Davis Nclex RN - Nursing Care of the Pediatric Client

Which nursing intervention should a nurse perform on a young child suspected of having a diagnosis of acute epiglottitis whose oxygen saturation measures 93% on room air? A) Allow the child to sit in a position of comfort. B) Provide small amounts of liquid orally via a syringe. C) Inspect the child's nares to assess degree of swelling. D) Apply 100% oxygen via mask.

A) Allow the child to sit in a position of comfort. Rationale - The child with acute epiglottitis is likely to be restless and agitated due to the progressive airway obstruction. The child should be allowed to maintain a position of com- fort (e.g., sitting upright) to avoid further agitation and impaired oxygenation.

A school nurse is creating an informational brochure for parents regarding the treatment of head lice. What form of treatment should the nurse caution against? A) Applying repeated doses of permethrin for as long as it takes until the infestation clears. B) Washing all clothing and linens in hot water followed by drying them in a hot dryer. C) Wearing gloves when washing the child's hair or inspecting for nits. D) Removing nits daily from the child's hair with a fine- tooth comb.

A) Applying repeated doses of permethrin for as long as it takes until the infestation clears. Rationale - Although permethrin is an over-the-counter medication for the treatment of pediculosis (head lice), repeated doses may become toxic over time; parents should be cautioned against such treatments. A nurse should stress that nonpharmacologic treatments such as nit removal may be more effective and pose less risk to the child.

A nurse prepares to administer a chelating agent to a child with lead poisoning. Which laboratory tests should be obtained prior to the administration of this agent? A) BUN and creatinine. B) PT, PTT. C) Urine specific gravity. D) CBC.

A) BUN and creatinine. Rationale - The chelating agent binds with lead and is excreted by the kidneys; therefore, normal kidney function should be established beforehand; blood urea nitrogen (BUN) and creatinine provide the best evidence of function.

A nurse would be most correct in withholding digoxin (Lanoxin) prescribed to an infant if the heart rate falls below which parameter? A) Below 100 beats per minute. B) Below 120 beats per minute. C) Below 140 beats per minute. D) Below 160 beats per minute.

A) Below 100 beats per minute. Rationale - digoxin (Lanoxin) should be withheld if the heart rate of the infant falls below 90 to 110 beats per minute (bpm). If digoxin (Lanoxin) is given when the infant's heart rate is 100, the resulting cardiac output may not be adequate.

Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome who is hospitalized awaiting the second stage of surgical repair? Select all that apply. A) Call physician for oxygen saturations below 85%. B) Daily weights. C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute. D) Strict I&O. E) Enfamil formula ad lib.

A) Call physician for oxygen saturations below 85%. C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute. E) Enfamil formula ad lib. Rationale - The nurse should question an order that requires the nurse to call the physician for an oxygen saturation that is appropriate for an infant waiting surgical repair for a severe cyanotic heart defect. This parameter is too low. The heart rate should be at least 100 when administering digoxin (Lanoxin) to an infant. An infant with a con- genital heart defect frequently requires formula with extra calories per ounce. Regular Enfamil formula would not provide sufficient calories.

While suctioning a child with a tracheostomy tube in place, a nurse discovers that the suction catheter will not advance inside the tracheostomy tube and the child is becoming pale and anxious, with noticeable suprasternal retractions. What should be the nurse's priority action? A) Change the tracheostomy tube at once. B) Instill normal saline into the tracheostomy tube and attempt suctioning again. C) Obtain a pulse oximetry reading. D) Auscultate lung sounds.

A) Change the tracheostomy tube at once. Rationale - The child is displaying symptoms of respiratory distress due to tracheostomy occlusion since the nurse is unable to pass the catheter through the tracheostomy tube. This is an emergency requiring the nurse to promptly change the tracheostomy tube.

A nurse is working with a nursing student in the care of a young child status post-appendectomy. The student checks the current order of IV gentamicin and discovers the ordered dose is above the safe dose range based on the child's weight. What should be the nurse's first action? A) Check the child's recent lab work. B) Contact the physician. C) Order a hearing test. D) Obtain an order for BUN and creatinine.

A) Check the child's recent lab work. Rationale - The nurse should first check the child's recent laboratory work to see if a gentamicin level has been done. The physician may have increased the dose of IV gentamicin above the safe dose range if the child's gentamicin level fell below that which is effective. The safe dose range is the starting point for this medication, but the dose is then increased or decreased to achieve therapeutic blood levels.

A nurse enters the room of a child following the placement of a ventriculoperitoneal shunt. The child is sitting up in bed, crying, and has vomited a small amount on the bed linens. What are the priority nursing actions? Select all that apply. A) Complete a neurological assessment. B) Place the child in the supine position. C) Administer the antiemetic as ordered. D) Complete a pain assessment. E) Increase the child's IV rate.

A) Complete a neurological assessment. C) Administer the antiemetic as ordered. D) Complete a pain assessment. Rationale - The nurse should assess the child thoroughly to determine whether the child's neurological status has changed since the last assessment. Nausea and vomiting are common following neurosurgery. The antiemetic should be administered because vomiting needs to be prevented since it increases intracranial pressure (ICP). Determining the child's pain level should be part of the physical assessment. It is expected that the child may have pain from this surgery.

A hospitalized child is experiencing sickle cell vaso-occlusive crisis. The child is currently receiving an intra- venous (IV) fluid bolus, pain medication every 4 hours, and warm compresses to the extremities per physician orders. During the midday assessment, the child reports no pain. Which action should a nurse take? A) Continue to apply warm compresses per physician order. B) Hold the next dosage of pain medication. C) Hold the next round of warm compresses. D) Contact the physician for a change in orders.

A) Continue to apply warm compresses per physician order. Rationale - The child is currently receiving a fluid bolus, which may be providing temporary improvement of pain symptoms. Ongoing application of warm compresses will continue to promote circulation in the extremities, thereby preventing pain. Once the fluid bolus is completed, the nurse should reassess the child's pain and circulation.

A child is admitted with acute exacerbation of asthma. A physician orders 100% oxygen via mask. Which physician order should be a nurse's next priority? A) Continuous inhaled albuterol. B) IV Solu-Medrol 2 mg/kg loading dose. C) IV fluids at maintenance rate. D) Chest x-ray.

A) Continuous inhaled albuterol. Rationale - The nurse's priority is to alleviate airway inflammation, and administration of a beta agonist such as albuterol is recommended.

An infant is admitted for probable pyloric stenosis. A physician orders IV fluids and makes the infant NPO pending a surgical consult. The infant is crying vigorously and the parents express frustration that they cannot feed their baby even though the surgery is not yet definite. Which is the best action for the nurse to take now? A) Explain to the parents that feeding an infant with pyloric stenosis can lead to electrolyte imbalances from possible vomiting. B) Offer the parents a pacifier for the infant. C) Place a call to the surgeon to find out how long it will be before the consult. D) Feed the infant a small amount of Pedialyte since the surgical repair for this condition will most likely not occur until the following day.

A) Explain to the parents that feeding an infant with pyloric stenosis can lead to electrolyte imbalances from possible vomiting. Rationale - The best action for the nurse is to help the parents under- stand that the NPO status is to avoid vomiting. This message should be delivered while expressing empathy for the situation.

