EXAM 1 PRACTICE QUESTIONS

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority? Place the child on a soft diet. Administer acetaminophen. Initiate intravenous access. Assess cervical lymph nodes.

Initiate intravenous access. A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids.

A group of students is reviewing material about ways parents can help to foster a child's self-esteem. The students demonstrate a need for additional studying when they identify which method as promoting self-esteem? Using positive reinforcement while limiting criticism Limiting the choices and decisions that the child makes Showing respect and support to the child Acting as a coach rather than a cheerleader

Limiting the choices and decisions that the child makes To promote self-esteem, parents should praise the child's achievements, show respect and support to the child, allow the child to make decisions, listen to the child, and spend time with the child. The parents need to be a coach to the child rather than just a cheerleader who merely praises accomplishments.

A 9-year-old child has undergone a temporary colostomy in the ascending colon several days ago. The nurse has just completed discharge teaching to the child and the parents. Which statements by the child or parents warrants additional instruction from the nurse? Select all that apply. "I know the location of the colostomy may cause stool to be of somewhat liquid consistency so the appliance will need to be emptied frequently." "It is important to change the pouch and skin appliance every other day to decrease the risk of problems with the skin." "This is probably going to be very difficult for our child with returning to school because of the care of the appliance and pouching system." "We will need to use an antimicrobial soap to cleanse the area around the stoma in order to prevent any skin infection." "We should let the doctor know right away if the stoma becomes pale."

"It is important to change the pouch and skin appliance every other day to decrease the risk of problems with the skin." "We will need to use an antimicrobial soap to cleanse the area around the stoma in order to prevent any skin infection." Appliances and pouches can be left in place for 4 days as long as the appliance is intact; changing more frequently can lead to skin impairment. Regular soap, not antimicrobial soap, and water is all that is needed to clean around the stoma site. Antimicrobial and perfumed soaps may be irritating to the skin. An ascending colostomy will produce unformed, thick liquid stool so emptying the pouch more frequently will be necessary; this will likely be a challenge for the child at school initially. A pale stoma indicates poor perfusion; this should be reported to the physician immediately.

The mother of an infant tells the nurse during a routine visit to the clinic that she often notices a bulging mass in the lower abdominal and groin area when her baby cries. She asks the nurse if this is normal. How should the nurse respond? "The muscle wall of infants are not yet strong so it isn't unusual to see this happening when the baby is crying or straining." "I will be sure to note this in your child's chart so it is something we will continue to monitor in future visits." "I didn't notice any masses while I was assessing your infant. It may just appear they have a mass due to pressure in the abdomen when crying." "I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately."

"I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." The mother is describing common symptoms of an inguinal hernia. It may be possible to visualize the mass, but often the mass is seen only during crying or straining, making it difficult to actually identify in the clinic setting. It is important to notify the physician so treatment can be initiated.

The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond? "It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain." "Maybe your child doesn't really like the foods your making. This could lead to not gaining sufficient weight." "Are you sure you are making nutrient-dense foods?" "It's hard to get your child to eat enough at this age to maintain their weight since they are expending so much energy with the heart condition."

"It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain." Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child.

The nurse is caring for an infant with Down syndrome who has been diagnosed with atrioventricular canal defect. The parents asks the nurse, "Why do you not put oxygen on our baby more often when his lips and fingernails are blue?" What is the best response by the nurse? "I can only place oxygen on your child if the doctor orders oxygen." "Oxygen isn't always the best treatment for your child's condition. Surgery is necessary." "This is something we should talk with the physician about. Maybe it would help your baby." "While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help."

"While it seems that oxygen would help, it actually worsens this condition. Treating the cause of the disease will help." For children with congenital defects with increased pulmonary blood flow, oxygen supplementation is not helpful. Oxygen acts as a pulmonary vasodilator. If pulmonary dilation occurs, pulmonary blood flow is even greater, causing tachypnea, increasing lung fluid retention, and eventually causing a much greater problem with oxygenation; therefore, preventing the development of pulmonary disease via early surgical correction is essential.

