NURS 403 peds MC questions part uno
A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Encourage the parents to rock the infant. B. Offer the infant a pacifier. C. Administer ibuprofen as needed for pain. D. Position the infant on her abdomen.
A A rocking motion will calm and soothe the infant. Additionally, involving the parents in the infant's care can reduce feelings of helplessness.
A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? A. "Placing your child on her back when sleeping will decrease the risk of SIDS." B. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." C. "SIDS rates have been rising over the last 10 years." D. "Sleep apnea is the main cause of SIDS."
A The nurse should instruct the mother to position in the infant on her back during sleep to prevent SIDS. The incidence of SIDS has declined since the Back to Sleep campaign started in the 1990s.
A nurse is teaching car seat safety to a parent of an infant who weighs 4.5 kg (10 lb). Which of the following car seat positions should the nurse include in the teaching? A. Rear-facing in the middle of the back seat B. Forward-facing in the back seat C. Forward-facing in the front passenger seat D. Rear-facing in the back seat next to a window
A The safest position for infants is rear facing in the center of the back seat. Infants should ride rear-facing until age 2 or until the child outgrows the height or weight limits of a rear-facing seat. Studies have shown that children who ride properly restrained in the middle of the back seat have a 43% decreased risk for injury compared to children who are placed near a window.
A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "Our car seat is an infant model and is anchored in the car." B. "Our car seat is front-facing in the back seat." C. "I can fit my hand between the baby and the car seat harness." D. "The car seat is rear-facing in the front passenger seat."
A This statement by the parent indicates correct use of the infant care seat.
A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply.) A. Coughing B. Apnea C. Sunken abdomen D. Cyanosis E. Frothy saliva
A, B, D, E Coughing is correct. Coughing is a finding associated with a tracheoesophageal fistula. Apnea is correct. Apnea is a finding associated with a tracheoesophageal fistula. Cyanosis is correct. Cyanosis is a finding associated with a tracheoesophageal fistula. Frothy saliva is correct. Frothy saliva is a finding associated with a tracheoesophageal fistula. Sunken abdomen is incorrect. Abdominal distension, rather than a sunken abdomen, is a finding associated with a tracheoesophageal fistula.
A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months
B Birth weight typically doubles by 6 months of age.
Which of the following are healthy foods for adolescents? (Select all that apply) A. Cottage cheese with tomato B. Albacore tuna salad sandwich C. Extra buttered popcorn D. Foot long hot dog with chili E. Banana chocolate chip muffin
A, B Extra buttered popcorn, hot dogs, and chocolate chip muffins are high in fat. Extra buttered popcorn and hot dogs are high in sodium.
The nurse teaches a parent appropriate healthy food groups for his school aged child. Which of the following statements made by the parent indicates appropriate understanding? A. "When I go to the grocery store, I will select foods that are on sale, within my budget, and his favorites." B. "When I go to the grocery store, I will select foods from meats, grains, vegetables, fruit, and dairy." C. "When I go to the grocery store, I will purchase foods that we saw on Nickelodeon from television." D. "When I go to the grocery store, I will select foods from his favorite colors like green, red, and orange."
B Food pyramid recommendations for school aged children are from the 4 groups of meats (proteins), grains, fruits, veggies, and dairy
A nurse is caring for a 2-year-old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child's stress? A. Set of building blocks B. Toy hammer and pounding board C. Picture book about hospitals D. Stuffed animal
B A toy hammer and pounding board helps the child to express the anger and frustration he feels about the parent leaving but lacks the verbal ability to express.
A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant is unable to imitate animal sounds. B. The infant does not sit steadily without support. C. The infant cannot turn pages in a book. D. The infant cannot build a tower of three or four cubes.
B An 8-month-old infant should be able to sit steadily without support. A 10-month-old infant should be able to change from a prone to sitting position, stand while holding onto furniture, and lift one foot while standing.