A physician prescribes digoxin (Lanoxin) for a toddler with congestive heart failure (CHF). Before administering the medication, it is most important for the nurse to: A) First obtain an apical heart rate. B) Determine the serum potassium. C) Review the child's admission electrocardiogram (ECG). D) Mix the medication with a pleasant-tasting food.

A) First obtain an apical heart rate Rationale - Apical heart rate must be obtained by the nurse prior to the administration of digoxin (Lanoxin) to a child. Unless otherwise prescribed, the medication is typically withheld for a heart rate below 90 to 110 bpm in young children

An infant is admitted to a pediatric unit with labored breathing and moderate amounts of thick nasal secretions. What nursing intervention is most likely to improve the infant's oxygenation? A) Frequent suctioning of the nares with a nasal olive. B) Providing supplemental oxygen via nasal cannula. C) Strict monitoring of oxygen saturation levels. D) Placing the child in an infant seat.

A) Frequent suctioning of the nares with a nasal olive. Rationale - Infants are obligatory nose breathers. A nurse should attempt to keep nasal passages open through frequent suctioning with a nasal olive.

When teaching a class on home safety to new parents, on which type of exposure should a nurse focus as the primary cause of lead poisoning in children? A) Ingesting paint dust or chips from an old home. B) Having a parent who works near lead products. C) Riding in a car that uses leaded gasoline. D) Chewing on pencils with lead tips.

A) Ingesting paint dust or chips from an old home. Rationale - The primary means of lead exposure in children results from ingestion. The presence of lead-based paint should be suspect- ed in homes built prior to the late 1970s when these paints were discontinued. Children can ingest paint chips or dust by chewing on contaminated surfaces such as windowsills, and they can become exposed by playing in contaminated soil.

A school-age child visits a school nurse and states that a family member has been behaving inappropriately by touching the child near the groin area. What should be the school nurse's priority action? A) Make a report to the proper child protective authorities as mandated by law. B) Contact the child's parents to share what the child has reported. C) Question the child to determine all of the details of the inappropriate touching. D) Provide the child with a safe and calm environment in which to continue the discussion.

A) Make a report to the proper child protective authorities as mandated by law. Rationale - The nurse's priority is to fulfill the legal duties of a mandated reporter by contacting the agency responsible for taking reports of suspected child abuse.

An infant in a newborn nursery is identified as having phenylketonuria (PKU). What is the best initial source of nutrients for an infant with this diagnosis? A) Maternal breast milk. B) Pregestimil. C) Lofenalac. D) Isomil.

A) Maternal breast milk Rationale - The child with PKU is missing the enzyme needed to digest the amino acid phenylalanine. Maternal breast milk has many beneficial properties and it contains low levels of phenylalanine. Therefore, breast milk should be given until laboratory findings demonstrate the child is not tolerating the breast milk.

A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What are the priority nursing diagnoses related to this child's care? Select all that apply. A) Risk for infection. B) Impaired elimination. C) Risk for injury. D) Disturbed body image. E) Chronic pain. F) Activity intolerance.

A) Risk for infection. C) Risk for injury. D) Disturbed body image. F) Activity intolerance. Rationale - Children with beta-thalassemia are at increased risk for infection due to the impaired oxygen-carrying capacity of their blood. These children are at risk for injury from an increased destruction of red blood cells. As red blood cells die, iron is released with deposits in the liver and spleen, enlarging these organs and impairing their function while also causing vomiting from abdominal pressure. These children may experience bone deformities, growth retardation, and delayed maturation of the sexual organs. These symptoms (e.g., broad forehead, short stature, immature appearance) may be troubling for an adolescent, whose main concern is to fit in with the peer group. Chronic hypoxia results from the production of abnormal red blood cells. If the body does not have sufficient red blood cell production, oxygen is not supplied to the tissues adequately, leading to activity intolerance and fatigue.

What assessment findings should a nurse expect in a child with acute post-streptococcal glomerulonephritis? Select all that apply. A) Severe hematuria. B) Pallor. C) Decreased urine specific gravity. D) Weight gain. E) Headache. F) Massive proteinuria.

A) Severe hematuria. B) Pallor. D) Weight gain. E) Headache. Rationale - The child with acute glomerulonephritis has large amounts of red blood cells in the urine due to ruptured glomerular capillaries. Pallor is a symptom of acute glomerulonephritis as a result of anemia. The child with acute glomerulonephritis gains weight due to fluid retention. The child with acute glomerulonephritis may have a headache as a result of hypertension caused by hypervolemia.

In developing a plan of care for a hospitalized preschooler, a nurse recognizes that it is most essential to consider: A) That the child may believe the hospitalization is a punishment. B) Ways to provide visitation from peers. C) How to incorporate play activities with other children. D) Ways to promote privacy and independence.

A) That the child may believe the hospitalization is a punishment. Rationale - Preschoolers may perceive hospitalization as a punishment. The nurse should create a plan of care that reassures the child and helps the child understand the reasons for hospitalization.

When providing client teaching to the caregivers of a young child with sickle cell disease, a nurse should stress that: A) The child's diet should include whole grains and leafy green vegetables. B) Immunizations should be delayed until the child enters school. C) There is a 50% chance that the child's future offspring will have sickle cell anemia. D) The parents should request IV Demerol if the child is hospitalized with pain crisis.

A) The child's diet should include whole grains and leafy green vegetables. Rationale - These foods are high in fiber and folic acid. Fiber prevents constipation, a potential side effect of pain medication, and folic acid is needed for healthy red blood cell production.

A nurse is planning to teach a group of 10-year-old children about drug and alcohol prevention. Which characteristics of this age group are important for the nurse to consider when developing the teaching plan? Select all that apply. A) These children are achievement-oriented. B) They expect good behavior to be rewarded. C) Their problem-solving approach tends to be concrete and systematic. D) The central persons in their lives tend to be friends. E) These children are nearing puberty.

A) These children are achievement-oriented. B) They expect good behavior to be rewarded. C) Their problem-solving approach tends to be concrete and systematic. D) The central persons in their lives tend to be friends. E) These children are nearing puberty. Rationale - This is a developmental characteristic of the school-age child. The teaching plan should include activities that allow the children to succeed, such as games with a drug-free focus. This is a developmental characteristic of the school-age child. The teaching plan should provide for rewards (e.g., giving children pencils with fun slogans in exchange for signing a no-drug pledge form). This is a developmental characteristic of the school-age child. The teaching plan should include basic steps for avoiding substance abuse, such as ways to refuse substances when offered by peers. This is a developmental characteristic of the school-age child. The teaching plan should remind children that the majority of their peers do not abuse illicit substances. This is a developmental characteristic of the school-age child. The teaching plan should include discussions regarding physical and emotional consequences of substance abuse in boys and girls.

A nurse teaches a child with spina bifida how to perform urinary self-catheterization. Which steps should the nurse include in the teaching? Place each correct step in sequential order. A) Wash hands. B) Open latex catheter package. C) Lubricate tip of catheter. D) Wash catheter with soap and water. E) Cleanse perineum with Betadine swabs.

A) Wash hands. C) Lubricate tip of catheter. D) Wash catheter with soap and water. Rationale - The first step because the child should wash hands prior to the procedure to prevent infection. The second step because lubricating jelly should be applied. After insertion and removal of the catheter, the third (and last) step is to cleanse the catheter for storage

An infant is hospitalized following a febrile seizure. When a nurse teaches the infant's family about the prevention of future seizures, what would be the nurse's best recommendation? A) Place the child in a tepid bath during the next febrile illness. B) Administer antipyretics around the clock the next time the child has a fever. C) Contact the physician for antibiotics if the child becomes feverish again. D) Take the child's temperature frequently during the next illness.

