Unit 1

A maternity nurse is providing instruction to a new mother regarding the

psychosocial development of the newborn infant. Using Eriksons psychosocial
development theory, the nurse would instruct the mother to
a. Allow the newborn infant to signal a need
b. Anticipate all of the needs of the newborn infant
c. Avoid the newborn infant during the first 10 minutes of crying
d. Attend to the newborn infant immediately when crying
Rationale:
According to Erikson, the caregiver should not try to anticipate the newborn infants
needs at all times but must allow the newborn infant to signal needs. If a newborn is
not allowed to signal a need, the newborn will not learn how to control the
environment. Erikson believed that a delayed or prolonged response to a newborns
signal would inhibit the development of trust and lead to mistrust of others.
Unit 2
A client and her husband are positive for the sickle cell trait. The client asks the
nurse about the chances of her children having sickle cell disease. Which of the
following is appropriate response by the nurse?
a.
b.
c.
d.

one of her children will have sickle cell disease

only the male children will be affected
each pregnancy carries a 25% chance of the child being affected
is she had four children, one of them would have the disease

Rationale:
In autosomal recessive traits, both parents are carriers. There is a 25% chance
with each pregnancy that a child will have the disease.

Unit 3
Which of the following should the nurse do first after noting that a child with
Hirschsprung disease has a fever and watery explosive diarrhea?
a. Notify the physician immediately
b. Administer antidiarrheal medications
c. Monitor child every 30 minutes
d. Nothing, this is characteristic of Hirschsprung disease
Rationale:
For the child with Hirschsprung disease, fever and explosive diarrhea indicate
enterocolitis, a life-threatening situation. Therefore, the physician should be notified
immediately. Generally, because of the intestinal obstruction and inadequate

propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung

disease. The child is acutely ill and requires intervention, with monitoring more
frequently than every 30 minutes. Hirschsprung disease typically presents with
chronic constipation.
Unit 4
A nurse is caring for an infant with spina bifida cystica (meningomyelocele type)
who had the sac surgically removed. The nurse plans which of the following in the
postoperative period to maintain the infant's safety?
a) covering the back dressing with a binder
b) placing the infant in a head-down position
c) strapping the infant in a baby seat sitting up
D) elevating the head with the infant in the prone position
Rationale:
Elevating the head will decrease the chance of cerebrospinal fluid collecting in the
cranial cavity. The infant needs to be prone for several days to decrease the
pressure on the surgical site on the back. Binders and a baby seat should not be
used because of the pressure they would exert on the surgical site