Maternity Exam 3

Late manifestations of hypoxemia in pediatric patients

Confusion and stupor Cyanosis of skin and mucous membranes Bradypnea Bradycardia Hypotension or hypertension

A nurse is developing an educational program about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (SATA) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vacine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)

B. Pneumococcal conjugate vacine (PCV) D. Haemophilus influenzae type B (Hib) vaccine

fine motor skills

motor skills that involve more finely tuned movements, such as finger dexterity

permissive parenting

style of parenting in which parent makes few, if any demands on a child's behavior and consults the child when making decisions

Order of sexual maturation in boys

testicular enlargement pubic hair growth penile enlargement axillary hair growth facial hair growth vocal changes

Pavlik Harness

used for hip dysplasia in infants less than 6 months

1st line treatment for asthma?

Bronchodilator

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication? A. Give with a 240 mL (8 oz) glass of milk. B. Administer at mealtimes. C. Give with orange juice. D. Administer at bedtime.

C. Give with orange juice. Answer Rationale: Citrus fruit or juice aids absorption of this medication.

Which vaccines decrease the instances of bacterial meningitis in children >2 months old.

Hib & PCV vaccines

Girls tend to stop growing about 2 years after this?

Menarche

surgery to place tubes in ears, can be performed to treat chronic otitis media.

Myringotomy

When does menarche occur?

around 14 years old

Babinski reflex

birth to 1 year

Scabies treatment

(permethrin) insecticide cream

mild dehydration in infants

3%-5% weight loss

Offer first food to baby after what age?

6 months

Scoliosis is

A lateral curvature of the spine that can develop in times of growth

A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. C. Install accordion style gates. D. Set the water heater at 65.6° C (150° F). E. Fit the mattress so that it is snug against the sides of the crib.

A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. E. Fit the mattress so that it is snug against the sides of the crib.

intussusception s/s

-Sudden onset of severe, intermittent abdominal pain -screaming and drawing up legs with periods of calm in between episodes -currant jelly stools (blood and mucus) -sausage shaped mass in RUQ

pyloric stenosis s/s

-olive size mass in RUQ -projectile vomiting!** -hungry and irritable after vomiting -dehydration

Head lice treatment

1. *Permethrin 1% cream rinse*. (OTC) - kills adult lice and nits - wash clothes and bedding in hot water -*Must remove nits with a fine tooth comb daily until no more nits are found* - bag laundry that cannot be washed 14 days

at what age Tdap and meningococcal vaccine

11-12 years old

When does the anterior fontanelle close?

12-18 months

Girls stop growing how many years after menarche

2 years

When does the posterior fontanelle close?

2-3 months

authoritarian/dictatorial parenting

A parenting style in which the parents are demanding, expect unquestioned obedience, are not responsive to their children's desires, and communicate poorly with their children.

A nurse is preparing to assess a preschool-age child. Which of the following is an appropriate action by the nurse to prepare the child? A. Allow the child to role-play using miniature equipment. B. Use medical terminology to describe what will happen. C. Separate the child from her parent during the examination. D. Keep medical equipment visible to the child.

A. Allow the child to role-play using miniature equipment. Will help reduce anxiety and fear related to the examination

A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (SATA) A. Amnesia B. Systemic hypertension C. Bradycardia D. Respiratory depression E. Confusion

A. Amnesia E. Confusion

A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, "My son knows he better do what I say." Which of the following parenting styles is the parent exhibiting ? A. Authoritarian B. Permissive C. Authoritative D. Passive

A. Authoritarian The parent controls the adolescents behaviors and attitudes through unquestioned rules and expectations.

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support

A. Closed posterior fontanel Rationale: The infant's posterior fontanel should close by about 8 weeks of age.

a nurse is performing a family assessment. Which of the following should the nurse include? (SATA) A. Medical history B. Parent's Education level C. Child's physical growth D. Support system E. Stressors

A. Medical history B. Parent's Education level D. Support system E. Stressors

A reactive airway disease in children caused by an increased histamine response and is often triggered by something in the environment.

Asthma

A nurse is assessing a 6-month old infant. Which of the following reflexes should the infant exhibit? A. Moro B. Plantar grasp C. Stepping D. Tonic neck

B. Plantar grasp Exhibited from birth to 8 months

A nurse in an emergency department is caring for an adolescent following a suicide attempt. After reviewing the client's history, the nurse should determine that which of the following is the priority risk factor for suicide completion? A. Active psychiatric disorder B. Previous suicide attempt C. Loss of a parent D. History of substance abuse

B. Previous suicide attempt Answer Rationale: A prior suicide attempt is found in as many as half of the adolescents who attempt suicide.

