NCLEX Pediatrics questions

A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" *4. "Did the child have a sore throat or an unexplained fever within the past 2 months?"* *Rationale:* Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

Several children have contracted rubeola (measles) in a local school and the school nurse conducts a teaching session for the parents of the school-children. Which statement, if made by a mother, indicates a need for further teaching regarding this communicable disease?

1. "Small blue-white spots with a red base may appear in the mouth." 2. "The rash usually begins centrally and spreads downward to the limbs." *3. "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."* 4. "Respiratory symptoms such as a very runny nose, cough, and fever occur before the development of a rash." *Rationale:* The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal (catarrhal) stage. Options 1, 2, and 4 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik spots. Option 3 describes the incubation period for rubella, not rubeola.

A child has a basilar skull fracture. Which of the following health care provider's prescriptions should the nurse question?

1. Restrict fluid intake. 2. Insert an indwelling urinary catheter. 3. Keep an intravenous (IV) line patent. *4. Suction via the nasotracheal route as needed.* *Rationale:* Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary.

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse would question this prescription if the child had documented evidence of which condition?

1. Arthralgia 2. Joint pain 3. Facial edema *4. A viral infection* *Rationale:* Anti-inflammatory agents, including aspirin, may be prescribed by the health care provider for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections such as influenza because of the risk of Reye's syndrome. Options 1 and 2 are clinical manifestations of RF. Facial edema may be associated with the development of a cardiac complication.

A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record?

1. Incessant crying 2. Coughing at nighttime *3. Choking with feedings* 4. Severe projectile vomiting *Rationale:* Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

The appropriate child position after a tonsillectomy is which of the following?

1. Supine position *2. Side-lying position* 3. High Fowler's position 4. Trendelenburg's position *Rationale:* The child should be placed in a semi-prone or side-lying position after tonsillectomy to facilitate drainage. Options 1, 3, and 4 will not achieve this goal.

A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?

1. The communicable period is unknown. 2. The communicable period ranges from 2 weeks or less up to several months. 3. The communicable period is 10 days before the onset of symptoms to 15 days after the rash appears. *4. The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.* *Rationale:* The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions. In roseola the communicable period is unknown. Option 2 describes diphtheria. Option 3 describes rubella.

A nurse has reinforced home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement, if made by the mother, indicates the need for further instructions?

1. "A balance of rest and exercise is important." *2. "I can apply lotion or powder to the incision if it is itchy."* 3. "Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after this surgery." *Rationale:* The mother should be instructed that lotions and powders should not be applied to the incision site because these items can affect the skin integrity and the healing process. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

A nurse is caring for an 18-month-old child who has been vomiting. The appropriate position in which to place the child during naps and sleep time is:

1. A supine position *2. A side-lying position* 3. Prone, with the head elevated 4. Prone, with the face turned to the side *Rationale:* The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, and 4 will place the child at risk for aspiration if vomiting occurs.

An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse who is assisting in caring for the infant will ensure that the gastrostomy tube is:

1. Placed to gravity 2. Attached to low suction 3. Taped to the bed linens *4. Elevated* *Rationale:* In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass to the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. Options 1, 2, and 3 are incorrect.

A nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which of the following findings would the nurse expect to note in this child?

1. Bradycardia *2. Tachycardia* 3. Hyperactivity 4. A reddened appearance to the cheeks *Rationale:* Clinical manifestations of iron deficiency anemia will vary with the degree of anemia but usually include extreme pallor with porcelain-like skin, tachycardia, lethargy, and irritability.

A nurse is assisting with performing admission data collection on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is:

1. Hypotension *2. Generalized edema* 3. Increased urinary output 4. Frank, bright red blood in the urine *Rationale:* Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased, and the blood pressure is normal or slightly decreased.

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

*1. "When picking up your infant, support the infant's neck and head with the open palm of your hand."* 2. "Feed your infant in a side-lying position." 3. "Place a helmet on your infant when in bed." 4. "Hyperextend your infant's head with a rolled blanket under the neck area." *Rationale:* Hydrocephalus is a condition characterized by an enlargement of the cranium caused by an abnormal accumulation of cerebrospinal fluid within the cerebral ventricular system. This characteristic causes the increase in the weight of the infant's head. The infant's head becomes top heavy. Supporting the infant's head and neck when picking it up prevents hyperextension of the neck area and the infant from falling backward. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant's head can put pressure on the neck vertebrae, causing injury.

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which of the following interventions has the highest priority in the care of this child immediately following the procedure?

*1. Assess for any bleeding on the dressing.* 2. Position the child's leg so that it is straight. 3. Assess the strength and presence of the distal pulses. 4. Take the vital signs including blood pressure and oxygen saturation. *Rationale:* Bleeding is a primary concern following this procedure. Although options 2, 3, and 4 are correct interventions, they are not the priority.

A nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing:

*1. Decorticate posturing* 2. Decerebrate posturing 3. Flexion of the arms and legs 4. An expected position post-head injury *Rationale:* Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists, and an extension of the lower extremities with some internal rotation.

A female adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse would instruct the adolescent to:

*1. Eat six graham crackers or drink a cup of orange juice before practice or game time.* 2. Eat half the amount of food normally eaten at lunchtime. 3. Take the prescribed insulin one half hour before practice or game time rather than in the morning. 4. Take two times the amount of prescribed insulin on practice and game days. *Rationale:* An extra snack of 15 to 30 g of carbohydrate eaten before activities such as cheerleader practice will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased.

A nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3 and the platelet count is 150,000 cells/mm3. Which of the following nursing interventions will the nurse incorporate into the plan of care?

*1. Maintain strict isolation precautions.* 2. Encourage the child to use a soft toothbrush. 3. Avoid unnecessary injections. 4. Encourage quiet play activities. *Rationale:* The normal WBC ranges from 5000 to 10,000 cells/mm3 and the normal platelet count ranges from 150,000 to 400,000/mm3. Strict isolation procedures would be required if the WBC count were low to protect the child from infection. Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury.

A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

*1. Rectal* 2. Axillary 3. Electronic 4. Tympanic *Rationale:* Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, the nurse plans to inform the mother of the child that:

*1. The child will need to be hospitalized for observation.* 2. The child may go home with a prescription for antibiotics. 3. The child will need to return to the hospital for a chest x-ray in 1 week. 4. The child will require a bronchoscopy for follow-up evaluation in 1 month. *Rationale:* Removal of foreign bodies from the respiratory tract may need to be performed by direct laryngoscopy or bronchoscopy. After the procedure the child should remain hospitalized for observation for laryngeal edema and respiratory distress. Cool mist is provided, and antibiotic therapy is prescribed if appropriate. Options 2, 3, and 4 are incorrect.

A nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which of the following are characteristic of this illness? *Select all that apply.*

*1. The cough is harsh and metallic.* *2. Inspiratory stridor may be present.* *3. Symptoms usually worsen at night and are better during the day.* 4. Symptoms usually worsen during the day and are relieved during sleep. *5. It is usually preceded by several days of upper respiratory infection symptoms.* *Rationale:* Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. It is characterized by a sudden onset of a harsh, metallic cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day.

A nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which of the following instructions?

1. "Call the health care provider if the infant is fussy." 2. "Position the infant on the side of the shunt when the infant is put to bed." 3. "Expect an increased urine output from the shunt." *4. "Call the health care provider if the infant has a high-pitched cry."* *Rationale:* If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected. Option 1 is a concern only if other signs indicative of a complication are occurring.

A nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit information about the cause of this disease?

1. "Did your child sustain any injuries to the kidney area?" *2. "Did your child recently complain of a sore throat?"* 3. "Has your child had any diarrhea?" 4. "Have you noticed any rashes on your child?" *Rationale:* Group A beta hemolytic streptococcal infection is a cause of glomerulonephritis. Often the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The questions to the mother in options 1, 3, and 4 are unrelated to a diagnosis of glomerulonephritis.

The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother replies:

1. "I know that my infant needs to drink predigested formula until she has her stool pattern developed." 2. "When I begin feeding my infant cereal, I will make sure to warm the cereal and administer the pancreatic enzyme mixed in." 3. "I will make sure that I give my infant fat-free milk as a supplement to her predigested formula, because she is not able to digest fat." *4. "I know I need to monitor my infant's stools and if there are more than four stools a day, I will increase the pancreatic enzyme."* *Rationale:* Cystic fibrosis requires a high-calorie, high-protein diet with pancreatic enzyme replacement therapy. The infant needs to remain on the predigested formula until 1 year of age, when formula can be discontinued and then fat-free milk consumed. The pancreatic enzyme should not be mixed with warmed foods because this inactivates the enzyme. Stools must be monitored, and pancreatic enzymes are administered based on the stool pattern.

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother of the test results and provides instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding of the care measures?

1. "I need to keep my child on bedrest for 3 weeks." 2. "I will call the health care provider if my child is still feeling tired in 1 week." *3. "I need to call the health care provider if my child complains of abdominal pain or left shoulder pain."* 4. "I need to isolate my child so that the respiratory infection is not spread to others." *Rationale:* The mother needs to be instructed to notify the health care provider if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bedrest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse provides instructions to the mother regarding cast care at home. Which of the following instructions would the nurse provide to the mother?

1. "The cast should be dry in about 6 hours." 2. "The cast is water resistant, so the child is able to take a bath or a shower." 3. "The cast will not mold to the body and should heal the fracture in no time at all." *4. "The cast needs to be kept dry because, when wet, it will begin to disintegrate."* *Rationale:* Plaster of Paris is a heavier material than that used in a synthetic cast. It molds easily to the extremity and is less expensive than a synthetic cast. It takes about 24 hours to dry, and drying time could be longer depending on the size of the cast. Plaster of Paris is not water resistant, and when wet, it will begin to disintegrate.

A nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which of the following priority items at the newborn's bedside?

1. A blood pressure cuff 2. A rectal thermometer 3. A specific gravity urinometer *4. A bottle of sterile normal saline* *Rationale:* The newborn with spina bifida is at risk for infection before the closure of the gibbus. A sterile normal-saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. A thermometer will be needed to assess the temperature, but in this newborn the priority is to maintain sterile normal-saline dressings over the gibbus.

A nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing that in this disorder:

1. A single vessel overrides both ventricles. 2. Frequent episodes of hypercyanotic spells occur. *3. There is no communication from the right atrium to the right ventricle.* 4. There is no communication from the systemic and pulmonary circulations. *Rationale:* In tricuspid atresia, there is no communication from the right atrium to the right ventricle. Option 1 describes truncus arteriosus. Option 4 describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot.

A nurse reviews the record of a 1-year-old child seen in the clinic and notes that the health care provider has documented a diagnosis of celiac crisis. Which of the following symptoms would the nurse expect to note in this condition?

1. Anorexia 2. Joint pain *3. Profuse, watery diarrhea* 4. Constipation *Rationale:* Clinical manifestations associated with celiac crisis include profuse, watery diarrhea and vomiting that quickly lead to severe dehydration and metabolic acidosis. The cause of the crisis is usually infection or hidden sources of gluten. The child may require intravenous fluids to correct fluid and acid-base imbalances, albumin to treat shock, and corticosteroids to decrease severe mucosal inflammation.

A nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). In the preoperative period, the priority nursing action is to monitor:

1. Blood pressure *2. Moisture of the normal saline dressing on the gibbous area* 3. Specific gravity of the urine 4. Anterior fontanel for depression *Rationale:* The newborn is at risk for infection before closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to determine during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. Depression of the anterior fontanel is a sign of dehydration. With spina bifida, an increase in intracranial pressure is more of a priority. A complication of spina bifida would demonstrate a bulging or taut anterior fontanel.

A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The initial nursing action is to:

1. Call a code. 2. Contact the respiratory therapy department. 3. Place the infant in a prone position. *4. Place the infant in a knee-chest position.* *Rationale:* If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The nurse would contact the registered nurse, who would then contact the health care provider. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia.

An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. The appropriate initial nursing intervention is to:

1. Call the child's mother for permission to treat the child. 2. Call the school health care provider immediately. 3. Let the child rest until the blood glucose has an opportunity to rise. *4. Give the child 6 oz of a regular cola drink.* *Rationale:* A blood glucose level below 70 mg/dL indicates hypoglycemia. The child is participating in an activity that requires more energy than that of the normal routine at school. Insulin and food requirements change with situations that require more energy. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Options 1, 2, and 3 do not address the hypoglycemic state immediately and delay required treatment.

A nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). To monitor for a major symptom associated with this disorder, the nurse:

1. Checks the capillary refill on the nail beds of the upper extremities 2. Tests the urine for blood 3. Palpates the abdomen for masses *4. Checks for responses to painful stimuli from the torso downward* *Rationale:* Newborns with spina bifida (myelomeningocele type) demonstrate lack of nerve innervation from below the site of the gibbus (sac containing the meninges and spinal cord). They therefore show diminished or no responses to painful stimuli in the areas below the gibbus. Options 1, 2, and 3 are incorrect because the area above the gibbus is not affected. The capillary refill would be normal. The urine would not have blood present. If the kidneys are affected, proteinuria could be present but this is not generally noted in the newborn period. No masses are present besides the gibbus on the back area, externally protruding from the vertebral deformity.

A nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse monitors the child for central nervous system (CNS) involvement by checking which of the following?

1. Color, motion, and sensation of the extremities 2. Pupillary reaction *3. Level of consciousness (LOC)* 4. The presence of petechiae in the sclera *Rationale:* The CNS is monitored because of the risk of infiltration of blast cells into the CNS. The child's level of consciousness is assessed, and the child is monitored for signs of irritability, vomiting, and lethargy. Color, motion, and sensation of the extremities are neurovascular assessments. Changes in pupillary reaction are most often noted in conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign that may occur in leukemia.

A nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flowmeters. The nurse identifies which of the following as an appropriate goal for this child?

1. Denies shortness of breath or difficulty breathing 2. Has regular respirations at a rate of 18 to 22 breaths per minute *3. Expresses feelings of mastery and competence with breathing devices* 4. Watches the educational video and reads printed information provided *Rationale:* School-age children strive for mastery and competence to achieve the developmental task of industry and accomplishment. Options 1 and 2 do not relate to the knowledge deficit, which is the subject of the question. Option 4 is an intervention rather than a goal.

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would do which of the following in order to protect the child from injury? *Select all that apply.*

1. Keep a padded tongue blade at the bedside for use during a seizure. *2. Remove toys that have bright, blinking lights on them.* *3. Keep side rails and other hard objects padded.* *4. Turn the client to the side during a seizure.* 5. Restrict the client's fluid intake. *Rationale:* Attempting to place something in a child's mouth during a seizure is not helpful even if it is padded. The mouth is usually clenched, and one would have to use force to open the mouth. One must attempt to keep the airway clear and can do that by positioning (option 4). Option 2 may be helpful in preventing a seizure, and option 3 safeguards the client's physical safety. Option 5 is not necessary.

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as what level of dehydration?

1. Mild dehydration 2. Severe dehydration 3. Very mild dehydration *4. Moderate dehydration* *Rationale:* Moderate dehydration demonstrates itself with a weight loss in children of 6% to 8% of weight. Mild dehydration would not present with these symptoms. In severe dehydration, additional findings would include lethargy and listlessness. The symptoms listed are all characteristics of moderate dehydration. Very mild dehydration is not a term used to describe dehydration.

A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which of the following is associated with this type of cancer?

1. Normal bone marrow is replaced by blast cells. 2. Red blood cells (RBCs) and platelet production become affected. 3. The reticuloendothelial system is affected. *4. Reed-Sternberg cells are found on biopsy.* *Rationale:* In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually RBC and platelet production is affected and the child becomes anemic and thrombocytopenic. The reticuloendothelial system is affected, thus disturbing the body's defense system and rendering these children unable to fight infections normally. The Reed-Sternberg cell is found in Hodgkin's disease.

A nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which of the following is the appropriate nursing intervention?

1. Notify the registered nurse immediately. *2. Document the findings.* 3. Apply ice immediately. 4. Elevate the buttocks. *Rationale:* A fresh colostomy stoma will be red and edematous but this will decrease with time. The colostomy site will then be pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse would document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate interventions.

A health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse instructs the mother regarding this procedure and tells the mother to:

1. Place the patch on both eyes. *2. Place the patch on the left eye.* 3. Place the patch on the right eye. 4. Alternate the patch from the right to left eye hourly. *Rationale:* Eye patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the "good" eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

A mother of a child with cystic fibrosis asks the clinic nurse about the disease. The nurse tells the mother that it is:

1. Transmitted as an autosomal dominant trait *2. A chronic multisystem disorder affecting the exocrine glands* 3. A disease that causes the formation of multiple cysts in the lungs 4. A disease that causes dilation of the passageways of many organs *Rationale:* Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and the pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis?

1. A veggie salad and a caramel apple 2. A strawberry jelly sandwich and pretzels 3. A plate of nachos and cheese and a cupcake *4. A piece of fried chicken and a loaded baked potato* *Rationale:* Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. A piece of fried chicken and a loaded baked potato provides a high-calorie and high-protein meal that includes fat.

A nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?

1. Checking the quality of the radial pulse 2. Checking the child's ability to extend the fingers 3. Checking for effectiveness of analgesics administered for pain *4. Checking the child's ability to perform range of motion to the shoulder area of the affected extremity* *Rationale:* Compartment syndrome occurs when swelling causes pressure to rise within a compartment (sheath of inelastic fascia). The increased pressure compromises circulation to the muscles and nerves within the compartment and can result in paralysis and necrosis of tissues. Signs of compartment syndrome include severe pain, often unrelieved by analgesics, and signs of neurovascular impairment. Compartment syndrome is not uncommon in fractures of the forearms; therefore the quality of the radial pulse and the ability to extend the fingers should be assessed. If extension of the fingers produces pain, the health care provider should be notified. Option 4 is unlikely to provide information about compartment syndrome.

A nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?

1. Creatinine 2. Urinalysis *3. Platelet count* 4. Blood urea nitrogen (BUN) *Rationale:* Before the surgical procedure, the child is assessed for signs of active infection and for redness and exudate of the throat. Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin (PT), partial thromboplastin time (PTT), platelet count, hemoglobin and hematocrit (H&H), white blood cell (WBC) count, and urinalysis are performed preoperatively. The platelet count result would identify a potential for bleeding. The BUN and creatinine would not determine the potential for bleeding but rather evaluate renal function.

A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF?

1. Immunoglobulin 2. Red blood cell count *3. Antistreptolysin O titer* 4. White blood cell count *Rationale:* A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 4 will not assist in confirming the diagnosis of RF.

The nurse should implement which of the following in the care of a child who is having a seizure? *Select all that apply.*

*1. Time the seizure.* 2. Restrain the child. *3. Stay with the child.* 4. Insert an oral airway. 5. Place the child in a supine position. *6. Loosen clothing around the child's neck.* *Rationale:* During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which of the following is the appropriate nursing action?

*1. Withhold the medication.* 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication. *Rationale:* Digoxin is effective within a narrow therapeutic range (0.5 to 2 ng/mL). Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats per minute in an infant, the nurse would withhold the dose and notify the registered nurse and health care provider. Options 2, 3, and 4 are incorrect actions.

A nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse makes which response to the mother?

1. "In 1 week". *2. "In 3 weeks".* 3. "Two days following surgery". 4. "When the health care provider says it's OK". *Rationale:* Rough, scratchy foods or spicy foods are to be avoided for 3 weeks. Citrus juices, which irritate the throat, need to be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. A full liquid diet is allowed on the second postoperative day, and soft foods are allowed as the child tolerates them.

A nurse is assigned to care for a child who is in skeletal traction. The nurse avoids which of the following when caring for the child?

1. Keeping the weights hanging freely 2. Ensuring that the ropes are in the pulleys *3. Placing the bed linens on the traction ropes* 4. Ensuring that the weights are out of the child's reach *Rationale:* Bed linens should not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, and 4 are appropriate measures when caring for a child who is in skeletal traction.

A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse looks for which early sign of CHF?

1. Pallor 2. Cough *3. Tachycardia* 4. Slow and shallow breathing *Rationale:* The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with CHF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with CHF, but it is also not an early sign.

A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. *Select all that apply.*

1. Use the fingertips to lift the cast while it is drying. *2. Keep small toys and sharp objects away from the cast.* 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. *5. Contact the health care provider if the child complains of numbness or tingling in the extremity.* *6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.* *Rationale:* While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.

A nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further instructions?

1. "We need to encourage adequate fluid intake." 2. "Coughing spells may be triggered by dust or smoke." *3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."* 4. "Good hand-washing techniques need to be instituted to prevent spreading the disease to others." *Rationale:* Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 4 are components of home care instructions.

A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate?

1. Pallor 2. Hyperactivity *3. Exercise intolerance* 4. Gastrointestinal disturbances *Rationale:* The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

A nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by a parent would indicate a need for further teaching?

*1. "Our child sleeps in our bedroom at night."* 2. "We worry about injuries when our child has a seizure." 3. "Our child is involved in a swim program with neighbors and friends." 4. "Our babysitter just completed cardiopulmonary resuscitation (CPR) training." *Rationale:* Parents are especially concerned about seizures that might go undetected at night. The nurse should suggest a baby monitor. Reassurance by the nurse should ensure parental confidence and decrease parental overprotection. Option 2 is a common concern. Options 3 and 4 demonstrate the parents' ability to choose respite care and activities appropriately. The parents need to be reminded that, as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care are appropriate to minimize complications.

A nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? *Select all that apply.*

*1. Restrict fluid intake.* 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply nasal oxygen at 2 L per minute. 5. Provide a high-calorie, high-protein diet. *6. Administer meperidine (Demerol) 25 mg for pain.* *Rationale:* Sickle cell anemia is one of a group of diseases called hemoglobinopathies in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell, and insufficient oxygen causes the cells to assume a sickle shape; the cells become rigid and clumped together, thus obstructing capillary blood flow. Oral and intravenous fluids are important parts of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, which is a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Therefore, the nurse would question the prescriptions for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are important parts of the treatment plan.

A nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse appropriately responds by saying:

1. "Do you feel guilty because about your child's weight gain?" *2. "In most cases, medication and diet will control fluid retention."* 3. "Wearing loose-fitting clothing should help conceal the extra weight." 4. "When children are little, it's expected that they'll look a little chubby." *Rationale:* It is important to give the mother information that addresses the issue that is the parent's concern. Most children experience remission with treatment. Options 1 and 3 are nontherapeutic and may add to the mother's guilt. Option 4 does not acknowledge the concern and is a stereotypical response.

A nurse provides home care instructions to the parents of a child with congestive heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction?

1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the health care provider." 3. "I will take my child's pulse before administering the medication." *4. "If my child vomits after medication administration, I will repeat the dose."* *Rationale:* The parents need to be instructed that, if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed and it is not noticed until 4 hours later, the dose should not be administered.

A nurse reinforces home-care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further instructions?

1. "I will supervise my child closely." 2. "I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." *4. "I will avoid immunizations and dental hygiene treatments for my child."* *Rationale:* The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma (especially trauma that involves the joints), and they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse understands that which diagnostic study will confirm this diagnosis?

1. A platelet count 2. A lumbar puncture *3. Bone marrow biopsy* 4. White blood cell (WBC) count *Rationale:* The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. The WBC count may be high or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that are indicative of central nervous system disease. An altered platelet count occurs as a result of chemotherapy.

Choose the interventions for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL. *Select all that apply.*

1. Administer regular insulin. 2. Encourage the child to ambulate. *3. Give the child a teaspoon of honey.* 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. *6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.* *Rationale:* Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If able, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; the rapid-releasing sugar (such as honey) is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste can be squeezed onto the gums, and the blood glucose level is retested. If the child does not improve within 15 minutes, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. In the hospital setting the nurse should be prepared to administer dextrose intravenously. Encouraging the child to ambulate and administering regular insulin will result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

A nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is:

1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation *4. A chronic disability characterized by a difficulty in controlling the muscles* *Rationale:* Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. *Select all that apply.*

1. Call a code blue. *2. Notify the registered nurse.* 3. Place the infant in a prone position. *4. Prepare to administer morphine sulfate.* *5. Prepare to administer intravenous fluids.* *6. Prepare to administer 100% oxygen by face mask.* *Rationale:* The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

1. DTaP (diphtheria, tetanus, acellular pertussis), MMR (measles, mumps, rubella), IPV (inactivated poliovirus vaccine) 2. MMR, Hib (Haemophilus influenzae type b), DTaP *3. DTaP, Hib, IPV, pneumococcal vaccine (PCV)* 4. Varicella and hepatitis B vaccines *Rationale:* DTaP, Hib, IPV, and PCV are administered at 4 months of age. DTaP is administered at 2 months, 4 months, 6 months, between 12 and 18 months, and between 4 and 6 years of age. Hib is administered at 2 months, 4 months, 6 months, and between 12 and 15 months of age. IPV is administered at 2 months, 4 months, 6 months, and between 4 and 6 years of age. The first dose of MMR is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered between birth and 2 months, the second dose is administered between 1 and 4 months, and the third dose is administered between 6 and 18 months of age. Varicella zoster vaccine is administered between 12 and 18 months of age. PCV is administered at 2, 4, and 6 months of age and between 12 and 15 months of age.