Annie's parents are doctors. Her grandparents are doctors. In fact, Annie's parents have told her that after her high school graduation, they are looking forward to her entering the same college and medical school they attended. Annie waits for just the right time to announce her plans to travel to Europe after high school to pursue her interest in drawing and painting, and to learn Italian. A. Trust vs mistrust B. Industry vs inferiority C. Identity vs role confusion D. Autonomy vs shame and doubt E. Initiative vs guilt
C marked physical changes, storage with past roles and roles they will play
A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? A. Uses a unidextrous grasp B. Has a fear of strangers C. Shows preferences towards foods D. Babbles one-syllable sounds
D A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.
During assessment, the nurse notes an infant's head circumference has increased almost 6 cm since the last hospitalization six months ago. The nurse understands the increase in head circumference in this infant indicates which of the following? A. Higher IQ B. Increased hearing acuity C. Increased sense of sight D. Brain growth
D One parameter of the growth of the developing child is the head circumference; this indicated brain growth. The average head growth occurs in the pattern of 12 cm during the first year
A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A. Broth B. Water C. Diluted apple juice D. Oral rehydration solution
D Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea.
A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? A. Inability to raise head when in prone position B. Inability to sit without support C. Inability to pick up an object with her fingers D. Inability to bring an object to her mouth
A A 3-month-old infant should be able to raise her head and shoulders from prone position; therefore, the nurse should report this finding to the provider.
A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant? A. Oral electrolyte solution B. Half-strength infant formula C. Half-strength orange juice D. Sterile water
A After gastrointestinal surgery, infants should receive clear liquids that contain glucose and electrolytes, such as an oral electrolyte or rehydration solution. They should then advance to formula or breast milk as they demonstrate tolerance.
A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. C. Install accordion style gates. D. Set the water heater at 65.6° C (150° F). E. Fit the mattress so that it is snug against the sides of the crib.
A, B, E Serve food in small, non-circular pieces is correct. Infants have small airways. Food items are a common cause of aspiration. The foods most associated with choking and aspiration are hot dogs, candy, nuts, and grapes. Tie plastic bags in knots before discarding them is correct. Tying the bags in knots prevents the child from placing the plastic over her head. Install accordion style gates is incorrect. This type of gate can cause the child to pinch herself or to become entangled in the openings. Set the water heater at 65.6° C (150° F) is incorrect. Water heaters should be set to a temperature of 48.9° C (120° F) or lower to prevent burns. Fit the mattress so that it is snug against the sides of the crib is correct. The mattress should be fit snugly to prevent the child from being caught between the slats of the crib and the mattress.
The nurse needs to check the six rights of safe medication administration before giving the patient his medication. These include the: (Select all that apply) A. Right dose and right medication B. Right time and right documentation C. Right pharmaceutical company D. Right route and right patient E. Right room and right patient number
A, B, E The six rights are: right dose, right med, right patient, right documentation, right route, and right time
Which of the following foods are examples of carbohydrates? (Select all that apply) A. Spaghetti with tomato sauce B. Extra lean hamburger C. Cinnamon graham crackers D. Scrambled eggs and bacon E. Macaroni and Cheese
A, C, E Carbs are found in vegetables, roots, and legumes
A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Management of tantrums B. How to establish trust C. How to encourage cooperative play D. Dental care E. Need for increased caloric intake
A, D Management of tantrums is correct. It is expected for toddlers to have temper tantrums. How to establish trust is incorrect. According to Erickson, establishing trust is the developmental goal associated with infancy. How to encourage cooperative play is incorrect. Toddlers engage in parallel play. Preschool-age children engage in cooperative play. Dental care is correct. Toddlers should be receiving dental care. Need for increased caloric intake is incorrect. The growth rate during the toddler years slows, which decreases the child's need for calories, protein, and fluid.
A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Inspection B. Superficial palpation C. Deep palpation D. Auscultation
A, D, B, C When performing an abdominal assessment on a child, the nurse should first inspect the abdomen without touching and observe for anything that could indicate a medical concern. Because palpation prior to auscultation can alter the bowel sounds, the nurse should auscultate the abdomen for bowel sounds next. Then, the nurse should palpate the abdomen superficially so the child won't tense her abdominal muscles. Finally, the nurse should perform a deep palpation of the abdomen, making sure to palpate any painful areas last.