A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? A. Set of building blocks B. Toy hammer and pounding board C. Picture book about hospitals D. Stuffed animal

B. Toy hammer and pounding board Rationale: A toy hammer and pounding board helps the child to express the anger and frustration he feels about the parent leaving but lacks the verbal ability to express.

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse to say to the child? A. "I promise I won't tell anyone about this." B. "Let's discuss what happened with your family." C. "Your family is bad for doing this to you." D. "It is not your fault that this happened."

D. "It is not your fault that this happened." Answer Rationale: The nurse should reinforce to the child that the abuse is not his fault.

A nurse is checking a child's ears. Which of the following is an expected finding ? A. Light reflex is located at the 2 o'clock position. B. Tympanic membrane is red in color. C. Bony landmarks are not visible. D. Cerumen is present bilaterally.

D. Cerumen is present bilaterally.

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Autonomy vs. shame and doubt B. Industry vs. inferiority C. Identity vs. role confusion D. Initiative vs. guilt E. Trust vs. mistrust

E. Trust vs. mistrust A. Autonomy vs. shame and doubt D. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A. Broth B. Water C. Diluted apple juice D. Oral rehydration solution

Oral rehydration solution Answer Rationale: Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea.

Passive parenting style

Parents are uninvolved, indifferent, and emotionally removed

Prepubescence occurs in ?

Preadolescence

What age group of children exhibit magical thinking and animism?

Preschool age

What puts infants at 3-6 months at greater risk for respiratory infections

Short and narrow upper airway short overall respiratory tract decreasing levels of maternal antibodies

Early manifestations of hypoxemia in pediatric patients

Tachypnea Tachycardia Restlessness Pallor of the skin and mucous membranes Evidence of respiratory distress

Otis Media Signs and Symptoms

Very fussy Fever Pulling or tugging on ear

palmar grasp reflex

birth to 3 months

tonic neck reflex

birth to 3-4 months

moro reflex

birth to 4 months

startle reflex

birth to 4 months

sucking and rooting reflex expected age

birth to 4 months

stepping reflex

birth to 4 weeks

Plantar Grasp Reflex

birth to 8 months

A priority nursing intervention for a child with any type of head trauma

head/spine stabilization

hip spica cast

hip dysplasia cast for older children

first infant food

iron fortified cereal, usually introduced after 6 months

What is scoliosis?

lateral curvature of the spine

bacterial epiglottitis

medical emergency! Airway could close

Mannitol

osmotic diuretic can be given IV decrease intracranial pressure and cerebral edema

authoritative/ democratic parenting

parents set limits and enforce rules but are flexible and listen to their children

marks left on hands by scabies

pencil marks

gross motor skills

physical skills that involve the large muscles

Prepubescence occurs during

preadolescence

Kernig's sign

resistance to extension of the child's leg from a flexed position

Brudzinski's sign

flexion of extremities occurring with deliberate flexion of the child's neck

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? A. 3 years B. 4 years C. 5 years D. 6 years

A. 3 years Rationale: At age 3, children can typically ascend stairs using alternating feet but still descend by placing both feet on each step.

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake? _______________________mL

260 ½ CUP juice = 4 oz. 4 oz x 30ml/oz= 120 mL 3 oz gelatin x 30ml/oz = 90 mL 1 oz ice pop= 30 mL 20 mL ginger ale 120 + 90 + 30 + 20 = 260mL

Birth weight doubles by

5 months

moderate dehydration in infants

6-9% weight loss

severe dehydration in infants

>10% weight loss

A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A. A needleless syringe and a doll B. A video game C. A story book about a child who has diabetes D. A period of play in the playroom

A. A needleless syringe and a doll Answer Rationale: Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act out feelings of anger and helplessness.

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures.

A. Have a parent stay with the child during procedures. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her.

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching? A. "I only need to catheterize myself twice every day." B. "I carry a water bottle with me because I drink a lot of water." C. "I use a suppository every night to have a bowel movement." D. "I do wheelchair exercises while watching TV."

A. "I only need to catheterize myself twice every day." Answer Rationale: The client has paralysis from the level of the defect down. In the majority of cases, this condition affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent emptying of the bladder can result in stasis and urinary tract infections.

