Ati nurs 37500 maternal newborn exam 3
Total Questions : 35
Showing 25 questions, Sign in for moreA 20-month-old is in what stage according to Erikson's stages of psychosocial development?
Explanation
Choice A rationale
The Industry vs. Inferiority stage, according to Erikson, occurs from age 6 to puberty, where children focus on learning, developing skills, and striving for competence. A 20-month-old
child is not yet in this stage.
Choice B rationale
The Trust vs. Mistrust stage is the earliest stage in Erikson's theory, occurring from birth to about 18 months. While a 20-month-old child has recently transitioned out of this stage, it
is not the stage applicable to their current developmental phase.
Choice C rationale
The Autonomy vs. Shame and Doubt stage occurs from approximately 18 months to 3 years. At 20 months, children are striving for independence, making choices, and developing a
sense of self-control, which is characteristic of this stage.
Choice D rationale
The Initiative vs. Guilt stage occurs from ages 3 to 6 years, where children begin to assert power and control through directing play and other social interactions. A 20-month-old child
is not in this stage yet.
A nurse is caring for a newborn who was born to a mother with gestational diabetes. The newborn is large for gestational age.
The nurse should recognize which of the following newborn complications as the priority focus of care?
Explanation
Choice A rationale
Monitoring for hypoglycemia is critical in newborns born to mothers with gestational diabetes, as they can experience significant drops in blood sugar levels post-birth due to the
sudden discontinuation of the high glucose supply from the mother.
Choice B rationale
Physiological jaundice is common in many newborns but does not represent the most immediate threat. It typically resolves within a few days with appropriate monitoring and care.
Choice C rationale
Hyperthermia can be a concern for newborns, but it is not the primary immediate complication in newborns born to gestational diabetic mothers. Hypoglycemia poses a greater
immediate risk.
Choice D rationale
Development of rash is generally a less critical concern and does not represent an immediate threat to the newborn’s well-being in comparison to hypoglycemia.
A nurse is teaching about crib safety with the parent of a newborn.
Which of the following statements by the client indicates understanding of the teaching?
Explanation
Choice A rationale
Placing a baby’s crib next to a heater can pose a risk of overheating or burns. Newborns should be kept at a safe distance from heaters to prevent accidents.
Choice B rationale
Removing extra blankets from the crib is recommended to reduce the risk of suffocation and sudden infant death syndrome (SIDS). This choice reflects an understanding of crib safety.
Choice C rationale
Padding the mattress can pose suffocation risks and is not recommended. A firm mattress without any padding is the safest option for newborns.
Choice D rationale
Placing a baby on their stomach to sleep increases the risk of SIDS. The recommended sleeping position for newborns is on their back, as this significantly reduces the risk.
A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic.
Which of the following information should the nurse include in the discharge instructions?
Explanation
Choice A rationale
While knowing the adverse effects of medication is important, understanding why the child is taking the medication is crucial for ensuring adherence and proper administration.
Choice B rationale
Stopping medication when the child feels better can lead to incomplete treatment and antibiotic resistance. This is incorrect advice to give to parents.
Choice C rationale
Knowing the reason for taking the medication ensures that parents understand its importance, which promotes adherence to the prescribed regimen.
Choice D rationale
Using a kitchen spoon to administer medication can lead to inaccurate dosing. A proper measuring device, such as an oral syringe, should be used.
An infant grabbing things with their entire hand before developing a pincer grasp is an example of what direction of growth?
Explanation
Choice A rationale
Proximodistal development refers to growth from the center of the body outward to the extremities. An infant grabbing with their whole hand (palmar grasp) before developing a
pincer grasp demonstrates this pattern, as they gain control of arm movements before fine motor skills in the fingers.
Choice B rationale
Cephalocaudal development refers to growth from head to toe, such as gaining control over head and neck muscles before the limbs. This does not directly explain the grasping
behavior described.
Choice C rationale
Distoproximal is not a recognized term in developmental science and does not describe a growth pattern.
Choice D rationale
Top-to-bottom is another way of describing cephalocaudal development but does not specifically address the described behavior in grasping development. .
A nurse is providing health promotion teaching to the parents of a toddler.
Which of the following information should the nurse include in the teaching?
