Pediatric Nursing Exam Questions and Answers, Exams of Nursing

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□ A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which of the following findings is noted? A The infant turns to the side that is touched. B The fingers curl tightly and the toes curl forward. C The toes flare and the big toe is dorsiflexed. Correct D There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. □ Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited. □ □ Test-Taking Strategy: Knowledge regarding the method of testing and the expected response of the Babinski reflex is needed to answer this question. Recalling that to elicit Babinski reflex the nurse would stroke the lateral sole of the foot will direct you to the correct option. Review the procedure for testing this reflex in an infant and the expected response if you had difficulty with this question. □ □ Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 516). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Analyzing □ □ Client Needs: Health Promotion and Maintenance □

□ Integrated Process: Nursing Process/Assessment

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□ Content Area: Newborn Awarded 1.0 points out of 1.0 possible points. □ 2.ID: 283572974 A nurse is assessing language development in a toddler from a bilingual family. The nurse expects that the child’s language development: A Is slower than expected Correct B Is developing as expected C Is more advanced than expected D Will require assistance from a speech therapist □ Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a bilingual family does not require assistance from a speech therapist to ensure language development. □ □ Test-Taking Strategy: Use the process of elimination. Note that there are no data in the question to indicate that the child needs assistance from a speech therapist. When selecting from the remaining options, noting the word "bilingual" in the question and recalling the factors that affect language development will direct you to the correct option. Review the factors that affect language development if you had difficulty with this question. □ □ Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 111). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Understanding □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Assessment

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□ Content Area: Cultural Diversity Awarded 1. points out of 1.0 possible points. □ 3.ID: 283573460 A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately: A Notify the nurse-midwife or physician B Perform a vaginal examination on the mother C Position the mother so that her hips are elevated Correct D Insert a gloved finger into the mother's vagina to feel for cord compression □ Rationale: Conditions that restrict blood flow through the umbilical cord may result in variable decelerations. If cord compression is suspected, the mother is immediately repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal presenting part toward her diaphragm. A hands-and-knees position may also reduce compression of a cord that is trapped behind the fetus. Several position changes may be required before the pattern improves or resolves. The nurse may need to contact the nurse-midwife or physician, but this would not be the immediate action. Although the nurse may check the woman’s vaginal area for the presence of the umbilical cord, a vaginal exam is not performed because of the possibility of further compromise of blood flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved finger into the vagina to feel for the cord. □ □ Test-Taking Strategy: Note the strategic word "immediately" in the query of the question and use the ABCs — airway, breathing, and circulation — to answer the question. The only action that would provide circulation is positioning the mother so that her hips are elevated, which would relieve cord compression. Review the immediate nursing measures when cord compression is suspected if you had difficulty with this question.

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□ References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 400). St. Louis: Elsevier.

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□ Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4th ed., p. 432). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Implementation □ □ Content Area: Critical Care Awarded 1.0 points out of 1.0 possible points. □ 4.ID: 283573402 A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? A The infant babbles. B The infant says "Mama." Correct C The infant smiles and coos. D The infant babbles single consonants. □ Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age. □ □ Test-Taking Strategy: Use the process of elimination and focus on the age of the infant. Recalling the language development that occurs during infancy will direct you to the correct option. Remember that an 8- to 9-month-old infant can string vowels and consonants together. Review the developmental milestones related to language development in an infant if you had difficulty with this question. □

□ Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 80, 99). St. Louis: Elsevier.