A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make? A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." B. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." C. "Your child did not seem upset, so I wouldn't worry about it if I were you." D. "Why does it bother you that your child has wet the bed?"

A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." Answer Rationale: A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. The nurse should reassure the parents that regression is an expected behavior in children who are hospitalized and that her child will regain bladder control when she is feeling better.

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." B. "My child has recently lost both front top teeth." C. "My child often cheats when we play board games." D. "Sometimes my child acts bossy with his friends."

A. "The teacher says my child has to squint to see the board." Answer Rationale: Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn.

A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (SATA) A. Report of headache B. Alteration in pupillary response C. Increased motor response D. Increased sleeping E. Increased sensory response

A. Report of headache B. Alteration in pupillary response D. Increased sleeping

11. A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority? A. Respiratory rate B. Burns of the mouth C. Bowel sounds D. Visual acuity

A. Respiratory rate Answer Rationale: Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.

A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? A. "My morning blood glucose should be between 90 and 130." B. "I should eat a snack half an hour before playing soccer." C. "I should not take my regular insulin when I am sick." D. "I can store unopened bottles of insulin in the freezer."

B. "I should eat a snack half an hour before playing soccer." Answer Rationale: Exercise lowers blood glucose levels. The child should eat a snack half an hour prior to physical activity. If the exercise is prolonged, the child might require a snack during the activity.

The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make? A. "Let your child sleep in your bed with you." B. "Keep a night light on in your child's room." C. "Tell your child that monsters are not real." D. "Stay with your child until the child is asleep."

B. "Keep a night light on in your child's room." Answer Rationale: Fears of the dark and "monsters" are common in preschool-age children who are imaginative thinkers and have difficulty distinguishing between real and make-believe. After the parent reassures the child that there are no monsters, the night light provides enough illumination for the child to see that there is nothing hiding in the closet.

A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months

B. 6 months Rationale: Birth weight typically doubles by 6 months of age.

A nurse is administering vaccines at a county health immunization clinic. Which of the following clients should the nurse plan to administer the meningococcal conjugate (MCV4) vaccine? A. A 4-year-old child B. An 11-year-old school-age child C. A 4-month-old infant D. A 2-year-old toddler

B. An 11-year-old school-age child Answer Rationale: A school-age child between the ages of 11 to 12 years should receive a single dose of the MCV4 vaccine and a booster shot at 16 years of age.

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? A. Carotid artery B. Apex of the heart C. Brachial artery D. Radial artery

B. Apex of the heart Rationale: The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart.

A nurse is teaching a parent of a 2-year-old child about safe food choices. Which of the following foods should the nurse recommend? A. Grapes B. Bananas C. Celery D. Raw carrots

B. Bananas Rationale: Bananas are a safe choice for a 2-year-old child because they are easy to chew and swallow.

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate? A. Neutropenic B. Bleeding C. Contact D. Droplet

B. Bleeding Answer Rationale: The nurse should initiate bleeding precautions for a child who has a low platelet count. Bleeding precautions involve specific measures to reduce the risk of bleeding, such as using soft-bristled toothbrushes, avoiding IM injections, and preventing constipation.

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? A. Identity crisis B. Body image changes C. Feelings of displacement D. Loss of privacy

B. Body image changes Answer Rationale: Body image changes are the most common behaviors observed in adolescents who have scoliosis and require surgery.

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? A. Restrain the child physically. B. Ignore the temper tantrums. C. Tell the child that temper tantrums are not acceptable. D. Distract the child by offering to play a game.

B. Ignore the temper tantrums. Rationale: Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly.

A nurse is caring for a child who has ICP. Which of the following actions should the nurse take? (SATA) A. Suction the endotracheal tube every 2 hours. B. Maintain a quiet environment. C. Use two pillows to elevate the head of the bed. D. Administer stool soften E. Maintain body alignment

B. Maintain a quiet environment. D. Administer stool soften E. Maintain body alignment

A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take? A. Initiate the IV per the parent's request. B. Notify the provider of the situation. C. Administer a sedative to calm the client. D. Offer the client an antiemetic.

B. Notify the provider of the situation. Answer Rationale: The nurse should consult with the provider before proceeding. Although the parent must give consent for a minor, the nurse should obtain the minor's assent when the minor is able to give it.

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings? A. Place the infant in a prone position. B. Place the infant in an infant seat. C. Place the infant on his left side. D. Place the infant on his right side.