Explanation
Choice A rationale
Toddlers are at a stage where they are increasingly curious and mobile, which requires close supervision to ensure their safety. They are also prone to tantrums as they test
boundaries and express frustration due to limited communication skills. Effective management of tantrums and supervision can help parents guide their child's behavior and ensure
their safety.
Choice B rationale
Solitary play and identity development are more characteristic of older children. Toddlers engage more in parallel play, where they play alongside other children but not directly with
them. Encouraging solitary play is not as developmentally appropriate for toddlers.
Choice C rationale
Establishing trust is crucial in infancy when infants learn to trust their caregivers to meet their needs. Dental care should start around the toddler years, but the primary focus should
be on supervision and behavior management rather than dental care initiation.
Choice D rationale
Establishing relationships and developing self-confidence are vital across all developmental stages, but in toddlers, the priority lies in providing a safe environment and guiding
behavior through supervision and tantrum management.
A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery.
He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what APGAR Score for this infant?
Explanation
Choice A rationale
An APGAR score of 5 indicates significant distress and poor adjustment to extrauterine life, which is not consistent with the provided description of the infant's condition.
Choice B rationale
An APGAR score of 6 suggests moderate difficulty with extrauterine adaptation, which is still not entirely consistent with the overall assessment of the infant.
Choice C rationale
An APGAR score of 7 aligns with the described observations of the newborn: pink trunk and head, bluish extremities, active movement, heart rate of 130/min, and a response to
suctioning, which suggest the infant is in reasonably good condition with some minor issues that need monitoring.
Choice D rationale
An APGAR score of 8 would indicate that the newborn is in very good condition with only slight adjustments needed, which does not fully match the infant's description with the noted
issues like a weak cry and bluish extremities.
A nurse is assessing a 4-month-old infant on a pediatric unit.
Which of the following findings should the nurse expect?
Explanation
Choice A rationale
A pincer grasp, using the thumb and index finger to pick up small objects, typically develops around 9 to 12 months of age, not at 4 months.
Choice B rationale
The posterior fontanel typically closes by the age of 2 to 3 months, so a 4-month-old infant would be expected to have a closed posterior fontanel. This finding is consistent with normal development.
Choice C rationale
Lateral incisors, the teeth on either side of the front teeth, typically erupt around 9 to 13 months of age, not at 4 months.
Choice D rationale
Sitting steadily without support generally occurs closer to 6 to 8 months of age, so it would not be expected in a 4-month-old infant.
A nurse is teaching a parent of a 6-month-old infant about car seat safety.
Which of the following statements by the parent indicates an understanding of the teaching?
Explanation
Choice A rationale
A front-facing car seat for an infant does not provide adequate protection in the event of a collision. Infants should always be in a rear-facing car seat to support their head, neck, and spine.
Choice B rationale
Using an infant model car seat designed specifically for the car ensures that the seat meets safety standards and is appropriate for the child's size and developmental needs, providing optimal protection.
Choice C rationale
Being able to fit a hand between the baby and the car seat harness indicates the harness is too loose. The harness should be snug enough that only one or two fingers can fit between the strap and the baby's chest to provide secure restraint.
Choice D rationale
A rear-facing car seat should not be placed in the front passenger seat due to the risk of injury from airbags. The safest position for a rear-facing car seat is in the back seat, away from active airbags.
A 22 lb child is prescribed ibuprofen 10 mg/kg every 6 hours.
The medication is available as 100 mg/5 mL. How many mL will you give per dose? (Round the answer to the whole number.)
Explanation
Answer and explanation
11: Step 1 is (22 lb ÷ 2.2) = 10 kg.
Step 2 is 10 kg × 10 mg = 100 mg.
Step 3 is (100 mg ÷ 100 mg) × 5 mL = 5 mL. Answer: 5 mL
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment.
The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
Explanation
Choice A rationale
Preterm newborns have underdeveloped mechanisms for thermoregulation, making it difficult for them to maintain stable body temperatures without external assistance.
Choice B rationale
Preterm newborns do not sweat significantly because their sweat glands are not fully developed; thus, this rationale is incorrect.
Choice C rationale
Preterm newborns actually have a larger body surface area relative to their weight, contributing to their difficulty in maintaining body temperature.
