Burns Pediatric Primary Care 7th Edition Test Bank

Burns Pediatric Primary Care 7th Edition Test Bank Related

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A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. How should the nurse interpret this action?

  • A. Normal development
  • B. Significant developmental lag
  • C. Slightly delayed development due to prematurity
  • D. Suggestive of a neurologic disorder such as cerebral palsy
Correct Answer: C

Rationale: At 3 months of age, most infants should be able to voluntarily grasp objects placed in their hands. This infant, who was born at 38 weeks of gestation, is showing signs of slight delay in development. Premature infants often have developmental delays, especially in motor skills, compared to full-term infants. The fact that the infant can hold a rattle if it is put in her hands is a positive sign, indicating that she is on the right track developmentally but might be a little behind schedule. Continuing to monitor the infant's progress and providing appropriate developmental stimulation can help promote further motor skill development. There is no indication at this point to suspect a significant developmental lag or a neurologic disorder like cerebral palsy without further assessment and observation.

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A nurse is doing an assessment on a newborn. Which is characteristic of a newborn's vision at birth and an expected finding during the assessment?

  • A. Ciliary muscles are mature.
  • B. Blink reflex is absent.
  • C. Tear glands function.
  • D. Pupils react to light.
Correct Answer: D

Rationale: At birth, a newborn's vision is not fully developed. However, one of the characteristics of a newborn's vision is that their pupils are able to react to light. This response helps to protect the newborn's developing eyes from excessive light exposure. During a newborn assessment, it is expected that the nurse will observe the pupil constriction in response to a bright light source, indicating a normal functioning of the pupillary reflex. This physiological response is vital for assessing the newborn's neurological integrity and visual function.

In terms of gross motor development, which should the nurse expect a 5-month-old infant to do? (Select all that apply.)

  • A. Roll from abdomen to back.
  • B. Put feet in mouth when supine.
  • C. Roll from back to abdomen.
  • D. Sit erect without support.
Correct Answer: A

Rationale: At 5 months old, an infant would typically be able to roll from abdomen to back (Choice A). This is an important gross motor skill that develops during this stage. Additionally, putting their feet in their mouth when lying on their back (Choice B) is also a common movement seen at this age. Both these actions demonstrate the increasing strength and coordination of the infant's muscles as they develop and explore their physical abilities. Rolling from back to abdomen (Choice C) and sitting erect without support (Choice D) typically develop later, around 6-7 months and 8-9 months, respectively. Moving from prone to sitting position (Choice E) and adjusting posture to reach an object (Choice F) are usually mastered around 8-9 months as well.

A 5 years old boy presents with joint swelling after minor trauma, mother gives history of prolonged bleeding from circumcision site. His platelets count is 170000, PT is 10 seconds and APTT is 60 seconds. What is most likely the diagnosis?

  • A. Idiopathic thrombocytopenic purpura
  • B. Platelets function defect
  • C. Von Willebrand disease
  • D. Hemophilia
Correct Answer: D

Rationale: Hemophilia is characterized by prolonged APTT with normal platelet count and PT, indicating a coagulation factor deficiency.

A 12-year-old male has short stature because of a constitutional growth delay. What should the nurse be the most concerned about?

  • A. Proper administration of thyroid hormone
  • B. Proper administration of human growth hormones
  • C. Child's self-esteem and sense of competence
  • D. Helping child understand that his height is most likely caused by chronic illness and is not his fault
Correct Answer: C

Rationale: The nurse should be most concerned about the child's self-esteem and sense of competence. A 12-year-old male with short stature due to a constitutional growth delay may experience feelings of inadequacy or embarrassment because of his height. It is important for the nurse to address these emotional aspects of the condition and support the child in developing a positive self-image. By promoting the child's self-esteem and sense of competence, the nurse can help the child navigate any challenges associated with his height and build confidence in his abilities and worth as an individual.

An 18-year-old with a groin rash and itching is worried about having an STD and does not want his parents to know. What should the nurse say?

  • A. We will need to contact your parents.
  • B. We will not contact your parents regarding this visit.
  • C. Who would you like us to contact about your visit today?
  • D. We cannot promise that the hospital will not contact your parents.
Correct Answer: B

Rationale: Adolescents have the right to privacy regarding sexual health, unless there is a risk to life.

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