Nursing care of children ATI quiz bank
supine with legs in frog position
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions?
tetanus
lock jaw and muscle rigidity. no rash
-2 months -4 months -6 months -fourth dose between 12-18 months
pneumococcal vaccine administration schedule
"I will add rice cereal to my baby's feedings.": The mother should add 1 tsp to 1 tbsp of rice cereal per ounce of formula or expressed breast milk to thicken the feedings because this will decrease the number of vomiting episodes. -avoid feeding before bedtime place infant in a infant seat or at a 30 degree angle for 1 hr after feeding give lansoprazole 30 min before feeding
A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
"I will record the highest reading of three attempts."
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching?
"I will administer the iron tablet with orange juice."
A nurse is teaching parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching?
my infant drinks atleast 2 quarts of skim milk each day
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching?
Diphtheria, tetanus, and pertussis (DTaP): given between the ages of 4-6 y/o
A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give?
Head lags when pulled from a lying to a sitting position
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?
minimize physical contact with the child initially
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
Ensure the child's dietary intake of calcium and iron is adequate.
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching?
Adult tetanus booster (Td) wound prophylaxis for those over 7 y/o. Td recc. every 10 years after the age of 18 y/o
A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering?
"Injury by a corrosive liquid is more extensive than by a corrosive solid." -do not neutralize chemical can cause heat injury -dont use activated charcoal
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion?
birth weight is tripled. -by 12 months it should be tripled; by 30 months it should be quadrupled.
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse?
Legs remain crossed and extended when supine
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment?
BP 86/40 mm Hg: indicative of hypotension and bleeding.
A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider?
tachypnea
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration?
Presence of sparse, fine pubic hair -sign of precocious puberty
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse?
The child complains daily about going to school.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation?
Inability to vocalize vowel sounds
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay?
FACES pain scale
A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level?
Cup: The infant should be fed clear liquids using a cup for 7 to 10 days following a cleft palate repair to prevent trauma and injury to the suture line.
A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments?
wear a mask when assisting the toddler with meals
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take?
building towers of blocks
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child?
Increase the child's protein intake.
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make?
Small, frequent bottle feedings of electrolyte solution: Feedings begin 4 to 6 hr after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water.
A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure?
"An abdominal ultrasound will confirm the pocket in the intestine." -confirmed w/: x-ray, ultrasound, or CT scan
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make?
"Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include?
Meningococcal polysaccharide
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory?
periorbital edema
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
"Your child will need a botulinum toxin A injection to help with muscle spasticity."
A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make?
Monitor the child for increased temperature.
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan?
Explain sounds the child is hearing.
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?
Babinski reflex present until 1 y/o
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following highlight reflexes should the nurse expect to find?
observe parents actions when feeding the child maintain detailed record of food & fluid intake
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
"I will inspect my child's mouth every day for sores." *increased risk for mucositis*
A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?
Keep the child away from people who have an infection.
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?
i will help my child blow bubbles during the injection
A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
scrambled eggs
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend?
"The pneumococcal and influenza vaccines are recommended for your child."
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?
Place a plastic bag over the cast when showering
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching?
"I can take my brace off for about an hour daily to shower." wear brace for 23 hrs/day even at night
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching?
"My child should consume 1,000 calories per day."
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching?
copies a circle
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group?
"I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." need 15 g of simple carbs
A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching?
Massage the anterior area of the infant's ear following administration. -for kids <3 y/o auricle should be down and back -for kids >3 y/o pull auricle up and back
A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include?
Potassium 2.5 mEq/L
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider?
Hgb 6 g/dL
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider?
1.035: SG should be concentrated because the child is dehydrated
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect?
"I will place a pressure dressing over the area following the procedure." to prevent bleeding from the site. -place in prone position for procedure
A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make?
barking cough
A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching?
"I lock my medications in the medicine cabinet."
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching?
plastic stethoscope for imitation play
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play?
-frequent hospitalizations -6 months-5 y/o -lack of parent bonding -irritable & difficult temperament
A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization?
follow a nightly routine & established bed time
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include?
Vastus lateralis *can use deltoid after 18 months old*
A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection?
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer?
Inspect the toddler's toys for sharp edges. -during bleeding episodes elevate & rest affected joint
A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan?
hoarseness
a finding present in someone with acute spasmodic laryngitis
fifth disease
bright red cheeks "slapped cheek appearance" rash will later appear on extremities and trunk. rash fades centrally and gives a lacy appearance
Murmur at the left sternal borders
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect?
The child views death as similar to sleep The child believes his thoughts can cause death The child thinks death is a punishment
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child?
25
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
object permanence
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child?
maintain child on bed rest
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
wash and dry the infant's genitalia and perineum thoroughly. -do not use any lubricant, oil, or powder -you can place the penis and scrotum to ensure there is a snug fit -check frequently and remove when urine is obtained
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take?
rock the child in long rhythmic movements
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take?
Schedule the child for a preoperative visit to the facility.
A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take?
Give the medication at the side of the infant's mouth.
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
Demonstrate the injection technique on an orange.
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first?
"I will give my child a dose of albendazole today and again in 2 weeks." -collect pinworm specimen in morning before bathing and bowel movements -shower bath instead of tub bath to prevent reinfection -clean clothes/linen in hot water
A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching?
cow's milk
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children?
Positioning the car seat so it is rear-facing Securing a safety gate at the top and bottom of the stairs Maintaining the water heater temperature at 49° C (120° F)
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.)
-2 months -4 months -6 months -fourth dose between 12-18 months
Hib vaccine schedule
-birth -1 to 2 month old -6 to 18 months old
Hep B vaccination schedule
Sudden decrease in wheezing: A sudden decrease in wheezing can be an indication that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilator failure and an imminent respiratory arrest.
A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?
Determine the child's breathing pattern.
A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first?
drooling
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis?
check the child's respiratory status
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse?
put a no abdominal palpation sign over the child's bed
A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take?
Heart rate 175/min
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider?
Weight gain of 1.8 kg (4 lb)
A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider?
Use the FACES scale.
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain?
Koplik spots:Koplik spots are small, irregular oral lesions with a bluish-white center and are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash appears and are accompanied by manifestations of fever, malaise, conjunctivitis, and other cold manifestations.
A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect?
varicella
A nurse is caring for a child who has a vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expect that the child has which of the following conditions?
check the child's BP Q 4 hr to monitor for HTN
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take?
"The PICC line will last several weeks with proper care." -inserted using local anesthetic by trained personnel -no need to immobilize extremity
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent?
inability to clear secretions
A nurse is caring for a child who has cystic fibrosis and a pulmonary infection. Which of the following findings is the nurse's priority?
Apply continuous pressure to the child's nose for at least 10 min.
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?
Serum cholesterol 700 mg/dL: high serum cholesterol due to increase of plasma lipids
A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect?
Encourage the child to use an incentive spirometer.
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority?
frequent swallowing can be bleeding
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?
"The test shows us if your child had a recent strep infection."
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make?
Reinforce teaching with the client about how to push the button to deliver the medication.
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?
Suction the infant gently with a bulb syringe PRN. -place infant upright -clean incision w/ sterile saline or sterile water
A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take?
call poison control
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance?
hydrocephalus: In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered; therefore, the infant is at risk for hydrocephalus and the nurse should monitor the infant for this condition.
A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications?
diastolic murmur
finding in atrial septal defect
Cyanosis that increases with crying
finding in atrioventricular canal defect
widened pulse pressure
finding in patent ductus arteriosus