A parent brings an infant in for poor feeding and listlessness. Which assessment data would most likely indicate a coarctation of the aorta? Pulses weaker in lower extremities compared to upper extremities Pulses weaker in upper extremities compared to lower extremities Cyanosis with feeding Cyanosis with crying

Pulses weaker in lower extremities compared to upper extremities With coarctation of the aorta there is a narrowing causing the blood flow to be impeded. This produces increased pressure in the areas proximal to the narrowing and a decrease in pressures distal to the narrowing. Thus, the infant would have decreased systemic circulation. The upper half of the body would have an increased B/P and be well perfused with strong pulses. The lower half of the body would have decreased B/P with poorer perfusion and weaker pulses.

Which assessment findings if noted in a 4-month-old infant would the nurse recognize as normal growth and development? rolls over, grasp reflex fading, cooing sound holds head up when prone, bears partial weight on legs, reflexes are fading uses palmer grasp, starts to make vowel sounds, reaches out follows object past midline with eyes, keeps hands fisted, rolls over

holds head up when prone, bears partial weight on legs, reflexes are fading

The nurse is teaching the mother of an infant with a temporary ileostomy about stoma care. What is the most important instruction to emphasize to the mother to avoid an emergency situation? "You may need adhesive remover to ease pouch removal." "You must be meticulous in caring for the surrounding skin." "Gather all of your supplies before you begin." "Call the doctor immediately if the stoma is not pink/red and moist."

"Call the doctor immediately if the stoma is not pink/red and moist." A healthy stoma is pink and moist. If the stoma is dry or pale, the mother must notify the health care provider immediately because it could indicate compromised circulation.

The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which response by the mother would lead the nurse to suspect that the child is experiencing heart failure? "He gets sweaty when he eats." "He does not seem short of breath." "He does not seem sick." "He seems to have a normal appetite."

"He gets sweaty when he eats." Diaphoresis with nipple feeding indicates heart failure. Shortness of breath would suggest heart failure. Children with heart failure experience subtle signs that suggest that something is wrong. Children with heart failure often display subtle signs such as difficulty feeding.

The nurse is caring for a 2-year-old boy with an umbilical hernia and is term-53teaching the mother about this condition. Which response from the mother indicates a need for further teaching? "I can tape a quarter over the hernia to reduce it." "My son could have some appearance-related self-esteem issues." "An incarcerated hernia is rare, but it can occur." "I need to watch for pain, tenderness, or redness."

"I can tape a quarter over the hernia to reduce it."

The nurse has performed client education for a 15-year-old boy with Crohn disease and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning has occurred? "I may end up with a colectomy because the disease is continuous from the beginning to the end of my intestines." "I have to be careful because I am prone to not absorbing nutrients." "It's unusual for someone my age to get Crohn disease." "I have a lot of diarrhea every day because of how my small intestine is damaged."

"I have to be careful because I am prone to not absorbing nutrients." Crohn disease typically affects the small intestine more than the large intestine and its onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevent absorption of nutrients that normally occurs.

The nurse is performing discharge teaching for an adolescent diagnosed with peptic ulcer disease. Which statement(s) by the adolescent demonstrate learning has occurred? Select all that apply. "My proton pump inhibitor should be taken when I feel discomfort." "The prednisone that I take for my rheumatoid arthritis may be a cause of my peptic ulcer disease." "It is important to take my histamine agonist medication at the appropriate time." "I will need to make sure to take all of the antibiotic prescribed." "I will just take the proton pump inhibitor instead of the histamine agonist because it works faster."

"I will need to make sure to take all of the antibiotic prescribed." "It is important to take my histamine agonist medication at the appropriate time." "The prednisone that I take for my rheumatoid arthritis may be a cause of my peptic ulcer disease."

The parent of a 3-week-old infant brings the infant in for an evaluation. During the visit, the parent tells the nurse that the infant is spitting up after feedings. Which response by the nurse would be most appropriate? "Do not worry; you are just feeding your infant too much." "Thicken the formula by adding rice cereal." "Infants this age commonly spit up." "Your child might have an allergy."

"Infants this age commonly spit up." In infants younger than 1 month of age, the lower esophageal sphincter is not fully developed. Therefore, infants younger than 1 month of age frequently regurgitate after feedings.

The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply. "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Gluten is found in most wheat products, rye, barley and possibly oats." "Most children with celiac disease are diagnosed within the first year of life." "The only treatment for celiac disease is a strict gluten-free diet." "The entire family will need to eat a gluten-free diet."

"Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." "Gluten is found in most wheat products, rye, barley and possibly oats." "The only treatment for celiac disease is a strict gluten-free diet." Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is consuming a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.

The parents of a 2-year-old toddler newly diagnosed with tricuspid atresia ask the nurse, "I do not understand why our toddler's fingertips are spread out and rounder than normal fingertips?" Which response by the nurse is best? "The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." "Increased cardiac workload from your toddler's heart defect affects various parts of the body, including the fingers." "The number of red blood cells has significantly increased from the heart defect, resulting in the cells pooling in the fingertips." "This is a common complication of tricuspid atresia. Unfortunately, there is nothing we can do to treat it."

"The low blood oxygen levels from the heart defect causes the lack of oxygen to the fingers, causing these changes." Clubbing (which is what the parents are describing) of fingertips or toes can occur from the chronic hypoxia that occurs with disorders with decreased pulmonary blood flow, such as tricuspid atresia.

The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis? "We will give enemas until clear and then teach you how to do these at home." "Your child will be treated with oral iron preparations to correct the anemia." "The treatment for the disorder will be a surgical procedure." "Your child will receive counseling so the underlying concerns will be addressed."

"The treatment for the disorder will be a surgical procedure." "PULL-THROUGH" SURGERY

The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate? "The health care provider will remove about half of the herniated contents during the procedure." "All this means is that the herniated intestines are twisted and edematous, which is why you need surgery." "If you do not understand this, I need to cancel your surgery and have the health care provider come back." "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery."

"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity.

A child is experiencing an acute exacerbation of Crohn disease for which she is prescribed prednisone. The nurse teaches the parents and child about this medication. Which statement by the parents indicates that the teaching was successful? "This drug helps to control the abdominal cramping." "We might notice some of the medication in her stool." "We should not stop this medication abruptly." "She might lose some weight initially."

"We should not stop this medication abruptly." Prednisone is a corticosteroid. Stopping the medication abruptly could lead to adrenal insufficiency. Weight gain would be associated with corticosteroid use. Weight loss is associated with the disease. Corticosteroids help to reduce inflammation and suppress the normal immune response.

The nurse is administering medications to the child with congestive heart failure (CHF). Large doses of what medication are used initially in the treatment of CHF to attain a therapeutic level? Spironolactone Albuterol sulfate Ferrous sulfate Digoxin

Digoxin The use of large doses of digoxin at the beginning of therapy to build up the blood levels of the drug to a therapeutic level is known as digitalization. During the 24 hours digitalization is occurring, the child should be on a cardiac monitor and the nurse should monitor the PR interval and a decreased ventricular rate.

A 3-year-old child is hospitalized. The parents are concerned because the child is now refusing to use the potty and is wetting the bed even though the child has achieved toilet training. Which response by the nurse is most appropriate? "Your child is experiencing regression as a result of stress." "Why do you believe your child is refusing to use the potty?" "Once discharged, your child will quickly learn to use the toilet again." "Do not worry. This is a normal response to being in the hospital."

"Your child is experiencing regression as a result of stress." Regression is a change from present behaviors to past developmental levels of behavior. This is a normal response among children during times of intense stress, such as a hospitalization or the birth of a new sibling. The nurse should not tell the parents not to worry. The child will not have to learn to use the toilet again. The behavior is already learned.

The nurse is caring for children at a local hospital. Which child warrants immediate attention from the nurse? 2-year-old child with clubbing noted on the fingers 1-year-old child with a temporal temperature of 101°F (38.3°C) 6-month-old infant with edema on the face and presacral area 1-week-old newborn whose oxygenation is not improving with oxygen

1-week-old newborn whose oxygenation is not improving with oxygen A newborn whose oxygenation is not improving with oxygen warrants immediate attention. Congenital heart disease needs to be suspected in the cyanotic newborn who does not improve with oxygen administration.

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? Indomethacin Furosemide Alprostadil Digoxin

Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force.

The nurse is assessing a toddler's fine motor skills. Which finding by the nurse could be a safety concern? Ability to hold a crayon to write Put shapes into matching openings Able to use a spoon to self-feed Ability to turn door knobs

Ability to turn door knobs Turning knobs opens doors and may allow the child access to the outdoors or unsafe areas within the home. The other abilities promote growth and development and involve lesser safety hazards.