B) Administer antipyretics around the clock the next time the child has a fever. Rationale - Febrile seizures are thought to occur when a child who is ill has a sudden high fever. To prevent this situation, the parents should be instructed to administer an antipyretic around the clock during the next febrile illness.

A nurse is preparing to administer an unpleasant-tasting liquid medication to a toddler. What is the best method for administering this medication? A) Mix the medication with a cup of ice cream to mask the taste. B) Ask the child to choose between two types of fluids as a chaser. C) Request the parents hold the child firmly so the nurse can place the medication into the mouth. D) Offer the child a toy out of the toy box as a reward if the child agrees to take the medication.

B) Ask the child to choose between two types of fluids as a chaser. Rationale - The child should be given a choice of fluid chaser to wash the unpleasant taste out of the mouth following ingestion of the medication. The child is not given a choice of whether or not to take the medication.

A child with status post-Harrington rod placement for the correction of scoliosis is being cared for on the pediatric unit. The child suddenly experiences facial sweating and complains of a headache. A nurse notes also a slower heart rate on the monitor. What action should the nurse take first? A) Call the surgeon immediately. B) Assess patency of the urinary catheter. C) Administer pain medication as ordered. D) Complete a neurological assessment.

B) Assess patency of the urinary catheter. Rationale - The child is experiencing symptoms of autonomic dysreflexia, an excessive stimulation of the sympathetic nervous system that is a potential complication of spinal cord surgery. Since bladder distention can lead to this problem, the nurse should first assess the urinary catheter for obstruction or malfunction.

While preparing for an admission, a nurse hears the alarm sound on the cardiac monitor of a child in the next bed. The nurse views the screen and sees what appears to be ventricular fibrillation. What is the best initial action by the nurse? A) Call out for help. B) Assess the child. C) Begin chest compressions. D) Press the "Code Blue" button.

B) Assess the child. Rationale - The nurse should first assess the child's physical condition before assuming that the monitor is accurate. The monitor could be displaying an artifact as a result of the child's activity.

A child diagnosed with hypopituitarism is to begin receiving daily injections. At what time should a nurse instruct the child's parents to administer the injection each day? A) Before breakfast. B) At bedtime. C) With lunch. D) Any time the child prefers.

B) At bedtime. Rationale - The child will be receiving growth hormone injections and these should be timed to simulate the body's normal growth hormone peak that occurs within the first 2 hours of sleep.

A nurse is caring for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory test would the nurse be least likely to obtain? A) Urine specific gravity. B) Blood glucose. C) Serum sodium. D) Urine osmolality.

B) Blood Glucose Obtaining a blood glucose level is not expected for a child diagnosed with SIADH since the priority measures involve blood and urine osmolality. Blood glucose is a likely laboratory test in a child with diabetes insipidus.

An RN and LVN/LPN are working as a team on a pediatric unit. Which task should the RN perform rather than delegating to the LVN/LPN? A) Obtain a 12-lead ECG on a 10-year-old. B) Change the dressing and examine the decubitus ulcer of a preschooler. C) Administer a gavage feeding to an infant with failure to thrive. D) Check the blood sugar of a teen in DKA.

B) Change the dressing and examine the decubitus ulcer of a preschooler. Rationale - The RN should change the wound dressing and assess the condition of the decubitus.

An infant is hospitalized for congenital adrenal hyperplasia (CAH). Which medication should a nurse anticipate to be part of the child's treatment plan? A) Insulin. B) Cortisone. C) Growth hormone. D) Thyroid hormone.

B) Cortisone. Rationale - The child with congenital adrenal hyperplasia (CAH) is given cortisone to stop the increased production of adrenocorticotropic hormone (ACTH), thereby inhibiting adrenocorticoid secretion and virilization of girls/early genital development in boys.

A nurse is performing discharge teaching with the parents of a preschooler diagnosed with cystic fibrosis. What part of the teaching plan will best assist the parents to prevent future pulmonary infections in this child? A) Teaching the parents proper administration of pancreatic enzymes. B) Emphasizing the need for regular and consistent chest physiotherapy. C) Stressing the need to seek prompt medical attention for increased work of breathing. D) Instructing the parents to monitor the child's daily fluid intake for adequacy.

B) Emphasizing the need for regular and consistent chest physiotherapy. Rationale - Chest physiotherapy (CPT) is essential to help loosen sticky respiratory secretions and facilitate sputum removal in the child with cystic fibrosis. Failure to implement this treatment would create a ready environment for pulmonary infection

Which assessment findings would cause a nurse to withhold scheduled immunizations in a child? Select all that apply. A) Current cold symptoms (e.g., runny nose, cough). B) History of recent blood transfusion. C) Currently taking corticosteroids. D) Mild diarrhea without symptoms of dehydration. E) Family history of penicillin allergy. F) Positive for HIV.

B) History of recent blood transfusion. C) Currently taking corticosteroids. F) Positive for HIV. Rationale - Antibodies present in the transfused blood can inhibit the immune response to the immunization. Corticosteroids can suppress the immune response, limiting the effectiveness of immunization. A child with HIV should not receive immunizations that contain live viruses (e.g., varicella), as these may lead to infection.

A nurse is caring for a child newly diagnosed with congen- ital heart disease. The nurse should monitor the child with the understanding that the earliest sign of heart failure is: A) Audible lung crackles. B) Increased heart rate. C) Weight gain. D) Generalized edema.

B) Increased heart rate. Rationale - The body tries to compensate for a failing heart by first increasing the heart rate as a way to increase circulating blood volume.

A child, hospitalized with nephrotic syndrome, has been receiving corticosteroids for a week. What should the nurse recognize as early evidence that the child is responding well to treatment? A) Decreased general edema. B) Increased urinary output. C) Improved general appetite D) Hemoglobin and hematocrit within normal limits

B) Increased urinary output. Rationale - The earliest sign that a child with nephrotic syndrome is improving is an increase in urine output.

A child with type 1 diabetes is being prepared for dis- charge from a hospital. What should a nurse include as part of the teaching regarding diabetes care? A) Expect hypoglycemic episodes to always occur after meals. B) Insulin dosage may need to be decreased during sports activities. C) The child should not self-administer injections until the teen years. D) Insulin should never be administered during febrile illnesses.

B) Insulin dosage may need to be decreased during sports activities. Rationale - The body becomes more sensitive to insulin with physical activity, and it may be necessary to reduce the child's insulin dosage with sports participation.

A toddler with Kawasaki disease is being evaluated by a primary care clinic nurse 1 week following discharge. The nurse understands that it is a priority to instruct the parents to contact the clinic immediately if the child: A) Throws frequent temper tantrums. B) Is exposed to someone with chickenpox. C) Experiences night terrors. D) Develops a low-grade fever.

B) Is exposed to someone with chickenpox. Rationale - Children with Kawasaki disease are placed on aspirin therapy, so exposure to chickenpox puts the child at risk for Reye syndrome.

A client is attending a newborn discharge class and asks a nurse about the bump on the infant's head. Upon assessment, the neonate has a large, diffuse swelling on the left occiput that crosses the sagittal suture line. The nurse should explain to the mother that: Select all that apply. A) This is a collection of blood under the skull bone of the infant. B) It is edematous swelling that overlies the periosteum. C) It leads to hyperbilirubinemia in the infant. D) It will require no treatment to resolve. E) It is caused by pressure on the fetal head before delivery.

