APPENDIX A

Answers to QSEN Checkpoint Questions

CHAPTER 1
A Framework for Maternal and Child Health Nursing
1.1 C. The nurse should inform the team members that a Magnet hospital is one that
stresses exemplary nursing care. It does not necessarily denote care for acute
patients. This designation is not conferred by the American Medical Association.
1.2 C. The nurse explains that the perinatal period is the time between 20 weeks of
pregnancy and 4 to 6 weeks following birth.
1.3 C. The trend toward quality improvement through technology can become
overwhelming for families if nursing support is not included in care. Premature
infants require extensive care, and there are no immunizations for all childhood
diseases. Nursing is predicted to maintain an important role in health care.
1.4 A. The nurse should assess if Mr. Chung is open to trying skin-to-skin contact
with his newborn. Skin-to-skin contact is important for newborns and may help
fathers bond with their infants. It would be incorrect to withhold this until after
discharge.
1.5 B. The nurse should acknowledge the patient’s concerns while affirming her
efforts rather than downplaying her concerns or providing false assurance.
1.6 D. The nurse should explain that consent is required for all patients regardless of
age and the amount of pain involved in the procedure and can be given by
telephone or e-mail for long distance consultation.

CHAPTER 2
Diversity and Maternal Child Nursing
2.1 B. The nurse assessing a family’s structure and decision-making norms is a
component of culturally competent care. These patterns of behavior differ
significantly between cultures. Nurses should avoid assumptions that may border
on being stereotypes, such as equating a preference for tacos with a patient who is
Hispanic.
2.2 A. The nurse should encourage the care provider to communicate as naturally and
clearly as possible; imitating Maria’s accent is inappropriate. There is no
 particular need to avoid pop culture references if these are contextually
appropriate.
2.3 D. It is important for the nurse to avoid interactions between home remedies and
prescribed medicine. For the nurse to use the words “you people” is a term of
disrespect.
2.4 B. It would be discriminatory for the nurse to presume that Maria will not “fit in”
by virtue of her ethnicity.
2.5 D. The nurse respecting food choices is a way of respecting cultural diversity.
The nurse addressing the taste of the food does not focus on Maria’s concerns.
2.6 B. The nurse should reinforce the results of the study and state that “Children
raised in same-sex parent houses do just as well as children raised with different
sex parents.” Questioning whether Sofia will be a good parent based on sexual
orientation, defining the situation as a challenge to raising a child, or assuming
the child needs a male figure is disrespectful to the family structure.

CHAPTER 3
The Childbearing and Childrearing Family in the Community
3.1 B. The nurse should address that fact that because women earn less than men and
single-parent families are usually headed by women, finances are a common
concern. Communication, emotional engagement, and education are not
necessarily lacking as often.
3.2 B. The nurse should be aware that the person who allows information in or out of
a family is the gatekeeper.
3.3 D. The nurse knows that the oldest child marks a family stage; because the
Hanovans’ oldest child is 17 years of age, they are at a family with an adolescent
stage.
3.4 D. The nurse should teach parents that automobile accidents are a major cause of
death in adolescents. Rates of such accidents exceed those among younger
children.
3.5 B. The nurse should ensure the parents are aware that teenagers need responsible
adult supervision in both custodial settings. It would be inappropriate for the
nurse to suggest shared custody, to suggest quitting work, or to assume that the
situation will be independently resolved.
3.6 C. The nurse should teach parents that the AAP recommends television viewing
be restricted until a child is 2 years of age to reduce exposure to violence and
stimulate language development.

CHAPTER 4
Home Care and the Childbearing and Childrearing Family
4.1 C. The nurse could suggest that Lisa needs a sedentary activity to interact with
friends. Shouting for basketball teams or joining in with cheerleading would
 contradict bed rest. She is unable to safely go on outings due to her activity
restriction. Journaling does not meet her socialization needs.
4.2 A. The nurse’s first visit will involve gathering a health history, so having a
parent present would be helpful. The nurse should not dictate a time because this
is not an effective way to empower or involve a patient in planning care.
4.3 D. The nurse should always call for help if he or she feels in danger. Leaving the
home would leave the patient still in danger. Changing the locks would not solve
the immediate problem. It is difficult and often unsafe to reason with angry
people.
4.4 A. The nurse should assure Lisa that privacy rules apply to home care as well as
hospital care; health records are not copyrighted.
4.5 C. The nurse should suggest drinking more fluid as an adequate fluid intake helps
prevent constipation. Walking is contraindicated as Lisa is on bed rest. The size
of meals or calcium intake shouldn’t make a difference.
4.6 A. Lisa’s community is probably safe enough for her to stay alone. The nurse
should worry about the mother “trying to quit smoking” because it is not enough
to prevent exposure to secondary smoke and toxic tobacco contaminants because
smoke particles cling to clothing. If the mother “usually” smokes outside, then
this implies that she is sometimes smoking in the home.

CHAPTER 5
The Nursing Role in Reproductive and Sexual Health
5.1 C. The nurse should teach the client that thelarche refers to breast development.
Adrenarche is development of other secondary sex characteristics; menarche is
the first menstrual period.
5.2 C. The nurse should state that because the vas deferens is easy to locate, it is the
organ blocked/ligated for a vasectomy.
5.3 D. The nurse should explain that cystocele is herniation of the bladder into the
vagina and can lead to urinary tract infection.
5.4 D. The nurse could help the patient calculate the ovulation date by teaching that
ovulation usually occurs on the 14th day from the end of the menstrual cycle, or
in this instance, 14 from 34 or on the 20th day.

CHAPTER 6
Nursing Care for the Family in Need of Reproductive Life Planning
6.1 B. The nurse should teach Dana that cervical mucus is thin and watery at
ovulation. Subjective sensations of warmth, breast tenderness, and emotional
lability are not safe and reliable indicators.
6.2 B. The nursing care plan for Dana should include teaching her that female
condoms should be inserted before any sexual contact, they should not be reused,
and they already contain a spermicide.
6.3 D. The nurse should have Dana report severe migraine headaches because they
are a contraindication to COCs.
6.4 B. Intramuscular injections (DMPA) are associated with osteoporosis, so
recommending a high calcium intake is important.
6.5 A. The nurse should teach Dana that tubal ligation is a minor surgical procedure
in which the fallopian tubes are occluded by cautery, crushed, clamped, or
blocked, thereby preventing passage of both sperm and ova.
6.6 C. Having access to multiple methods, reliable methods, and highly effective
methods of birth control caused a 36% decrease in the pregnancy rate among
adolescents from 2007 to 2012. Teens were not likely to decrease sexual activity
or more likely to use abortion. Although community influence may play a role in
the rates of adolescent pregnancy, that was not measured in this study.

CHAPTER 7
Nursing Care of the Family Having Difficulty Conceiving a Child
7.1 C. The nurse should state that a year is the typical time to wait as, after trying to
conceive unsuccessfully for 1 year, a couple is said to be subfertile.
Acknowledging the reality of regretting a decision does not directly address her
concerns.
7.2 C. The nurse should remind couples with reduced fertility that just because they
are no longer using a contraceptive method, they still need to follow safer sex
precautions.
7.3 A. Patient teaching should include the fact that mild cramping may occur during
the procedure. X-ray is not used; no bleeding should result.
7.4 D. The nurse should document endometriosis on the health record because this
condition can affect fertility by blocking fallopian tubes and interfering with
sperm or ovum transport.
7.5 C. The nurse should state that patients who are to undergo intrauterine
insemination receive an injection of clomiphene (Clomid) or FSH 1 month prior
to the procedure. Estrogen, bedrest, and genetic testing are not indicated.
7.6 C. The nurse should tell Cheryl that women begin breastfeeding effectively but
may need additional support to continue it long term. Telling someone to not
worry is not effective counseling. IVF does not preclude normal breastfeeding.

CHAPTER 8
The Nursing Role in Genetic Assessment and Counseling
8.1 D. The nurse providing health information in a relevant and appropriate manner is
an important component of high-quality care. False hope must be avoided.
Journals and websites are not substitutes for health education provided by nurses
and may not meet Amy’s learning needs.
8.2 D. The nurse should recommend that in order for Mrs. Alvarez to make an
 informed choice about her future, talking to other parents might be helpful. False
hope should be avoided, and the nurse’s own personal views are not relevant.
8.3 B. The nurse should inform team members that infants with Down syndrome have
one palm crease instead of the usual three. Babies tend to be hypotonic, not
hypertonic. Sole creases are an indication of any mature fetus.