B. Place the infant in an infant seat. Rationale: An infant seat provides elevation and decreases the risk of aspiration.

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot stand upright without support. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob.

B. The toddler cannot stand upright without support. Rationale: The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay.

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names? A. Chickenpox B. Whooping cough C. Mumps D. Fifth disease

B. Whooping cough Rationale: Whooping cough is the common name for pertussis

A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (SATA) A. Instruct the child that the treatment will last 30 min. B. obtain vital signs C. Tell the child to take slow deep breaths. D. Determine if the child should use a mask. E. Attach the device to air source.

B. obtain vital signs C. Tell the child to take slow deep breaths. D. Determine if the child should use a mask. E. Attach the device to air source.

Menarche happens at what age

By age 14

A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide? A. "This technique opens the ear canal, allowing medication to reach the inner ear region." B. "When this technique is used, the toddler experiences less pain." C. "This is the safest and easiest way to administer this medication." D. "When this technique is used, the medication will not run out of the ear."

C. "This technique opens the ear canal, allowing medication to reach the inner ear region." Rationale: For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ear.

A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? A. "Share piercing needles only with close friends you trust." B. "Limit your caloric intake to avoid becoming overweight." C. "Your need for sleep will increase during periods of growth." D. "Tanning beds are much safer then lying in the sun."

C. "Your need for sleep will increase during periods of growth." Answer Rationale: The nurse should inform the adolescent that sleep needs increase during growth spurts. Adequate sleep and rest during the adolescent period is important for optimal health.

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first? A. Ask the toddler what caused the bruises. B. Notify the provider. C. Ask the parents what caused the bruises. D. Notify social services.

C. Ask the parents what caused the bruises. Rationale: The nurse should gather additional data. Inconsistencies between the history and the injury are the most important criterion on which to base the decision to report suspected abuse.

A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the findings should the nurse monitor for as an adverse reaction to mannitol? A. Bradycardia B. Weight loss C. Confusion D. Constipation

C. Confusion Rationale: Report to provider, increase confusion could indicate electrolyte imbalance.

A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate. B. Encourage the child to take deep breaths. C. Ensure proper placement of the sensor probe. D. Place the child in Fowler's position.

C. Ensure proper placement of the sensor probe.

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in a semi-Fowler's position. B. Admit the client to a private room. C. Measure head circumference every shift. D. Implement seizure precautions.

C. Measure head circumference every shift. Answer Rationale: The head circumference of a 6-year-old can't increase since the fontanels and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head circumference.

A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering? A. Pneumococcal polysaccharide vaccine B. Bacille Calmette-Guérin (BCG) vaccine C. Meningococcal polysaccharide vaccine D. Influenza vaccine

C. Meningococcal polysaccharide vaccine Answer Rationale: Recent studies have shown that college students, especially freshmen living in dormitories, are at an increased risk for meningococcal meningitis. The Centers for Disease Control and Prevention and the American Academy of Pediatrics now recommend that college students and parents be educated about meningococcal disease and consider vaccination.

A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.) A. Weigh the infant in a diaper. B. Use a stadiometer to measure the infant. C. Place a disposable covering on the scale. D. Measure the infant from crown of the head to the heels of feet. E. Balance the scale to 0 prior to use.

C. Place a disposable covering on the scale. D. Measure the infant from crown of the head to the heels of feet. E. Balance the scale to 0 prior to use.

A nurse in the emergency department is assessing a newly - admitted infant. Which of the following findings is an early indication of hypoxemia? A. Nonproductive cough B. Hypoventilation C. Tachypnea D. Nasal stuffiness

C. Tachypnea

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration? A. Place a bedside humidifier at the head of the client's bed. B. Suction the nasopharynx as needed. C. Withhold fluids until the client demonstrates a gag reflex. D. Perform chest physiotherapy.

C. Withhold fluids until the client demonstrates a gag reflex. Answer Rationale: Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or edema. To prevent aspiration, the gag reflex must be present before the client is allowed have fluids.

A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction? A. "I will encourage her to drink half a cup of water or sugar-free fluids every 30 minutes." B. "I will report a change in her breathing or any signs of confusion." C. "I will notify the doctor if her temperature is not controlled with acetaminophen." D. "I will continue to check his blood sugar two times every day."