B) It is edematous swelling that overlies the periosteum. D) It will require no treatment to resolve. E) It is caused by pressure on the fetal head before delivery. Rationale - Caput succedaneum is an edematous swelling that overlies the periosteum. The only management is observation. No treatment is needed for caput succedaneum. Caput succedaneum is the result of pressure on the fetal head before delivery.

A nurse admits a teenager in sickle cell crisis to a pediatric unit. The child has an elevated heart rate but normal blood pressure, respiratory rate, and temperature. The child has an oxygen saturation of 98% on room air and rates pain in the extremities at an 8 on a 1-to-10 numeric pain rating scale. Which actions should the nurse perform at this time? Prioritize the nurse's actions by placing each correct intervention in priority order. A) Administer oxygen. B) Obtain the child's weight. C) Administer IV fluids as ordered. D) Monitor I&O. E) Obtain an order for pain medication via PCA. F) Apply cool, moist compresses to extremities.

B) Obtain the child's weight. C) Administer IV fluids as ordered. E) Obtain an order for pain medication via PCA. D) Monitor I&O. Rationale - The nurse must first obtain an accurate weight before determining safe dosages of ordered medications and IV fluids. Additionally, the child's weight will be used to determine whether I&O are meeting appropriate targets. IV fluid administration is a priority treatment for the child in sickle cell crisis. After the child's weight is obtained, the nurse may safely administer the ordered IV fluids, being sure to calculate that the amount and rate is appropriate. The nurse should monitor intake and output for adequacy since hydration status is an important part of this child's assessment. I&O monitoring should take place after the child has been weighed and is started on IV fluids and medications. The child needs effective pain management, yet this is a lower priority than fluid administration. A teenager with a chronic painful condition is an excellent candidate for PCA (patient-controlled analgesia).

A nurse visits the home of a young child to administer the Denver II developmental assessment. The child is unable to perform several required items, and the parent expresses concern regarding the child's performance. What is the best way for the nurse to respond to the parent's concerns? A) Reassure the parent that the Denver II is not a measure of the child's IQ. B) Offer the parent some skill-building activities and explain that the child will be reassessed in 2 weeks. C) Advise the parent that the child's primary physician will be notified and will make any necessary referrals. D) Tell the parent that it is not unusual for children to fail the Denver II.

B) Offer the parent some skill-building activities and explain that the child will be reassessed in 2 weeks. Rationale - A "suspect" Denver II should be repeated in 1 to 2 weeks to rule out factors such as fatigue or illness that may influence the child's performance. The parent is also provided some skill-building activities to enjoy with the child to encourage development.

A nurse is working with a nursing student in caring for an infant who has just returned from the surgical recovery area following a cleft lip repair. Which action by the nursing student should cause the nurse to intervene? A) Placement of elbow restraints on the infant. B) Offering the parents a regular bottle with which to feed the infant. C) Positioning the infant in the semi-Fowler's position. D) Advising the parents of a plan to administer pain medication around the clock.

B) Offering the parents a regular bottle with which to feed the infant. Rationale - The infant should not be fed using a regular bottle. Postoperative feedings for the child with a cleft lip should be administered through special feeders to minimize trauma to the suture line. Since a cleft lip repair involves only the child's upper lip, the nurse should perform interventions that reduce the risk of damage or infection at the operative location.

A school nurse is preparing to teach a group of teenagers how to prevent meningitis. What aspect of meningitis prevention should the nurse be certain to include in the presentation? A) Getting a meningitis vaccine is the only way to guarantee prevention. B) Refraining from sharing food and drinks is a good way to prevent meningitis infection. C) Avoiding team sports is one way to stop the spread of meningitis infection. D) Meningitis prevention methods should be employed whenever children are in crowds.

B) Refraining from sharing food and drinks is a good way to prevent meningitis infection. Rationale - Meningitis is primarily spread through contact with droplets that arise from the nasopharynx of a person who is infected. Teenagers should be taught to not share food, drinks, or any other item that touches the nose or mouth of another person.

A nurse attempts to give a newborn infant the first bottle feeding. While sucking, the infant becomes cyanotic and coughs, and formula is seen coming out of the infant's nose. What should be the nurse's first action? A) Auscultate the lungs. B) Suction the child's airway. C) Obtain an order for an x-ray. D) Contact the physician.

B) Suction the child's airway. Rationale - The nurse's first action should be to clear the child's airway of formula. Since this is the infant's first feeding, the nurse should suspect a tracheoesophageal fistula (TEF) and should not attempt to feed the child again.

The parents of a 2-year-old child ask a nurse how to best assist the child to accomplish developmental tasks at this age. What is the best response by the nurse? A) "Make sure that the child's siblings insist that the child share toys at playtime." B) "Since the child understands the word 'no,' use this word frequently to establish house rules." C) "Ask grandparents and other child care providers to follow your home schedule as much as possible." D) "Attend to the child quickly during temper tantrums by hugging and offering reassurance."

C) "Ask grandparents and other child care providers to follow your home schedule as much as possible." Rationale - Toddlers prefer predictable schedules and routines. The child will feel more comfortable if the home schedule is implemented when away from the parents.

A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is pre- pared to care for the child when the student states: A) "I will be sure to let you know if the child's pupils become fixed and dilated." B) "I will keep the child straight in the supine position." C) "I will look for any changes in the child's respirations, pulse, or blood pressure." D) "I will notify the physician if the child becomes sleepy."

C) "I will look for any changes in the child's respirations, pulse, or blood pressure." Rationale - This statement is evidence that the student understands that alterations in any of these vital signs could be an indication of worsening condition and should be promptly noted.

When preparing an intramuscular injection for a 1-week-old infant, which needle would be the most appropriate for the nurse to select? A) 18 G, 7/8 inch. B) 21G,1inch. C) 25G,5/8inch. D) 25G,11/2inch.

C) 25G,5/8inch. Rationale - The most appropriate needle to select for use in administering IM injection to a 1-week-old infant would be a 25 gauge, 5/8 inch long.

A child with type 1 diabetes is receiving insulin based on carbohydrate intake. The child's insulin-to-carbohydrate ratio is 15:1. Of the items listed on the child's lunch menu shown below, the child ate 2 slices of bread, a slice of cheese, a glass of milk, a cup of soup, and half of a banana. How many units of insulin should the nurse administer based on the client's carbohydrate count? Round to the nearest whole number. Food Item with Carbohydrate level: Banana 22g Glass of low-fat milk 10g Bread slice 15g Cheese slice Free Cup of soup 10g A) 2 units. B) 3 units. C) 4 units. D) 5 units.

C) 4 units Rationale - 4 units of insulin would be required to metabolize 61 carbohydrates based on an insulin-to-carbohydrate ratio of 15:1.

A charge nurse is seated in front of a bank of cardiac monitors on a pediatric unit. There are four children receiving cardiac monitoring. Which finding should the charge nurse communicate at once to the child's nurse? A) A heart rate of 50 in a 15-year-old adolescent who is sleeping. B) A heart rate of 190 in a 1-month-old infant who is crying. C) A heart rate of 160 in a 2-year-old child who is walk- ing in the hallway. D) A heart rate of 75 in a 5-year-old child who is watch- ing television.