A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. The nurse bases the response on the fact that primary nocturnal enuresis:

1. Does not respond to treatment 2. Is caused by a psychiatric problem 3. Requires surgical intervention to improve the problem *4. Is common and most children will outgrow bed-wetting without therapeutic intervention* *Rationale:* Primary nocturnal enuresis is bedwetting and is described as occurring in a child that has never been dry at night for extended periods. It is common in children, most of whom will outgrow bedwetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system (CNS). It is not caused by a psychiatric problem. Behavioral conditioning with use of alarms has been used for treatment in the older child with nocturnal enuresis. A device that contains a moisture-sensitive alarm is worn on the child's pajamas. As the child starts to void, the alarm goes off, awakening the child. The alarm system may need to be used consistently over 15 weeks for resolution.

A nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor that:

1. Hemophilia is a Y-linked hereditary disorder. 2. A splenectomy resolves the bleeding disorders. *3. Hemophilia A results from deficiency of factor VIII.* 4. A bone marrow transplant is the treatment of choice. *Rationale:* The term "hemophilia" refers to a group of bleeding disorders. The identification of the specific factor deficiencies allows for definitive treatment with replacement agents. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome, not the Y chromosome. Neither a bone marrow transplant nor splenectomy is used to treat this disorder.

Which of the following assessment findings may indicate that a child had a tonic-clonic seizure during the night?

1. High-pitched cry 2. Blanched toenails *3. Blood on the pillow* 4. Migraine headaches *Rationale:* The complications associated with seizures include airway compromise, extremity and teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on the tongue. Seizures do not cause a high-pitched cry unless a tumor or intracranial pressure is the cause of the seizure diagnosis. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanching does not occur. Migraine headaches are not common in children with seizures.

A mother of a 6-year-old child with type 1 diabetes mellitus calls the clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it showed positive ketones. Which of the following would the nurse instruct the mother to do?

1. Hold the next dose of insulin. 2. Come to the clinic immediately. *3. Encourage the child to drink liquids.* 4. Administer an additional dose of regular insulin. *Rationale:* When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to help with clearing them. The child should be encouraged to drink liquids. It is not necessary to bring the child to the clinic immediately, and insulin doses should not be adjusted or changed.

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which of the following is the priority nursing action?

1. Increase oral fluids. 2. Document the finding. *3. Notify the registered nurse.* 4. Place the infant supine in a side-lying position. *Rationale:* The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanel may be a sign of increased ICP within the skull. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions. Although the nurse would document the finding, the first action is to report the finding to the registered nurse, who will then contact the health care provider.

A nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which of the following items should the nurse place at the bedside?

1. Oxygen and a tongue depressor *2. A suction apparatus and oxygen* 3. An airway and a tracheotomy set 4. An emergency cart and an oxygen mask *Rationale:* Seizures cause a tightening of all body muscles that is followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after the seizure. Suctioning and oxygen are helpful to prevent choking and cyanosis. Option 1 is incorrect; a tongue depressor is not needed and nothing is placed into the client's mouth during a seizure because of the risk for injury. Option 3 is incorrect, because inserting a tracheostomy is not done. Option 4 is incorrect, because an emergency cart would not be left at the bedside; however, it would be available in the treatment room or on the nursing unit.

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?

1. Platelet count 2. Hematocrit level 3. Hemoglobin level *4. Reticulocyte count* *Rationale:* A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells (RBCs) in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with SCD because the life span of their sickled RBCs is shortened.

The nurse provides instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. Which response by the nurse is accurate?

1. Respiratory isolation is not necessary. 2. Mumps is not transmitted by the respiratory system. *3. Respiratory precautions are indicated during the period of communicability.* 4. Respiratory precautions are indicated for 18 days after the onset of parotid swelling. *Rationale:* Mumps is transmitted via direct contact or droplets spread from an infected person and possibly by contact with urine. Respiratory precautions are indicated during the period of communicability. Options 1, 2, and 4 are incorrect.

The nurse assists in planning care for a child who sustained a burn injury based on which of the following accurate statements?

1. Scarring is not as severe in a child as in an adult. 2. Children are at a lower risk of infection than adults because of their strong immune systems. *3. Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner.* 4. Infants and children are at decreased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults. *Rationale:* Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. Scarring is more severe in a child; additionally, disturbed body image will be a distinct issue for a child or adolescent, especially as growth continues. An immature immune system presents an increased risk of infection for infants and young children. Infants and children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by:

1. Testing the child's urine for specific gravity 2. Asking the child what happens during a seizure 3. Obtaining a family history of psychiatric illness *4. Obtaining a history regarding factors that may occur before the seizure activity* *Rationale:* Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test, because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.

A nurse is reviewing the health record of a child who has been recently diagnosed with glomerulonephritis. Which finding noted in the child's record is associated with the diagnosis of glomerulonephritis?

1. The child fell off a bike and onto the handlebars. 2. The child has had nausea and vomiting for the last 24 hours. 3. The child had urticaria and itching for 1 week before diagnosis. *4. The child had a streptococcal throat infection 2 weeks before diagnosis.* *Rationale:* Group A β-hemolytic streptococcal infection is a cause of glomerulonephritis. The child often becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The data presented in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

A day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which of the following observations may be indicative of this condition?

1. The child has difficulty hearing. 2. The child does not respond when spoken to. *3. The child consistently tilts his or her head to see.* 4. The child consistently turns his or her head to see. *Rationale:* The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Options 1, 2, and 4 are not indicative of this condition.

A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse tells the mother to:

1. Use aspirin for pain relief. *2. Pad crib rails and table corners.* 3. Use a soft toothbrush for dental hygiene. 4. Use a generous amount of lubricant when taking a temperature rectally. *Rationale:* Establishment of an age-appropriate safe environment is of paramount importance for hemophiliac clients. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra "joint" padding on clothes, observing a mobile infant at all times, and keeping items that can be pulled down onto the infant out of reach. Use of a soft toothbrush is an appropriate measure for a child with hemophilia, but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophiliac individuals because of the risk of bleeding.

A nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which of the following would be included in the plan?

1. Wear gloves when administering the eardrops. 2. Pull the ear up and back before instilling the eardrops. *3. Pull the earlobe down and back before instilling the ear drops.* 4. Hold the child in a sitting position when administering the ear drops. *Rationale:* When administering eardrops to a child who is less than 3 years old, the ear should be pulled down and back. For children who are more than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but handwashing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

A nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which of the following questions to the mother will most specifically elicit information regarding this disorder?

*1. "Does your infant have foul-smelling, ribbon-like stools?"* 2. "Is your infant constantly vomiting?" 3. "Does your infant constantly spit up feedings?" 4. "Does your infant have diarrhea?" *Rationale:* Chronic constipation, beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul smelling, is a clinical manifestation of Hirschsprung's disease. Delayed passage or absence of meconium stool in the neonatal period is the cardinal sign. Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 2, 3, and 4 are not specific clinical manifestations of this disorder.

A nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further instructions?

*1. "I need to use a nipple with a small hole to prevent choking."* 2. "I need to stimulate sucking by rubbing the nipple on the lower lip." 3. "I need to allow my infant time to swallow." 4. "I need to allow my infant to rest frequently to provide time for swallowing what has been placed in the mouth." *Rationale:* The mother should be taught the ESSR method of feeding the child with a cleft palate: ENLARGE the nipple by cross-cutting a hole so that food is delivered to the back of the throat without sucking; STIMULATE sucking by rubbing the nipple on the lower lip; SWALLOW; then REST to allow the infant to finish swallowing what has been placed in the mouth.

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further instruction?

*1. "The cast will feel warm when it is dried."* 2. "If the cast becomes wet, a fan may be used to dry the cast." 3. "I need to call the health care provider if any blood or drainage appears on the cast." 4. "I can apply ice to the casted area to prevent swelling." *Rationale:* Once the cast dries, the cast will sound hollow and will be cool (not warm) to touch. A fan can be directed toward the cast to facilitate drying. The mother must be instructed to call the health care provider if any blood or drainage appears on the cast. Ice can be applied to the casted area to prevent swelling.

An emergency department nurse is gathering initial data on a child suspected of epiglottitis. The nurse's priority would be to:

*1. Assess for a patent airway.* 2. Prepare the child for an x-ray. 3. Prepare the child for tracheotomy. 4. Assist the health care provider with intubation. *Rationale:* When epiglottitis is suspected, the priorities are to maintain a patent airway and to next obtain an x-ray to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation. Although options 2, 3, and 4 may be components of care, they are not the priority.

A nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? *Select all that apply.*

*1. Fever* *2. Constipation* *3. Failure to thrive* 4. Intolerance to wheat *5. Abdominal distention* *6. Explosive, watery diarrhea* *Rationale:* Clinical manifestations of Hirschsprung's disease during infancy include failure to thrive, constipation, abdominal distention, episodes of diarrhea and vomiting, signs of enterocolitis, explosive and watery diarrhea, and fever. The infant appears significantly ill. Intolerance to wheat occurs in celiac disease.

A nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms would the nurse expect to find during the initial data collection? *Select all that apply.*

*1. Fever* 2. Cough *3. Irritability* 4. Hypothermia *5. Nuchal rigidity* 6. Closed anterior fontanel *Rationale:* The initial signs and symptoms of bacterial meningitis include fever, nuchal rigidity, and irritability. The anterior fontanel closes by 12 to 18 months of age. Cough usually is not associated with bacterial meningitis.

A child has epistaxis. The nurse understands that an appropriate treatment for epistaxis is which of the following?

*1. Have the child sit up and lean forward.* 2. Have the child assume a supine position. 3. Have the child sit up and tilt the head backward. 4. Apply continuous pressure to the nose for at least 3 minutes. *Rationale:* Correct treatment for epistaxis (a nosebleed) involves having a client sit up and lean forward. Therefore options 2 and 3 are incorrect. Continuous pressure should be applied to the nose for at least 10 minutes.

A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which of the following?

*1. It is a congenital aganglionosis or megacolon.* 2. It is a complete small intestinal obstruction. 3. It is a condition that causes the pyloric valve to remain open. 4. It is a severe inflammation of the gastrointestinal tract. *Rationale:* Hirschsprung's disease, also known as "congenital aganglionosis" or "megacolon," is the result of an absence of ganglion cells in the rectum and to varying degrees upward in the colon. Options 2, 3, and 4 are incorrect.

A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the health care provider's prescriptions would be important for the nurse to question?

*1. Obtain a throat culture.* 2. Obtain axillary temperatures. 3. Administer humidified oxygen. 4. Administer antipyretics for fever. *Rationale:* The throat of a child with suspected epiglottitis should not be examined or cultured, because any stimulation with a tongue depressor or culture swab could cause laryngospasm and complete airway obstruction. Humidified oxygen and antipyretics are components of the treatment. Axillary rather than oral temperatures should be taken.

A nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which of the following symptoms would be noted in determining this finding?

*1. Oliguria* 2. Pale skin color 3. Severely depressed fontanels 4. Slightly dry, mucous membranes *Rationale:* In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be very dry, the skin color would be dusky, and oliguria would be present. Options 2 and 4 describe mild dehydration. In mild dehydration, urine output would be decreased, but oliguria would not be present. Option 3 describes severe dehydration.

A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?

*1. Pain* 2. Diarrhea 3. Bradycardia 4. Blurred vision *Rationale:* Sickling crisis often causes pain in the bones and joints, accompanied by joint swelling. Pain is a classic symptom of the disease and may require large doses of opioid analgesics when it is severe. The symptoms listed in the other options are not part of the clinical picture.

A nurse is assigned to care for a child with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. Which of the following positions would the nurse place the child in during the preoperative period?

*1. Prone with the head of the bed elevated* 2. Prone with the head of the bed lowered to promote drainage 3. Supine with the head of the bed at a 30-degree angle 4. Supine with the head of the bed at a 45-degree angle *Rationale:* In the preoperative period, the infant is positioned prone with the head of the bed elevated to reduce the risk of aspiration. Options 2, 3, and 4 are inappropriate positions to prevent this risk.

A nurse is reviewing the record of a child admitted to the hospital with nephrotic syndrome. Which finding would the nurse expect to note documented in the record?

*1. Proteinuria* 2. Weight loss 3. Increased appetite 4. Hyperalbuminemia *Rationale:* The term "nephrotic syndrome" refers to a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. The child experiences fatigue, anorexia, increased weight, abdominal pain, and a normal blood pressure.

A nurse is monitoring a child following a tonsillectomy. Which finding may indicate that the child is bleeding?

*1. Restlessness* 2. A decreased pulse rate 3. Complaints of discomfort 4. An elevation in blood pressure (BP) *Rationale:* Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding. An elevated BP is not an indication of bleeding. Complaint of discomfort is an expected finding following a tonsillectomy.

A nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?

*1. Side-lying* 2. Trendelenburg's and on the right side 3. Supine 4. High Fowler's and on the left side *Rationale:* The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not facilitate drainage.

A nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:

*1. Signs of increased intracranial pressure* 2. The presence of protein in the urine 3. Signs of a bacterial infection 4. Signs of hyperglycemia *Rationale:* Intracranial pressure and encephalopathy are major complications of Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.

An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. How would the nurse determine whether the treatment is effective?

*1. The child has a productive cough of thick sputum.* 2. The child no longer has a fever. 3. The child's skin is no longer high in sodium. 4. The child's bowel movements are firmer. *Rationale:* Percussion treatments are intended to produce sputum. Thick sputum is characteristic of cystic fibrosis. Being afebrile is not necessarily reflective of effectiveness of percussion treatments. Although a high sodium content in the skin is a sign associated with cystic fibrosis, percussion treatments will not help this characteristic. The percussion treatments will not help bowel movements.

A nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?

*1. Urinary output is increased.* 2. Urinary output is decreased. 3. Serum sodium is decreased. 4. Urine specific gravity is increased. *Rationale:* A child with a diagnosis of diabetes insipidus experiences increased urinary output, increased serum sodium, and decreased urine specific gravity. Decreased urinary output, decreased serum sodium, and increased urine specific gravity are consistent with a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH).

A nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which of the following statements should the nurse make to the mother?

1. "Dress the child in loose-fitting clothing to hide the extra weight." 2. "Children always look a little bit fat, so don't be concerned." *3. "The fluid retention should be controlled by medication and diet."* 4. "The child will always have this appearance, and preparing the child for the body image change is important." *Rationale:* Most children experience remission with treatment and corticosteroids. Diuretics also may be a component of the treatment plan, and a restricted sodium diet is recommended. It is important to give the parent information in a matter-of-fact manner and address the issue that is the parent's concern. Options 1, 2, and 4 are inaccurate and inappropriate statements to the mother.

A nurse is providing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further instructions?

1. "I can give my child rice." *2. "I am so pleased that I won't have to eliminate oatmeal from my child's diet."* 3. "My child loves corn. I will be sure to include corn in the diet." 4. "I will be sure to give my child vitamin supplements every day." *Rationale:* Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

A nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?

1. "I'm going to take a painting class." 2. "I've learned to knit and sew my own clothes." *3. "When I'm feeling better, I'm returning to the soccer team."* 4. "I'm using a schedule to maintain my increased fluid intake." *Rationale:* Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

A nurse determines that an adolescent client with diabetes mellitus needs further information about glycosylated hemoglobin levels and their purpose if the client made which statement when told that a level will be drawn?

1. "Most of my recent blood glucose levels were close to 170 mg/dL, so this result will probably be a little high." 2. "Last time this test was taken the result was 13. I hope it will be lower this time." *3. "I already had a complete blood cell [CBC] count drawn an hour ago, so this test is not necessary."* 4. "I have followed my diet these past 3 months, so hopefully the test result will be OK." *Rationale:* Glycosylated hemoglobin reflects the average blood glucose levels during the previous 3 to 4 months. It assesses glucose control in the client with diabetes mellitus. Glucose molecules attach to the hemoglobin A molecules found in red blood cells (RBCs) and remain there for the lifetime of the RBCs, approximately 120 days.

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further information?

1. "Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash." 2. "Small blue-white spots with a red base may appear in the mouth." 3. "The rash usually begins behind the ears at the hairline." *4. "The infectious period ranges from 10 days before symptoms start to 15 days after the rash appears."* *Rationale:* The infectious period for rubeola ranges from 1 to 2 days before the onset of symptoms to 4 days after the rash appears. Options 1, 2, and 3 are accurate descriptions of rubeola. Option 4 describes the infectious period for rubella (German measles).

A nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year-old consumes approximately:

1. 90 mL per feeding 2. 100 mL per feeding *3. 175 mL per feeding* 4. 380 mL per feeding *Rationale:* A 1-year-old child consumes approximately 175 mL (6 ounces) of formula per feeding. Options 1, 2, and 4 are incorrect.

A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse would expect to find:

1. A hematocrit (Hct) count of 36 cells in 1 mL of peripheral blood 2. A hemoglobin (Hgb) count of 12 cells in 1 mL of peripheral blood *3. An erythrocyte (red blood cell [RBC]) count of 2 cells in 1 mL of peripheral blood* 4. A white blood cell (WBC) count of 15,000 cells in 1 mL of peripheral blood *Rationale:* ALL is diagnosed based on the history and the signs and symptoms a child presents during a health care provider's visit. The diagnosis also can be made during a routine physical exam or unrelated injury in which the child is brought to a medical clinic. A CBC is done initially to assist with a diagnosis. The CBC would indicate leukopenia (lower than normal WBCs), anemia, and thrombocytopenia. The values in options 1 and 2 are normal results for this age group and do not indicate anemia. Option 4 does not indicate leukopenia. Option 3 is the only laboratory value that is a lower result than a normal RBC count for this age group and is an indicator of anemia or possible leukemia.

A nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which of the following that is indicative of this common complication?

1. A red, swollen testicle *2. Nuchal rigidity* 3. Pain 4. Deafness *Rationale:* The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red, swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication.

A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse tells the mother that this disorder is:

1. An acute bowel obstruction *2. A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel* 3. A condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel 4. A condition that causes an acute inflammatory process in the bowel *Rationale:* Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process.

Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following would indicate this type of anemia?

1. An elevated hemoglobin level with a low hematocrit level 2. A decreased reticulocyte count 3. An elevated red blood cell (RBC) count *4. RBCs that are microcytic and hypo chromic* *Rationale:* The results of a complete blood cell count in children with iron deficiency anemia will show low hemoglobin levels and microcytic and hypochromic RBCs. The reticulocyte count is usually normal or slightly elevated.

A nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for:

1. An increase in the blood pressure 2. A decrease in the urinary output 3. A lack of appetite *4. An elevated temperature* *Rationale:* The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature.

The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these symptoms, the nurse might suspect that the newborn has which of the following conditions?

1. Atrial septal defect *2. Tracheoesophageal fistula* 3. Bronchopulmonary dysplasia 4. Respiratory distress syndrome *Rationale:* The first feeding a newborn receives is sterile water to assess whether the newborn might have one of the tracheoesophageal (TE) conditions. Although sterile water is more easily absorbed and causes less aspiration than formula, the newborn with a suspected TE fistula condition will cough and choke during feedings. These symptoms are not associated with the conditions noted in options 1, 3, or 4.

A nurse is reviewing a chart of a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which of the following would the nurse expect to note on data collection of the child?

1. Awake, alert, interacting with the environment 2. The ability to think clearly and rapidly is majorly impaired. 3. The ability to recognize place or person is severely affected. *4. Sleeps unless aroused and, once aroused, interacts poorly with the environment* *Rationale:* Obtunded indicates that the child sleeps unless aroused and, once aroused, has limited interaction with the environment. Full consciousness indicates that the child is alert, awake, orientated, and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize a place or person is lost.

A nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which of the following?

1. Damage to the midbrain 2. Dysfunction of the pons 3. Damage to the diencephalon *4. Dysfunction in the cerebral hemisphere* *Rationale:* Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons.

A nurse collecting data on a child suspects physical abuse. The nurse understands that which of the following is a primary and legal nursing responsibility?

1. Document the child's physical assessment findings accurately and thoroughly. *2. Report the case in which the abuse is suspected.* 3. Refer the family to the appropriate support groups. 4. Assist the family in identifying resources and support systems. *Rationale:* The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case.

A nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume, knowing that:

1. Each gram of diaper weight is equivalent to 0.5 mL of urine. *2. Each gram of diaper weight is equivalent to 1 mL of urine.* 3. Each gram of diaper weight is equivalent to 2 mL of urine. 4. Each gram of diaper weight is equivalent to 2.5 mL of urine. *Rationale:* When monitoring for fluid volume deficit, the nurse should weigh the infant's diaper after each voiding and stool. Each gram of diaper weight is equivalent to 1 mL of urine. Therefore options 1, 3, and 4 are incorrect.

A nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which of the following would be the priority in the plan of care for this child on return from the procedure?

1. Elevate the head of the bed. 2. Turn the child onto the right side. *3. Check circulation in the feet.* 4. Abduct the hips using pillows. *Rationale:* During the first few hours after a cast is applied, the primary concern is swelling that may cause the cast to produce a tourniquet-like effect and restrict circulation. Therefore circulatory assessment is a priority. Elevating the head of the bed of a child in a hip spica would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica immobilizes the hip and the knee. Turning the child side to side at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not as important as checking circulation.

A nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse should expect that which medication would be prescribed?

1. Enalapril (Vasotec) *2. Furosemide (Lasix)* 3. Prednisone 4. Cyclophosphamide *Rationale:* The child is usually placed on diuretic therapy with furosemide (Lasix) until protein loss is controlled. Enalapril is most commonly used to control hypertension. Corticosteroids, such as prednisone, may be prescribed to decrease inflammation. Corticosteroids also suppress the autoimmune response and stimulate vascular reabsorption of edema. Cyclophosphamide is an alkylating agent and may be used in maintaining remission.

A nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation should the nurse expect to note documented in the health record?

1. Frothy diarrhea *2. Profuse watery diarrhea and vomiting* 3. Foul-smelling ribbon stools 4. Diffuse abdominal pain unrelated to meals or activity *Rationale:* Celiac disease causes profuse watery diarrhea and vomiting. Option 1 is a clinical manifestation of lactose intolerance. Option 3 is a clinical manifestation of Hirschsprung's disease. Option 4 is a clinical manifestation of irritable bowel syndrome.

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. The nurse responds by telling the mother that surgery will probably be performed:

1. Immediately *2. Before the child is 3 years old* 3. Shortly before the child starts school 4. Just before the child begins to learn to read *Rationale:* In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. It is most often indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 3 years old.

A 2-year-old child is diagnosed with constipation. Which of the following describes a characteristic of this disorder?

1. Incomplete development of the anus 2. Invagination of a section of the intestine into the distal bowel *3. The infrequent and difficult passage of dry stools* 4. The presence of fecal incontinence *Rationale:* Constipation can affect any child at any time, although its incidence peaks at ages 2 to 3 years. Option 4 describes encopresis, which can develop as a result of constipation and is one of the major concerns regarding constipation. Encopresis generally affects preschool and school-age children. Option 1 describes imperforate anus, which is diagnosed in the neonatal period. Option 2 describes intussusception, which is the most common cause of bowel obstruction in children ages 3 months to 6 years.

A nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instructions are needed if the mother states that she will include which of the following in the child's nutritional plan?

1. Rice 2. Corn *3. Oatmeal* 4. Vitamin supplements *Rationale:* Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which of the following that is a characteristic of this disease?

1. Increased hematocrit count 2. Increased platelet count *3. Increased reticulocyte count* 4. Increased hemoglobin count *Rationale:* A laboratory diagnosis is established on the basis of a complete blood cell count, examination for sickled red blood cells (RBCs) on the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin, hematocrit, and platelet count, increased reticulocyte count, and the presence of nucleated red blood cells. Elevated reticulocyte counts occur in children with sickle cell disease because the life span of their sickled RBCs is shortened.

A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse would work with the child to meet these goals by:

1. Keeping the child in a special education classroom with other children with similar disabilities 2. Laying the child in the supine position with a 30-degree elevation of the head to facilitate feeding 3. Removing ankle-foot orthoses and braces once the child arrives at school *4. Placing the child on a wheeled scooter board* *Rationale:* Option 4 provides the child with maximum potential in locomotion, self-care, and socialization. The child can move around independently on the abdomen anywhere the child wants to go and can interact with others as desired. Orthoses must be used all the time to aid locomotion (option 3). Option 1 does not provide for maximum socialization and normalization; rather, children with CP need to be mainstreamed as much as cognitively able. Not all children with CP are intellectually challenged. Option 2 does not provide for normalization in self-care. Just as children without CP sit up and use assistive devices when eating, so should children with CP.

A nurse is observing a student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes to:

1. Limit insertion and suctioning time to 5 seconds. 2. Reoxygenate the child between suction catheter passes. *3. Apply continuous suction when inserting the catheter.* 4. Use a twisting motion on the catheter when withdrawing the catheter. *Rationale:* The nurse would not use continuous suction on the catheter during insertion; suction is applied only when withdrawing the catheter. Options 1, 2, and 4 represent correct interventions regarding this procedure.

A nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which of the following would the nurse expect to note in this infant?

1. Metabolic acidosis *2. Metabolic alkalosis* 3. Respiratory acidosis 4. Respiratory alkalosis *Rationale:* Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis as a result of the vomiting (depletes acid) that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate, and decreased chloride level.

Following tonsillectomy, which of the health care provider's prescriptions would the nurse question?

1. Monitor vital signs. 2. Monitor for bleeding. *3. Allow ice cream when awake.* 4. Offer clear, cool liquids when awake. *Rationale:* Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, which causes the child to clear the throat, increasing the risk of bleeding. Options 1 and 2 are important nursing interventions following any type of surgery.

A nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that the primary signs of meningitis include:

1. Nausea and delirium 2. Anorexia and back pain 3. Night blindness and confusion *4. Severe headache and neck stiffness* *Rationale:* The primary signs of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs. Night blindness is not related to meningitis.

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting to care for the newborn, the priority concern would be:

1. Pain 2. Infection *3. Aspiration* 4. The parents' concerns *Rationale:* Because TEF manifests itself with regurgitation and coughing, the concern that has the highest priority is aspiration. Although the other problems are an important part of care, the one with the highest concern relates to airway.

A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chickenpox (varicella). The nurse should take which of the following actions to provide safety for all children on the unit?

1. Place only the infected child in isolation. 2. Keep siblings from visiting the infected child. 3. Place the child and any other child who were exposed in isolation. *4. Place the infected child and any immunocompromised children in isolation.* *Rationale:* The period of communicability for chickenpox is 1 day before the eruption of vesicles to about 1 week when crusts are formed. The infected child should be isolated until vesicles have dried, and other high-risk children (immunocompromised) should be isolated from the infected client.

A nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position will the nurse place the child during this procedure?

1. Prone with knees flexed to the abdomen and head bent with chin resting on the chest 2. Modified Sims' position *3. Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest* 4. Lithotomy position *Rationale:* A lateral recumbent with the knees flexed to the abdomen and the head bent with the chin resting on the chest is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. Options 1, 2, and 4 are incorrect positions.

A 3-year-old child has returned to his room following a tonsillectomy. Which assessment finding needs immediate notification of the registered nurse?

1. Pulse rate 90, respirations 24 per minute *2. Nasal flaring and rib retractions* 3. Drooling slightly blood-tinged saliva 4. Refusal to take sips of his favorite soda *Rationale:* Nasal flaring and rib retractions are signs of respiratory distress, a major concern following a tonsillectomy. These signs require immediate notification. The vital signs are normal for a 3-year-old child. Drooling slightly blood-tinged saliva and refusal to take sips of liquids are common after a tonsillectomy.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? *Select all that apply.*

1. Restrict all visitors. *2. Place the child on a low-bacteria diet.* *3. Change dressings using sterile technique.* 4. Encourage the consumption of fresh fruits and vegetables. *5. Perform meticulous handwashing before caring for the child.* 6. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water. *Rationale:* For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous handwashing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

A nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which of the following is the priority for the child?

1. Restricting oral fluids 2. Allowing the child to play with the other children in the playroom *3. Promoting bedrest* 4. Encouraging visits from friends *Rationale:* Bedrest is required during the acute phase, and activity is gradually increased as the condition improves. Providing for quiet play according to the developmental stage of the child is important. Fluids should not be forced or restricted. Visitors should be limited to allow for adequate rest.

A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which of the following in the discussion during the conference?

1. SIDS usually occurs during sleep and is more common in girls. *2. SIDS usually occurs during sleep and is more common in premature infants.* 3. SIDS usually occurs during sleep and is more common in high-birth-weight infants. 4. SIDS usually occurs during sleep and most frequently occurs between 8 and 10 months of age. *Rationale:* SIDS usually occurs during sleep. It most frequently occurs between the second and fourth months of life. It is more common in boys, low-birth-weight infants, and premature infants.

A nursing student is asked to administer a tepid bath to a child with a fever. The student avoids which of the following when performing this procedure?

1. Squeezes water over the child's body, using a washcloth *2. Applies alcohol-soaked cloths over the child's body* 3. Uses a water toy to distract the child during the bath 4. Places lightweight pajamas on the child after the bath *Rationale:* Alcohol should never be used for bathing the child with a fever because it can cause rapid cooling, peripheral vasoconstriction, and chilling, thus elevating the temperature further. Washcloths can be used to squeeze water over the child's body. Towels are used to dry the child. Toys, especially water toys, can be used to provide distraction during the bath. Lightweight clothing should be placed on the child after the child is dried.

A nurse is caring for an infant with congenital heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the early development of congestive heart failure (CHF)?

1. Strong sucking reflex 2. Slow and shallow breathing 3. Pallor *4. Diaphoresis during feeding* *Rationale:* The early symptoms of CHF include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Pallor may be noted in the infant with CHF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of CHF.

A nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for the earliest sign of increased ICP by assessing for:

1. Tachycardia *2. Changes in level of consciousness (LOC)* 3. Posturing 4. Apnea *Rationale:* An altered level of consciousness is an early sign of increased ICP. Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

Following a cleft lip repair, the nurse provides instructions to the parents regarding cleaning of the lip repair site. Which of the following solutions would the nurse use in demonstrating this procedure to the parents?

1. Tap water *2. Sterile water* 3. Full-strength hydrogen peroxide 4. Half-strength hydrogen peroxide *Rationale:* The lip repair site is cleansed with sterile water using a cotton swab after feeding and as prescribed. The parents should be instructed to use a rolling motion from the suture line out. The parents should also demonstrate performance of the correct procedure to the nurse.

A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. The appropriate nursing action would be to:

1. Tell the mother that the child must stay in the tent 2. Call the health care provider and obtain a prescription for a mild sedative 3. Place a toy in the tent to make the child feel more comfortable *4. Let the mother hold the child and direct a cool mist over the child's face* *Rationale:* Crying aggravates laryngospasm and increases hypoxia, which may cause airway obstruction. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face. A mild sedative would not be administered to the child. Options 1 and 3 will not alleviate the child's fear.

A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of:

1. The need to repeat the test 2. Possible contamination of the specimen *3. Confirmation of the diagnosis* 4. A negative test *Rationale:* A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy CSF, and high protein and low glucose levels. Options 2 and 4 are incorrect. Option 1 is an unnecessary measure.

A nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:

1. The presence of dehydration 2. The presence of pain 3. Extreme fatigue *4. An airway obstruction* *Rationale:* Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. The data in the question do not relate to options 1, 2, or 3.

A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which of the following is a characteristic of this disorder?

1. The presence of fecal incontinence 2. Incomplete development of the anus 3. The infrequent and difficult passage of dry stools *4. Invagination of a section of the intestine into the distal bowel* *Rationale:* Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children age 3 months to 6 years. Option 1 describes encopresis. Option 2 describes imperforate anus, and this disorder is diagnosed in the neonatal period. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at ages 2 to 3 years. Encopresis generally affects preschool and school-age children.

A child is seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus vaccine). One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which of the following instructions would the nurse provide to the mother?

1. To return to the health care clinic immediately 2. To call the health care provider 3. To apply warm compresses on the site *4. To apply cold compresses for 24 hours following the injection* *Rationale:* For painful or red injection sites, the nurse should instruct the mother to apply cold compresses for the first 24 hours, then to use warm or cold compresses as long as needed. Options 1, 2, and 3 are incorrect. It is not necessary for the mother to bring the child to the clinic immediately, and it is not necessary for the mother to contact the health care provider.

A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?

1. Warm, dry skin 2. Increased wheezing *3. Decreased wheezing* 4. A pulse rate of 90 beats per minute *Rationale:* Decreased wheezing in a child who is not improving clinically may be interpreted incorrectly as a positive sign, when in fact it may signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Warm, dry skin indicates an improvement in the condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats per minute.

A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which of the following nursing interventions would be of highest priority?

1. Weigh morning and afternoon. 2. Maintain a strict intake and output. *3. Dipstick the urine for protein every 4 hours.* 4. Take vital signs with blood pressure every 4 hours. *Rationale:* Continuous monitoring of fluid retention and excretion is an important nursing intervention in the care of the child with nephrotic syndrome. Although it is important to maintain a strict intake and output in monitoring fluid retention and excretion, the goal of treatment with this child is to decrease the amount of protein lost in the urine. Because this is the goal, option 3 has the highest priority. Although weight is monitored, it is not necessary to check the weight morning and evening. Taking vital signs with blood pressure is important but is not the priority in this situation.

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse give to the mother to prevent the transmission of the disease?

*1. "Disease transmission is unknown."* 2. "The disease is transmitted through the urine and feces, so the other children should use a separate bathroom." 3. "The disease is transmitted through the respiratory tract, so the child should be isolated from the other children as much as possible." 4. "The disease is transmitted by contact with body fluids, so any items contaminated with body fluids need to discarded in a separate receptacle." *Rationale:* The method of transmission of roseola is unknown. Options 2, 3, and 4 are not correct transmission routes of roseola.

A child is scheduled for a tonsillectomy. Which of the following would present the highest risk of aspiration during surgery?

1. Difficulty swallowing 2. Bleeding during surgery 3. Exudate in the throat area *4. The presence of loose teeth* *Rationale:* In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect. Bleeding during surgery will be controlled via packing and suction as needed.

After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to:

*1. Turn the child to the side.* 2. Notify the RN or health care provider (HCP). 3. Administer the prescribed antiemetic. 4. Maintain nothing-by-mouth (NPO) status. *Rationale:* After a tonsillectomy, if bleeding occurs, the child is turned to the side, and the RN or HCP is notified. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

After a tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child?

*1. Yellow Jell-O* 2. Cold ginger ale 3. Vanilla pudding 4. Cherry Popsicle *Rationale:* After a tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided, because they may irritate the throat. Milk and milk products (pudding) are avoided, because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided, because they give the appearance of blood if the child vomits.

A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and thus to the need to notify the registered nurse?

1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) *4. A weight gain of 1 lb in 1 day* *Rationale:* A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of CHF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities.

A nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis?

1. Hypotension *2. Red-brown urine* 3. Low urinary specific gravity 4. A low blood urea nitrogen (BUN) level *Rationale:* Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, and hypertension is also common. A mid to high urinary specific gravity is associated with glomerulonephritis. BUN levels may be elevated.

A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?

*1. "I will give my child cough syrup if a cough develops."* 2. "During an attack, I will take my child to a cool location." 3. "I will give acetaminophen (Tylenol) if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day." *Rationale:* Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

A nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger and it returns to its original color in 2 seconds. Which action should be taken by the nurse?

*1. Document the findings.* 2. Notify the registered nurse (RN). 3. Prepare the child for bivalving the cast. 4. Elevate the extremity and recheck the capillary refill immediately. *Rationale:* When checking capillary refill, the nurse would expect to note that a compressed nail bed will return to its original color in less than 3 seconds. Options 2, 3, and 4 are unnecessary actions.

A nurse is assisting in developing a plan of care for a diagnosed with acute glomerulonephritis. The nurse includes which intervention in the plan of care?

*1. Encourage limited activity and provide safety measures.* 2. Force intake of oral fluids to prevent hypovolemic shock. 3. Catheterize the child to strictly monitor intake and output. 4. Encourage classmates to visit and to keep the child informed of school events. *Rationale:* Activity is limited and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause a risk of infection. Fluids should not be forced. Visitors should be limited to allow for adequate rest.

A nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse plans to:

*1. Restrict fluids, as prescribed.* 2. Administer analgesics, as prescribed. 3. Care for the arteriovenous (AV) fistula. 4. Encourage the intake of foods that are high in potassium. *Rationale:* HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be on fluid restrictions. Pain is not associated with HUS, and potassium would be restricted rather than encouraged if the child was anuric. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately?

*1. Temperature 100.9° F* 2. Pulse 78 beats per minute 3. Blood pressure 110/70 mm Hg 4. Respirations 22 breaths per minute *Rationale:* Fever may be an indication of an infection of the shunt, which is the primary concern in the postoperative period, related to a shunt insertion. All of the other vital signs are normal findings for this child.

An infant with congestive heart failure (CHF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output (I&O). Which is the best method for the nurse to use to monitor the urine output?

*1. Weighing the diapers* 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula *Rationale:* The best method to monitor urine output in an infant on diuretic therapy is to weigh the diapers. The weight of dry diapers is subtracted from the weight of wet diapers to determine the amount of urine excreted: 1 g is equivalent to 1 mL of urine. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the best method and places the infant at risk for infection.

A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. Which is the correct response by the nursing student?

1. "Bone marrow depression occurs because of the development of sickled cells." 2. "Sickled cells increase the blood flow through the body and cause a great deal of pain." 3. "The sickled cells mix with the unsickled cells and cause the immune system to become depressed." *4. "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."* *Rationale:* All the clinical manifestations of sickle cell disease are a result of the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are inaccurate.

A nurse provides home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further instruction?

1. "I need to check for jaundiced skin and eyes every day." 2. "I need to have my child nap during the day to provide rest." 3. "I need to decrease the stimuli at home to prevent intracranial pressure." *4. "I need to give frequent, small, nutritious meals if my child starts to vomit."* *Rationale:* The vomiting that occurs in Reye's syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small, frequent meals will not affect the amount of vomiting, and the health care provider is notified if vomiting occurs. Options 1, 2, and 3 are all correct statements. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome.

A nurse provides instruction to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further instructions?

1. "I need to use proper handwashing techniques." *2. "I need to take my child's rectal temperature daily."* 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions." *Rationale:* The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. After an x-ray, it is determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further instructions?

1. "The cast may feel warm as it dries." *2. "I can use lotion or powder around the cast edges to relieve itching."* 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow-dryer set on the cool setting may be used to dry it." *Rationale:* The mother needs to be instructed to not use lotion or powders on the skin around the cast edges or inside the cast, because they can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate instructions.

The primary goal to be included in the plan of care for a child who has cerebral palsy is to:

1. Eliminate the cause of the disease. 2. Improve muscle control and coordination. 3. Prevent the occurrence of emotional disturbances. *4. Maximize the child's assets and minimize the limitations.* *Rationale:* The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.

A nurse who is caring for a child with aplastic anemia reviews the laboratory results and notes a white blood cell (WBC) count of 6000 cells/ mm3 and a platelet count of 27,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

1. Encourage naps. 2. Encourage a diet high in iron. *3. Encourage quiet play activities.* 4. Maintain strict isolation precautions. *Rationale:* Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which of the following during this episode of nausea?

1. Low-calorie foods *2. Cool, clear liquids* 3. Low-protein foods 4. The child's favorite foods *Rationale:* When the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small amounts because small portions are usually better tolerated. Cool, clear fluids are also soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. It is best to offer small, frequent meals of high-protein and high-calorie content once the nausea has been controlled with medication or has subsided.

A child is diagnosed with infectious mononucleosis. The nurse provides home-care instructions to the parents about the care of the child. Which information given by the nurse is accurate?

1. Maintain the child on bedrest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider if the child develops a fever. *4. Notify the HCP if the child develops abdominal or left shoulder pain.* *Rationale:* The parents need to be instructed to notify the HCP if abdominal pain (especially in the left upper quadrant) or it left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until the splenomegaly resolves. Bedrest is not necessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol).

A nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?

1. Observing for nonverbal signs of pain *2. Using pillows to elevate the head and shoulders* 3. Checking neurovascular status of the extremities 4. Placing the child on a stretcher and bringing the child to the playroom *Rationale:* Pillows should not be used to elevate the head or shoulders of a child in a body cast because the pillows will thrust the child's chest against the cast and cause discomfort and respiratory difficulty. Neurovascular checks are a critical component of care to ensure that the cast is not causing circulatory compromise. The nurse should observe for nonverbal signs of pain and ask the older child if pain is experienced. A ride on a stretcher to the playroom or around the hospital provides changes of position and scenery.

A child is scheduled to receive a measles, mumps, and rubella (MMR) vaccine. The nurse who is preparing to administer the vaccine reviews the child's record. Which finding should make the nurse question the health care provider's prescription?

1. Recent recovery from a cold 2. A history of frequent respiratory infections *3. A history of an anaphylactic reaction to neomycin* 4. A local reaction at the site of a previous MMR vaccine injection *Rationale:* The MMR vaccine contains minute amounts of neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to the MMR vaccine. The general contraindication to all immunizations is a severe febrile illness. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is treated with cool packs for the first 24 hours after injection, and this is followed by warm or cool compresses if the inflammation persists.

A nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?

1. Soccer 2. Basketball *3. Swimming* 4. Field hockey *Rationale:* Children with hemophilia need to avoid contact sports and need to take precautions, such as wearing elbow and knee pads and helmets, when participating in other sports. The safest activity that will prevent injury is swimming.

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is:

1. Taking the apical pulse 2. Taking the blood pressure 3. Testing the urine for protein *4. Palpating the anterior fontanel* *Rationale:* A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

A nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?

1. The synthetic cast takes 24 hours to dry. 2. The synthetic cast is heavier than a plaster cast. 3. The synthetic cast is stronger than a plaster cast. *4. The synthetic cast allows for greater mobility than a plaster cast.* *Rationale:* Synthetic casts dry quickly (in less than 30 minutes) and are lighter than plaster casts. Synthetic casts allow for greater mobility than a plaster cast. However, synthetic casts are not as strong as plaster casts and are more expensive.

A nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?

1. Watery diarrhea *2. Projectile vomiting* 3. Increased urine output 4. Vomiting large amounts of bile *Rationale:* Clinical manifestations of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

A health care provider has prescribed oxygen as needed for a 10-year-old child with congestive heart failure (CHF). In which situation would the nurse administer the oxygen to the child?

1. When the child is sleeping 2. When changing the child's diapers 3. When the mother is holding the child *4. When drawing blood for the measurement of electrolyte levels* *Rationale:* Oxygen administration may be prescribed for the infant with CHF for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.

A nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further instruction?

*1. "I will place a steam vaporizer in my child's room."* 2. "I will take my child out into the cool, humid night air." 3. "I will place a cool-mist humidifier in my child's room." 4. "I will place my child in a closed bathroom and allow my child to inhale steam from the running water." *Rationale:* Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended as compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the cool, humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

A nurse reinforces home-care instructions to the parents of a child with celiac disease. Which of the following food items would the nurse advise the parents to include in the child's diet?

*1. Rice* 2. Oatmeal 3. Rye toast 4. Wheat bread *Rationale:* Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

A nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care, knowing that this type of fracture involves:

1. The entire bone fractured straight across *2. A greater risk of infection than a simple fracture* 3. One side of the bone being broken and the other side being bent 4. The bone being fractured but not producing a break in the skin *Rationale:* In a compound (open) fracture, a wound in the skin leads to the broken bone, and there is an added danger of infection. Option 1 describes a transverse fracture. Option 3 describes a greenstick fracture. Option 4 describes a closed or simple fracture.

A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would the nurse expect to note in this child?

1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting *4. Blood and mucus in the stools* *Rationale:* The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. Vomiting may be present, but it is not projectile. Bright red blood and mucus are passed through the rectum and commonly described as currant jelly-like stools. Ribbon-like stools are not a manifestation of this disorder.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. The nurse tells the child to:

*1. Drink a half a cup of orange juice before soccer practice.* 2. Eat twice the amount that is normally eaten at lunchtime. 3. Take half of the amount of prescribed insulin on practice days. 4. Take the prescribed insulin at noontime rather than in the morning. *Rationale:* An extra snack of 10 g to 15 g of carbohydrates eaten before activities and for every 30 to 45 minutes of activity will prevent hypoglycemia. A half cup of orange juice will provide the needed carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration, and meal amounts should not be doubled.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse provide to prevent another crisis from occurring? *Select all that apply.*

*1. Drink plenty of fluids.* 2. Avoid foods high in folic acid. 3. Use cold packs to relieve joint pain. 4. Restrict all activity to quiet board games. *5. Wash hands before meals and after playing.* *6. Report a sore throat immediately.* *Rationale:* Sickle cell crisis can be precipitated by cold, dehydration, stress, or infection. Increasing the amount of fluids will reduce the viscosity of blood, thus preventing vascular occlusion. A conscious effort to wash hands can improve the child's health by preventing infection. A sore throat is a sign of an infection and must be reported. It is important to avoid cold temperatures of any kind because this can cause vaso-occlusion. Folic acid avoidance is not necessary. Children need to be encouraged to set their own limits in play.

A nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation?

*1. Level of consciousness* 2. Amount of edema at the site of the burn injury 3. Heart rate 4. Lung sounds *Rationale:* The sensorium, or level of consciousness, is an important guide to the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of consciousness in the child. Options 2, 3, and 4, although important in the assessment of the child with a burn injury, would not provide an accurate assessment of the adequacy of fluid resuscitation.

A nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the following would be a component of the plan of care? *Select all that apply.*

*1. Pad the side rails of the bed with blankets.* *2. Maintain the bed in a low position.* 3. Restrain the child if a seizure occurs. *4. Place the child in a side-lying lateral position if a seizure occurs.* *5. Protect the child's head, body, and extremities if a seizure occurs.* 6. Place a padded tongue blade in the child's mouth if a seizure occurs. *Rationale:* Restraints are not to be applied to a child with a seizure because they could cause injury to the child. The side rails of the bed are padded with blankets, and the bed is maintained in a low position to provide safety if the child has a seizure. The child's head and the rest of the body are protected from injury if a seizure occurs. Positioning the child on his or her side will prevent aspiration as the saliva drains out of the child's mouth during the seizure. Neither a padded tongue blade nor any other object is placed in the child's mouth once a seizure has started.

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of:

*1. Peripheral hypoxia* 2. Chronic hypertension 3. Delayed physical growth 4. Destruction of bone marrow *Rationale:* Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxemia and polycythemia. Options 2, 3, and 4 are not causes of clubbing.

A nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which of the following should the nurse expect to note in the child?

*1. Petechiae spots located on the palate* 2. Small blue-white spots noted on the buccal mucosa 3. A fiery red edematous rash on the cheeks 4. Swelling of the parotid gland *Rationale:* Forchheimer sign refers to petechiae spots, which are reddish and pinpoint and located on the soft palate. Small blue-white spots noted on the buccal mucosa are known as Koplik's spots seen in rubeola. A fiery red edematous rash on the cheeks, also called "slapped cheeks" is seen in erythema infectiosum. Swelling of the parotid gland is seen in mumps.

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives in the unit, the nurse would first:

*1. Place the child on a pulse oximeter.* 2. Weigh the child. 3. Take the child's temperature. 4. Ask the parents about the child. *Rationale:* To adequately determine whether the child is getting enough oxygen, the child is placed on a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately placed on a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. The nurse would then gather data including taking the child's temperature and weight and asking the parents about the child.

A nurse is caring for a 1-year-old child following a cleft palate repair. Which solution should the nurse use after feedings to cleanse the child's mouth?

*1. Water* 2. Diluted hydrogen peroxide 3. A soft lemon glycerin swab 4. Half-strength povidone-iodine (Betadine) solution *Rationale:* Following a cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Options 2, 3, and 4 are incorrect procedures, and the solutions identified in these options should not be used.

A nurse is collecting data on a child with a diagnosis of rheumatic fever. Which of the following questions would the nurse initially ask the mother of the child?

1. "Has the child had any diarrhea?" 2. "Has the child been vomiting?" 3. "Does the child complain of chest pain?" *4. "Has the child complained of a sore throat within the past few months?"* *Rationale:* Rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether any family members have had a sore throat or unexplained fever within the past 2 months. Although options 1, 2, and 3 may be asked during data collection, they would not be the initial concerns for a child with rheumatic fever.

A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the health care provider did not prescribe antibiotics. The nurse makes which response to the mother?

1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." *3. "Antibiotics are not indicated unless a bacterial infection is present."* 4. "The child still has the maternal antibodies from birth and does not need antibiotics." *Rationale:* Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. In addition, the question does not include any supporting data to indicate that the child may be allergic to antibiotics.

When instructing the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver states:

1. "I will encourage my child to avoid standing for too long." 2. "I will instruct my child to not put anything inside the cast." *3. "I will allow my child to put cotton balls inside the cast to relieve pressure."* 4. "I will encourage my child to keep the injured extremity elevated while resting." *Rationale:* Cast care includes keeping the casted extremity elevated on pillows or similar support for the first day, or as directed by the health professional; elevating a lower limb when sitting and avoid standing for too long; encouraging frequent rest for a few days; keeping the injured extremity elevated while resting; and not allowing the child to put anything inside the cast.

A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?

1. "The brain herniates downward and around the tentorium cerebelli." 2. "The herniation can be either unilateral or bilateral in nature." *3. "It involves only the anterior portions of the client's brain."* 4. "It can cause death if large amounts of tissue are involved." *Rationale:* Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. It can be unilateral or bilateral and may involve anterior or posterior portions of the brain. If a large amount of tissue is involved, it can cause death because vital brain structures are compressed and become unable to perform their functions.

A nurse is providing instructions to a mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother?

1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series." *4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."* *Rationale:* It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis also should receive yearly influenza vaccines.

A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 AM, 12 noon, and at 6:00 PM The nurse tells the mother that the postural drainage should be performed at:

1. 8:00 AM, 2:00 PM, and 6:00 PM 2. 9:00 AM, 1:00 PM and 6:00 PM 3. 8:00 AM, 12:00 noon, and 6:00 PM *4. 10:00 AM, 2:00 PM and 8:00 PM* *Rationale:* Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is also important to perform these treatments before bedtime to clear airways and facilitate rest.

A nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which of the following?

1. An elevated T4 level *2. An elevated thyroid-stimulating hormone (TSH) level* 3. A decreased TSH level 4. A normal T4 level *Rationale:* Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. Options 1, 3, and 4 are not diagnostic findings in this condition.

A nurse is preparing for the administration of ribavirin (Virazole) to a child with respiratory syncytial virus. Which of the following supplies will the nurse obtain for the administration of this medication?

1. An intravenous (IV) pole 2. An intramuscular (IM) syringe *3. A pair of goggles* 4. A protective isolation gown *Rationale:* Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A mask may be worn. Handwashing is to be performed before and after any child contact. A gown is not necessary. The medication is administered via hood, face mask, or oxygen tent, not by the IM or IV route.

A nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. The appropriate procedure to elicit Kernig's sign is to:

1. Bend the head toward the knees and hips and check for pain. 2. Tap the facial nerve and check for spasm. 3. Compress the upper arm and check for tetany. *4. Extend the leg and knee and check for pain.* *Rationale:* Kernig's sign is pain that occurs with extension of the leg and knee. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.

A nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 AM, the child suddenly complains of weakness, headache, and blurred vision. The nurse should immediately:

1. Give the child ½ cup of orange juice to drink. *2. Obtain a blood glucose reading.* 3. Call the dietary department and ask that the lunch tray be delivered early. 4. Contact the health care provider. *Rationale:* The signs of hypoglycemia and hyperglycemia may be difficult to distinguish. Weakness, headache, and blurred vision can occur in either blood glucose alteration. A blood glucose reading will assist in confirming the diagnosis so that the appropriate action can be taken. Option 1 would be implemented if the child had hypoglycemia. Option 3 is inappropriate because the child should eat meals at basically the same time each day to achieve the best diabetic control. Contacting the health care provider would not be the immediate action; however, the nurse should inform the registered nurse of the situation.

A child with croup is being discharged from the hospital. The nurse provides home care instructions to the mother and advises the mother to bring the child to the emergency department if the child:

1. Is irritable 2. Appears tired *3. Develops stridor* 4. Takes fluids poorly *Rationale:* The mother should be instructed that if the child develops stridor at rest, cyanosis, severe agitation or fatigue, moderate to severe retractions, or is unable to take oral fluids, to bring the child to the emergency department.

A nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which of the following actions would the nurse take?

1. Lower the head of the bed. *2. Document the findings.* 3. Place the infant on nothing-by-mouth (NPO) status. 4. Ask the registered nurse to notify the health care provider immediately. *Rationale:* The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 18 to 24 months of age. The posterior fontanel closes by 2 to 3 months of age. A bulging or tense fontanel may result from crying or increased ICP. If the nurse notes a bulging fontanel when the infant cries, this is a normal finding that should be documented and monitored. It is not necessary to notify the health care provider for this finding. Options 1 and 3 are inappropriate actions.

A nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. The nurse should give the child which of the following to treat the reaction?

1. One sugar cube 2. 1 teaspoon of sugar 3. ½ cup of diet cola *4. ½ cup of fruit juice* *Rationale:* Hypoglycemia is immediately treated with 10 to 15 g of carbohydrate. Glucose tablets or glucose gel may be administered. Other items used to treat hypoglycemia include ½ cup of fruit juice, ½ cup of regular (nondiet) soft drink, 8 ounces of skim milk, 6 to 10 hard candies, 4 cubes of sugar or 4 teaspoons of sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup. The items in options 1, 2, and 3 would not adequately treat hypoglycemia.

A nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which of the following findings would most likely assist in verifying the suspicion?

1. Poor hygiene *2. Bald spots on the scalp* 3. Lacerations in the anal area 4. Swelling of the genitals *Rationale:* Bald spots on the scalp are most likely to be associated with physical abuse. The most likely findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain; swelling or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may be indicative of physical neglect.

A nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests including in the plan to position the infant in a(n):

1. Prone position *2. Side-lying position* 3. Modified Trendelenburg's position 4. Infant car seat with the head of the seat in a flat position *Rationale:* The vomiting infant or child should be placed in an upright or side-lying position to prevent aspiration. The positions identified in options 1, 3, and 4 will increase the risk of aspiration if vomiting occurs.

A nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which of the following food items will the nurse mix with the medication?

1. Tapioca *2. Applesauce* 3. Hot oatmeal 4. Mashed potatoes *Rationale:* Pancreatic enzyme powders are not to be mixed with hot foods or foods containing tapioca or other starches. Enzyme powder should be mixed with non-fat, non-protein foods such as applesauce. Pancreatic enzymes are inactivated by heat and are partially degraded by gastric acids.

A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which of the following laboratory tests would rule out a past streptococcal infection in the child?

1. Urinalysis 2. Throat culture *3. Antistreptolysin titer* 4. Creatinine clearance *Rationale:* Option 3 is the only laboratory test that will determine if a streptococcal infection was present. The other options do not relate to a past streptococcal infection. Option 1 will determine if protein is present in the urine, which is present in glomerulonephritis. Option 2 will determine if a current throat infection is present. Option 4 will determine glomerular filtration rate.

The nurse is caring for a pediatric client in skin traction. To prevent skin breakdown, the best nursing intervention for this child is to:

1. Vigorously massage bony prominences every 4 hours. 2. Replace the elastic bandage on skin traction every 8 hours. *3. Stimulate circulation with gentle massage over pressure areas.* 4. Change the child's position at least every 4 hours to relieve pressure. *Rationale:* Nonadhesive straps and/or elastic bandage on skin traction are replaced when permitted and/or when absolutely necessary. Circulation should be stimulated with gentle, not vigorous, massage over pressure areas. The child's position should be changed at least every 2 hours to relieve pressure.

A nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which of the following is the priority when performing this procedure?

1. Taking the temperature 2. Taking the blood pressure 3. Checking the apical heart rate *4. Checking the peripheral pulse in the affected arm* *Rationale:* The neurovascular check for tissue perfusion is performed on the toes or fingers distal to an injury or cast and includes checking peripheral pulse, color, capillary refill time, warmth, motion, and sensation. Options 1, 2, and 3 may be components of care, but they are not the priority in this situation.

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which of the following in the plan of care?

*1. Initiating seizure precautions* 2. Using a wheelchair for out-of-bed activities 3. Assisting the child with ambulation at all times 4. Avoiding contact with other children on the nursing unit *Rationale:* Safety of the child is the nursing priority. Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. A thorough neurological assessment should be performed on the child, and the child's safety should be assessed before allowing the child to get out of bed without help. Assessment of the child's gait should be assessed daily. However, options 2 and 3 are not required unless functional deficits exist. Isolating the child, option 4, is not necessary.

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse tells the mother that she should:

*1. Keep the child in a room with dim lights.* 2. Give the child warm baths to help prevent itching. 3. Allow the child to play outdoors, because sunlight will help the rash. 4. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever. *Rationale:* A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome. Warm baths and the sun will aggravate itching. In addition, the child needs to rest.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?

*1. Prone* 2. Supine 3. Trendelenburg's 4. High Fowler's *Rationale:* The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

A nursing student is assigned to help administer immunizations to children in a clinic. The nursing instructor asks the student about the contraindications to receiving an immunization. Immunization is contraindicated in the presence of which condition?

1. A cold 2. Otitis media 3. Mild diarrhea *4. A severe febrile illness* *Rationale:* A severe febrile illness is a reason to delay immunization, but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea are not contraindications to immunization.

A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? *Select all that apply.*

*1. Time the seizure.* 2. Restrain the child. *3. Stay with the child.* 4. Place the child in a prone position. *5. Move furniture away from the child.* 6. Insert a padded tongue blade into the child's mouth. *Rationale:* During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration, because saliva will drain out of the corner of the child's mouth. The child is not restrained, because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure.

A nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further instruction?

1. "It is extremely contagious." 2. "It is most common during humid weather." *3. "Lesions are most often located on the arms and chest."* 4. "It begins in an area of broken skin, such as an insect bite." *Rationale:* Impetigo is most common during the hot and humid summer months. It begins in an area of broken skin, such as an insect bite. It may be caused by Staphylococcus aureus, group A β-hemolytic streptococci, or a combination of these bacteria. It is extremely contagious. Lesions are most often located around the mouth and nose, but they may be present on the extremities.

A nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder?

1. A child of Mexican descent *2. A child of Mediterranean descent* 3. A child whose intake of iron is extremely poor 4. A child breast-fed by a mother with chronic anemia *Rationale:* Beta-thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations. Options 1, 3, and 4 are not risk factors for this disorder.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position in which to place this infant at this time is:

1. A flat position 2. A prone position *3. On his or her left side* 4. On his or her right side *Rationale:* After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case, it is best to place the infant on his or her left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

A nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which of the following symptoms led the mother to seek health care for the infant?

1. Diarrhea 2. Projectile vomiting 3. The regurgitation of feedings *4. Foul-smelling, ribbon-like stools* *Rationale:* Chronic constipation that begins during the first month of life and that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are incorrect.

A nurse is performing a neurovascular check on a child with a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should be taken by the nurse?

1. Elevate the extremity. 2. Document the findings. *3. Notify the health care provider (HCP).* 4. Ambulate the child with crutches. *Rationale:* Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding should be reported to the registered nurse or HCP. Options 1, 2, and 4 are inappropriate and would delay the required and immediate interventions.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

1. Enteric 2. Contact 3. Protective *4. Respiratory* *Rationale:* Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory precautions are required, and a mask is worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 2, and 3 are not indicated for rubeola.

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. *3. Apply an ice pack to the injection site.* 4. Leave the injection site alone, because this always occurs. *Rationale:* Occasionally tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with cool packs for the first 24 hours and followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention, but it is not specific to the subject of the question.

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which of the following is the priority nursing intervention?

1. Monitoring the output 2. Checking for hearing loss 3. Changing the body position every 2 hours *4. Providing a quiet atmosphere with dimmed lights* *Rationale:* The major elements of care for a child who has Reye's syndrome are to maintain effective cerebral perfusion and to control intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue and the neuron responses. Cerebral edema is a progressive part of this disease process. Hearing loss and output are not affected. Changing the body position every 2 hours would not directly affect the cerebral edema and intracranial pressure. The child should be in a head-elevated position to decrease the progression of the cerebral edema and to promote the drainage of cerebrospinal fluid.

A nurse is assisting in preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which dietary intervention is most appropriate for this child?

1. Provide a high-salt diet. 2. Provide a high-protein diet. 3. Discourage visitors at mealtimes. *4. Encourage the child to eat in the playroom.* *Rationale:* Mealtimes should center on pleasurable socialization. The child should be encouraged to eat meals with other children on the unit. A diet that is normal in protein with a sodium restriction is normally prescribed for a child with nephrotic syndrome. Parents or other family members should be encouraged to be present at mealtimes with a hospitalized child.

A child with a fractured femur is placed in Buck's skin traction and the nurse is planning care for the client. Which information about this type of traction is correct?

1. Requires frequent pin care 2. Places the child at risk for infection 3. Uses skeletal traction and weights to provide a counterforce *4. Is a type of skin traction that pulls the hip and leg into extension* *Rationale:* Buck's skin traction is a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension. Countertraction is applied by the child's body. Options 1, 2, and 3 describe skeletal traction.

A nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is accurate?

1. Ten days after using the antibiotic ointment 2. One week after using the antibiotic ointment *3. Forty-eight hours after using the antibiotic ointment* 4. Twenty-four hours after using the antibiotic ointment *Rationale:* The child should not attend school for 24 to 48 hours after the initiation of systemic antibiotics or for 48 hours after the use of the antibiotic ointment. The school should be notified of the diagnosis. Therefore options 1, 2, and 4 are incorrect.

A nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?

*1. "If my baby has a high-pitched cry, I should call the doctor."* 2. "I should position my baby on the side with the shunt when sleeping." 3. "My baby will pass urine more often now that the shunt is in place." 4. "I should call my doctor if my baby refuses purees." *Rationale:* If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a high-pitched cry in the infant. The baby should not have pressure when on the shunt side. Skin breakdown and possible compression to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. Option 4 is only a concern if the baby becomes malnourished or dehydrated, which could then raise the body temperature. Otherwise, refusal to eat purees has no direct relationship to the shunt functioning.

A child with croup is placed in a cool-mist tent. The mother asks if the child may have her security blanket inside the tent. The appropriate response is:

*1. "The child may have the security blanket inside the tent."* 2. "Objects from home are not allowed to be brought to the hospital." 3. "The blanket is not allowed because it will promote the growth of bacteria." 4. "The blanket is not allowed but the child may have a toy from the hospital playroom." *Rationale:* Familiar objects provide a sense of security for children in the strange hospital environment. The child is allowed to have a favorite toy or blanket while in the mist tent. Options 2, 3, and 4 are inappropriate statements.

A nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. The appropriate nursing response is which of the following?

*1. "This type of breathing is used to mobilize secretions so that they can be easily coughed out."* 2. "This type of breathing prolongs inspiration time." 3. "This type of breathing moves air out of the lower lungs." 4. "This type of breathing moves air through the lungs." *Rationale:* The "huff" maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly whispering the word, "huff." Options 2, 3, and 4 are not the purpose of this breathing technique.

A nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than:

*1. 20,000/mm3* 2. 100,000/mm3 3. 120,000/mm3 4. 150,000/mm3 *Rationale:* If a child is severely thrombocytopenic, with a platelet count of less than 20,000/mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes or Toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000/mm3.

A nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which of the following is essential information to obtain before the administration of this vaccine?

*1. Allergy to eggs* 2. A recent cold 3. The presence of diarrhea 4. Any recent ear infections *Rationale:* Before the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of allergy to gelatin or eggs because the live measles vaccine is produced by chick embryo cell culture. MMR also contains a small amount of the antibiotic neomycin. Options 2, 3, and 4 are not contraindications to administering this immunization.

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse provides instructions to the adolescent regarding home care for treatment of the sprain and tells the adolescent which of the following?

*1. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.* 2. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. 3. Immobilize the extremity and maintain the extremity in a dependent position. 4. Elevate the extremity and maintain strict bedrest for a period of 7 days. *Rationale:* To treat a sprain, the injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for no longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bedrest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

A nurse teaches a child with cystic fibrosis how to perform the "huff" maneuver and tells the child to take a:

*1. Deep breath then exhale, rapidly whispering the word "huff"* 2. Shallow breath then exhale, rapidly whispering the word "huff" 3. Deep breath, hold it for 15 seconds, then exhale slowly, whispering the word "huff" 4. Shallow breath, hold it for 10 seconds, then exhale rapidly, whispering the word "huff" *Rationale:* The "huff" maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly, whispering the word "huff."

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron:

1. Just before a meal 2. Just after a meal *3. Between meals* 4. With a fruit low in vitamin C *Rationale:* The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body.

A child is scheduled for a tonsillectomy in the day-stay surgical unit. On the day following surgery, the mother calls the surgical unit and expresses concern because the child has a very bad mouth odor. The nurse makes which response to the mother?

1. "The child probably has an infection." 2. "You need to contact the health care provider immediately." *3. "Bad mouth odor is normal and may be relieved by drinking more liquids."* 4. "Have the child gargle with mouthwash." *Rationale:* Bad mouth odor is normal following tonsillectomy and may be relieved by drinking more liquids. Options 1, 2, and 4 are incorrect. Additionally, mouthwash gargles will irritate the throat.

A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. The nurse tells the mother to immediately:

1. Apply a tepid compress to the child's hand. 2. Apply an ice pack to the child's hand. *3. Place the child's hand under cool running water.* 4. Apply a sterile bandage tightly over the burn area to prevent swelling. *Rationale:* Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps alleviate pain. Ice is contraindicated because it may add more damage to already injured skin. Option 4 is an incorrect measure. In addition, the mother may not have a sterile dressing available.

A nursing student is assigned to care for an infant with a diagnosis of congestive heart failure (CHF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by:

1. Asking the health care provider for permission to insert a Foley catheter 2. Monitoring the intake closely 3. Comparing the intake with the output *4. Weighing the diapers* *Rationale:* The best method to assess urine output in an infant is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the intake is not directly related to the subject of the question. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant. In addition, insertion of a Foley catheter places the infant at risk for infection.

A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. The nurse's initial action would be to:

1. Assess the child's growth status. *2. Obtain a complete history of the child's feeding habits.* 3. Assess whether any other children in the family have had the same problem. 4. Explain to the mother that the health care provider will prescribe a barium swallow and upper gastrointestinal (GI) series. *Rationale:* In most situations, a complete history and physical examination of the child is the initial step in diagnosing gastroesophageal reflux disease. The child's feeding habits will give the nurse an indicator of the growth status. The child is weighed and measured after the initial interview is completed with the parent. Hereditary factors are not the priority. Further diagnostic studies may be ordered but only after a complete history is obtained.

A nurse is reviewing the record of a child scheduled for a health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which of the following when collecting data?

1. Bowel function *2. Bladder function* 3. Motor development 4. Nutritional status and weight gain *Rationale:* Enuresis refers to a condition in which the child is unable to control bladder function, although he or she has reached an age at which control of voiding is expected. Nocturnal enuresis, or bed-wetting, is common in children.

A sweat test is performed on a child with a suspected diagnosis of cystic fibrosis (CF). Which test result is suggestive of cystic fibrosis and will require further assessment and investigation?

1. Chloride level of 5 mEq/L 2. Chloride level of 10 mEq/L 3. Chloride level of 20 mEq/L *4. Chloride level of 40 mEq/L* *Rationale:* In a sweat test, sweating is stimulated on the child's forearm with pilocarpine, the sample is collected on absorbent material, and the amount of sodium and chloride is measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level greater than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L is suggestive of CF and requires a repeat test. Options 1, 2, and 3 do not identify results that are positive for CF.

A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research?

1. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. *2. Males inherit hemophilia from their fathers.* 3. Females inherit the carrier status from their fathers. 4. Hemophilia A results from deficiency of factor VIII. *Rationale:* Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Some females who are carriers have an increased tendency to bleed, and, although it is rare, females can have hemophilia if their fathers have the disorder and their mothers are carriers of the genetic disorder. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse would expect the blood pressure in the child's legs and arms to be:

1. Increased in the arms and the legs 2. Decreased in the arms and the legs *3. Decreased in the legs and increased in the arms* 4. Increased in the legs and decreased in the arms *Rationale:* Coarctation indicates a narrowing in the aorta. This would indicate an increased pressure proximal to the defect and a decreased pressure distal to the defect. This would result in a lower blood pressure in the legs and a higher blood pressure in the arms, which is indicated in option 3. Therefore options 1, 2, and 4 are incorrect.

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which of the following will be prescribed initially?

1. Insertion of a nasogastric tube *2. Insertion of a Foley catheter* 3. Administration of an anesthetic agent for sedation 4. Application of an antimicrobial agent to the burns *Rationale:* A Foley catheter is inserted into the child's bladder so that urine output can be measured accurately on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed and treated after assessment, but this would not be the initial action. Intravenous fluids are administered at a rate sufficient to keep the child's urine output at 1 mL/kg of body weight per hour, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention.

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. The mother inquires about the infectious period associated with varicella, and the nurse tells the mother that the infectious period:

1. Is unknown *2. Is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions* 3. Is 10 days before the onset of symptoms to 15 days after the rash appears 4. Ranges from 2 weeks or less up to several months *Rationale:* Varicella is known as chickenpox. The infectious period for varicella is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions. In roseola, the infectious period is unknown. Option 3 describes rubella. Option 4 describes diphtheria.

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn and the results indicate a glucose level of 60 mg/dL. The appropriate intervention is to:

1. Keep the child NPO. 2. Contact the health care provider. *3. Give the child a glass of fruit juice.* 4. Let the child rest until the dizziness subsides. *Rationale:* A blood glucose less than 70 mg/dL indicates hypoglycemia. When signs of hypoglycemia occur, the child needs an immediate source of glucose. Options 1, 2, and 4 do not address the hypoglycemic condition.

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle accident for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?

*1. Nausea* 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size *Rationale:* Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?

*1. Notify the registered nurse of the finding.* 2. Assess for other associated anomalies and document carefully. 3. Tell the mother and father that this may indicate spina bifida. 4. Recognize that this is normal in the neonate and continue the bath. *Rationale:* The legal role of the LPN is to practice under the supervision of the registered nurse. In this instance, the tuft of hair may be indicative of a spinal anomaly, and the registered nurse should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this is the responsibility of the health care provider, if an anomaly is suspected or diagnosed. The LPN should take the priority intervention of notifying the registered nurse before documenting in the chart.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? *Select all that apply.*

*1. Pallor* *2. Edema* *3. Anorexia* *4. Proteinuria* 5. Weight loss 6. Decreased serum lipids *Rationale:* Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?

1. Nausea *2. Bradycardia* 3. Bulging fontanel 4. Dilated scalp veins *Rationale:* Late signs of increased ICP include a significant decrease in the level of consciousness, bradycardia, and fixed and dilated pupils. Nausea is an early sign of increased ICP. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant rather than in a 5-year-old child.

A nurse instructs the mother of a child with sickle cell disease regarding the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions?

1. Stress 2. Trauma 3. Infection *4. Fluid overload* *Rationale:* Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

A child has been diagnosed with Reye's syndrome. The nurse understands that a major symptom associated with Reye's syndrome is:

*1. Persistent vomiting* 2. Protein in the urine 3. Symptoms of hyperglycemia 4. A history of a Staphylococcus infection *Rationale:* Persistent vomiting is a major symptom that is associated with increased intracranial pressure (ICP). Options 2, 3, and 4 are incorrect. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.