C have the child flex the knees and look for uneven

c. Have the child flex the knees and look for uneven knee height.
d. Look at the childs shoulders and hips while fully clothed.
ANS: A
The nurse looks at the back as the child bends forward for general body alignment and asymmetry.
DIF: Cognitive Level: Application REF: Page 570-571
OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. What nursing action will significantly decrease the risk of serious complications for a child in Bryants
traction?
a. Neurovascular checks are done frequently.
b. Bandages are wrapped tightly.
c. The child is restrained from rolling over.
d. The childs buttocks are resting on the bed.
ANS: A
The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is
obstructed.
DIF: Cognitive Level: Application REF: Page 562 OBJ: 7
TOP: Traction: Volkmanns Ischemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid
arthritis?
a. Wearing splints at night to prevent extension contractures
b. Applying moist heat packs upon awakening
c. Taking a warm tub bath the evening before
d. Sleeping with two pillows under the head
ANS: B
Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness.
DIF: Cognitive Level: Application REF: Page 569 OBJ: 12
TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Implementation

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015) 223
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?
a. Wear the brace directly against the skin.
b. Wear the brace over regular clothing.
c. Wear the brace over a T-shirt 23 hours a day.
d. Remove the brace before sleeping.
ANS: C
A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protects the skin.
DIF: Cognitive Level: Application REF: Page 570 OBJ: 13
TOP: Scoliosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. Which observation may cause the nurse to consider the possibility of child abuse when a mother says that
her young child fell down the basement stairs?
a. Red, green, and yellow bruises on his body
b. Bruises are dispersed on his head, arms, and legs
c. A broken arm last year, and the child being described as accident-prone
d. The mother is very anxious for her son to get medical attention
ANS: A
As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all
occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of
what happened.