Chapter 012

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 12: Conception Through Adolescence
MULTIPLE CHOICE
1. Which of the following data is the most important for the nurse to assess when caring for
a woman in her second trimester of pregnancy?
1. Detection of fetal movement
2. Observation that the uterus is below the pubis
3. Confirmation of the desire to breast- or bottle-feed
4. Determination of the presence of morning sickness
ANS: 1
During the second trimester, between 16 and 20 weeks gestation, the mother begins to
feel fetal movement. During the second trimester, the uterus should be above the level of
the symphysis pubis. Confirmation of the desire to breast- or bottle-feed is more likely to
take place during the third trimester. Morning sickness is most likely to occur during the
first trimester.
DIF: C
REF: 151
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and
Maintenance/Ante/Intra/Postpartum and Newborn Care; Physiological
Integrity/Reduction of Risk Potential/System Specific Assessments
2. Which one of the following newborn reflexes should the nurse be able to elicit at a 6month well-baby visit?
1. Moro
2. Startle
3. Babinski
4. Extrusion
ANS: 3
The Babinski reflex is a normal reflex found in a 6-month-old infant. The Moro reflex is
seen in the newborn. The startle reflex is seen in the newborn. Before 6 months of age,
the extrusion reflex causes food to be pushed out of the mouth. It is normally present
from birth to 4 months.
DIF: A
OBJ: Knowledge TOP: Nursing Process: Assessment
3. In evaluating an infants physical status and growth, the nurse expects to find:
1. Birth weight triples by 6 months
2. Anterior fontanel closes 4 to 8 weeks after birth
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
12-2
3. Chest circumference is larger than head circumference at 12 months

4. Birth height increases 1 inch each month for the first 6 months
ANS: 4
Height increases an average of 1 inch during each of the first 6 months and inch the
next 6 months. Birth weight doubles in approximately 5 months and triples by 12 months.
The anterior fontanel closes at about 12 to 18 months. The head and chest circumference
are equal at 1 year of age.
DIF: A
REF: 155
OBJ: Knowledge
4. Upon evaluation of a 6-month-old infants developmental status, the nurse expects that
the child at this age will be able to:
1. Completely roll over
2. Pull self to a standing position
3. Creep on all four extremities
4. Assume a sitting position independently
ANS: 1
A 6-month-old infant is able to roll over. A 9-month-old infant is able to pull self to a
standing position, creep on all four extremities, and attain a sitting position
independently.
DIF: A
OBJ: Knowledge TOP: Nursing Process: Assessment
MSC: NCLEX test plan designation: Health Promotion and Maintenance/Growth and
Development; Physiological Integrity/Reduction of Risk Potential/System Specific
Assessments
5. For a 2-year-old child, cognitive development is characterized by:
1. Recognizing right and wrong
2. Initiating play with other children
3. Having a vocabulary of at least 1000 words
4. Using short sentences to express independence
ANS: 4
A 2-year-old child uses short sentences to express independence and control, does not
understand the concepts of right and wrong, may engage in solitary play and begin to
participate in parallel play, may initiate play with other children, and has a vocabulary up
to 300 words.
DIF: A
REF: 159
OBJ: Knowledge
Test Bank
12-3