CHAPTER 9
Nursing Care During Normal Pregnancy and Care of the Developing
Fetus
9.1 D. The nurse should state to team members that the baby is an embryo during the
period between implantation and 5 to 8 weeks. After that, it is a fetus.
9.2 B. The nurse’s assessment findings of a normal umbilical cord would be one vein
and two arteries. Other patterns are associated with cardiac or chromosomal
disorders.
9.3 A. The nurse should explain that surfactant, a phospholipid substance, is formed
and excreted by the alveolar cells of the lungs beginning at approximately the
24th week of pregnancy. This decreases alveolar surface tension on expiration,
preventing alveolar collapse and improving the infant’s ability to maintain
respirations in the outside environment at birth.
9.4 A. The study reveals alcohol consumption, low socioeconomic status, and
depression contribute to smoking. The nurse should counsel the client regarding
the effects of smoking and alcohol on the fetus.
9.5 C. The nurse should teach that a full bladder improves the accuracy of the scan.
There is no pain involved.
9.6 A. If the client is having the amniocentesis after week 20 of pregnancy, the nurse
should ensure the client voids prior to the amniocentesis to prevent puncturing the
bladder.

CHAPTER 10
Nursing Care Related to Psychological and Physiologic Changes of
Pregnancy
10.1 A. The nurse is aware that women in the study reacted both positively and
negatively at the thought of a second pregnancy. Lauren’s paradoxical response
represents this.
10.2 B. The nurse counsels Lauren that ensuring safe passage for the fetus consists of
accepting the pregnancy (first trimester), accepting the coming baby (second
trimester), and preparing for parenthood (third trimester).
10.3 C. The nurse would tell the unlicensed care provider that narcissism refers to
interest in yourself in contrast to interest in others.
10.4 D. The nurse should teach that the three positive signs of pregnancy are fetal
 heartbeat heard by examiner or seen on sonogram and fetal movement felt by
examiner.
10.5 D. The nurse should explain that Chadwick’s sign is a color change in the vagina
from pink to purple because of increased formation of blood vessels and blood
flow.
10.6 A. The nurse should state that with insulin becoming ineffective, glucose levels
rise, serving to safeguard the fetus from hypoglycemia. Maternal insulin does not
cross the placenta.

CHAPTER 11
Nursing Care Related to Assessment of a Pregnant Family
11.1 C. The nurse should explain that the odds of experiencing a medication-free birth
are far higher when a nurse-midwife leads care. It is inaccurate to characterize
nurse-midwives as always being more “patient-friendly,” and it is not appropriate
to wholly defer teaching or advice when the patient initiates.
11.2 C. The nurse should state that prenatal care is a prime time for health education;
during this time, nurses play an important role in effective prenatal care.
Ultimately, this promotes safe pregnancy, labor, and delivery. This is more
important than collecting statistical data or promoting social interaction. Allergies
are not correlated with preterm labor. Despite the patient’s wishes, regular
prenatal care should be strongly encouraged.
11.3 B. The nurse should ask Sandra about past surgery because surgery such as for
appendicitis can leave adhesions, which then might interfere with uterine growth.
Risks of uterine rupture and preterm labor are not higher in women with a
surgical history.
11.4 D. The nurse should teach that palmar erythema commonly occurs from
increasing estrogen levels. It is not a result of Rh incompatibility, edema, or
anxiety.
11.5 D. The nurse should know that relaxation is important to reduce pain with a
pelvic examination and teach her to breathe slowly and evenly when being
examined. Holding the breath or pushing down on the diaphragm does not relax
abdominal muscles.
11.6 C. The nurse should have Sandra report a weight gain more than 3 lb a week
during the second trimester as this would be a potential sign of gestational
hypertension. The other listed changes do not constitute safety risks.

CHAPTER 12
Nursing Care to Promote Fetal and Maternal Health
12.1 C. The nurse should teach Julberry that she can still contact a sexually transmitted
infection, so she still needs to use precautions. However, a condom would not tear
the membranes. Julberry’s other responses reflect a sound understanding or self-
 care during pregnancy.
12.2 A. The nurse should recognize that jogging is not recommended during
pregnancy because the extra weight of the pregnancy can cause knee injuries. The
other health promotion statements are accurate.
12.3 C. The nurse assesses that all of the things Julberry describes are concerns, but it
is the accumulation of symptoms that apparently leads to depression.
12.4 D. The nurse should counsel Julberry to use witch hazel as it feels cool and may
shrink hemorrhoids. Mineral oil is contraindicated because it prevents absorption
of vitamin A; eating fiber should not be omitted because it is helpful in
preventing constipation; she can’t lie on her stomach because she is pregnant.
12.5 C. The nurse would recognize that Julberry has read the correct information on
ankle edema. Ankle edema is a common occurrence in pregnancy and occurs
from increased pressure on lower extremity veins. It can be relieved by resting
with feet elevated.
12.6 C. The nurse should teach that pregnant women should check with their
healthcare provider before taking medicine during pregnancy. All over-the-
counter medicine is not safe; measles vaccine contains a live virus so is
contraindicated during pregnancy.

CHAPTER 13
The Nursing Role in Promoting Nutritional Health During Pregnancy
13.1 B. The team should recommend that Tori gain 15 to 25 lb during her pregnancy
because she is slightly overweight.
13.2 D. The nurse should confirm that iron is absorbed best from an acid medium.
Crushing the pills or taking them with milk or carbonated beverages is not
advised.
13.3 C. The nurse should recommend leafy green vegetables to eat during pregnancy.
Leafy green vegetables are rich in many of the dietary components that are
lacking women’s diets. Protein, fiber, and iron are all important during pregnancy
so should be encouraged. Dieting should normally be discouraged.
13.4 C. The assessment document should specify a 24-hour recall history to secure the
most accurate nutrition pattern.
13.5 A. The nurse identifies eating erasers as a sign of pica. Some women report a
craving for foods such as oranges or chocolate. Women with pica, however, crave
a nonfood substance, in this case, an eraser. Typically, these cravings include
clay, dirt, cornstarch, or ice cubes.
13.6 D. The nurse would note that vitamin B12 is found only in animal sources and
would be omitted in a vegetarian diet.

CHAPTER 14
Preparing a Family for Childbirth and Parenting
14.1 D. The nurse recognizes that the statement that best assures a workable birth plan
is keeping the plan “flexible.” Rigid expectations can lead to disappointment and
anxiety. The partner’s wishes are indeed secondary, but they should not be wholly
rejected. Interventions such as opioids should not be included solely on the
recommendation of a parent.
14.2 B. The nurse should suggest squatting or tailor sitting to tighten perineal muscles.
Tightening and relaxing them (Kegel exercises) would also strengthen them. The
nurse should not recommend vigorous exercise and bearing down forcefully as
these actions carry safety risks.
14.3 C. The nurse should make Elena aware that women who give birth in upright
positions have fewer obstetric and anal sphincter injuries. Voicing the fact that
she is willing to try different positions should achieve this. Media presentations of
labor are not always realistic.
14.4 A. The Lamaze philosophy is based on the gate control theory of pain perception,
which states that pain sensations can be interrupted. This philosophy does not
deny the reality of pain or the inevitability of pain during labor.
14.5 D. The nurse should teach that slow breathing is adequate for early contractions; a
cleansing breath is always important. Hypoventilation is relieved by breathing
into a paper bag. Rapid breathing is contraindicated.
14.6 C. The nurse should emphasize that emergency care is more readily available in a
hospital setting than in other birth settings. Childbirth is not pain-free, and the
cost of present-day hospital stays is typically high. Hospitals, like all birth
settings, are not sterile environments.

CHAPTER 15
Nursing Care of a Family During Labor and Birth
15.1 A. The nurse is aware that an occipitoanterior position means the lie is cephalic—
the back of the baby’s head is facing the right anterior quadrant of the mother’s
pelvis. Full flexion means the smallest diameter of the fetal head is presenting to
the cervix. This position is considered to be ideal and is most conducive to a
healthy delivery that requires fewer interventions.
15.2 D. An important teaching point for Celeste would have been that cervical dilation
is a mark of true labor. For the mucus plug to be loosened, cervical dilatation
must be occurring.
15.3 A. The nurse should be most concerned that Celeste is “losing a grasp on things.”
In the study, a feeling of loss of control severely affected women’s impressions of
whether labor was traumatic or not.
15.4 D. The nurse should assure her that a placenta loosens quickly so waiting time
will not be long. Pulling on the cord, pushing on the uterine fundus, or hard
pushing could all cause additional bleeding. The placenta must normally be
delivered spontaneously.
15.5 B. The nurse should report a contraction 70 seconds long as it is long enough to
compromise fetal oxygenation. In the context of labor, pain is not necessarily
indicative of pathophysiology.
15.6 B. The nurse would document FHR decreasing in rate 30 seconds after the start of
a contraction as a late deceleration. A late deceleration means the FHR decreases
as a contraction ends, rather than at the beginning of a contraction, as is usual.

CHAPTER 16
The Nursing Role in Providing Comfort During Labor and Birth
16.1 C. The nurse’s best answer would be that a doula is a second support person in
labor. She doesn’t replace a woman’s partner and does much more than time
contractions. The use of a doula is an individual choice.
16.2 D. Based on the study, the nurse could confirm that music is best used in early
labor to help a woman relax.
16.3 C. The nurse should recommend slow breathing. Slow breathing calls for
concentration. Consequently, it can be used as a distraction technique. Women
should not lie on their back during labor in order to prevent hypotension. Women
should not hold their breath as long as possible, and rapid breathing should not be
encouraged.
16.4 B. The nurse should state that warm water is comforting during labor; it may be
contraindicated if membranes are ruptured because of the increased risk of
infection.
16.5 A. The nurse should inform Jonny that peripheral relaxation can lead to systemic
hypotension with epidural anesthesia. A slowed second stage of labor also may
occur.
16.6 C. The nurse should have a drug to speed gastric emptying on hand in case of
general anesthesia use. A drug to increase gastric emptying helps to avoid
vomiting. The other listed drugs do not have this therapeutic effect.