A child who has successfully completed the emergent (resuscitative) phase of treatment for a severe burn injury is started on a high protein, high calorie diet. Which snacks should the nurse encourage between meals? (Select all that apply) A. Crackers and cheese B. White bread and honey C. Orange juice and cookies D. Banana pudding and whipped cream E. Frozen yogurt and chocolate sprinkles
A, D, E The cheese increases protein intake, that is needed for tissue repair, and the crackers contain carbohydrates that provide calories for the increased metabolism. The milk in the pudding contains protein and whipped cream contains fat. The banana is high in potassium. All of these nutrients are essential for tissue repair. Frozen yogurt contains both protein and calories. The other options are incorrect because: Although bread and honey increase caloric intake, they furnish little protein needed for tissue repair. Although orange juice and cookies increase vitamin and fluid intake, they do not supply protein, which is needed for tissue repair.
During hospitalization, a school-age child sucks his thumb and wets his bed every day. Which of the following nursing actions is most appropriate? A. Place the child in "time out." B. Clean the patient's bed and give him emotional support C. Call the patient's parents so the child can be disciplined D. Notify the pediatrician and request medication
B In a stressful situation such as hospitalization, a child with undue anxiety can regress and reactivate a behavior more appropriate to an earlier stage of development
A nurse in an acute pediatric unit is caring for a 2 year old child who has separation anxiety when her parents leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse B. The child is withdrawn and refuses to talk C. The child attempts to run away to find her parents D. The child screams and cries loudly
B Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair.
A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs? A. "Can I listen to your lungs?" B. "I am going to listen to your heart." C. "I am going to take your blood pressure now." D. "Can you stand very still while I feel how warm you are?"
B The nurse should inform the toddler of the procedure prior to taking vital signs. The nurse should not ask yes/no questions. Negativism is exhibited by toddlers as a way of asserting self-control and gaining independence. Therefore, toddlers tend to answer questions with a negative response and are likely to initially resist attempts to measure their vital signs. If the nurse asks the question, the toddler responds "no," and the nurse proceeds anyway, it creates an environment of mistrust between the toddler and the nurse. The nurse should avoid using the word "take" when measuring vital signs. The toddler might interpret the words literally and think his blood pressure will be taken away from him.
A child who had full-thickness burns is to have skin grafts. The nurse explains to the child's parents that for permanent grafts the child must have: A. Steroids B. Autografts C. Homografts D. Immunosuppressives
B These grafts use tissue from the individual's own body; there is minimal chance of rejection. The other options are incorrect because: A-this is not part of the therapy for skin grafts C-These grafts use tissue from genetically different members of the same species, usually a cadaver; they are used as a temporary graft. D-this is not part of the therapy for skin grafts
A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Offer fluids through a straw. B. Apply bilateral wrist restraints. C. Administer opioids for pain. D. Implement a soft diet.
C Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler? A. Explains the difference between right and wrong B. Prints letters and numbers C. Separates easily from primary care giver for short periods of time D. Cooperates in doing simple chores
C By 3 years of age, a toddler's psychosocial development should include the ability to accept separating from a primary care giver for short periods of time. A toddler should also be able to express likes and dislikes and begin to play with children and others outside the family.
Timmy's mom pours him a bowl of Cheerios and milk. She directs him to go sit at the kitchen table. Timmy reaches for the bowl of Cheerios announcing "I carry it!" On the way to the table, lots of milk and cereal spill on the floor. Mom quietly cleans up the mess and thanks Timmy for his "help." A. Trust vs mistrust B. Industry vs inferiority C. Initiative vs guilt D. Autonomy vs shame and doubt
C Enterprise, strong imagination explore the world and their power, abilities (bad = guilt)
A nurse is caring for a toddler who is having difficulty sleeping during hospitalization. Which of the following actions should the nurse take to promote sleep? A. Explain the source of the toddler's fears. B. Turn off the room light. C. Provide bedtime rituals. D. Encourage play exercises in the evening.
C Establishing a bedtime routine is important. Reading a familiar book or providing a favorite stuffed toy or blanket will help decrease the child's insecurity and fears.