Assessments
6. In planning nursing care for an 18-month-old child, the nurse should know that the
predominant developmental characteristic of children this age is:
1. Parallel play
2. Peer pressure
3. Mutilation anxiety
4. Imaginary playmates
ANS: 1
During toddlerhood, the child begins to participate in parallel play, which is playing
beside rather than with another child. Peer pressure is seen with the school-age child. A
fear of the preschool child is bodily harm. The preschool child may have imaginary
playmates.
DIF: A
REF: 159
OBJ: Knowledge
TOP: Nursing Process: Planning
Assessments
7. The nurse, in working with children of this age, plans to allow a 5-year-old boy who was
admitted to the surgical center to have his tonsils removed to:
1. Perform his own preoperative hygienic care
2. Have alone time to relax before the procedure
3. Handle the equipment when taking his blood pressure
4. Have access to age-appropriate magazines and puzzles for diversion
ANS: 3
Preschool children may cooperate if they are allowed to manipulate the equipment. A
preschooler is unable to take responsibility for his or her own preoperative hygienic care.
Leaving the preschooler alone may increase the childs anxiety. Magazines and puzzles
would be more appropriate activities for the older child. The preschool child likes to
engage in pretend play, using their imagination and imitating adult behavior.
DIF: A
REF: 160
OBJ: Comprehension
Assessments
8. A parent of a 3-year-old boy states that she is concerned because he was potty trained
long before hospitalization but now refuses to use the toilet. What is the correct response
by the nurse?
1. Your son is probably feeling neglected, and you should make an effort to spend
more time with him.
Test Bank
12-4
2. This is common behavior that is expressed when the hospitalized child is stressed
or anxious.
3. You may need to include discipline because children easily lose the ability to be
toilet trained during hospitalization.
4. Your son was probably not ready to be potty trained, and you may want to
continue the training for the next 6 months.
ANS: 2
During times of stress or illness, preschoolers may revert to bed-wetting or thumbsucking and want the parent to feed, dress, and hold them. Reassuring the parent that this
is normal coping behavior may help alleviate their concern. Reverting to a prior level of
functioning, such as a child who was potty trained now refusing to use the toilet, does not
indicate the child is feeling neglected. The behavior demonstrates that the child is
experiencing stress and this is a coping behavior. Disciplining the child would not be a
correct response. The child should be provided with experiences he or she can master.
Such successes help the child to return to their prior level of independent functioning.
Reverting to a prior level of functioning, such as a child who was potty trained now
refusing to use the toilet, does not indicate the child was unready to be potty trained. The
behavior more likely demonstrates that the child is experiencing stress, and this is a
coping behavior.
DIF: A
REF: 161
OBJ: Comprehension
Assessments
9. A 4 1/2-year-old child is crying from pain related to her fractured leg. Which of the
following is the most appropriate nursing response to her alteration in comfort?
1. Please try to not move your leg and that will make it feel better.
2. Ill give you a shot of medicine that will help take the pain away.
3. Its okay if you need to cry. Would you like to hold your favorite doll?
4. Would you like to tell me now where you want me to give you your shot?
ANS: 3
Telling the child its okay to cry and hold a toy informs the child what they can do, and
involves an age-appropriate familiar toy to provide comfort. Telling the child not to move
when they are in pain is unlikely to be effective. A preschool child may have difficulty in
understanding the request. Telling the child they are going to get a shot may increase their
anxiety, as they fear bodily harm. If a child is allowed to determine the site for
administration of an injection, specific sites should be offered as choices. However, the
nurse needs to avoid allowing procrastination by the child.
DIF: A
REF: 160
OBJ: Comprehension
Test Bank
12-5
Assessments
10. When teaching basic infant safety to the parents of a 3-month-old, the nurse should
emphasize:
1. Placing gates at stairways
2. Keeping bathroom doors closed
3. Giving large, hard teething biscuits
4. Removing feeding bibs at bedtime
ANS: 4
Bibs should be removed at bedtime to avoid suffocation. Placing gates or fences at
stairways is an appropriate safety measure to prevent falls of the 8- to 12-month-old
infant. Keeping bathroom doors closed is an appropriate safety measure to prevent
drowning of the 8- to 12-month-old infant. Caution should be exercised when giving
teething biscuits to a 4- to 7-month-old infant because large chunks may be broken off
and aspirated. Teething biscuits are typically not given to a 3-month-old.
DIF: A
REF: 156
OBJ: Comprehension
Assessments
11. The parents of a 3-month-old ask the nurse what behavior they should expect. The nurse
informs the parents that the child will be able to:
1. Say Da-da
2. Smile responsively
3. Differentiate strangers
4. Play social peekaboo games
ANS: 2
Two- and 3-month-old infants begin to smile responsively rather than reflexively. By 1
year of age, infants have two- or three-word vocabularies such as Da-da. By 8 months,
most infants can differentiate a stranger from a familiar person. By 9 months, infants play
simple social games such as patty-cake and peekaboo.
DIF: A
REF: 155
OBJ: Comprehension
Assessments
12. A client in her first trimester of pregnancy asks the nurse about how the baby is growing.
The nurse responds correctly by telling the client that:
1. The sex of the baby can be determined.
2. There is a fine hair that covers the body.
3. Fingers and toes are differentiated clearly.
Test Bank
12-6
4. The organ systems are beginning to develop.