C) A heart rate of 160 in a 2-year-old child who is walk- ing in the hallway. Rationale - The normal heart rate in a 2-year-old child is from 80 to 120 beats per minute. Even though the child is active, this heart rate is quite high and should be investigated further.

A clinic nurse prepares to perform a physical assessment on a preschool child. What are the appropriate actions for the nurse to take when preparing for and perform- ing the examination? Prioritize the nurse's actions by placing each correct step in sequential order. A) Allow child to keep underpants on. B) Allow child to undress in private. C) Ask child's preference for parental involvement. D) Inspect ears, eyes, and mouth. E) Proceed in head-to-toe direction. F) Gain cooperation with bright objects as a distraction.

C) Ask child's preference for parental involvement. A) Allow child to keep underpants on. E) Proceed in head-to-toe direction. D) Inspect ears, eyes, and mouth. Rationale - The preschool child may feel more comfortable keeping underpants on during the assessment because a common fear of preschoolers is genital mutilation. The nurse should first ask the child if the parents should participate in the procedure. The child should be given options for parent participation, such as whether parents should be present, if the child would like help undressing, and if the child would prefer to sit on the parent's lap or sit alone on the examination table. Although the nurse proceeds in a head-to-toe direction, inspecting eyes, ears, and mouth is invasive and is best performed at the end of the assessment in order to not disrupt the rest of the examination. The nurse should proceed in a head-to-toe direction while keeping the most invasive assessments for the end.

A child is seen in an emergency department following the ingestion of lighter fluid. Which nursing action is of the highest priority at this time? A) Induce vomiting. B) Determine the amount of poison ingested. C) Assess the respiratory system. D) Administer Mucomyst as ordered.

C) Assess the respiratory system. Rationale - When a child ingests a hydrocarbon such as lighter fluid, there is an immediate danger of aspiration. Therefore, the nurse's first priority is to assess the lungs.

When visiting the home of a school-age child who is dying, what would be the best action by a hospice nurse? A) Speak softly (whisper) when speaking in the child's presence. B) Provide as little interaction with the child as possible. C) Avoid correcting the child who is in denial about dying. D) Rely on the parents for pain assessment.

C) Avoid correcting the child who is in denial about dying. Rationale - Many children use denial as a defense mechanism in the face of their own death. A nurse should not take away the child's defenses; rather, the nurse should be honest when answering the child's questions while allowing the child to accept death when ready.

A nurse is planning to teach a child safety class to a group of new parents. When preparing a lesson regarding car seats, what should the nurse recommend? A) Children should be seated in the rear of the car until 6 years of age. B) Infants should face forward in an infant seat until 20 pounds. C) Children should face the rear of the car until as close to 1 year of age as possible. D) Make sure to use the automobile air bags as these enhance the safety of car seats.

C) Children should face the rear of the car until as close to 1 year of age as possible. Rationale - Infants should face the rear of the vehicle until they weigh 20 pounds, from birth to as close to the first birthday as possible.

What is the priority nursing diagnosis for an infant receiving treatment for hyperbilirubinemia? A) Imbalanced body temperature. B) Alteration in elimination. C) Deficient fluid volume. D) Interrupted family processes.

C) Deficient fluid volume. Rationale - An infant with hyperbilirubinemia will have increased fluid needs due to increased insensible fluid losses from phototherapy treatment and increased fluid losses resulting from loose stools as the bilirubin is eliminated through the bowels. Failure to monitor and treat potential fluid volume imbalances can quickly put the infant at risk for dehydration.

A 3-year-old child is hospitalized with multiple fractures as a result of a car accident. What is the best way for a nurse to assess this child's pain level? A) Ask the child to rate pain using a numeric pain rating scale. B) Rely on vital sign measurements as a way to verify pain ratings. C) Employ the FACES pain scale with every nursing assessment. D) Try to have the child describe the pain's intensity and quality.

C) Employ the FACES pain scale with every nursing assessment. Rationale - The FACES pain rating scale can be used with children as young as 3 years of age, and pain should be investigated with every nursing assessment.

A nurse assesses the respiratory status of an infant. Which finding should be of most concern to the nurse? A) Tachypnea. B) Scattered rhonchi. C) Expiratory grunt. D) Abdominal breathing.

C) Expiratory grunt. Rationale - Grunting respirations indicate that the infant is attempt- ing to increase positive airway pressure to prevent airway collapse.

A nurse is caring for a newborn infant diagnosed with hypospadias. The parents ask when the surgical repair will be complete. The nurse knows that the most likely time for completion of the surgical repair will be: A) Within the first month of life. B) Not until the child reaches puberty. C) Nearer the child's first birthday. D) Before the child begins school.

C) Nearer the child's first birthday. Rationale - The surgical repair of hypospadias generally begins within the first few months of life and continues in stages, finishing between 6 and 18 months of age, before the child begins toilet training.

A nurse prepares to insert a nasogastric tube in a 10-month-old child. Which actions should the nurse take to complete this procedure? Prioritize the nurse's actions by placing each correct step in sequential order. A) Aspirate gastric contents. B) Have the child begin a bottle feeding. C) Place child supine with head and neck elevated. D) Inject 10 mL of air into the tube while auscultating the stomach. E) Tape tube securely to infant's cheek. F) Measure from the infant's earlobe to the area of the stomach.

C) Place child supine with head and neck A) Aspirate gastric contents. E) Tape tube securely to infant's cheek. Rationale - The child should first be placed on the back with the chest elevated prior to NG tube placement, to prevent aspiration if the child gags during the procedure Once the tube is inserted, placement must be verified by both auscultation and aspiration of gastric contents. . Taping the tube to the cheek after it has been inserted prevents the child from being able to get fingers around the tube and pull it out.

In assessing the reflexes of a 15-month-old child, which finding would indicate that the child is experiencing normal development? A) Positive Babinski reflex. B) Asymmetric tonic neck reflex. C) Positive patellar reflex. D) Presence of doll's eye reflex.

C) Positive patellar reflex. Rationale - A positive patellar reflex is part of a normal assessment. The reflex is obtained when the practitioner strikes the patellar tendon, causing the leg to kick.

A newborn arrives in a neonatal intensive care unit with a myelomeningocele. A physician writes orders to keep the infant in the prone position. A nurse should know that the most important rationale behind this order is to: A) Prevent infection. B) Promote circulation in the lower extremities. C) Prevent trauma to the meningeal sac. D) Promote comfort.

C) Prevent trauma to the meningeal sac. Rationale - The most important rationale for the prone position is to prevent damage to the meningeal sac, which could result in damage to the nerves and infection.

A nurse assesses a child who is 12 hours status post- tonsillectomy and adenoidectomy. The child reports feeling nauseated and shows the nurse a moderate amount of red-tinged vomitus in the emesis basin. Which action should the nurse take first? A) Administer an antiemetic as ordered. B) Offer the child ice chips as tolerated. C) Report the findings to the physician. D) Apply bilateral pressure to the child's neck.

C) Report the findings to the physician. Rationale - The appearance of moderate red-tinged vomitus could indicate hemorrhage in the surgical area. The physician should be notified immediately of this potentially harmful complication.

The mother of a child asks a clinic nurse how to safety- proof the home. What should the nurse recognize as the most effective means to prevent accidental poisoning? A) Keep the Poison Control Center phone number near the phone. B) Store poisons in the garage rather than in the home. C) Scan the home from the child's eye level and remove accessible toxins. D) Tell children where toxic substances are kept and instruct them not to go there.