A nurse is caring for a 1-month-old infant who had surgery to repair a cleft lip. What should the nurse use to facilitate feeding during the immediate postoperative period? A. Soft nipple B. Plastic spoon C. Feeding syringe D. Nasogastric tube
C Feeding with a syringe provides nutrition without placing stress on the suture line. The other options are incorrect because A-sucking stresses the suture line B-a spoon may injure the suture line D-NG feedings are unnecessary because fluid can be ingested orally
During administration of an IV fluid to a child, the nurse assesses redness and swelling at the IV catheter insertion site. Which of the following is the most appropriate course of action for the nurse? A. Continue the infusion until it is complete B. Discontinue the infusion after calling the doctor C. Discontinue the IV fluid infusion D. Ask another RN to assess the IV site
C If signs and symptoms of complications or infiltration are noted, the IV infusion is discontinued and the physician should be notified
A child who is unable to verbalize his feelings may express feelings and thoughts through which of the following? A. Diet B. Clothing C. Play D. Watching television
C Play can greatly facilitate communication with children. Children are less likely to be inhibited when participating in play interactions.
A nurse is preparing to perform a physical exam on a 10 year old child. Which of the following interventions should the nurse implement? A. Allow the child to touch and play with the equipment B. Play games while performing the physical examination C. Explain how the equipment works using correct medical terminology D. Discuss the benefits of performing the examination with the child
C School aged children are interested in learning and building language skills. Therefore, the nurse should explain the function of the equipment using correct medical terminology. D is incorrect because it's best used with adolescents because discussing the benefits and long-term consequences of the examination requires abstract thinking. This developmental skill does not appear until adolescence
A nurse is caring for a 1 year old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk of a delay in development? A. Fine motor skills B. Visual acuity C. Speech patterns D. Hand to eye coordination
C Speech patterns are developed through auditory experiences.
To assess the Point of Maximum Impulse (PMI) of a child who is 10 years old, the nurse assesses the apical pulse at the: A. Third intercostal space, lateral to the midclavicular line B. Fourth intercostal space, lateral to the midclavicular line C. Fifth intercostal space at the midclavicular line D. Space anywhere around the left nipple
C The PMI in a child older than 7 years old is located in the fifth intercostal space in the midclavicular line
A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler. Which of the following statements by the parents indicates an understanding of the teaching? A. "I should expect him to have an increased appetite." B. "His average daily intake should be about 3,000 calories." C. "The quality of food I provide him is more important than the quantity." D. "Because he is such a picky eater, I will give him one of my vitamins each day."
C Toddlers are very picky eaters and usually eat only one or two meals each day. Therefore, it is essential that the meals are balanced with essential nutrients. The nutritious quality of the food is much more important than the quantity. Toddlers generally prefer finger foods because of increasing autonomy.
When safely administering otic drops to a five year old child, the appropriate nursing action(s) is to: A. Grasp pinna at lobe, pull down and back B. Grasp ear at the center, pull backwards C. Pull pinna at the lobe, pull up and back D. Pull the pinna of the ear up and back
D Administering otic drops-for a child older than 3 years old, pull the pinna of the ear up and back
A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? A. Imaginary playmates B. Erikson's stage of initiative versus guilt C. Demonstrations of sexual curiosity D. Negative behaviors characterized by the need for autonomy
D Assertion of autonomy is seen in toddlers as they begin their language and social development.
A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching? A. Have the child remain at the table after meals to increase food intake. B. Add fruit juice to the child's diet to increase vitamin intake. C. Emphasize the quantity, rather than the quality, of food consumed. D. Expect that food consumption might not decrease significantly.
D Food consumption varies and most preschool-age children consume an adequate quantity of food despite their fads and preferences.
A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders? A. Encopresis B. Enterocolitis C. Pyloric stenosis D. Hirschsprung's disease
D Hirschsprung's disease is an inadequate motility of part of the intestine resulting in a mechanical obstruction.
The nurse understands caring for a child means the nurse is caring for the: A. Family dog and the child B. Child and his siblings C. Child only D. Whole family as the client
D In 2003, family centered care was adopted as a philosophy of care for pediatric nursing by the Society of Pediatric Nurses.