CHAPTER 17
Nursing Care of a Postpartal Family
17.1 C. The taking-hold phase means a woman is interested in actively caring for her
baby. The nurse should encourage her to participate in the care of her baby by
bathing the baby. Telling her she did well or encouraging the naming of the baby
does not help to usher in the taking-hold phase.
17.2 A. The nurse assesses that an “en face” position suggests she is interested in
becoming acquainted with the newborn.
17.3 A. The nurse should teach Leana that tampons should not be used postpartum to
help prevent infection.
17.4 B. If the uterine fundus does not grow firm with massage, extreme atony, possibly
retained placenta fragments, or an excess amount of blood loss may be occurring;
 the nurse should notify the woman’s primary care provider. A uterine fundus
decreases in size at a rate of one fingerbreadth a day. The fundus should be
located midline. Firm massage will result in pain, but this is not acceptable
nursing practice.
17.5 D. The nurse worries about Leana’s comment that the baby will sleep fine. This
statement may suggest that Leana is unprepared for the fact that her infant may
spend more time crying than sleeping. Her expectations for her own levels of rest
may be unrealistic.
17.6 B. The nurse records that Leana’s uterine fundus sinks below the symphysis pubis
at about 10 days after birth. This is a normal finding.

CHAPTER 18
Nursing Care of a Family With a Newborn
18.1 D. The nurse is aware that conduction is the transfer of body heat to a cold object
that touches the infant. Each of the other factors can result in heat loss, but none
involves heat loss by conduction.
18.2 C. The nurse should lift the baby’s head and allow it to fall back 1 in. to elicit a
Moro reflex. This action best initiates a Moro reflex. Making a noise or shaking a
crib is less effective way to test the reflex.
18.3 A. Using the apgar test, the nurse assesses heart rate, respiratory effort, muscle
tone, reflex irritability, and color.
18.4 A. The nurse should advice Beth that milia spots will disappear on their own, so
she doesn’t need to take any action.
18.5 C. The nurse would confirm that a week is an average time for a dried cord to
detach.
18.6 C. Shaking infants is potentially dangerous because it can cause head injury; the
nurse educating about newborn abilities helps parents better understand a
newborn reacts the way he or she does. This approach is likely more effective
than the nurse immediately addressing shaken baby syndrome, which may be a
premature and “heavy-handed” approach. A sedative is contraindicated with
breastfeeding.

CHAPTER 19
Nutritional Needs of a Newborn
19.1 A. Nursing assessment of infant nutrition begins during pregnancy with
assessment of the mother’s and her partner’s attitudes and choices about infant
feeding. This is an important aspect of patient-centered care and should normally
precede other assessments.
19.2 A. The nurse sees having prenatal care as an indication that Linda will
successfully breastfeed. Prenatal care is associated with success at exclusive
breastfeeding. Smoking, young age, and low income are negatively associated.
19.3 B. The nurse should teach Linda that breast milk provides not only nutrition but
also aspects of immunity. Breastfeeding may reduce the risk of obesity but does
not ensure the infant will never become obese. It does not necessarily prevent
cancer.
19.4 C. The nurse determines that Linda stating that she should drink 12 glasses of
fluid a day warrants further teaching. Drinking 12 glasses of fluid a day is
extreme; 6 to 8 is a better recommendation.
19.5 A, B, D. The nurse should teach that breastfeeding exclusively for 6 months can
reduce the risk of obesity later in life and decrease the risk of breast and ovarian
cancer for the mother, and a pacifier can be used to decrease the risk of sudden
infant death syndrome once breastfeeding is established. Formula feeding does
not increase calcium density of the spine.
19.6 D. Educational literature should include the fact that discarding leftover milk
discourages the growth of pathogens. The presence of yellowish stools is
consistent with breast milk. A microwave should not be used to warm breast milk,
and propping a bottle risks for aspiration.

CHAPTER 20
Nursing Care of a Family Experiencing a Pregnancy Complication From
a Preexisting or Newly Acquired Illness
20.1 C. An appropriate nursing action for Angelina is allowing her to choose a
subcutaneous site for the injection. Heparin is administered subcutaneously.
Hemoglobin levels and WBC do not need to be monitored during therapy.
20.2 C. The nurse is alerted to the fact that the woman is taking an iron pill every day.
Women with sickle-cell anemia are not prescribed iron pills during pregnancy
because sickle cells are unable to incorporate as much iron in their structure as
normal red cells. The woman’s other statements reflect a sound understanding of
sickle cell disease.
20.3 C. Nurses should emphasize that good perineal care, a generous fluid intake,
wearing cotton underwear, and avoiding bath salts are common ways to avoid
urinary tract infections so should be followed during pregnancy.
20.4 A. The nurse should alert care team members that because the fetus requires
calcium to build bones, calcium-surrounded tuberculosis lesions can be activated
if a woman doesn’t ingest adequate calcium.
20.5 B. The nurse should explain that continuous insulin administration with no food
intake can lead to hypoglycemia. Women should typically eat a high-
protein/complex carbohydrate snack such as peanut butter and celery before
bedtime to prevent fetal hypoglycemia from ingesting little food during the night.
20.6 A. The nurse should be concerned about Angelina wanting to “shed some
pounds.” Concerns about gaining weight and having to have a cesarean birth were
the two factors most associated with depression following pregnancy with
 gestational diabetes. Wanting to “shed some pounds” is suggestive of earlier
weight gain that is perceived as being excessive.

CHAPTER 21
Nursing Care of a Family Experiencing a Sudden Pregnancy
Complication
21.1 C. The nurse should advise saving any clots or material passed to help the
healthcare provider assess the amount of bleeding and whether the miscarriage
process is incomplete or complete and allows them to be assessed for the
possibility of gestational trophoblastic disease. A woman should not use a
tampon, so the amount of bleeding she is having can be evaluated. Vaginal
bleeding always needs to be investigated during pregnancy.
21.2 B. The nurse should check if Beverly received Rh immune globulin (RhIG or
RhoGAM) because it is the medication used to minimize the risk of
isoimmunization.
21.3 C. It is important for the nurse to assess for vaginal bleeding and clear fluid
leakage every shift. Vaginal examinations are contraindicated as this procedure
may cause bleeding. If the previa is not total, a cesarean birth may not be
necessary.
21.4 B. The nurse identifies assessing FHR and whether she is having contractions as
the best first actions. Walking stimulates contractions. Hydration, not
dehydration, may reduce contractions.
21.5 D. The nurse recognizes that edema is often a first symptom of gestational
hypertension a woman notes. The edema associated with gestational hypertension
can be separated from the typical ankle edema of pregnancy because it begins to
accumulate in the upper part of the body as well. Beverly’s other statements are
not necessarily indicative of gestational hypertension.
21.6 B. The nurse is aware that activities at work were not associated with
development of hypertension of pregnancy. Not taking time to eat regularly could
lead to fetal hypoglycemia and would be a significant concern that the nurse
should address.

CHAPTER 22
Nursing Care of a Pregnant Family With Special Needs
22.1 C. The nurse should support Mindy in her attempts to take responsibility for her
own care. Pregnant adolescents are emancipated minors so are capable of and
appreciate support for making healthcare decisions. It would be unwise for the
nurse to create a climate that would alienate the mother as, although an
emancipated minor, Mindy will still need the support and help of her mother.
22.2 C. The nurse should check Mindy’s lab results. Reticulocytes are immature red
blood cells that will start to grow rapidly if sufficient iron is available. Mindy’s
 oral report may or may not be reliable. Urine testing and assessment of her nail
beds are not reliable indicators.
22.3 D. Nurses should be aware that gestational hypertension is caused by marked
vasospasm and monitor women over the age of 40 years. Hypertension becomes
even more acute if blood vessels have limited elasticity, as in older individuals.
22.4 C. It is imperative for the nurse to provide information that is appropriate to the
patient’s cognitive level. The patient herself must not be excluded from
education. Written material is unlikely to be ideal.
22.5 D. The nurse should refer Mindy to addictions support services. Substance
dependence is such an all-encompassing phenomenon, and such women need
support from an interprofessional team because pregnancy is a long time to
remain drug free. Toxicology testing will confirm the type of substance being
abused but will not give Mindy support to quit. The nurse telling her to quit
without providing support would be futile.
22.6 B. The nurse should halt bleeding by putting pressure on the edges of the
laceration as the priority nursing action. This may be difficult to achieve in the
lower extremities because venous pressure is so greatly increased in the legs
during pregnancy. After cleansing and applying lidocaine, the area can be sutured
through each layer of tissue involved to approximate the edges.

CHAPTER 23
Nursing Care of a Family Experiencing a Complication of Labor or Birth
23.1 D. It would be important for the nurse to document the characteristics of
Rosann’s contractions to see if they are irregular; even though ineffective, they
are still painful so she needs pain relief.
23.2 C. The nurse would question her labor augmentation with oxytocin because with
a large fetus cephalopelvic disproportion may be present. Amniocentesis, elevated
blood pressure, and ruptured membranes do not contraindicate the use of
oxytocin.
23.3 C. Discontinuing the oxytocin infusion would be the nurse’s first step in the
management of Rosann’s change in labor progress. Turning to the left side and
increasing fluid are second and third steps.
23.4 D. Although not evidence based, the nurse would want team members to know a
hands-and-knees position appears to aid fetal occipital rotation more than the
other listed positions.
23.5 C. The research results revealed an increase in shoulder dystocia, which can result
in diaphragmatic paralysis. Because this affects breathing, it is the nurse’s
primary assessment taken after the birth.

CHAPTER 24
Nursing Care of a Family During a Surgical Intervention for Birth
24.1 C. A danger of amniotomy is that the fetal cord can prolapse which will interfere
with fetal circulation. This makes the nurse’s immediate assessment of the fetal
heart rate important.
24.2 A. The urinary catheter inserted by the nurse will keep the bladder empty.
Oxytocin contracts the uterus, not the bladder. Restricting fluid and administering
a diuretic could lead to fluid volume deficit.
24.3 C. Moja will want her dominant hand free to hold her baby after birth, so the
nurse needs to identify this. The nurse giving Moja this choice exemplifies
patient-centered care.
24.4 A. The nurse’s priority in this situation is to protect confidential health
information. Leaving or minimizing the record until the nurse who left it open
returns may expose Moja’s health information. Reporting this error to the nurse-
manager is not the immediate priority.
24.5 C. Women rated spontaneous vaginal birth as the most satisfying type. Nurses
should be knowledgeable about best evidence and use this knowledge to guide
their practice. A coworker’s personal experience might not be a reliable opinion.
Instrumental vaginal births were rated lower than cesarean sections, so it would
be inaccurate to describe all vaginal births as being more satisfying than all
cesarean births.
24.6 D. Moja needs reassurance from the nurse that incisional pain only lasts about 7
days following surgery. Although women need to be comfortable while
breastfeeding, many medications are contraindicated. Referral to a lactation
consultant may or may not be necessary, and the nurse should not insist on this
action.

CHAPTER 25
Nursing Care of a Family Experiencing a Postpartum Complication
25.1 D. The nurse should assess uterine tone and height for the potential to prevent
uterine hemorrhage. Collection of this assessment datum is a priority over
assessing the patient’s perineal care, oxygen saturation, or skin integrity.
25.2 C. The nurse would expect a human chorionic gonadotropin test to reveal a
retained fragment is present. Human chorionic gonadotropin hormone is produced
by the placenta. As a result, it will be present as long as any placenta is present.
Estrogen, progesterone, and oxytocin levels are not assessed for this purpose.
25.3 A. The nurse should advise that an upright position prevents pooling of infected
lochia. Supine, prone, and Trendelenburg positions should be avoided.
25.4 D. The nurse should promote early ambulation as a safeguard against the
development of blood stasis, which could lead to a blood clot. None of the other
listed measures is a prevention against venous thromboembolism.
25.5 B. The nurse is aware that according to the study, a depressed person would be
more likely to be withdrawn in behavior with the infant. In this case, the father is
 not talking to the baby yet. Misunderstanding an explanation does not necessarily
suggest a lapse in memory. The other statements are not suggestive of depressed
mood.
25.6 C. The nurse is aware that postpartum psychosis means a woman has separated
from reality, such as stating “I’m happy not to have any children.” Each of the
other statements can be linked to Bailey’s current reality.

CHAPTER 26
Nursing Care of a Family With a High-Risk Newborn
26.1 C. It is critical to guard against hypothermia in low–birth-weight infants because
they are unable to increase their metabolic rate to warm themselves. The study
revealed that stockinette caps alone are not adequate to do this. The nurse should
provide teaching to Mrs. Atkins regarding precautions to prevent hypothermia.
26.2 C. Developmental care is aimed at instilling a sense of safety and security into the
child by reducing stimuli such as loud noise or bright lights. The nurse
recommending a homemade blanket could give him a feeling of being sheltered.
None of the other listed actions would have this beneficial effect.
26.3 B. The nurse should teach Mrs. Atkins that surfactant is not a relaxant, and it does
not influence respiratory rate. It acts on the surface of the alveoli to help them not
to stick together upon expiration. Without surfactant, the sticky alveoli collapse,
the sides stick together, and are very difficult to inflate.
26.4 B. The nurse should flick the foot gently to stimulate the infant to remember to
breathe. Theophylline would not be an initial intervention. Both rectal
temperature assessment and vigorous suctioning can produce a vagal stimulation
causing bradycardia. In addition, the infant should only be suctioned as needed,
not every 2 hours.
26.5 B. Nurses should urge all mothers to breastfeed early. Early feeding enhances
bilirubin clearance. Infants should be in a well-lit environment to enhance binding
of bilirubin. Phototherapy is not initiated until the infant’s total serum bilirubin
level rises to a specific age- and gestational age–dependent level. An older
therapy, phenobarbital is rarely used today to combat neonatal jaundice.
26.6 A. The nurse should explain that if a woman with diabetes has hyperglycemia
during pregnancy; her baby is apt to be born large and lethargic—facts that are a
potential source of stress. The infant will not necessarily have diabetes, impaired
respiratory function, or cognitive deficits.

CHAPTER 27
Nursing Care of the Child Born With a Physical or Developmental
Challenge
27.1 A. The nurse should teach Maia to perform baby neck stretching exercises.
Simple neck stretching should relieve torticollis in infants. Giving aspirin with
 each feeding would result in an overdose and would not alleviate the problem.
Application of a warm towel is insufficient.
27.2 C. Pavlik harnesses seem simple, but because they hold the hip in adduction, they
are very effective. The nurse should state that they should be worn constantly
except for bathing. Looking at blog sites for specific care advice could supply
misinformation.
27.3 B. The nurse should role-model better interaction with the infant to demonstrate
warmer parent–child interactions. Although the mother may not realize she is not
reacting warmly to her child, people do not usually change behavior simply by
being told to change it.
27.4 D. The nurse should keep the herniated intestines moist to keep them from drying.
Warmth is important but not by a radiant heater because this would dry the bowel.
Resting on the abdomen could cause intestine to twist.
27.5 C. The nurse sitting the infant in an infant chair encourages the herniated bowel
to sink against the diaphragm, freeing up lung space. Lying on the left side allows
getter respirations in the unaffected lung.
27.6 C. The nurse should report changes in vital signs. Changes in vital signs with
increased cranial pressure are easy to remember because they move in opposite
directions: Temperature and blood pressure increase, and pulse and respiratory
rate decrease.

CHAPTER 28
Principles of Growth and Development
28.1 B. The nurse should explain that the lymphatic system reaches such a peak in
early school-age children; their throats appear to be “all tonsils.”
28.2 B. Young children in the study recognized what overweight was but were unable
to apply the concept to themselves. The nurse recognizes John’s inability to
connect his own appearance with the pictures is consistent with this tendency.
28.3 C. The interprofessional team should recognize that Freud stressed that school
age is a latent stage and that it is not a stage of great advancement.
28.4 D. The nurse should choose health promotions activities for John based on
Erikson’s theory that the developmental task of the school-age child is to learn
industry or to do things well.
28.5 A. The nurse recognizes that ascribing human properties to inanimate objects is
indicative of magical thinking.
28.6 C. The nurse understands that conservation is learning that two different shapes
can actually be equal in mass or volume, and John has not yet learned this
concept.

CHAPTER 29
Nursing Care of a Family With an Infant
29.1 C. Infants sit steadily at 8 months of age.
29.2 A. Children at 12 months usually say two words beside “ma-ma” and “da-da.”
They are not incapable of understanding, but they cannot express their needs
verbally.
29.3 A. Infants understand permanence when they look for someone or something out
of sight.
29.4 D. A mother who “always has a hot cup of coffee in her hand” could easily spill
that on the infant while giving care or holding the infant.
29.5 D. Aspiration and falls are the most frequent unintentional injuries in infants.
29.6 D. Focusing on abilities rather than inabilities promotes efficacy and well-being
among the family members of a child with unique needs. This practice
exemplifies patient-centered care. Lowering the family’s expectations is normally
inappropriate and unnecessary.