What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease? Ensure output of a minimum 5 wet diapers daily. Feed on schedule every 4 hours to promote rest. Assess weight gain monthly. Breastfeed with small, frequent feeds.

Breastfeed with small, frequent feeds. Some infants with congenital heart disease (CHD) tire easily and will require small, frequent breastfeeding to manage their energy and meet caloric needs. Their output and weight gain should be watched closely. Parents should anticipate more frequent weight checks in the first weeks, and a minimum of 6 to 8 wet diapers daily.

A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting? Feeding problems Bradypnea Bradycardia Yellowish color

Feeding problems The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. In a child with CHF, tachypnea would be seen, not bradypnea. The heart beats faster in an attempt to increase blood flow.

The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child? clear lung sounds fever no joint swelling report of a headache

Fever An increasing temperature could be the manifestation of the inflammation worsening or the development of an abscess and subsequent infection. The progression of the disease will be reported to the health care provider.

The nurse has completed an examination of a 32-month-old girl with normal gross and fine motor skills. Which observation would suggest the child is experiencing a problem with language development? She talks incessantly. She uses complete 3- to 4-word sentences. Her vocabulary is between 10 and 15 words. She asks many questions.

Her vocabulary is between 10 and 15 words. A 3-year-old child typically has a vocabulary of approximately 900 words, asks many questions, uses complete sentences consisting of 3 to 4 words, and talks incessantly. Thus a vocabulary of 10 to 15 words suggests a language problem.

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? Ulcerative colitis (UC) Gastroenteritis Hirschsprung disease Short bowel syndrome (SBS)

Hirschsprung disease The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting.

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time? Preparing family for home care Improving hydration Promoting comfort Maintaining skin integrity

Improving hydration Preoperatively, the highest priority for the child with pyloric stenosis is to improve nutrition and hydration.

A nurse is reviewing blood work for a child with a cyanotic heart defect. What result would most likely be seen in a client experiencing polycythemia? Increased RBC Decreased WBC Increased WBC Decreased RBC

Increased RBC Polycythemia can occur in clients with a cyanotic heart defect. The body tries to compensate for having low oxygen levels and produces more red blood cells (RBCs).

A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant? Lower left Lower right Upper right Upper left

Lower right With appendicitis, percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness present with palpation in the right lower quadrant is referred to as the McBurney point.

The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. What food will the nurse recommend as an appropriate diet choice? oatmeal bananas canned soup toast

People with idiopathic celiac disease will need to avoid gluten in the diet. Of the foods listed, the nurse should recommend the child eat bananas, which do not contain gluten and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded. The nurse should teach the family that gluten is often hidden in processed or canned food; for example, many canned soups contain hidden gluten.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority? Place the child in a knee-to-chest position. Use a calm, comforting approach. Provide supplemental oxygen. Administer morphine as prescribed.

Place the child in a knee-to-chest position. The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority? Prepare the infant for surgery. Place the infant in the knee-chest position. Raise the head of the bed. Start an IV for fluids.

Place the infant in the knee-chest position. Placing the infant in the knee-chest position is the first priority when caring for an infant with tetralogy of Fallot.

In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? Assist in doing a barium enema procedure on the infant. Change the infant's diet to one that is lactose-free. Medicate the infant with analgesics. Prepare the infant for surgery.

Prepare the infant for surgery. In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy.

Which activity will the nurse encourage new parents to complete in order to assist their infant in accomplishing Erikson's developmental task for the first year of life? Appropriately enunciate words when speaking to the infant. Respond promptly when the infant cries. Praise the infant when a new milestone is reached. Read age-appropriate books to the infant daily.

Respond promptly when the infant cries. The developmental task of the infant year, according to Erikson, is to gain a sense of trust. This can be accomplished by promptly meeting the infant's needs during the first year of life. If the infant does not learn to trust, mistrust will develop.

The nurse in a community clinic is assessing a 2-month-old infant. The parent asks if the infant is developing normally. The nurse refers to which finding as suggestive of normal development in infants from birth to 2 months of age? The infant transfers objects from one hand to the other. The infant stays seated in the tripod position. The infant laughs aloud and responds to name. The infant raises head and chest while on stomach.