To obtain an appropriate pain assessment of a preschool aged child, the nurse uses which of the following tools? A. Numeric rating scale B. FLACC C. CRIES pain scale D. FACES pain rating scale
D Most appropriate - FACES pain rating scale is for 3 years old and older. Numeric-Child 9 years and older. FLACC-infants, preverbal or nonverbal child. CRIES-neonates, 0-6 months old
The most appropriate communication skill the pediatric nurse should use when caring for an adolescent patient is: A. Using toys and games B. The use of smart phones for texting C. Having family present at all times D. Listening nonjudgmentally
D Nurses who work with adolescents must develop communication skills that include remaining nonjudgemental, making no assumptions, making the adolescent feel comfortable.
It's soccer season and fourth-grader, Sophie, can't wait! Last spring she was on a club team and she scored at least one goal in every game! One game she scored the winning goal! A few of Sophie's friends have joined her team. Her coach, her teammates, and her family are all looking forward to the season! A. Autonomy vs shame and doubt B. Initiative vs guilt C. Trust vs mistrust D. Industry vs inferiority E. Identity vs role confusion
D Want to be workers, carry task through to completion
Which of the following are appropriate and safe toys for infants? (Select all that apply) A. Latex balloons with ribbons B. Car keys with plastic ring C. Cell phone with Elmo case D. Soft bright teething toy E. Plastic nesting container
D, E For infants, provide bright rattles, tactile toys, a mirror, bath toys, large ball, plastic stacking or nesting containers, and/or cloth, cardboard, or plastic books. Always provide supervision during play time with infants.
A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'm glad that my child's ostomy is only temporary." B. "I'm glad my child will have normal bowel movements now." C. "I want to learn how to use my child's feeding tube as soon as possible." D. "I want to learn how to empty my child's urinary catheter bag."
A Hirschsprung disease is also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." B. "Newborns do not expand their lungs fully with each respiration." C. "Activity will increase the respiratory rate." D. "The rate and rhythm of breath are irregular in newborns."
D Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.
While an adolescent is hospitalized, a source of anxiety for him is the: A. Separation from his computer B. Separation from his siblings C. Separation from his parents D. Separation from his friends
D While the adolescent is hospitalized, separation from his friends is a source of anxiety as he feels his peer group is important
A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility B. Inform the child he will be put to sleep for the procedure C. Read the child a story about a cartoon character having a similar operation D. Tell the child the appointment is to have his throat checked
A A preoperative visit to the facility allows the child to observe preoperative processes. This education helps the child feel at ease prior to the surgical procedure. B is incorrect because after 9 years of age, a child understands the concepts of death. The nurse should inform the child that he is taking a "special sleep" not that he is being "put to sleep." Children who have pets might regard being "put to sleep" as experiencing death. C. is incorrect because reading a cartoon book is developmentally appropriate for a preschool-age child or toddler. Participating in therapeutic play has benefits for those age groups.
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever
A A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.
A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching? A. "Our baby will sleep in our bed because I am breastfeeding." B. "We will give my baby a pacifier during naps and at bedtime." C. "We will place my baby on her back when sleeping." D. "We will remove blankets and toys from the crib."
A Allowing an infant to sleep in the same bed as an adult can lead to suffocation and falls. The parent should place the infant back in her crib or bassinet after breastfeeding.
A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? A. Irritability B. Slow, bounding pulse C. Decreased temperature D. Tetany
A An infant who is dehydrated will exhibit irritability.
A nurse observes a parent preparing lunch for his two year old child. Which of the following foods should be avoided as a potential choking hazard for this child? A. Peanut butter B. Toast strip C. Cooked carrot D. Cheese stick
A Avoid foods that are potential choking hazards such as peanut butter, nuts, grapes, hot dogs, raw carrots, tough meats, popcorn
A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. Body weight B. Skin integrity C. Blood pressure D. Respiratory rate
A Body weight is the most reliable indicator of fluid loss for infants and young children.
A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide? A. "This technique opens the ear canal, allowing medication to reach the inner ear region." B. "When this technique is used, the toddler experiences less pain." C. "This is the safest and easiest way to administer this medication." D. "When this technique is used, the medication will not run out of the ear."
A For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ear.