D. "I will continue to check his blood sugar two times every day." Answer Rationale: A client who has type 1 diabetes mellitus and is ill is at risk of developing DKA. DKA results in the breakdown of body fat for energy and the presence of ketones in the blood and urine. Because acute illness increases glucose levels, the child's glucose levels and the urine ketones should be checked every 3 hr. Checking the child's blood glucose two times per day is not enough to adequately monitor glucose levels.

A nurse is assessing a child in an area struck by an earthquake. The child, who is crying, walks well, can state their first name, and repeatedly says "All done" and "Go bye-bye now" during the assessment. The child has 20 deciduous teeth and their anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old? A. 12 B. 18 C. 24 D. 30

D. 30 Rationale: The nurse should estimate that the child is at least 30 months old because the child has completed their primary dentition (20 deciduous teeth), which occurs by 30 months of age. In addition, the nurse should recognize that the child is at least 18 months old because the anterior fontanel is closed and should recognize that the child is at least 24 months old because the child speaks in two- and three-word

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify? A. Maintain NPO status. B. Monitor oral temperature every 4 hr. C. Medicate the client for pain every 4 hr as needed. D. Administer sodium biphosphate/sodium phosphate.

D. Administer sodium biphosphate/sodium phosphate.

A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program? A. Changes in the voice signal the beginning of puberty. B. Gynecomastia commonly occurs during late puberty. C. Puberty might be delayed if scrotal changes have not occurred by the age of 11 years. D. Growth spurts in height occur toward the end of midpuberty.

D. Growth spurts in height occur toward the end of midpuberty. Answer Rationale: Growth spurts in height occur toward the end of midpuberty. Boys grow an average of 10 to 30 cm (4 to 12 inches) during this period.

A nurse is assessing a 4 month-old infant who has meningitis. Which of following manifestations should the nurse expect? A. Depressed anterior fontanel B. Constipation C. Presence of rooting reflex D. High pitched cry

D. High pitched cry

A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take? A. nitiate airborne precautions. B. Obtain a throat culture. C. Use a tongue depressor to observe the epiglottis. D. Monitor oxygen saturation.

D. Monitor oxygen saturation. Answer Rationale: The nurse should monitor the child's oxygen saturation levels to check for indications of respiratory distress or a decline child's condition.

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? A. Imaginary playmates B. Erikson's stage of initiative versus guilt C. Demonstrations of sexual curiosity D. Negative behaviors characterized by the need for autonomy

D. Negative behaviors characterized by the need for autonomy Rationale: Assertion of autonomy is seen in toddlers as they begin their language and social development.

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Prepare the child for a lumbar puncture. B. Administer an intravenous antibiotic. C. Obtain blood cultures. D. Place the child in isolation.

D. Place the child in isolation. Answer Rationale: Bacterial meningitis is highly contagious. Therefore, the nurse should protect others from infection by placing the child in isolation.

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? A. Attempt to stop the seizure. B. Restrain the child's arms. C. Use a padded tongue blade. D. Position the child laterally.

D. Position the child laterally. Answer Rationale: Positioning the child laterally facilitates airway patency.

. A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which of the following findings should the nurse expect? A. Skips and hops on one foot B. Has a vocabulary of 1,500 words C. Walks backwards heel to toe D. Stands on one foot for a few seconds

D. Stands on one foot for a few seconds Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off of the bottom step.

A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity? A. Increased blood pressure B. Hyperventilation C. Decreased PaCO2 D. Unconsciousness

D. Unconsciousness

Treatment for bacterial meningitis

Dexamethasone: Corticosteriod Antibiotics

sign of increased intracranial pressure (ICP).

High pitched cry

A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect? A. Dry, flushed skin B. Deep, rapid respirations C. Tachycardia D. Polyuria

Tachycardia Answer Rationale: A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have tachycardia due to increased circulating catecholamines and increased adrenergic activity.

A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? A. An anxiety reaction B. Regression C. Resentment toward the mother D. Developing autonomy

A. An anxiety reaction Rationale: Hospitalization is stressful, regardless of the age of the client. However, for an 18-month-old toddler, separation from parents adds to that stress. The toddler's behavior indicates an anxiety reaction to the stress of hospitalization. Separation anxiety initially causes demonstrations of protest. Remaining sad and quiet when a parent leaves indicates the second response to separation anxiety, which is despair.

A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take? A. Assess the rest of the child's body for a rash. B. Refer the family to child protective services. C. Question the parents about how the marks occurred on the child's cheeks. D. Obtain the child's temperature.