Choice D rationale
Preterm newborns have insufficient brown fat, not an excess, which impairs their ability to generate heat effectively.
The nurse is providing car seat safety education to the parent of an 18-month-old.
Which statement by the parent requires the nurse to re-educate them about this topic?
Explanation
Choice A rationale
AAP guidelines recommend rear-facing car seats for children under 24 months due to superior protection in a collision.
Choice B rationale
The chest buckle should be at armpit level to prevent injury in case of a crash.
Choice C rationale
Switching to a forward-facing car seat at 12 months contradicts safety recommendations; the child should remain rear-facing until at least 2 years old.
Choice D rationale
Car seats should always be placed in the back seat to minimize risk from front airbags during collisions.
In which of the following areas should a nurse administer an injection for a newborn infant?
Explanation
Choice A rationale
The deltoid muscle is not recommended for newborns due to its small size and underdevelopment.
Choice B rationale
The vastus lateralis muscle is well-developed in newborns and has a large enough surface area to safely accommodate injections.
Choice C rationale
The gluteus maximus muscle is not suitable for newborn injections due to the risk of nerve damage.
Choice D rationale
The rectus femoris muscle is less commonly used due to the potential for more pain and discomfort.
A parent asks the nurse why the newborn is getting a vitamin K injection in the birth room.
The nurse explains that the injection is necessary because:
Explanation
Choice A rationale
Vitamin K has no role in stabilizing blood glucose levels; hypoglycemia in newborns is managed differently.
Choice B rationale
Vitamin K is essential for blood clotting, and newborns typically have low stores at birth, necessitating supplementation to prevent bleeding disorders.
Choice C rationale
There is no established link between maternal fever and the need for vitamin K; prophylaxis is standard for all newborns regardless of maternal health.
Choice D rationale
Newborns do not have sufficient prothrombin or other clotting factors, which is why vitamin K administration is critical.
A nurse is assessing a toddler at a well-child visit.
At what point in the physical examination should the nurse examine the child's tympanic membrane?
Explanation
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
A nurse is planning care for a 4-year-old child who requires isolation and airborne precautions.
Which of the following activities should the nurse plan for this child?
Explanation
Choice A rationale
Constructing a model airplane may require smaller parts and more intricate work, not ideal for a 4-year-old child.
Choice B rationale
Putting together a large-piece puzzle is suitable for fine motor skills development and can be done while in isolation.
Choice C rationale
Playing in the hallway would expose the child to other areas and people, defeating the purpose of airborne precautions.
Choice D rationale
Watching a video game in the playroom is not feasible as it would require leaving the isolation area.
A nurse is caring for a newborn immediately following birth.
After assuring a patent airway, what is the priority nursing action?
Explanation
Choice A rationale
Administering vitamin K is important but not the immediate priority right after birth.
Choice B rationale
Administering eye prophylaxis is also necessary but comes after ensuring the newborn is dry to prevent heat loss.
Choice C rationale
Placing an identification bracelet is crucial but not as immediate as drying the skin to regulate the baby's temperature.
Choice D rationale
Drying the skin is the priority to prevent hypothermia by reducing evaporative heat loss right after birth
A nurse on a postpartum unit is giving discharge instructions for a client whose newborn had a circumcision with the Gomco clamp.
Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)
Explanation
Choice A rationale
Keeping the diaper loose in the front helps avoid pressure on the circumcision site, promoting healing and reducing discomfort for the infant.
Choice B rationale
A yellow crust or exudate forming on the circumcision site is a normal part of the healing process and should not be a cause for alarm. It is not an indication to call the doctor immediately unless other signs of infection or complications are present.
Choice C rationale
Notifying the healthcare provider in the case of significant bleeding is crucial. Excessive bleeding can indicate a complication that requires prompt medical attention to ensure the infant's safety and proper healing.
Choice D rationale
Applying petroleum jelly with each diaper change helps to protect the circumcision site from sticking to the diaper, promoting healing and reducing discomfort.
A nurse is preparing to administer a vaccine to a 4-year-old child.
Which of the following vaccines should the nurse administer?
Explanation
Choice A rationale
Hepatitis B (HepB) is typically given at birth and in subsequent doses but isn't scheduled for 4-year-olds.