A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions? A. An anxiety reaction B. Regression C. Resentment toward the mother D. Developing autonomy
A Hospitalization is stressful, regardless of the age of the client. However, for an 18-month-old toddler, separation from parents adds to that stress. The toddler's behavior indicates an anxiety reaction to the stress of hospitalization. Separation anxiety initially causes demonstrations of protest. Remaining sad and quiet when a parent leaves indicates the second response to separation anxiety, which is despair.
Christopher's mom feeds him every 3 or 4 hours, burps him, walks with him when he is fussy and makes sure he is dressed warmly every time he goes outside for a walk with her. A. Trust vs mistrust B. Industry vs Inferiority C. Identity vs role confusion D. Autonomy vs shame E. Initiative vs guilt
A Meeting their needs
A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? A. "Bring your baby in to the clinic today." B. "Burp your baby more frequently during feedings." C. "Give your infant an oral rehydration solution." D. "Try switching to a different formula."
A Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support
A The infant's posterior fontanel should close by about 8 weeks of age.
A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen
A When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows.
A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures.
A, C, D Have a parent stay with the child during procedures is correct. Maintaining parent-child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures. Cluster invasive procedures when possible is incorrect. Clustering creates an unnecessarily lengthy and painful period for the client, which is likely to increase her fear. Perform procedures as quickly as possible is correct. Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures. Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization. Use mummy restraints during painful procedures is incorrect. Mummy restraints help to immobilize very young children and keep them safe during procedures, but it is likely to increase fear in toddlers and preschoolers.
For which of the following reasons are infants and children at greater risk for infection? (Select all that apply) A. Their immune systems are not as robust as adults' immune systems B. Their parents do not give them chewable multi-vitamins every day C. They have a proportionately greater body surface area in relation to mass D. They do not drink enough Gatorade, Powerade, and energy drinks E. They have increased exposure to infections in daycares and schools
A, C, E In comparison to adults, infants and children have a proportionately greater body surface in relation to body mass, resulting in a greater potential for fluid loss through the skin and GI tract. Their immune systems are not as robust as adults, rendering young children more susceptible to infectious diseases, fever, gastroenteritis, and respiratory infections, all of which result in fluid and electrolyte disturbances and fluid-volume deficit. They are also at higher risk because of increased exposure to infections in a daycare, nursery, and school settings. (James et al., pg 337)
When checking a toddler's vital signs, the nurse initially assesses the: A. Heart rate B. Respiratory rate C. Blood pressure D. Temperature
B The nurse assesses the least invasive vital sign first and then progresses to most invasive. Thus, RR, HR, temperature, and then BP. (James et al., Ch 9 - physical assessment)
A hospitalized two year old child is crying because his mother is leaving. The most appropriate nursing action is to: A. Give the child some stuffed animals for play B. Ask the child life specialist to play with him C. Ask the mother what time she will be back D. Allow the child two minutes to stop crying
B The most appropriate nursing action is to ask the child life specialist to play with the toddler. The child life specialist is specially trained and educated to play with hospitalized children within their developmental levels and with the appropriate play therapies. Separation anxiety is a significant stressor in the hospitalized toddlers and infants
A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? A. Feed the infant with a spoon for 48 hr. B. Apply and release elbow restraints every hour. C. Keep the infant supine. D. Suction the mouth with an oral suction tube.
B It is essential to apply elbow restraints after surgery to keep the infant from placing her hands in and around her mouth. The nurse should remove them periodically to inspect the skin and allow the infant to exercise her arms.
A nurse is feeding an infant with a recent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding? A. Burp several times B. Rinse the suture line C. Place on the abdomen D. Hold for several minutes
B Meticulous care of the suture line is necessary because inflammation and sloughing of tissue disrupt healing. The other options are incorrect because A-burping should be done throughout the feeding C-placing on the abdomen is contraindicated not only because the infant may rub the face on the sheet and irritate the suture line, but because of its relationship to SIDS D-the infant can be held at any time
Daniel doesn't want to wear the pajamas his mother chose for him. Instead, he STRONGLY prefers last night's (dirty) PJs! Daniel's mom agrees and dresses him in his (dirty) PJ selection. A. Industry vs inferiority B. Autonomy vs shame and doubt C. Initiative vs guilt D. Trust vs mistrust E. Identity vs role confusion
B Shaming them when they are trying to do something
A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs guilt B. Industry vs inferiority C. Identity vs role confusion D. Autonomy vs shame and doubt
B The developmental task of industry vs inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (6-12) Initiative vs guilt is the developmental task of early childhood (ages 3 to 6) Identity vs role confusion is the task of the adolescent (ages 13 to 19) Autonomy vs shame and doubt is the developmental task of a toddler (ages 12 months to 3 years)
A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot stand upright without support. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob.