C) Scan the home from the child's eye level and remove accessible toxins. Rationale - The parents should bend down and view the home from the child's eye level to better examine potential access to poisonous substances. This includes checking all storage areas inside and outside the home that are easily accessible and those that may be reached by children when climbing

The parent of a young child phones an advice nurse to report that the child is ill. The child has a reddish pin- point rash most concentrated in the axilla and groin areas, a high fever, flushed cheeks, and abdominal pain. The parent also reports that the child's tongue is dark red with white spots. A nurse should recognize these symptoms as indicative of which infection? A) Mumps. B) Measles. C) Scarlet fever. D) Varicella.

C) Scarlet fever. Rationale - These symptoms are classic for scarlet fever. The child develops a high fever, abdominal pain, flushed cheeks, and strawberry tongue, as well as a generalized pinpoint red rash that is more concentrated in the axillae and groin.

A child is admitted for treatment of lead poisoning. A nurse recognizes that the priority nursing diagnosis for this child is: A) Alteration in comfort related to abdominal pain. B) Alteration in nutrition related to pica. C) Pain related to chelation therapy. D) Alteration in neurologic functioning.

D) Alteration in neurologic functioning. Rationale - The priority nursing diagnosis for this child is alteration in neurologic functioning due to the effects of lead on the central nervous system.

A clinic nurse has a follow-up appointment with an adolescent with juvenile idiopathic arthritis (JIA). What topic should be the nurse's top priority? A) Sleep patterns. B) Participation in daily exercise. C) Information regarding JIA support groups. D) Avoidance of alcohol use.

D) Avoidance of alcohol use. Rationale - Adolescents with JIA are frequently prescribed medications that are taxing to the liver, including NSAIDs, such as naproxen sodium, and SAARDs (slower- acting antirheumatic drugs), such as methotrexate. Alcohol abuse could cause serious complications when taking these medications. A nurse's top priority takes into consideration that the adolescent is facing increasing peer pressure to drink alcohol, which could lead to hepatotoxicity.

A school nurse advises the dietary staff that a special lunch tray must be created for a student who has celiac disease. What recommendation should the nurse provide to the dietary staff? A) Make sure the student has a whole-grain bread roll each day. B) The child may have cake if the staff is celebrating someone's birthday. C) The child's pizza should be topped with a variety of vegetables. D) Beans and rice are suitable side dishes for this student.

D) Beans and rice are suitable side dishes for this student. Rationale - Beans and rice are acceptable foods for a child with celiac disease, who requires a gluten-free diet.

A nurse prepares to administer spironolactone (Aldactone) to an infant with congenital heart disease. The nurse understands that the main purpose of this medication is to: A) Preserve the patent ductus arteriosus. B) Cause vasodilation of the blood vessels. C) Prevent the secretion of potassium. D) Block aldosterone, which leads to diuresis.

D) Block aldosterone, which leads to diuresis. Rationale - Spironolactone (Aldactone) is a diuretic that blocks aldosterone. Use of this medication is common among children with congenital heart disease for the prevention and treatment of congestive heart failure.

A child recovering from abdominal surgery removes the nasogastric tube accidentally. A nurse replaces the nasogastric tube and places it to low wall suction. Two hours later, the nurse discovers that there is no drainage from the tube. What should be the nurse's first action? A) Ask the child to change position. B) Place an urgent call to the surgeon. C) Flush the tube with 10 mL of sterile water. D) Check the suction mechanism and settings.

D) Check the suction mechanism and settings. Rationale - The most likely cause of poor drainage is ineffective suction. The suction tubing may have become dislodged or the settings may have been altered. A nurse should inspect this first, then continue to problem-solve if needed.

A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the child's ear level. What should be the nurse's priority action? A) Raise the drain to the child's ear level. B) Leave the drain as is and monitor the CSF drainage hourly. C) Quickly elevate the head of the bed. D) Clamp the drain and complete a neurological assessment.

D) Clamp the drain and complete a neurological assessment. Rationale - The external ventricular drain (EVD) should be at the level of the ventricles, or at the child's ear level. When the EVD is too low, CSF can drain quickly and lead to neurologic complications. A nurse should prevent the CSF from draining any further and assess the child.

The parents of a newborn infant ask a nurse how to prevent future ear infections. What is the best advice the nurse should provide these parents? A) Avoid crowds during the winter months. B) Allow the baby to bottle-feed in the supine position. C) Make sure the baby receives the DTaP vaccine as scheduled. D) Continue breastfeeding as close to the baby's first birthday as possible.

D) Continue breastfeeding as close to the baby's first birthday as possible. Rationale - Infants who are exclusively breastfed have a decreased incidence of otitis media (ear infections) compared to those who are formula-fed.

A young child diagnosed with iron-deficiency anemia is prescribed a liquid iron supplement. A nurse provides the parents with instructions on administration and should be certain to advise them that: A) The medication should be given along with the child's morning cereal breakfast. B) The child may experience some pale-colored stools. C) The child should be permitted to sip the medication from a medicine cup. D) The medication can be mixed with a small amount of fruit juice.

D) The medication can be mixed with a small amount of fruit juice. Rationale - Iron is best absorbed in the presence of vitamin C. The liquid iron supplement may be mixed with fruit juices such as orange juice to make the medication more palat- able while also increasing the absorption.

A nurse should suspect Hirschsprung's disease in a child who has which type of stooling pattern? A) Pale gray stools. B) Currant-jelly stools. C) Loose, yellow stools. D) Thin, ribbon-like stools.

D) Thin, ribbon-like stools. Rationale - The child with Hirschsprung's disease will have infrequent stools that appear thin and ribbon-like.

A 1-day-old infant, born at 39 weeks' gestation, weighs 4 pounds, 7 ounces at birth. A pediatrician diagnoses the neonate with intrauterine growth restriction (IGR). An RN observes the newborn to be irritable, difficult to con- sole, restless, fist-sucking, and demonstrating a high- pitched, shrill cry. Based on these assessment data, the RN should: A) Increase stimulation of the baby by handling the infant as much as possible. B) Schedule routine feeding times every 3 to 4 hours. C) Encourage stimulation by rubbing the infant's back and head. D) Tightly swaddle the infant in a flexed position.

D) Tightly swaddle the infant in a flexed position. Rationale - Tightly swaddling the baby promotes the infant's comfort and security and decreases the stimulation that may contribute to the infant's irritability.

In doing a child's admission assessment, which signs and symptoms should a nurse recognize as most likely related to rheumatic fever? A) Vomiting and diarrhea. B) Arthralgia and muscle weakness. C) Conjunctivitis and red, cracked lips. D) Bradycardia and hypotension.

B) Arthralgia and muscle weakness. Rationale - Symptoms of rheumatic fever include muscle weakness and arthralgia

A physician orders penicillin 200,000 units/kg/day IV q6h for a child weighing 16 kg. The penicillin on hand comes prepared in a concentration of 250,000 units/mL. In order to administer the correct dose, a nurse calculates that _______ mL of penicillin should be administered to the child. Fill in the blank.

3.2. Rationale - To solve this problem, first multiply the ordered 200,000 units per kilogram by the child's weight of 16 kg to get a total of 3,200,000 units per day. Next, divide the total daily units of 3,200,000 by 4 (since the drug is administered every 6 hours) to get a sin- gle dose of 800,000 units. Finally, take the single dose of 800,000 units and divide by the 250,000 units per mL to get a total of 3.2 mL.