A. Assess the rest of the child's body for a rash. Rationale: Fifth disease presents with erythema on the face, which resembles slap marks. The nurse should further assess the child's body and extremities to determine if the child has Fifth disease.

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen

A. At the end Rationale: When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows.

A nurse is caring for an 8-year-old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission? A. Auscultating the rate and characteristics of the child's heart sounds B. Using a pain-rating tool to determine the severity of the joint pain C. Identifying the degree of parental anxiety related to the diagnosis D. Assessing the client's erythematous rash

A. Auscultating the rate and characteristics of the child's heart sounds Answer Rationale: Using the airway, breathing, circulation approach to client care, the nurse should place priority on auscultating the client's heart rate and heart sounds. Rheumatic fever is an inflammatory disease that begins with a strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart valves are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications.

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority? A. Blood pressure 92/50 mm Hg B. Heart rate 72/min C. Abdominal pain rated 4 on a scale of 0 to 10 D. Respiratory rate 20/min

A. Blood pressure 92/50 mm Hg Answer Rationale: The expected reference range for blood pressure in an adolescent is 110/65 to 120/80 mm Hg. A blood pressure 92/50 mm Hg indicates the adolescent is hypotensive and unstable. Therefore, this finding is the priority. Blunt abdominal trauma can cause internal hemorrhage that leads to hypotension.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson? A. Encourage the client to complete school work. B. Vary the child's schedule each day. C. Discourage visits from the client's friends. D. Provide a daily session with a play therapist.

A. Encourage the client to complete school work. Answer Rationale: Erikson's stage of psychosocial development for a 10-year-old child is industry vs. inferiority. By providing school-age children the opportunity to keep up with their school work, they can continue to develop skills and knowledge and maintain a sense of accomplishment.

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Inspection B. Superficial palpation C. Deep palpation D. Auscultation

A. Inspection D. Auscultation B. Superficial palpation C. Deep palpation

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book

A. Large building blocks Rationale: Large building blocks are age-appropriate toys for a 12-month-old toddler.

A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Management of tantrums B. How to establish trust C. How to encourage cooperative play D. Dental care E. Need for increased caloric intake

A. Management of tantrums D. Dental care

A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply.) A. Measles, mumps rubella (MMR) B. Diphtheria, tetanus and acellular pertussis (DTaP) C. Varicella (VAR) D. Rotavirus (RV) E. Human papillomavirus (HPV4)

A. Measles, mumps rubella (MMR) C. Varicella (VAR)

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (SATA) A. Negative Gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC count E. Normal Protein content

A. Negative Gram stain B. Normal glucose content E. Normal Protein content

A nurse is caring for a client who has suspected meningitis and a decreased LOC. Which of the following actions should the nurse take? A. Place the client on NPO status. B. Prepare the client for a liver biopsy. C. Position the client dorsal recumbent. D. Put the client in protective environment.

A. Place the client on NPO status Rationale: Due to decreased LOC to prevent aspiration

A nurse is teaching an adolescent to self-administer a corticosteroid medication using metered-dose inhaler (MDI). Which of the following instructions should the nurse include? (SATA) A. Shake the device prior to use. B. Rinse and expectorate after administration. C. Inhale slowly with medication administration. D. Exhale quickly after medication administration. E. Wait for 30 seconds between puffs.

A. Shake the device prior to use. B. Rinse and expectorate after administration. C. Inhale slowly with medication administration.

A nurse in the emergency department is assessing a child following a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? A. Stabilize the child's neck. B. Clean the child's laceration with soap and water. C. Implement seizure precautions for the child. D. Initiate IV access for the child.

A. Stabilize the child's neck. Rationale: The greatest risk for a child following a motor vehicle crash is cervical injury.

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever

A. Sudden decrease in abdominal pain Answer Rationale: A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.) A. The reason why the child is taking the medication B. Written information about the medication C. Stopping the medication when the child feels better D. The adverse effects of the medication E. Using a kitchen spoon to administer the medication

A. The reason why the child is taking the medication B. Written information about the medication D. The adverse effects of the medication

Definitive test for meningitis

Lumbar puncture

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A."As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."

a. Rationale A nurse is required by law to report suspected child abuse. Therefore this is truthful, non accusatory response.

In toddlers, head circumference equals

chest circumference

A sign of hemorrhage post tonsillectomy

frequent swallowing

what should parents use to clean their babies mouth.

soft wash cloth

Evidence of respiratory distress

use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds