NCLEX questions

The nurse is checking a 2 month old's developmental status. What finding would be of concern to the nurse? 1. not able to hold head steady 2. does not bring hands to mouth 3. not able to roll over in either direction 4. does not push down with legs when feet are placed on a hard surface.

2. Does not bring hand to mouth.

The nurse is discussing appropriate toys for preschoolers with a group of parents. What toys should the nurse include? Select all that apply 1. Six piece jigsaw puzzles 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 5. Jump rope 6. Sewing cards

The nurse is discussing appropriate toys for preschoolers with a group of parents. What toys should the nurse include? Select all that apply 1. Six piece jigsaw puzzles 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 6. Sewing cards

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination 2. Second diphtheria vaccination 3. Third Hib vaccination 4. Influenza vaccination

1 In the US the first dose is recommended at birth. In Canada, the first dose is recommended between birth and two months. Diphtheria vacc is recommended at 2 months, and the second at 4 months The first Hib is recommended at 2 months, then 4 months, and then at 6 months

The nurse is talking to the parents of a 4 year old who is suspected to have iron deficiency anemia. What statement by the parents would suggest the cause of this anemia to the nurse?

Our child drinks 30 oz of mild a day. Drinking excess amounts of mild may lead to iron deficiency because the calcium in the milk blocks iron absorption.

What developmental milestone does the nurse expect to see in an 18 month old toddler? Select all that apply 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.

1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want.

The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? 1.Birthweight less than 3 pounds, 4 ounces (1.5 kg). 2. Gestational age 38 weeks. 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.

1.Birthweight less than 3 pounds, 4 ounces (1.5 kg). 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.

What interventions would be appropriate for the nurse to make for a child who is in Bryant's traction? Select all that apply 1. Perform neurovascular checks every 2 hours. 2. Maintain hip flexion at 90 degrees with buttocks raised 1 inch (2.54 cm) off the bed. 3. Reposition child infrequently so that traction is maintained. 4. Place child prone for one hour daily to prevent contractures. 5. Remove adhesive traction straps daily to prevent skin breakdown. 6. Use wrist restraints to keep child from turning over.

1.Perform neurovascular checks every 2 hours 2.Maintain hip flexion at 90 degrees with buttock raised 1 inch of bed Both legs are extending in a vertical position in order to maintain hip flexion at 90 degrees. This helps to keep the femur in the hip socket. Because the legs are extended upward the circulation and nerves can be affected. The feet should be assessed for color, pulses, warmth, and sensation every 2-4 hours. - the child should be repositioned every 1-2 hours to avoid skin breakdown. -Should not be placed on prone while on Bryant's traction -Traction should not be relieved, which is what would happen if straps are removed -A jacket restraint is used to keep the child from turning over in the bed.

A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse? 1. One year old child who has a heart rate of 150 bpm and is crying 2. Two year old child who has a heart rate of 165 bpm and is being rocked 3. Five year old child who has a heart rate of 100 bpm and is playing quietly 4. Thirteen year old adolescent who has a heart rate of 90 and is watching television

2. Two year old child who had a heart rate of 165 bpm and is being rocked. This required additional assessment. The normal heart rate for a 2 year old child is 80-120 bpm. This child experiencing tachycardia that warrants further investigation. Although a 1 year old's heart rate ranges from 80-130, the rate can increase to 150 with vigorous crying. If the child was at rest, a rate of 150 would warrant further investigation. The normal heart rate for a 5 year old child is 70-100 bpm Teenagers have heart rates that generally range from 60-90 bpm. Children who are athletic may have even lower heart rates, especially at rest.

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? 1. Has slight head lag when pulled to sitting position. 2. Walks holding onto furniture. 3. Able to sit, leaning forward on both hands. 4. Has neat pincer grasp.

3. Able to sit, leaning forward on both hands. -head lag should end around 5 mo. of age -generally does not walk holding onto furniture until around 11 months of age -a neat pincer grasp does not usually develop until around 11 months of age.

What developmental milestone does the nurse expect to see in a two month old baby?

Holds head up Turns head toward sound -a baby can respond to their own name by 6 months A baby can roll over from abdomen to back by 4 months Push down on legs when feet are on flat surface by 4 months Reaching for a toy with one hand by 4 months.

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? 1. 15 2. 30 3. 45 4. 90

4. 90 Bryant's traction is used for DDH. The childs body and the weights are used as tension to keep the end of the femur in the hip socket. Traction helps position the top of the femur into the hip socket correctly. This is accomplish with 90 degrees of hip flexion.

What measures should the school nurse implement for a child diagnosed with peanut allergies?

Maintain contact information for parents and pcp Review history of known food allergens and the severity of previous reactions Train designated personnel to administer prescribed medication in an anaphylaxis emergency

A child diagnosed with gastroenteritis is being given fluids in the ER for severe dehydration. Prior to discharge, the nurse instruction the mother to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child?

Bananas Toast Rice Tea The Bratt diet is useful for children following any type of gastroenteritis which includes nausea, diarrhea, or severe vomiting. The bland diet is used in the first 24 hours to allow the gut to rest and readjust slowly to foods that are low protein, low fat and low fiber. The BRATT diet is short term use only and consists of bananas, rice apple sauce, toast & tea.

Which observations should the home health nurse discuss with the parents of a two year old regarding potential safety threats in the home?

Cleaning supplies under sink cabinet Use of space heaters Water heater temp 140 F Use of tablecloths -Placing security gates at the stairs will prevent falls -If there are blinds, the string should be out of the child's reach.

A what age does the nurse expect to see a child build a tower of blocks?

Three By the age of 3 years, the nurse would expect the child to build a tower of 9-10 blocks.

A child weighing 75 lbs. (34.1 kg) is admitted to the unit with a diagnosis of bacterial meningitis. The child has been started on an IV of D5 NS at 100 mL per hour and IV antibiotic therapy has been initiated. Which assessment finding would need to be reported immediately to the healthcare provider?

Urinary output of 28 mL/hr. Change is LOC Sodium level of 130 mEq/L The urinary output should be at least 1 mL/kg/hr for a child. This child, who weighs 34.1 kg should have an output of at least 34 mL/hr. A change in the level of consciousness in this client with meningitis could indicate a worsening of the condition, resulting in neurologic changes, or could indicate the development of FVE and worsening cerebral edema. Careful management of fluid and electrolyte balance is always a very important aspect in the care of clients with meningitis. The sodium level is too low (hyponatremia). This can be due to fluid retention or other causes and can be very serious, if not corrected.