Which conditions in children and/or adolescents should a nurse identify as being associated with metabolic alkalosis? Select all that apply. A) Pyloric stenosis. B) Diabetes. C) Renal failure. D) Bulimia nervosa. E) Aspirin ingestion.

A) Pyloric stenosis. D) Bulimia nervosa. Rationale - Children with pyloric stenosis experience loss of stomach acid from excessive vomiting. Children with bulimia nervosa vomit frequently, resulting in a loss of stomach acid.

A nurse is caring for a child with tetralogy of Fallot. Which assessment findings should the nurse expect? Select all that apply. A) Ventricular septal defect (VSD). B) Atrial septal defect (ASD). C) Overriding aorta. D) Pulmonic stenosis. E) Right ventricular hypertrophy. F) Patent ductus arteriosus (PDA). G) Left-to-right shunting of blood. H) Aortic stenosis

A) Ventricular septal defect (VSD). C) Overriding aorta. D) Pulmonic stenosis. E) Right ventricular hypertrophy. G) Left-to-right shunting of blood. Rationale - A VSD is one of the components of tetralogy of Fallot. An overriding aorta is one of the components of tetralogy of Fallot. Pulmonic stenosis is one of the components of tetralogy of Fallot. Right ventricular hypertrophy is one of the components of tetralogy of Fallot. The blood flows from left to right in a child with tetralogy of Fallot through the VSD.

Which response to hospitalization is a nurse most likely to observe in a 4-year-old child? A) Fearfulness of loud noises and sudden movements. B) Frequent crying outbursts and agitation. C) Urinary frequency and fear of mutilation. D) Boredom or loneliness.

C) Urinary frequency and fear of mutilation. Rationale - Preschoolers have great concerns over body mutilation and may demonstrate somatic symptoms as a response to the stress of hospitalization.

A nurse performs a head-to-toe assessment on a newborn. Which finding should be of greatest concern to the nurse? A) Capillary refill time of 2 seconds. B) Transient mottling of the skin. C) Irregular respirations. D) Negative Babinski reflex.

D) Negative Babinski reflex. Rationale - The newborn should have a positive Babinski, or plantar, reflex. This reflex occurs when the toes extend in response to the stroking of the sole of the foot. A negative finding should occur in older infants and adults and is noted when the toes demonstrate a flexor response.

A nurse is caring for a child with meningococcemia who is on a ventilator. This morning, the nurse finds the child's mother sitting at the bedside, crying. The mother tells the nurse, "I thought it was the flu. This is my fault because I should have come to the hospital earlier." What is the best action by the nurse in response to the mother's statements? A) Tell the mother not to worry since many parents and even physicians frequently mistake meningitis symptoms for other infectious conditions. B) Make a referral to social services. C) Call the child's father and explain that the mother needs emotional support from him. D) Remind the mother that she did seek proper treatment as soon as she became concerned, and review the special care the child is receiving now.

D) Remind the mother that she did seek proper treatment as soon as she became concerned, and review the special care the child is receiving now. Rationale - The mother's statement expresses guilt feelings about the child's condition. A nurse needs to validate that the mother did seek treatment appropriately, and assist the mother to focus on what is happening now to help her child recover.

A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the nurse's first priority when caring for this child? A) Obtaining a daily weight. B) Palpating extremities frequently for edema. C) Assessing urine for hematuria. D) Obtaining the child's blood pressure every shift.

A) Obtaining a daily weight. Rationale - The primary concern in the child with glomerulonephritis is the monitoring of fluid balance. The nurse should obtain a weight for this child at the same time and on the same scale daily to monitor for changes.

Which statement made by the mother of a child with cystic fibrosis should indicate to a nurse that the mother is in need of further teaching regarding the administration of pancreatic enzymes? A) "I'll crush the capsules and mix with my child's food." B) "The capsule can be broken and its contents sprinkled onto food." C) "I may need to give more enzymes with larger meals." D) "I will administer the enzymes 30 minutes after the meal."

A) "I'll crush the capsules and mix with my child's food." Rationale - This statement by the mother indicates more teaching is needed, since crushing the capsule would destroy the enteric coating on the enzyme beads, leading to their destruction in the acid environment of the stomach.

A school-age child visits a school nurse with complaints of dizziness and shaking. The nurse confirms that the child has a history of type 1 diabetes mellitus when the child becomes diaphoretic and begins to faint. What should be the nurse's first action? A) Administer an injection of glucagon. B) Activate EMS. C) Squeeze glucose gel into the cheek. D) Test the child's blood sugar.

A) Administer an injection of glucagon. Rationale - The child is demonstrating symptoms of severe hypoglycemia and the nurse must administer an emergency dose of glucagon to prevent the child from going into shock.

A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when caring for this child after surgery? Select all that apply. A) Advancing diet as tolerated. B) Encouraging coughing to clear the throat. C) Monitoring PT and PTT. D) Administering pain medication around the clock. E) Suctioning mouth and throat frequently.

A) Advancing diet as tolerated. C) Monitoring PT and PTT. D) Administering pain medication around the clock. Rationale - Following tonsillectomy, the child may begin oral intake after surgery, beginning with ice chips and progressing as tolerated to avoid vomiting, which could injure the surgical site. Increased bleeding times put the child at risk for hemorrhage at the tonsillectomy site, which could compromise the airway. The nurse should expect that the child will have pain from the tonsillectomy. Pain control is best achieved with around-the-clock dosing. Without adequate pain control, the child may cry, putting stress on the surgical site.

Which would be an abnormal finding when doing a well-child checkup on a 1-week-old infant? A) An audible "clunk" during the Ortolani test. B) Symmetrical gluteal folds when the infant is held upright. C) Negative Barlow test. D) Symmetrical knee height when the infant is supine.

A) An audible "clunk" during the Ortolani test. Rationale - An audible, low-pitched, "clunk" during the Ortolani test is caused by the sound of the femur head exiting or entering the acetabulum, indicating hip dislocation.

Which symptom(s), if present in a child, should a nurse recognize as being characteristic of Kawasaki disease? Select all that apply. A) Strawberry tongue. B) High fever. C) Irritability. D) Cough. E) Desquamation of the extremities. F) Elevated ESR.

A) Strawberry tongue. B) High fever. C) Irritability. E) Desquamation of the extremities. F) Elevated ESR. Rationale - Strawberry tongue is a symptom of Kawasaki disease (mucocutaneous lymph node syndrome), occur- ring as the skin of the tongue sloughs off, leaving a bright red tongue with white spots. A symptom of Kawasaki disease is high fever lasting more than 5 days. Irritability is a symptom of Kawasaki disease. The child with Kawasaki disease may experience peeling of the hands (on palms and fingertips) and feet (on soles and tips of toes) following the initial inflammatory rash on these areas. An elevated erythrocyte sedimentation rate (ESR) is a symptom of Kawasaki disease. Elevated ESR is indicative of an inflammatory process, which would include Kawasaki disease.

Which child would be the best roommate for a 9-year- old child with myelodysplasia who is hospitalized for a foot infection? A) A 13-year-old with juvenile idiopathic arthritis. B) A 10-year-old with a fractured femur. C) An 8-year-old status post-appendectomy. D) A 6-year-old with bacterial meningitis.