CHAPTER 30
Nursing Care of a Family With a Toddler
30.1 B. The nurse should reaffirm with Jason’s father that toddlers typically walk with
a wide-based gait. Strong arch support would not make a difference.
30.2 B. The nurse would expect 2-year-olds to speak with two-word, noun–verb
sentences.
30.3 D. The nurse should teach that television viewing for toddlers should be carefully
limited; they need supervision to prevent pulling a television onto themselves.
30.4 D. The nurse should teach that locking medicine or placing it out of reach is the
best safeguard. Young children can occasionally open childproof caps.
30.5 A. The nurse enforces the rule that a child should sit still in time-out for as many
minutes as his age. This seems like a short time, but for a 2-year-old, sitting still
for 2 minutes is a long time.
30.6 C. The nurse should advise that reducing the number of questions asked reduces
the number of times a toddler can say no. Reasoning with toddlers or mimicking
behavior is rarely effective.

CHAPTER 31
Nursing Care of a Family With a Preschool Child
31.1 C. Although this is variable, the nurse should point out that preschoolers typically
ask 300 to 400 questions a day.
31.2 B. The nurse should suggest that watching chosen DVDs could improve the
quality of video material to which Cathy is exposed. Cartoons are often violent.
TV should be carefully limited but does not necessarily need to be withheld until
age 5 years.
31.3 C. Allowing a child to use a night-light, inspecting the child’s room for objects
that look particularly scary after dark, and limiting the child’s television viewing
 to programs not as frightening are recommendations that the nurse can make to
help decrease a child’s fears.
31.4 D. The nurse should advise the parents to instruct their child not to leave daycare
with anyone but them or a designated person. If the parents wish, it is acceptable
to have a child’s fingerprints taken and recorded. It is not likely necessary to limit
Cathy to her own home. Describing kidnapping is likely to elicit fear.
31.5 A. It is important for the nurse to encourage women to maintain contact with their
preschooler during the short time they are hospitalized for the new birth. This
fosters family cohesion. Each of the other teaching points may be necessary, but
none so clearly promotes family bonding.
31.6 C. The nurse should state that sexual education should be approached in a clear
but age-appropriate manner. At this age, it is not normally necessary to address
sexual intercourse and its consensual nature.

CHAPTER 32
Nursing Care of a Family With a School-Age Child
32.1 D. The nurse can establish a sense of industry in Shelly by encouraging her to
complete small projects or tasks that offer a reward when completed.
32.2 C. The school nurse could state that clubs can potentially foster social interaction
between children whose interests are similar. Clubs are frequently single-gender,
and they do not always have formal rules and regulations.
32.3 A. The nurse should advise that heavy backpacks can put unnecessary strain on
the back of school-age children. School-age children still need assistance with
evaluating illness. Eating healthy to avoid being overweight should start before
18 years of age. Booster seats are usually unnecessary at this age.
32.4 D. The study documents the fact that injuries occur in cheerleading activities.
However, the nurse should state that taking part is likely of benefit, provided
Shelly is cognizant of some of the risks. No mention is made of weight or calcium
intake.
32.5 B. The nurse should teach that candy that dissolves rapidly remains in contact
with teeth for the shortest time. This may be associated with a reduced risk of
dental caries.
32.6 C. The nurse should acknowledge that smoking is viewed as an adult activity;
therefore, adopting the habit can be considered a giant step on the road to
adulthood. Antismoking interventions must acknowledge this reality. The media
are not known to have exaggerated the risks of smoking.

CHAPTER 33
Nursing Care of a Family With an Adolescent
33.1 B. The nurse should teach that apocrine glands, found predominantly in the axilla
and groin, are responsible for body odor. This problem does not result from
 sebaceous activity or ethnicity, and hygiene is not the major contributing factor.
33.2 A, B, C, D. The nurse recognizes that all the options represent tasks adolescents
must complete to achieve a sense of identity: emancipation, body image, values,
and career choice.
33.3 B. The nurse should counsel that medications should not be shared with other
people. The nurse should also teach the warnings and precautions involved with
the administration of this drug, including the fact that it is a teratogen.
33.4 C. The nurse would note that whether stalking is done in person or by the
Internet, continuous, unwelcome actions are stalking.
33.5 C. The nurse is aware that alcohol is identified as the gateway drug or is the one
which is most apt to lead to further substance use disorders, especially if parents
condone early use.
33.6 D. The nurse is aware that sniffing cocaine can cause loss of nasal hair. Upon
assessment, the absence of nasal hair would suggest more extensive cocaine use.

CHAPTER 34
Child Health Assessment
34.1 C. The nurse should teach the father that household products were swallowed
most commonly by young children. These are often stored below sinks in
bathrooms or kitchens. The nurse should question if these cabinets are locked if
they contain household products.
34.2 B. Parents may be unwilling to discuss a chief concern until they feel comfortable
with an interviewer. The nurse should provide an open-ended invitation to
address any outstanding issues that can sometimes reveal important data.
34.3 B. Blood pressure is routinely assessed beginning at 3 years of age; therefore, the
nurse can exclude this assessment in this case.
34.4 B. The nurse should be aware that gagging a child who has a swollen epiglottis
can cause the epiglottis to obstruct breathing.
34.5 D. The nurse identifies the fourth or fifth left intercostal space at the nipple line as
the best place to assess mitral heart valve closing, although this is not its
anatomical position.
34.6 D. The nurse teaches the father that human papillomavirus virus (HPV) vaccine is
typically administered at 11 to 12 years of age.

CHAPTER 35
Communication and Teaching With Children and Families
35.1 D. The nurse should perform teaching in personal space, which is a distance of
about 18 in. to 4 ft, or conversational space. It is most appropriate for face-to-face
teaching.
35.2 C. The nurse should be guided by the principle that technology has the potential
to enhance learning and communication, but it cannot wholly substitute for the
 nurse’s sophisticated and thoughtful interpersonal communication skills.
35.3 B. The nurse is teaching using cognitive learning, which is learning facts or
increasing knowledge. A and D are affective learning; C is psychomotor or skill
learning.
35.4 A. Video resources must be vetted by the nurse to ensure that the material
presented is evidence-based, safe, and age-appropriate.
35.5 C. Neither the Web-based/DVD program nor the face-to-face instruction was
demonstrably superior; therefore, the nurse could allow the child to choose which
delivery method he or she preferred.
35.6 C. When teaching a 3-year-old, the nurse would probably do best by playing a
game. Lecture, group discussion, and reading a pamphlet are all more advanced
than this child’s age level.

CHAPTER 36
Nursing Care of a Family With an Ill Child
36.1 A. The nurse confirms that Becky’s symptoms of anxiety may indicate separation
anxiety. Protest, the first stage of separation anxiety, is marked by loud, intense
crying.
36.2 D. The most significant outcome of teaching patients and their families about the
perioperative process was a reduction in their anxiety. As an outcome of
education, this is more important than being able to adhere to instructions,
describe asepsis, or explain the rationale for surgery. While providing teaching,
the nurse should also focus on reducing anxiety for the child and caregivers.
36.3 B. School children do best with small tasks and a feeling of reward. The nurse
should use a collaborative approach with the caregivers to encourage Becky to
drink more water in small glasses, which is also more likely to prevent nausea and
vomiting. Warning her of negative consequences is less likely to result in positive
outcomes.
36.4 D. A children’s hospital playroom is designated as a “pain-free” zone to help the
child cope with the stressors of hospitalization. Reducing the ill effects of
separation and hospitalization to the extent possible should be a high priority for
the nurse. The nurse should encourage parents to stay whenever possible and tell
the child if they need to be separated from them for a time. The nurse should
ensure all procedures are performed in the treatment room, not at bedside, so the
child feels comfortable in the hospital room.
36.5 D. The nurse is aware that blocks that are 1-in. square are the smallest items that
can fit in a toddler’s mouth easily. The nurse should teach the parents that any
item smaller than the internal roll on toilet paper is a dangerous size to be
aspirated. The other listed toys do not pose a serious risk of aspiration.
36.6 B. The nurse could have Becky handle a bandage to address specifically what is
happening to Becky. She can apply it to the foot and become more comfortable
 with the concept of a bandage. Therapeutic play materials are best if they are
most relevant to a child’s condition or procedures.

CHAPTER 37
Nursing Care of a Family When a Child Needs Diagnostic or Therapeutic
Modalities
37.1 C. The nurse should provide support during procedures using the least amount of
restraint possible. In this case, the help of another nurse to hold the hand steady is
the best choice. The mother may not be capable of restraining the child during the
procedure in a safe manner.
37.2 D. Most parents are anxious to have diagnostic tests done so their child’s illness
can be identified. The nurse should ask her why she feels the way she does, which
might reveal that she needs a better understanding of what an MRI involves.
37.3 C. The commercial device reduced pain by serving as a distraction. The nurse
should collaborate with the mother to select a distraction technique that would be
effective with Felipe because his mother may know what will work most best.
Pre- and postprocedure assessment will not necessarily reduce his anxiety and
pain. The nurse telling him that he or she will try to distract him may be
counterproductive.
37.4 B. The nurse giving Felipe a choice of fingers to use can interest him in the
procedure. Comparing him to other children his age or threatening the
withholding of privileges or treats is inappropriate nursing responses.
37.5 A. The nurse should start the 24-hour urine collections from the discard of the
first urine to ensure it is truly a 24-hour specimen.
37.6 A. Measuring the amount a child vomits (emesis) can be challenging if it spills
onto clothing or bed linen. When this happens, the nurse should estimate the
amount in relation to the amount of food or fluid the child recently ate and
include the number of episodes and a description of the vomitus. The nurse
should not delegate estimating the quantity of the vomitus to Felipe’s mother.