The infant raises head and chest while on stomach. Infants have gained some neck control and can independently raise head and chest by 2 months of age. Transferring objects from one hand to another is expected at 7 months of age. Laughing aloud and responding to his or her name is expected between 4 to 5 months of age. Sitting in the tripod position is not expected until 6 months of age.

A mother asks the nurse if the reason the infant has a congenital heart defect is because of something she did while pregnant. What is the best response by the nurse? There are several reasons an infant can have a heart defect; let's talk about those causes. No, heart defects are mainly caused by genetic factors. The studies show it is impossible to know what causes heart defects. Yes, there is a chance you caused this defect.

There are several reasons an infant can have a heart defect; let's talk about those causes. Parents who have a newborn who has a defect are always concerned they did something wrong to cause the defect. They carry a large amount of guilt. The nurse should focus on the therapeutic communication in this situation, while still obtaining more information. A nurse should never blame the parent because it is not only nontherapeutic, but there are many reasons why congenital heart defects occur. The reason for the infant's heart defect may not be known. Using therapeutic communication will reduce the parent's anxiety and guilt. Congenital heart defects can be caused by genetic defects such as chromosomal anomalies but this is not always the case.

What occurs in the gastrointestinal system of the child with Hirschsprung disease? There is a severe narrowing of the lumen of the pylorus. There is an invagination or telescoping of one portion of the bowel into a distal portion. There is a partial or complete mechanical obstruction in the intestine. There is a relaxed sphincter in the lower portion of the esophagus.

There is a partial or complete mechanical obstruction in the intestine. Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. A narrowing of the lumen of the pylorus is associated with pyloric stenosis in young infants. The telescoping of the bowel is intussusception. The relaxed sphincter in the lower portion of the esophagus is related to gastrointestinal reflux disorder.

A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? Refusal to eat Vomiting about 2 hours after feeding Chronic diarrhea Vomiting immediately after feeding

Vomiting immediately after feeding With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening.

The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. Which foods would be permitted in the diet of the child with celiac syndrome? Select all that apply. bananas skim milk wheat bread rye bread applesauce

bananas skim milk applesauce The child is usually started on a gluten-free, low-fat diet. Skim milk and bananas are usually well tolerated. Lean meats, puréed vegetables, and fruits are gradually added to the diet. Wheat, rye, and oats (unless specifically gluten free) are not included in the diet.

Anticipatory guidance for an infant for the 4th month should include the fact that the infant will be able to achieve which developmental milestone? develop a fear of strangers be able to turn over onto the back insist on things being done the infant's way have many "blue" or moody periods

be able to turn over onto the back At four months of age, the infant is able to lift the head and look around. The infant can roll from prone to supine. When being pulled up, the head leads. The 4-month-old infant can make simple vowel sounds, laugh aloud, and vocalize in response to voices.

After assessing a child, the nurse suspects coarctation of the aorta based on a finding of: bounding pulse. hepatomegaly. femoral pulse weaker than brachial pulse. narrow pulse.

femoral pulse weaker than brachial pulse. A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta. Bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. A narrow or thread pulse is associated with heart failure or severe aortic stenosis. Hepatomegaly is a sign of right-sided heart failure.

The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis? sausage-shaped mass in the upper mid abdomen abdominal pain and irritability hard, moveable "olive-like mass" in the upper right quadrant perianal fissures and skin tags

hard, moveable "olive-like mass" in the upper right quadrant A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception.

A child is diagnosed with rheumatic fever. For which medication will the nurse educate the caregivers? phenytoin antiviral nonsterioidal anti-inflammatory drugs (NSAIDs) insulin

nonsterioidal anti-inflammatory drugs (NSAIDs) Medications used in the treatment of rheumatic fever include penicillin, NSAIDs, and corticosteroids.

A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child? pyloric stenosis appendicitis gastroesophageal reflux peptic ulcer disease

pyloric stenosis With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen.

A nurse is providing care to an 11-month-old infant diagnosed with intussusception. When assessing the appearance of the child's stool, the nurse expects to note which finding? hard, formed large brown stool red, currant jelly-like stool loose, dark green stool clay-colored, watery stools

red, currant jelly-like stool In approximately 70% of cases of intussusception, frank or occult blood is seen in the stool. The stool is described as having a "red currant jelly" appearance due to the blood and mucus it contains.