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□ Level of Cognitive Ability: Understanding □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Assessment □ □ Content Area: Developmental Stages □ Awarded 1.0 points out of 1.0 possible points. □ 5.ID: 283572566A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. On the basis of this finding, which action by the nurse is most appropriate? A Documenting the finding Correct B Helping the woman get out of bed and walk C Performing active and passive range-of-motion exercises D Reporting the finding to the nurse-midwife or physician immediately □ Rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may occur. The lower pulse rate reflects the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume and permits a slower heart rate to provide adequate maternal circulation. It is not necessary to notify the nurse-midwife or physician immediately, because a pulse rate of 55 beats per minute is a normal finding. The client should remain on bed rest in the immediate postpartum period. Although range-of- motion exercises are important for the client on bed rest, this action is unrelated to the data in the question. Therefore, the most appropriate nursing action is to document the finding. □ □ Test-Taking Strategy: Use the process of elimination. Recalling the physiological alterations that occur in the woman after delivery will direct you to the correct

option. Remember that after delivery bradycardia may occur and that it is a normal finding. Review the expected vital sign measurements in the immediate postpartum period if you

had difficulty with this question. □ □ Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 465). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Implementation □ □ Content Area: Maternity/Postpartum Awarded 1. points out of 1.0 possible points. □ 6.ID: 283572928 A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take on the basis of this finding? A Document the findings. Correct B Check the client's temperature. C Report the findings to the nurse-midwife. D Obtain a sample of the amniotic fluid for laboratory analysis. □ Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore the nurse would most appropriately document the findings. Checking the client’s temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife. □ □ Test-Taking Strategy: Use the process of elimination.

Noting the word "clear" in the question will help direct you to the correct option. Review the expected findings of amniotic fluid if you had difficulty with this question.

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□ Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal Child Nursing Care (4th ed., p. 455). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Implementation □ □ Content Area: Maternity/Intrapartum Awarded 1.0 points out of 1.0 possible points. □ 7.ID: 283574659 The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which of the following observations is a sign of physical readiness? A The child has been walking for 2 years. B The child can eat using a fork and knife. C The child no longer has temper tantrums. D The child can remove his or her own clothing. Correct □ Rationale: Signs of physical readiness for toilet training include the following: The child can remove her own clothing; is willing to let go of a toy when asked; is able to sit, squat, and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2 years, and an absence of temper tantrums are not signs of physical readiness. □ □ Test-Taking Strategy: Use the process of elimination. Noting the strategic words "physical readiness" in the question will assist you in eliminating the option that addresses temper tantrums. To select from the remaining options, visualize each to help direct you to the correct option. Review the signs of physical

readiness for toilet training if you had difficulty with this question. □ □ Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 111, 124). St. Louis: Elsevier.

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□ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Teaching and Learning □ □ Content Area: Developmental Stages Awarded 1.0 points out of 1.0 possible points. □ 8.ID: 283572518 A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question does the nurse ask? A "Are you dieting?" B "Do you smoke cigarettes?" Correct C "Do you engage in strenuous exercise such as jogging?" D "Do you normally have menstrual cramps with your periods?" □ Rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolitic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives. □ □ Test-Taking Strategy: Use the process of elimination and note that the question addresses the use of an oral contraceptive. Focusing on the subject, identification of risk factors, will direct you to the correct option. Review the risks associated with oral contraceptives if you had difficulty with this question. □

□ References: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 741). St. Louis: Saunders.

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□ McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., p. 193). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Analyzing □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Assessment □ □ Content Area: Pharmacology Awarded 1.0 points out of 1.0 possible points. □ 9.ID: 283573484A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which of the following actions does the nurse tell the client to take? Select all that apply. A Sleep lying on her back B Shower daily but avoid sitting in a bathtub C Apply cool compresses to the hemorrhoids Correct D Contact the nurse-midwife if any bleeding occurs E Elevate her hips on a pillow when resting or during sleep Correct □ Rationale: To relieve the discomfort of hemorrhoids, the client should take frequent tepid baths. The client is also instructed to apply cool witch hazel compresses or anesthetic ointment to the hemorrhoids and to assume a side-lying position with the hips elevated on a pillow. The client may experience some bleeding, which is normal. However, if the bleeding persists, the physician or nurse- midwife should be contacted. □ □ Test-Taking Strategy: Focus on the subject, alleviating the discomfort of hemorrhoids. Read each option carefully and think about the pathophysiology and the anatomical location of hemorrhoids to answer

correctly. Review the measures to relieve the discomfort of hemorrhoids if you had difficulty with this question. □ □ Reference: McKinney, E., James, S., Murray, S., &

Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp 271- 272). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Physiological Integrity □ □ Integrated Process: Teaching and Learning □ □ Content Area: Maternity/Antepartum Awarded 1.0 points out of 1.0 possible points. □ 10.ID: 283572560 A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? A Fetoscope B Stethoscope C Doppler transducer Correct D Pulse oximetry on the client and a fetoscope □ Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds. □ □ Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike and involve a fetoscope. To select from the remaining options, note the week of gestation of the client, which will direct you to the correct option. Review the equipment used for auscultating fetal heart sounds if you had difficulty with this question. □ □ References: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., pp. 206-207). St. Louis: Mosby. □ □ McKinney, E., James, S., Murray, S., & Ashwill, J. (2009).

Maternal-child nursing (3rd ed., p. 269). St. Louis: Elsevier.

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□ Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child nursing care (4th ed., p. 244). St. Louis: Elsevier. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Assessment □ □ Content Area: Maternity/Antepartum Awarded 1.0 points out of 1.0 possible points. □ 11.ID: 283572504 A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant: A Uses short sentences B Overarticulates words Correct C Uses facial expressions or gestures D Speaks at a normal rate and volume □ Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker’s face and lips. The nurse would watch to see that the nursing assistant avoided situations in which there is a glare or shadows on the client’s field of vision. The nurse would also remind the assistant to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The assistant should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues. □ □ Test-Taking Strategy: Note the strategic word "intervene" in the query of the question. This word indicates that you need to select the option that indicates an incorrect action by the nursing assistant. Visualize each of the options to help direct you to the

correct one. Review strategies to improve communication when a client has hearing loss if you

had difficulty with this question. □ □ References: Black, J., & Hawks, J. (2009). Medical- surgical nursing: Clinical management for positive outcomes. (8th ed., p. 1727). St. Louis: Saunders. □ □ Touhy, T. & Jett, K. (2010). Ebersole and Hess’ Gerontological nursing health aging (3rd ed., p. 32). St. Louis: Mosby. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Implementation □ □ Content Area: Leadership and Management Awarded 1.0 points out of 1.0 possible points. □ 12.ID: 283572964 A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, the nurse should: A Check the infant for jaundice B Check the infant's temperature C Obtain parental consent to administer the vaccine Correct D Request that a hepatitis blood screen be performed on the infant □ Rationale: Hepatitis B vaccine is for immunization against infection caused by all known subtypes of hepatitis B virus. The usual recommended schedule is to administer the vaccine at birth, at 1 month of age, and again at 6 months of age. Parental consent must be obtained before the vaccine is administered. Checking the infant’s temperature, checking for jaundice, and requesting that a hepatitis blood screen be performed on the infant are all unnecessary. □ □ Test-Taking Strategy: Knowledge regarding

the administration of the hepatitis B vaccine to a newborn is required to answer this question. Remember, parental consent is required before the vaccine is administered.

Review the procedure for administering this vaccine to a newborn if you had difficulty with this question. □ □ Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed., p. 504). St. Louis: Mosby. □ □ Level of Cognitive Ability: Applying □ □ Client Needs: Health Promotion and Maintenance □ □ Integrated Process: Nursing Process/Implementation □ □ Content Area: Newborn Awarded 1.0 points out of 1.0 possible points. □ 13.ID: 283574670 A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications? A The client's son B The client's father C The client's mother Correct D The client's grandson □ Rationale: African-American families are oriented around women. Within the African-American family structure, the wife/mother is often charged with the responsibility of protecting the health of family members. The African- American woman is expected to assist each family member in maintaining good health and in determining the course of treatment if a family member becomes ill. The nurse must recognize the importance of the African-American woman in disseminating information and in assisting the client in making decisions. Although the African-American man may be included in the decision-making process, the African- American family is often matrifocal, so the nurse ensures that the woman is present. Therefore the other options are incorrect. □