CHAPTER 38
Nursing Care of a Family When a Child Needs Medication
Administration or Intravenous Therapy
38.1 C. Any drugs are transported attached to plasma proteins; a deficit of these can
interfere with medication distribution. ABGs, gallbladder function, and renal
function are important assessments, but none directly gauges drug distribution.
38.2 C. In the absence of an ID band, the nurse should ask a parent to identify her.
Children may lie about their name or give a false name out of fear or being
playful.
38.3 C. The nurse should recommend that using something that dissolves easily, like
 ice, can allow children to practice swallowing in a safe and effective way.
Drawing a picture or tipping the child’s head forward is not effective. The nurse
should never refer to medicine as candy.
38.4 D. The nurse should keep the child’s head turned to the side to allow the
medication to stay in the ear longer and increase absorption. Self-administration is
unsafe and impractical. For a child older than age 2 years, the nurse should pull
the ear pinna up and back.
38.5 D. The nurse is aware that the point of watching television is to create a
distraction. If Terry is absorbed in her watching her present program, changing
the channel could exacerbate her pain by removing the distraction.
38.6 A. Reading a story to Terry is an appropriate distraction. To help guard the
stability of the intravenous site while still meeting her psychosocial needs, Terry
needs the nurse to initiate an activity which is quiet and which does not include
use of her hands.

CHAPTER 39
Pain Management in Children
39.1 B. The nurse would document somatic pain. Bone pain is somatic pain.
Cutaneous pain is skin pain; visceral is pain from body organs.
39.2 B. The nurse ensuring that the doses are correct is a priority; drug doses are based
on weight, not age. Site compatibility is irrelevant because the two drugs have
two different routes.
39.3 A. The nurse knows that the advantage of a patient-controlled pump is that it
offers the child a sense of control and rapid analgesia. Nursing care is not
reduced, and there is still a chance of adverse effects.
39.4 D. The nurse should instruct colleagues to tell the child she will be sleepy but
able to talk. This is a comforting and accurate explanation. It is inappropriate to
tell a child that he or she will be “knocked out.” A description of analgesia and
anesthetic is too technical for a 3-year-old.
39.5 C. Distraction techniques need to be individualized; therefore, that nurse should
ask the mother what technique is apt to be most successful. Reassuring the
parents before the procedure so they do not radiate extensive fear would be a
better action than asking them to leave or not talk.
39.6 C. Imagery requires a child to be able to replace a painful image with a
nonpainful one. This requires a working imagination, which is a characteristic of
childhood.

CHAPTER 40
Nursing Care of a Family When a Child Has a Respiratory Disorder
40.1 A. The nurse should advise the parent to pinch the lower part of the nose (alae
nasi) for 10 minutes without releasing pressure. The nurse should also advise the
 parent to keep the child in an upright position with his head tilted slightly forward
to minimize the amount of blood pressure in nasal vessels and to keep blood
moving forward, not back into the nasopharynx.
40.2 B. Choanal atresia is blockage of the posterior nares in newborns. The nurse may
assess this health problem by holding the newborn’s mouth closed, then gently
compressing first one nostril, and then the other. If atresia is present, infants will
struggle as they experience air hunger when their mouth is closed.
40.3 C. The nurse should teach the parents a full course of prescribed antibiotics is
necessary to prevent glomerulonephritis or rheumatic fever.
40.4 D. Cold decreases edema and promotes healing. Foods that are salty, have sharp
edges, or tarts are difficult to swallow and should be avoided.
40.5 D. Because initiating gagging may cause further airway closure, the nurse should
never elicit a gag reflex on children with a high fever, barky cough, and sore
throat. Instead, the nurse should assess his throat with simple inspection.
40.6 C. The nurse should instruct the child who is undergoing peak flow testing to
place the meter in his or her mouth and blow out as hard and fast as possible.

CHAPTER 41
Nursing Care of a Family When a Child Has a Cardiovascular Disorder
41.1 D. The nurse would be alerted to the mother’s comment that nausea and vomiting
are expected side effects for the first few weeks of treatment. Although nausea
and vomiting are side effects of digoxin (and many medications), the child would
not automatically experience these symptoms after initiation of the medication. If
the child does experience these symptoms, the provider should be contacted
immediately and the family should not wait several weeks. All of the other
statements are true.
41.2 B. Henry’s surgery to repair his VSD is open-heart surgery, performed through
the breastbone, and he does require cardiopulmonary bypass. But overall, children
who have a VSD repaired do very well. There was a recent study in 2017 where
the researchers noted that VSD surgeries overall go very well and infrequently
have significant complications. They did note that children with genetic
syndromes and low weight for age at the time of surgery do tend to have
prolonged ICU stays with longer mechanical ventilation times, but they ultimately
did well. Therefore, Henry may need his breathing tube in the ICU for a few days,
but he should recover without major complications.
41.3 D. The nurse should emphasize that after heart surgery requiring a median
sternotomy approach, infants and children will require 6 weeks for the sternum to
heal. Limiting participation in physical activities and heavy lifting (including
heavy backpacks for school) will ensure strong healing of the bone and minimal
pain for the child. During this time, children should not be lifted under their arms
or pulled by the arms as this will cause significant pain for the child. Infants
 should be scooped behind the neck and under their bottoms. Children should be
assisted by supporting behind the back. Surgeries that required a lateral
thoracotomy approach are also very painful, and maintaining these same
guidelines is appropriate. Regardless of the surgical approach, all children should
use car seat belts, booster seats, or car seats as recommended. Appropriate
placement and fit of these safety restraints will not harm the child after surgery.
41.4 B. The nurse notes that this heart rate is exceptionally high for a child of this age.
This rate and rhythm meet all of the criteria for SVT: The rate is greater than 160
bpm, it is a narrow complex that does not change with activity level, and the P
waves are not visible. Sinus tachycardia would most likely not have a rate this
high, and the P waves would be visible. Torsades de pointes is a chaotic and
pulseless rhythm so the child would not have other vital signs that were life
sustaining. Ventricular tachycardia in children is typically a very wide complex
rhythm; it may or may not have associated vital signs that are near normal. This
child has presented with classic symptoms, ECG, and onset pattern of SVT.
41.5 D. The nurse knows that regardless of the child’s underlying medical disorder or
etiology of a pediatric arrest, ensuring a patent airway and providing appropriate
respirations is paramount. Children more frequently experience a pure respiratory
decompensation or arrest prior to any cardiac involvement, even in children with
underlying cardiac disorders. Positioning the child in a sniffing position to ensure
an optimal airway and providing respiratory support through bag/mask ventilation
will likely reverse the bradycardia. Regardless, the nurse should begin with
respiratory support and provide cardiac support with compressions once the nurse
is able or when help arrives. The nurse should never leave a child who is
decompensating to retrieve equipment or personnel. As more personnel arrive,
they will fill the other necessary roles of CPR provider, documentation,
medications, and medical support.
41.6 C. It is important for the nurse to include the child when discussing management
strategies. Adolescents (and many school-age children) are quite capable of
participating in conversations about their health and wellness, and any treatment
plan will be better followed if the child was included in its development or has an
understanding of the importance of such a plan. Charlene needs to address not
only her diet but also her weight and most likely her activity level. By working
with both Charlene and her mother, the nurse’s treatment strategies are more
likely to be effective.

CHAPTER 42
Nursing Care of a Family When a Child Has an Immune Disorder
42.1 D. The nurse is aware that repeated exposures to latex can create allergies in
sensitive children. Distraction does not help protect his safety, and the use of a
new blood pressure cuff does not prevent allergic reactions.
42.2 A, C. A complete blood count with differential is always the best starting point to
evaluate a child like Dexter. Allergic children generally have a higher number or
proportion of eosinophils in the blood. Children with immunodeficiencies may
have elevated neutrophil counts if they have an active bacterial infection. At
baseline, a reduced lymphocyte count or percentage may be a “red flag” for an
immunodeficiency. Allergic children generally have elevated IgE levels, both the
overall serum IgE as well as allergen-specific IgE.
42.3 C. The nurse should teach that hyposensitization increases the number of IgG
immunoglobulins, which then block the action of IgE immunoglobulins that are
involved in an allergic response. Immunotherapy does not improve the broader
function of the immune system or protect against infection.
42.4 C. Epinephrine is the drug of choice for an anaphylactic reaction because it
quickly causes bronchodilation, immediately enlarging a constricted airway. The
nurse would administer 0.3 mg of the drug.
42.5 A. The nurse would deem treatment successful if the child is able to maintain age-
appropriate activities despite having allergies. “Curing” allergies is not always a
possibility.
42.6 B. The nurse knows that many accidental ingestions occur because food was
offered by another person. A willingness to share may include sharing food and a
consequent allergic reaction that would best be treated by an EpiPen.