Choice B rationale
Meningococcal (MenACWY) vaccine is generally recommended for older children and adolescents.
Choice C rationale
Varicella (VAR) vaccine is recommended for children around 4 years old to protect against chickenpox.
Choice D rationale
Human papillomavirus (HPV) vaccine is recommended for preteens starting at age 11, not 4-year-olds.
According to Piaget's Theory of Development, what stage would an 11-month-old be in?
Explanation
Choice A rationale
Preoperational stage starts around age 2 to 7 years, characterized by symbolic thinking.
Choice B rationale
Concrete operational stage starts around age 7 to 11 years, involving logical thinking about concrete events.
Choice C rationale
Sensorimotor stage (birth to 2 years) is when infants know the world mostly in terms of their sensory impressions and motor activities.
Choice D rationale
Formal operational stage begins at approximately age 12 and involves abstract and hypothetical thinking.
A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb.
The amount available is acetaminophen 120 mg/5 mL.
How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
Step 1 is to convert the child's weight from pounds to kilograms: 28 lb ÷ 2.2 lb/kg = 12.727 kg.
Step 2 is to calculate the dose: 10 mg/kg × 12.727 kg = 127.27 mg.
Step 3 is to determine how many mL is needed: 127.27 mg ÷ (120 mg/5 mL) = 5.3029 mL.
Step 4 is to round to the nearest tenth: 5.3 mL. Final answer: 5.3 mL
A nurse is providing care to a 1-year-old and has noted negativism.
Which statement by the nurse to the toddler will help decrease negativism when administering medications to the toddler?
Explanation
Choice A rationale
This choice offers the toddler control and options within boundaries. By allowing the child to choose between two cups, it reduces the power struggle inherent in negativism, where the child often says "no" to assert independence.
Choice B rationale
This choice presents a direct option of now or later, which may still lead to refusal due to the toddler's negativism. Toddlers often respond better to choices that are less direct.
Choice C rationale
Asking if the child can take the medicine is likely to result in a "no" due to the nature of negativism at this developmental stage. It does not give the toddler a sense of control or choice.
Choice D rationale
Asking the child to be "good" places a moral judgment on taking the medicine, which is not developmentally appropriate and may lead to resistance.
A nurse is providing care to a 2-year-old and has noted negativism.
Which statement by the nurse to the toddler will help decrease negativism when administering medications to the toddler?
Explanation
Choice A rationale
Giving the toddler a choice between two cups helps to decrease negativism by providing options that still achieve the desired outcome, thereby reducing the likelihood of refusal.
Choice B rationale
Asking the child to take medicine now offers no real choice and is likely to be met with resistance, which is characteristic of negativism in toddlers.
Choice C rationale
This question is too open-ended and can easily be refused, as it does not provide a sense of control or choice for the toddler.
Choice D rationale
Telling the child they "need" to take medicine is directive and authoritarian, which often triggers negativism and a refusal.
The community health nurse is providing teaching to parents of a 10-month-old infant about home safety.
Which of the following statements, if made by the parent, would show the need for further teaching?
Explanation
Choice A rationale
Storing a firearm in a top drawer is unsafe, even if it is out of the child’s immediate reach. Firearms should be securely locked in a location inaccessible to children.
Choice B rationale
Locking cleaning products under the sink is a safe practice to prevent accidental poisoning, demonstrating correct safety precautions.
Choice C rationale
Placing safety covers on electrical outlets is a safe practice to prevent electrical shocks, indicating proper home safety measures.
Choice D rationale
Installing safety gates at the top and bottom of stairs is a recommended safety measure to prevent falls, showcasing awareness of proper childproofing.
The nurse would assess respirations in a 9-month-old infant when the client is:
Explanation
Choice A rationale
Playing might cause irregular breathing patterns due to excitement or activity, making it hard to get an accurate respiratory rate.
Choice B rationale
Crying can alter the normal breathing rate and pattern, resulting in an inaccurate assessment of respirations.
Choice C rationale
Sleeping provides the most accurate assessment of respirations, as the infant’s breathing will be at its natural, resting rate.
Choice D rationale
Laughing, similar to crying, causes irregular breathing patterns due to physical exertion and emotions, affecting accuracy.
Sign Up or Login to view all the 35 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
