessory muscles to breathe.
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RSV is:
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A common virus that usually does not require hospitalization.
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Infants and young children are at high risk for f and e imbalances. Which of the following factors contributes to the vulnerability?
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Increased ECF volume
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A 1 month old infant is brought to the clinica by his mother. The nurse suspects pyloric stenosis because the mother gives a hx of:
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Projectile vomiting
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Where is aldosterone excreted from?
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Adrenal Cortex
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What symptom would not be present with hyperkalemia?
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Decreased deep tendon reflexes
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WHich factor predisposes an infant to fluid imbalances?
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Immature kidney function
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An iV site is swollen, cool, pale and causes pain. This would be:
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Infiltration
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WHat is the most common type of dehydration?
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Isotonic
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What is one cause of hyperkalemia?
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Major tissue trauma
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A 2 month old breast fed infant is successfully rehydrated with oral rehydration solutions for acute diarrhea. Instructions to the mother about breastfeeding include:
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Continue breastfeeding
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An IV site is warm, swollen and has a red streak at the vein site and causes pain. This would be from:
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Phlebitis
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Which is not a compensatory mechanism for hypertonic fluid volume deficit?
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Vasoconstriction
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What vital sign changes would you expect to see in a patient receiving 5% sodium solution IV for hyponatremia?
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Increase in BP
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THe nurse checks for patency of an IV saline lock by:
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FLushing IV with NSS and assessing site.
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What is the cause of hypertonic fluid volume excess?
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Increase in sodium intake
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Which is a lab value you could expect to see with isotonic rehydration?
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Increased hemoglobin
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When vomiting is uncontrolled in an infant, initially a nurse should watch for signs of what?
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alkalosis
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Which of the following is not a sign of fluid overload?
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Bradycardia
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If a healthy client drinks 1500 mls in his diet, how much should he void?
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1500 mls
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What is the body's most abundant extracellular cation?
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Sodium
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A client had an IV site started at 3/1/08 at 0600. When should she be due for a new IV site?
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3/4/08 0600
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What kind of solution would you give to treat hypernatremia?
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Hypotonic solution
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You are taking care of a client who is diagnosed with hypertonic dehydration. Which solution might the nurse expect to be ordered for this client?
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0.45% sodium chloride
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