ANS: 4
During the first trimester of pregnancy, the organ systems are beginning to develop.
During the second trimester of pregnancy, the sex of the fetus can be determined, and fine
hair, called lanugo, covers most of the body of the fetus. Also during the second trimester
of pregnancy, fingers and toes are differentiated.
DIF: A
REF: 150
OBJ: Comprehension
13. The nurse assists the family of a 9-year-old with nutritional information. A recommended
after-school snack for a child this age is:
1. Milk shakes
2. Potato chips
3. Plain popcorn
4. Bite-size candy
ANS: 3
Plain popcorn, fresh fruit, raw vegetables, cheese, skim-milk pudding, and hot chocolate
are appropriate after-school snacks. Thick milk shakes would be high in fat and calories.
There are better food choices for after-school snacks. Potato chips should be discouraged
as a snack because they are high in fat and low in nutritional value. Candy bars should be
discouraged as a snack because they are high in fat and calories, are low in nutrition, and
are cariogenic.
DIF: A
REF: 168
OBJ: Comprehension
Assessments
14. The elementary school nurse is responsible for evaluating each childs overall physical
development. During the school-age years, the nurse anticipates that:
1. The childs body weight will almost triple
2. There will be few physical differences among children
3. The child will grow an average of 1 to 2 inches per year
4. Body fat will gradually increase, contributing to a heavier appearance
ANS: 3
Test Bank
12-7
During the school-age years, the child will grow an average of 1 to 2 inches per year and
gain an average of 4 to 7 pounds a year. Many children double, not triple, their weight
during these middle childhood years. Growth accelerates at different times for different
children. There will be many physical differences apparent among children at the end of
middle childhood. The school-age child appears slimmer as a result of changes in fat
distribution and thickness.
DIF: A
REF: 164
OBJ: Comprehension
Assessments
15. A 6-year-old is hospitalized for asthma. Which of the following activities would be
appropriate to help this child resolve the crisis of hospitalization?
1. Crayons and a coloring book
2. A 1000-piece puzzle to complete
3. A CD player with soothing CDs
4. A Nerf football to throw around the room
ANS: 1
Providing a 6-year-old with crayons and a book to color in would be an age-appropriate
activity to help the child with the crisis of hospitalization. Painting, drawing, playing
computer games, and making models allow children to practice and improve newly
refined skills. A 1000-piece puzzle would be too much for a 6-year-old to complete. A CD
player with soothing CDs would not be an age-appropriate activity for a 6-year-old.
Throwing a Nerf football around the room may not be appropriate for a hospitalized child
with asthma.
DIF: A
REF: 164
OBJ: Comprehension
Assessments
16. Which one of the following statements is correct regarding the preadolescence
developmental stage?
1. It appears 2 years earlier in boys than in girls.
2. Intimate feelings are confided in the parents.
3. Interest in the opposite sex is not a factor for this group.
4. It signals the development of secondary sex characteristics.
ANS: 4
The preadolescence developmental stage (puberty) signals the development of secondary
sex characteristics. Physical changes often begin 2 years earlier in girls than in boys.
Preadolescents usually develop best friends with whom they share intimate feelings.
New interest in the opposite sex develops in the preadolescence developmental stage.
Test Bank
12-8
DIF: A
REF: 167
OBJ: Knowledge
Assessments
17. The nurse is teaching parents about probable warning signs that a teenager is considering
suicide and tells parents to be alert to:
1. An increase in appetite
2. A sudden interest in school activities
3. An unexplained increase in sleepiness
4. Talking about death and personal harm
ANS: 4
A warning sign that a teenager is considering suicide includes verbalization of suicidal
thoughts. Appetite disturbances, usually a decrease in appetite, may be a warning sign
that a teenager is considering suicide. A decrease in school performance and loss of
initiative are possible warning signs that a teenager is considering suicide. Sleep
disturbances, such as the inability to sleep, are a warning sign for suicide.
DIF: A
REF: 172
OBJ: Knowledge
TOP: Nursing Process: Implementation
Assessments
18. In order to obtain the most information, which of the following is the most appropriate
question asked of a 14-year-old female who is visiting the county health center for birth
control help?
1. Have you told your parents that you are sexually active?
2. Are any of your friends participating in sexual behaviors?
3. What can you tell me about any of your past sexual activities?
4. Have you been physically protecting yourself with safe sex measures?
ANS: 3
The nurse can be proactive by using the interview process and open-ended questions such
as this one, to identify risk factors in the adolescent. Once identified, the risk factors
should lead to strategies for prevention. Inquiring what the client has told parents does
not obtain the most information. Asking about friends activities does not address the
individual and does not obtain the most information about the health behaviors of the
client. Asking whether the client is having safe sex may be answered with a yes or no
response and therefore does not obtain the most information.
DIF: A
REF: 173-174
OBJ: Comprehension
Test Bank
Development; Physiological Integrity/Reduction of Risk Potential+G1222
12-9

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Potter & Perry: Fundamentals of Nursing, 7th Edition

3. Chest circumference is larger than head circumference at 12 months

Development; Physiological Integrity/Reduction of Risk Potential/System Specific

4. The organ systems are beginning to develop.

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