CHAPTER 43
Nursing Care of a Family When a Child Has an Infectious Disorder
43.1 B. The nurse should stress handwashing and the role parents have in setting a
good example with this practice. Parents’ hand-washing practices were noted to
influence handwashing in their children. Frequent reminders, teaching children
about bacteria, and characterizing hand hygiene as “grown up” were not
specifically noted to be effective interventions.
43.2 C. The nurse knows that coughing and sneezing requires droplet precautions
(gloves, mask, and gown). If Jack wears a mask, there may be contaminated
surfaces in the room so the nurse needs to guard against these surfaces.
43.3 B. Although rating his pain would be informative, to stop the itching,
administration of an antihistamine by the nurse would be most effective. Children
need their hands free to facilitate self-care.
43.4 B. The nurse would assess for mono by evaluating the spleen by nontouching
maneuvers using the scratch test. The spleen enlarges to destroy the affected cells,
so the spleen could rupture easily on pressure. Petechiae should not be massaged;
percussion and the use of a Doppler are unnecessary during assessment.
43.5 C. Mumps cause a parotid gland enlargement without skin erythema in the
majority of patients. This enlargement will obscure the angle of jaw and therefore
is helpful from differentiating it from submaxillary adenitis (inflammation of
 lymph nodes). The best method of differentiation is to place a hand along the jaw
line. If the major amount of swelling is above the hand, it is probably mumps.
43.6 D. The nurse would inform the school nurse that scarlet fever is contagious for 1
to 7 days after the appearance of disease symptoms, so Jack will no longer be
infectious after a week. A faster return to school may result in the infection of
other children.

CHAPTER 44
Nursing Care of a Family When a Child Has a Hematologic Disorder
44.1 B. The nurse reassuring Lana’s mother that the consequent risks of infection will
be addressed acknowledges potential risks while still providing reassurance. It
would be inappropriate for the nurse to have the child’s mother restrain her during
a painful procedure. It would also be inaccurate to reassure her that this is a one-
time event.
44.2 A. The nurse knows the mother understands iron chelation therapy when she
states that the drug acts to remove excess iron from her child. Iron chelation
therapy removes excess iron from the body to prevent hemosiderosis. The mother
needs to assess voiding, not pulse, before administration.
44.3 B. The nurse could suggest that swimming would be a healthy and low-risk
activity. To protect the father, playing football would be inadvisable. Sedentary
activities are not an advantage for either father or son.
44.4 B. Pain control is paramount during sickle-cell crises. As a result, evidence of
adequate pain control is a nursing priority over positive expressions about his
time in hospital, even though these are certainly desirable. The nurse should
perform health education also, but pain control is the priority.
44.5 D. The nurse should inform the team members that autoimmune acquired
hemolytic anemia affects red blood cell counts and a CBC should be performed
promptly.
44.6 A. Idiopathic thrombocytopenia purpura (ITP) is a deficiency of platelets so the
nurse should caution Lana and her mother that Lana will bruise easily.
Assessments related to blood glucose levels, headache, and proteinuria are not
priorities.

CHAPTER 45
Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
45.1 C. The nurse would expect metabolic alkalosis, which occurs because of the loss
of gastric acid that occurs with emesis.
45.2 C. The nurse should teach that raw chicken is a potential source of Salmonella.
None of the other listed actions prevents this foodborne illness.
45.3 A. The nurse should assess the baby for vomiting immediately after feeding
because that is a symptom of pyloric stenosis. The vomiting occurs due to the
 thickened pylorus muscle causing a delay in gastric emptying.
45.4 B. The nurse recognizes that hepatitis A can be transmitted via fecally
contaminated shellfish. The nurse should advise parents to carefully consider the
origin of sushi or shellfish served to their family.
45.5 A. The nurse should keep the parents informed by encouraging daily interaction
with the medical team.
45.6 C. Kwashiorkor results from a deficiency of protein in the diet; therefore, the
nurse would anticipate the dietitian to prioritize quality protein in the diet.

CHAPTER 46
Nursing Care of a Family When a Child Has a Renal or Urinary Tract
Disorder
46.1 C. The nurse should keep in mind that because preschoolers have recently been
taught that voiding is a private activity, voiding while an X-ray is taken may feel
uncomfortable. Dye capsules are not used, and the test does not occur in a metal
tube.
46.2 C. The nurse realizes that the grandmother received adequate education on the
prevention of UTIs when she says she will be certain to administer all the
antibiotic pills prescribed. Taking the full antibiotic prescription helps prevent
recurrence of infection. Avoidance of dairy and exercise is unnecessary. The use
of bath salts is not recommended.
46.3 B. The nurse recognizes that the first symptom of poststreptococcal
glomerulonephritis is often bright red hematuria. Abdominal pain and joint pain
are atypical.
46.4 C. The nurse teaches the grandmother that testing for urine protein is important
with nephrotic syndrome because a large amount of protein is lost in urine. The
other listed actions do not directly address this health problem.
46.5 A, B, C, E. The following findings suggest to the nurse that Carey’s kidneys are
failing: Anemia develops from a lack of erythropoietin and vitamin D cannot be
synthesized, phosphorus cannot be excreted, and fluid overload causes
hypertension. Creatinine levels increase, not decrease, in cases of renal failure.
46.6 A. Parents thought support from healthcare professionals was important;
therefore, it was an appropriate action for the nurse to assure the grandmother that
she can call the clinic any time with questions. Asking the grandmother to keep a
journal or ignore family members could make her time management even more
stressful.

CHAPTER 47
Nursing Care of a Family When a Child Has a Reproductive Disorder
47.1 C. The nurse would teach the parents that although children with precocious
puberty appear older, they function at their chronologic age. Both sexes can be
 fertile even at such a young age. Dietary and activity restrictions are unnecessary.
47.2 C. The nurse would recommend that Navi participate in an exercise program.
Yoga may be an effective measure to reduce symptoms of dysmenorrhea.
Increased exercise intensity is not a guarantee of a proportionate reduction in
pain. The benefits of yoga were not limited to improved coping.
47.3 B. The nurse should teach Navi that polycystic ovary syndrome leads to obesity,
hirsutism, irregular menstrual cycles, and subfertility. It is not easy to reverse the
syndrome.
47.4 C. The nurse should counsel Navi that if having small breasts interferes with self-
esteem, a girl can have surgical augmentation, but this needs careful consideration
regarding whether it is necessary at this young age. There is no increase in disease
risk, and breastfeeding is unaffected.
47.5 C. The nurse would refer the adolescent for further treatment if she had a white,
cheese-like vaginal discharge. Candidal vaginal infections usually cause a thick,
pruritic, white vaginal discharge. All of the listed complaints warrant follow-up,
but they are not indicative of candidiasis.
47.6 A. The nurse needs to teach Navi that gonorrhea may be spread by singular sexual
contact. The disease has a bacterial etiology. All forms of sexual contact carry
risks, and saliva is not bactericidal.

CHAPTER 48
Nursing Care of a Family When a Child Has an Endocrine or a Metabolic
Disorder
48.1 A, B. The nurse should teach that growth hormone is an injectable and can be
discontinued in adolescence when full growth is achieved. It is not recommended
to take in the oral form.
48.2 C. The school nurse should be aware that hyperthyroidism increases metabolism,
so it leads to rapid, jittery movements.
48.3 C. A function of aldosterone is to retain sodium in the body.
48.4 D. The nurse understands that when children with diabetes first begin injections
of insulin, it “reminds” their pancreas to produce insulin, so for a short period, the
child may not need exogenous insulin administered or may need minimal
amounts.
48.5 B. The total amount of carbohydrates included in this lunch is 75 g. At a ratio of
1:10, he would inject 7.5 units of regular insulin.
48.6 A. Based on the study, the nurse would believe LaRoya’s family situation is not
ideal because she has lost friends. The study found that loss of friends had a
negative effect on quality of life. The other statements do not reflect an influence
on quality of life.

CHAPTER 49
Nursing Care of a Family When a Child Has a Neurologic Disorder
49.1 B. Neurologic examinations are lengthy so it’s difficult to keep children’s
attention unless the nurse presents the examination as being interesting. There is
no “pass” or “fail.” Alluding to the possibility of tumors or an “unhealthy brain”
will likely cause undue anxiety.
49.2 A. The nurse should inform Tasha that before a lumbar puncture is performed, the
lumbar region is cleansed with a solution that creates a temporary sensation of
cold. The procedure is not necessarily painless, and EMLA should be applied
approximately 1 hour beforehand. A side-lying position is used to perform a
lumbar puncture.
49.3 D. The nurse should teach the parents that as the child needs fine motor control to
achieve at writing or ambulating, the loss of function may seem more acute.
Cognitive and physical effects of the disease do not necessarily exist in the same
degree. Vaccinations do not cause cerebral palsy.
49.4 B. The nursing team should maintain respiratory precautions for at least 24 hours
following the beginning of antibiotic therapy.
49.5 B. The nurse should suspect depression when Tasha’s mother expresses sadness.
None of the other listed statements is as clearly suggestive of depression.
49.6 A, C, D. It is not likely a child would require a tracheostomy. The nurse should
have the call bell, suction, and supplementary oxygen available to maintain safety
and the integrity of the child’s airway.