B) A 10-year-old with a fractured femur. Rationale - This child is close in age and development and is likely to be immobilized in the injured leg due to a cast and/or traction. Since the child with myelodysplasia is likely to have impaired mobility in the infected foot or even complete paralysis of both lower extremities, these children share similar limitations and the nursing staff can encourage them to play video games or participate in suitable activities.

An infant is brought to an emergency department with a chief complaint of nausea and vomiting. Which nursing assessment finding should indicate to a nurse that the infant's dehydration is severe? A) The infant is lethargic with a urinary output of less than 1 mL/kg/hr. B) The infant has weak pulses, poor skin turgor, and cool, mottled skin. C) The infant has warm skin, increased pulse, and capillary refill of 2 seconds. D) The infant is irritable, with dry mucous membranes and increased respirations.

B) The infant has weak pulses, poor skin turgor, and cool, mottled skin. Rationale - These symptoms describe a child with significantly diminished circulation as a result of dehydration. An infant with severe dehydration has weak to absent pulses, poor skin turgor, and cool, discolored skin.

The parents of a child recently discharged with acute spasmodic laryngitis contact a nurse to report that the child continues to have croupy coughing spells at nighttime but is otherwise fine. What should the nurse recommend? A) Contact the child's physician for another round of antibiotics. B) Treat the spasms by sitting in the bathroom while a hot shower runs. C) Bring the child back to the emergency department as soon as possible. D) Elevate the child's head at bedtime using pillows.

B) Treat the spasms by sitting in the bathroom while a hot shower runs. Rationale - The humidity of the shower will create an environment that is soothing to the child's airway. Cool-mist humidifiers are also recommended for the child's room to relieve the symptoms of spasmodic croup. Any of the croup syndromes may be treated with humidified air. In the case of acute spasmodic laryngitis, both warm mist and cool mist are acceptable interventions since the problem is airway spasm rather than severe inflammation.

What should be the expected weight of an infant at 12 months of age whose birth weight was 3600 grams? A) 5600 grams. B) 7200 grams. C) 11 kilograms. D) 15 kilograms.

C) 11 kilograms. Rationale - An infant is expected to triple its birth weight in the first year of life; therefore, 11 kilograms (11,000 grams) is the best answer of the options given.

A charge nurse is creating nursing assignments for a pediatric unit when one of the oncoming nurses calls to say, "Sorry, I'll be a few minutes late since I have a child home ill with the chickenpox." What type of assignment would be most acceptable for the nurse who will be late? A) Any assignment is fine as long as the nurse wears a mask. B) The nurse needs an assignment that does not include children with neutropenia. C) The nurse should not be given an assignment and should be called off. D) Any care assignment is acceptable, without restrictions.

C) The nurse should not be given an assignment and should be called off. Rationale - The nurse has been exposed to someone with varicella (chickenpox). The charge nurse must first determine the nurse's varicella immune status before permitting the nurse to provide care.

A nursing student prepares to administer eyedrops to a young child. What action by the nursing student should cause a registered nurse to intervene? A) The student positions the child supine with head extended. B) After administration, the student asks the child to close eyes and move them around. C) The student schedules medication administration to occur just before lunchtime. D) Prior to administration, the student pulls the lower lid down, forming a sac.

C) The student schedules medication administration to occur just before lunchtime. Rationale - Eyedrops should be administered when they are least likely to interfere with an activity that requires effective vision. A nurse should intervene and advise the student that the child should eat lunch first.

A child is receiving chemotherapy for the treatment of osteosarcoma. Which morning laboratory result must a nurse report immediately to the physician? A) Absolute neutrophil count of 1200. B) Platelet count of 150,000. C) Urine dipstick positive for heme. D) WBC count of 4500.

C) Urine dipstick positive for heme. Rationale - A positive urine dipstick for the presence of red blood cells could indicate hemorrhagic cystitis, a com- plication of chemotherapy agents, including cyclophosphamide and ifosfamide. This finding should be communicated immediately to the physician.

A child arrives in an emergency department with a chief complaint of asthma exacerbation. Which assessment information is most important for the nurse to obtain first? A) Whether the child has been taking asthma medications as prescribed. B) When the child began having symptoms. C) Whether the child is able to speak in full sentences. D) The child's ABG levels.

C) Whether the child is able to speak in full sentences. Rationale - The nurse should first assess the child's airway to determine the severity of respiratory symptoms. One way to assess shortness of breath is to determine whether the child speaks in full sentences, short phrases, or barely at all.

When providing anticipatory guidance to the parents of a child with hemophilia, a nurse should stress that: A) Active range-of-motion exercise should be used to treat sore joints. B) Aspirin should be given for minor bumps and bruises. C) Warm compresses should be applied to wounds to promote circulation. D) A soft toothbrush should be used to promote oral health.

D) A soft toothbrush should be used to promote oral health. Rationale - A soft toothbrush will prevent trauma to the child's gums (i.e., bleeding) while keeping the teeth clean.

An LVN/LPN from an orthopedic unit is floated to a child health unit. In creating assignments, which child should the charge nurse avoid assigning to the LVN/LPN? A) A 10-year-old in traction for a fractured femur. B) An 8-year-old child with Legg-Calvé-Perthes disease. C) A 4-year-old with osteogenesis imperfecta. D) A teenager receiving chemotherapy for osteosarcoma.

D) A teenager receiving chemotherapy for osteosarcoma. Rationale - The child with osteosarcoma is receiving chemotherapy, which requires continuous monitoring for complications. This child would not be an appropriate client for the LVN/LPN due to the need for frequent assessment by a registered nurse.

A nurse visits the home of a toddler. With what aspect of the home environment would the nurse be most concerned? A) Power cords plugged into capped electrical outlets. B) Presence of a television in the child's bedroom. C) A swimming pool located in the backyard. D) Cooking pot handle turned toward the front of the stove.

D) Cooking pot handle turned toward the front of the stove. Rationale - Toddlers like to reach for objects. Having pot handles turned toward the front of the stove creates the potential for the child to pull the pot and its contents onto the child, causing a severe burn injury. The parents should be instructed to turn handles toward the back of the stove and consider placing a safety guard at the front of the stove.

A 12-month-old child with infantile eczema is seen at the clinic for several open lesions on the arms and legs. What should a nurse caution the child's parents against? A) Initiating a diet free of milk products. B) The use of topical hydrocortisone cream. C) Adding cornstarch to bath water. D) Immunization during eczema exacerbations.

D) Immunization during eczema exacerbations. Rationale - The child should not receive immunizations during an acute exacerbation of eczema (atopic dermatitis), as this may lead to complications such as allergic reaction. The child with atopic dermatitis is experiencing an inflammatory response. Care should be directed at relieving inflammation and avoiding exposure to substances thought to trigger an immune response.

A nurse performs a scoliosis screening at a local school. Which assessment finding by the nurse would least likely result in a scoliosis referral? A) Unilateral rib hump noted when the child is bent forward. B) Asymmetrical hip height noted when the child is standing erect. C) Uneven wear noted on the bottom of the child's pant legs. D) Rounded shoulders noted when the child is standing erect.

D) Rounded shoulders noted when the child is standing erect. Rationale - The nurse is least likely to refer a child for scoliosis follow-up based on an assessment finding of rounded shoulders. This finding may simply reflect the child's poor posture or in severe cases may indicate the condition of kyphosis, not scoliosis.