B The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay.
A nurse in the ER is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child? A. 6 months old B. 12 months old C. 18 months old D. 24 months old
B The nurse should know that this infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months old due to the presence of 6 teeth. Her skills--sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)--should also help the nurse estimate the infant's age as 12 months.
A nurse is caring for a child with severe burns who has extensive eschar formation on the arms. What is the priority nursing intervention? A. Removing blisters B. Checking radial pulses C. Maintaining respiratory isolation D. Performing range of motion exercises
B The radial pulses are a reflection of how the child is adapting to the eschar formation. Eschar is rigid and may restrict circulation, leading to loss of perfusion to the limbs. The other options are incorrect because: A-blisters are a protective adaptation and should not be disturbed. C-there are no data to indicate that the child has a respiratory infection D-Although range of motion exercises are important, adequate arterial perfusion is the priority
A nurse is assessing a 4 year old child's cognitive development during a well child visit. Which of the following should the nurse expect the child to display? A. Conservation B. Development of the superego C. Concrete operational thought D. Separation anxiety
B This is the development of the conscience. Preschoolers begin to develop an understanding of right from wrong. While they might be able to understand the "why" of acceptable vs unacceptable behaviors, they learn the concept through punishment and reward and the principles to which their parents adhere
A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take? A. Notify the provider. B. Continue to monitor the client. C. Provide oral rehydration fluids. D. Perform a bladder scan at the bedside.
B This urine output is within the expected reference range for a toddler. The child's urine output should be greater than 1 mL/kg/hr. The client weighs 33 lb, which converts to 15 kg. 15 kg x 8 hr = 120 mL. This client's output indicates an adequate amount of urinary output during 8 hr. Other signs of adequate fluid volume are moist mucous membranes, capillary refill of 2 seconds or less, brisk skin turgor, balanced fluid intake and output, and electrolytes within expected range.
When appropriately assessing an infant's heart rate, it is important for the nurse to: (Select all that apply) A. Count for 15 seconds and multiply by 4 B. Count the heart rate for one full minute C. Count the brachial pulse with one finger D. Ask the parent to look at her watch while counting the pulse E. Assess the apical pulse using a stethoscope
B, E The HR is most accurate when it is assessed with a stethoscope, for one full minute by the nurse, especially for children less than 2 years old
A nurse is planning preoperative teaching for a 5 year old child. Which of the following interventions should the nurse include? A. Explain the long term benefits of the procedure B. Provide diagrams and pictures while explaining the procedure C. Use correct medical terminology during the teaching session D. Explain the procedure in terms of what the child will feel, see, hear, and taste
D Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure B. is incorrect because the nurse should use dolls or stuffed animals to explain the procedure the procedure and allow the child to handle the equipment if possible C is incorrect because teaching for a preschooler should be done using simple, familiar terms
A safe volume of medication for an intramuscular injection of an infant is: A. 2 mL B. 1.5 mL C. 1.1 mL D. 0.5 mL
D The safe volume of medication for an IM injection for the infant is 0.5 mL, especially if they have smaller muscle mass. The maximum amount of volume for an IM injection for a premature infant is 0.5 mL; a neonate is 0.5-1.0 mL; an infant from 1-12 months is up to 1.0 mL. Proper assessment of the infant's muscle mass is appropriate.
A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings? A. Tracheoesophageal fistula B. Inguinal hernia C. Hypertrophic pyloric stenosis D. Intussusception
D These findings are associated with a diagnosis of intussusception. Other associated findings include vomiting, lethargy, periods of screaming and drawing the knees to the chest followed by periods of normal behavior, and eventual fever and signs of peritonitis.