CHAPTER 50
Nursing Care of a Family When a Child Has a Vision or Hearing Disorder
50.1 B. The nurse notes that the mother covering the stronger eye will encourage
central vision to develop in the weaker eye. Each of the other actions is
counterproductive.
50.2 C. The nurse teaches that wiping infectious discharge away from the other eye
prevents infection from spreading to the second eye. The other listed actions are
not indicated.
50.3 C. The nurse should prevent vomiting because increased intraocular pressure
from vomiting could disrupt a suture line.
50.4 C. The nurse is aware that the hallmark of glaucoma is increased intraocular
pressure.
50.5 D. The nurse would be concerned that he listens to music with earbuds. The study
showed that long exposure to loud noise may be responsible for lowering hearing
level in teenagers. An individual is more likely to listen at high volume when
using earphones (as when on a bus or in a subway car). Listening to computer
speakers may not be as loud.
50.6 B. The nurse recognizes that otitis media is an infection of the middle ear; otitis
externa is infection of the ear canal. Both diagnoses can be painful.
CHAPTER 51
Nursing Care of a Family When a Child Has a Musculoskeletal Disorder
51.1 C. The nurse should teach Jeffrey that it’s important to bear weight on his arms,
not his axillae, so nerves and blood vessels that cross at the axilla are not injured.
If crutches are properly fitted, there should be a space of 1 to 1½ in. between the
axilla crutch pad and the child’s axilla. The nurse should ensure that when Jeffrey
stands upright and places his hands on the hand rests of the crutches, the elbows
flex about 20 degrees. Stairs present a fall risk.
51.2 A. Osteomyelitis is a severe bone infection that needs IV antibiotic therapy to
ensure that microorganisms do not cause chronic infection and deformity. The
nurse’s vigilant administration of antibiotics is thus a priority over health
education, even though this should be performed. ADLs should be encouraged
within his current limitations. Fluid restriction is not indicated.
51.3 D. Application of heat and administration of a nonsteroidal anti-inflammatory
agent are first-line therapies for children with juvenile arthritis.
51.4 B. The nurse should prioritize preventing weight gain and encouraging the child
to be as mobile as possible to prolong function in muscular dystrophy as muscles
weaken. Purines and calcium are not focuses of dietary modifications.
51.5 B. The team members should be aware that an elbow cast that is too tight can lead
to compartment syndrome and result in permanent nerve damage. Frequent
neurovascular assessment is necessary, and this could be safely performed by the
LPN. Sepsis is not likely, and cleanliness of cast is not a priority over
neurovascular assessment.
51.6 A. The nurse should advise Jeffrey not to swing his sister by the arms. Holding
preschoolers by the arm and swinging them is the most common cause of a
traction injury. The other listed activities are not considered to be high risk.

CHAPTER 52
Nursing Care of a Family When a Child Has an Unintentional Injury
52.1 A. Based on Damashek and Corlis (2017) study, visual and proximity in
combination are predictive in preventing injuries
52.2 D. The nurse is aware that increasing temperature and blood pressure are marks of
increasing intracranial pressure. Amnesia is frequently seen with a head
concussion.
52.3 B. The appropriate nursing action is to administer acetylcysteine or activated
charcoal. Acetylcysteine is the specific antidote for acetaminophen poisoning;
activated charcoal may be given if no acetylcysteine is immediately available.
Educating the parents is important but is not the immediate priority.
52.4 D. The nurse would assess for paint chips in the home. Paint chips taste sweet so
children enjoy their taste; they are the most common source of lead poisoning in
children.
52.5 C. The nurse would recommend applying cool water to reduce the water
temperature and stop the burning as well as reduce the pain.
52.6 D. The nurse would instruct the care team to allow Sage to speak of the incident.
Being burned is such a frightening event, children need “debriefing” afterward, so
they are assured they are now safe and healing. The other listed actions are
appropriate.

CHAPTER 53
Nursing Care of a Family When a Child Has a Malignancy
53.1 D. The nurse confirms that hand hygiene prevents the mother from spreading
microorganisms to her son, but it does not protect her from the possible effect of
handling toxic drugs. The nurse needs to tell her to wear gloves to handle oral
chemotherapy agents. The other listed actions are appropriate.
53.2 C. The nurse would confirm the early signs of ALL are fatigue and leg bruises.
Because so many white blood cells are produced in cases of ALL, red blood cell
and platelet production falls leading to fatigue and bleeding disorders.
53.3 A. The nurse would confirm Hodgkin disease usually presents with a single
isolated lymph node and suspect its development. The other listed signs and
symptoms are not closely associated with this disease.
53.4 B. The nurse explains that straining to pass stool causes increased ICP. A
Trendelenburg position would rarely be used because this would increase ICP.
53.5 C. The nurse should inform Gerri’s mother that osteosarcoma is often discovered
when a sports injury causes an athlete to report pain or a swelling at the injury site
for some time, but sports injury is not the cause of osteosarcoma. Calcium intake
is unrelated.
53.6 C. The nurse should keep the child’s immediate surroundings free of plants,
flowers, and goldfish, all of which could harbor mold spores. If the child comes in
contact with the flowers at the nurse’s desk, it could still be an infection risk.

CHAPTER 54
Nursing Care of a Family When a Child Has an Intellectual or Mental
Health Disorder
54.1 C. The nurse understands that chronic sorrow is apt to be most acute at the time
of developmental milestones such as beginning first grade or high school
graduation.
54.2 C. The nurse recognizes that repetitive movements such as whirling, rocking, or
watching a spinning top are common symptoms of autistic spectrum disorder. The
other listed symptoms are not consistent with this health problem.
54.3 C. The nurses know that the most common side effects of methylphenidate
hydrochloride (Ritalin) are insomnia and lack of appetite. Weight gain and iron-
deficiency anemia are atypical.
54.4 B. Eating disorders in the study occurred more often in female athletes than in
nonathletes.
54.5 D. The nurse would check if Cheyenne received an assessment for depression.
Because tics are poorly understood, children who have them can be the victim of
bullying or teasing and develop low self-esteem.
54.6 D. The nurse would suspect schizophrenia after Cheyenne says she hears her
friends plotting against her at night. Hearing voices, or hallucinations, is a
prominent symptom of schizophrenia. The other listed statements are not
consistent with this disorder.

CHAPTER 55
Nursing Care of a Family in Crisis: Maltreatment and Violence in the
Family
55.1 A. The average parent describes their child in a positive manner. Stating that a
child is “not pretty” would alert the nurse to assess for child maltreatment because
it is considered to be more negative than describing her as “clumsy.”
55.2 B. The nurse would be alerted to shaken baby syndrome if retinal hemorrhages
develop. Shaking a baby causes small hemorrhages in the retina of the eye as well
as possibly more serious injuries such as subdural hematoma. Broken bones are
associated with maltreatment but not specifically with shaking.
55.3 B. According to this study, most adolescents reveal sexual maltreatment to a
trusted peer.
55.4 C. Children who have been physically maltreated may reveal the maltreatment
through having dolls simulate a sex act. The nurse should want to learn more
about their reaction, not stop the play.
55.5 A. The nurse should counsel that it is important to preserve any DNA evidence
that could reveal the identity of the rapist so a woman should not bath or shower
until after an internal examination. Property loss is comparatively insignificant,
and it would be highly inappropriate to address prevention at this time.
55.6 A. The nurse should be aware of the fact that intimate partner violent offenders
are often men who were raised in a household with violence.

CHAPTER 56
Nursing Care of a Family When a Child Has a Long-Term or Terminal
Illness
56.1 B. The nurse is aware that as with any crisis, support people can offer help and
guidance. Privacy and a belief in alternative therapies may not necessarily
enhance their coping skills. Wealth can be an asset during treatment but does not
necessarily help the family cope with the child’s illness.
56.2 C. The nurse assesses that the parents are in the fourth stage of grief or
 depression. This is the stage when parents start to realize death will happen.
56.3 D. The nurse notes that this is a mature question for a 3-year-old. Before
answering, it would be important to know why the child is asking the question.
Has he heard he is dying or just interested in what happened to a favorite cartoon
character he just saw “die” on television?
56.4 B. The nurse should inform nursing colleagues that anticipatory grieving can
make it hard for parents to relate to their child because they have already grieved
as if the child were dead.
56.5 A. The study revealed parents wanted most to just continue to be effective
parents. The nurse should promote enhancing his comfort by keeping him neat
and clean as the sort of activity that might meet that need. None of the other listed
actions would be normally appropriate.
56.6 A. The nurse should be aware that if a gag reflex is not intact, children can
aspirate easily. Hearing may not be lost; parents usually appreciate giving final
care.