Tiêu đề WORKBOOK - PEDIA (SC).pdf ✅

Situation: A full-term baby boy is delivered an hour ago via NSD. 39. For which of the following findings should the nurse notify the physician? A. Absent Pupillary reflex B. Expiratory grunt C. Respiratory rate of 40 breath/minutes D. Full breast areola 40. Which of the following assessment findings would alert the nurse that a newborn needs special attention? A. birth weight of 3,500 grams B. APGAR score of 3 C. positive babinski reflex D. RBC = 6 million/cu mm 41. The following are true in Apgar Scoring except: A. done by the birth attendant at 1 minute then 5 minutes after baby’s birth B. must have a perfect score of 10 at one minute to guarantee baby’s survival C. determines prioritization of the baby’s care after birth D. shows capability of the baby to adapt to extra-uterine life Situation: The nurse is caring for a neonate delivered by cesarean section at 43 weeks’ gestation. The neonate weighed 7 lbs, 8 oz. and had Apgar score of 7 at 1 minute and 9 at 5 minutes. 42. While assessing the neonate, the nurse explains to the mother that post-term neonates typically have A. soft, oily skin B. a long, thin body C. very few sole creases D. abundant lanugo 43. Soon after delivery, the neonate receives an injection of Vitamin K. The nurse explains to the mother that Vitamin K is given to the neonate because A. neonates have no gastrointestinal bacteria B. neonates are susceptible to clotting disorders C. hemolysis of the fetal red blood cells destroys vitamin K D. the neonate’s liver does not produce vitamin K 44. In caring for a newborn the nurse should consider the following normal EXCEPT: A. meconium which colored greenish black is passed 20 hours after birth B. yellow discoloration of skin and sclera 6 hours after birth C. secretions coming from slightly engorged breast D. urine is colorless, odorless Situation: A nurse is assigned at the NICU. During endorsement rounds the nurse performs her assessment of the newborn. 45. A newborn’s bilirubin level is 12mg/dl. The Doctor ordered Phototherapy. Which of the following interventions is NOT appropriate? A. Covering eyes and scrotum with an opaque mask B. Exposing the infant’s skin to light, turning q2h C. Assess capillary Blood glucose q6h D. Measure Intake and output 46. Which of the following interventions is done in order to hasten the excretion of Direct Bilirubin in a Newborn? A. Gentle exercise to stop muscle breakdown B. Keep Infant in a warm & dark environment C. Administration of oxygen supplement D. Early feeding Situation: Nurse Pauline works in a children’s clinic and helps with care for well and ill children of various age. 47. A nurse performs physical assessment to a two-month-old infant. Which of the following findings would require further investigation? A. Closed anterior fontanelle B. Symmetrical magnet reflex C. Multiple mongolian spots D. Positive moro reflex 48. An infant’s parent says “The soft spot near the front of my baby’s head is still big. When will it close?” The nurse’s best response would be at A. 2 to 4 months B. 5 to 8 months C. 9 to 11 months D. 12 to 18 months 49. When providing instructions regarding play to a mother of a 4-month old infant, the nurse should include which of the following? A. A rattle is an appropriate toy for baby this age B. A teething ring is an appropriate toy for baby his age. C. The baby should be provided with a playpen where he can roll over D. The mother can play peek-a-boo with the baby to stimulate cognitive development 50. When developing plan of care for a child, the nurse identifies which Eriksonian stage as corresponding to Freud’s oral stage of psychosexual development? A. Initiative vs. Guilt B. Autonomy vs. Shame & Doubt C. Industry vs. Inferiority D. Trust vs. Mistrust 51. A mother of a 5-month-old baby asks the nurse which tooth typically erupts first? A. lower central incisor B. upper central incisor C. lower lateral incisor D. upper lateral incisor 52. When teaching the mother on accident prevention on a 6-month-old infant, the nurse should emphasize that at this age the infant can usually A. sit up B. roll over C. crawl lengthy distances D. stand while holding on a furniture 53. An infant’s developmental task in the psychosocial theory is “trust vs mistrust”. Which of the following interventions will help the infant develop trust? A. Attend to the infant’s needs B. Motivate to explore and produce C. Allow child to make simple choices D. Encourage creativity and imagination 54. When obtaining vital signs on a sleeping 3-month old infant, which of the following assessments would the nurse obtains first A. Respiratory rate B. Apical pulse C. axillary temperature D. blood pressure 55. A 2 1⁄2-year-old child is brought with her 2-month-old sibling to the clinic by his father, who explains that the older child says “no” whenever asked to do something. The nurse would explain that the negativism demonstrated by toddlers is frequently an expression of A. a need to expend excess energy B. a pursuit of autonomy C. separation anxiety D. sibling rivalry 56. A father brings his 18 month old son to the clinic. He asks the nurse why his son is so difficult to please, has temper tantrums, and annoys him by throwing food from the table. The nurse should explain that A. Toddlers need to be disciplined at this stage to prevent the development of antisocial behaviors B. The child is learning to assert independence, and his behavior is considered normal for his age C. This is the usual way that the toddler expresses his needs during the initiative stage of development D. It is best to leave the child alone in his crib after calmly telling him why his behavior is unacceptable 57. Ear drops, instilled twice a day, are prescribed for a 2 year old child. When observing the parent instilling the drops, the nurse decides the teaching concerning how to position the ear lobe when instilling drops is effective when the parent pulls the toddler’s ear lobe A. up and forward B. up and backward C. down and forward D. down and backwards 58. Mrs. Wallace expresses concern because Robby has begun thumb sucking which he had previously outgrown. The nurse would note this behavior as: 3 | Page