Pediatric Nursing 3.0 Test

A nurse in a pediatric clinic is caring for a client who is bottle feeding their 6-month-old infant. Which of the following statements should the nurse plan to include in the anticipatory guidance about nutrition? "You can begin now to introduce cow's milk to your infant." "You can place infant cereal in a bottle if your baby doesn't like the spoon." "Offer one new food for 3 to 5 days when beginning solid foods." "Sippy cups with a soft spout that requires sucking are preferred."

"Offer one new food for 3 to 5 days when beginning solid foods." When introducing new foods, it is important to observe the infant closely for allergic reactions. The nurse should instruct the client to introduce one new food at a time for 3 to 5 days while monitoring the infant closely for allergic reactions.

A nurse is assessing a 7-year-old school-age child at a well-child check. The parent says the child has been 'acting out' since starting first grade. Which of the following should the nurse identify as a potential stressor for the child? (Select All that Apply.) Navigating peer relationships Bullying by peers Feeling supported Parental divorce Academic success

Navigating peer relationships is correct. School-age children can experience stress related to aspects of peer relationships, such as making friends and feeling pressure to maintain a certain appearance. Bullying by peers is correct. School-age children can experience stress related to peer interactions. Experiences such as playground bullying can induce stress in a school-age child. Parental divorce is correct. School-age children are impacted by familial relationships. Divorce, changes in parental emotional state, and parental fighting are common stressors for school-age children.

A nurse is providing anticipatory guidance to the guardians of a 7-day-old newborn who is bottle feeding. Which of the following should the nurse include in the teaching? (Select All that Apply.) Teach the guardians to place the newborn's car seat in a rear-facing position. Teach the guardians to discard formula that was heated and has been sitting out for 1 hr or more. Encourage the parents to place the newborn to sleep on a soft sleep surface. Encourage the guardians to prop the newborn's bot

Teach the guardians to discard formula that was heated and has been sitting out for 1 hr or more is correct. The nurse should teach the guardians of bottle feeding newborns to discard formula that has been sitting out for 1 hr or more to prevent bacterial contamination. Teach the guardians to place the newborn's car seat in a rear-facing position is correct. The nurse should teach the guardians that the newborn should be appropriately secured in an approved car seat that is rear-facing in the middle of the back seat.

A nurse is assessing the vital signs of a 7-year-old school-age child. Which of the following findings should the nurse expect? Temperature 37.1° C (98.8° F) orally; respiratory rate 28/min; heart rate 100/min Temperature 37.0° C (98.6° F) orally; respiratory rate 24/min; heart rate 92/min Temperature 37.1° C (98.8° F) orally; respiratory rate 24/min; heart rate 118/min Temperature 37.0° C (98.6° F) orally; respiratory rate 20/min; heart rate 54/min

Temperature 37.0° C (98.6° F) orally; respiratory rate 24/min; heart rate 92/min These vital signs are within the expected reference range for a school-age child. The expected reference range for respiratory rate for a school-age child is 20 to 25/min. The expected reference range for heart rate for a school-age child is 60 to 110/min.

A nurse on a pediatric unit is teaching a newly licensed nurse how to assess blood pressure on a preschooler. Which of the following statements should the nurse include in the teaching? Select the 2 statements the nurse should include. "Any cuff smaller than an adult cuff will work." "The cuff bladder width must be at least 40% of the midpoint circumference of the upper arm." "The cuff labeled 'preschool' will be best." "Use the smallest adult-sized cuff available to measure the systolic pres

"The cuff bladder width must be at least 40% of the midpoint circumference of the upper arm." is correct. Children of the same age vary in size. To obtain an accurate blood pressure measurement, the cuff must be appropriately sized. The cuff bladder width should be at least 40% of the midpoint circumference of the child's upper arm, and the cuff bladder length should be 80% to 100% of the circumference of the child's upper arm. "The cuff bladder length is at least 80% to 100% of the circumference of the upper arm." is correct. Children of the same age vary in size. To obtain an accurate blood pressure measurement, the cuff must be appropriately sized. The cuff bladder width should be at least 40% of the midpoint circumference of the child's upper arm, and the cuff bladder length should be 80% to 100% of the circumference of the child's upper arm.

A nurse has finished teaching the guardians of an 8-year-old school-age child about safety. Which of the following statements by the guardians indicates an understanding of the teaching? "We will wait to talk to our child about the dangers of smoking." "We keep the ammunition and handgun locked in our gun safe." "We signed up for swim lessons at the local community center." "Now that our child is 8 years old, they no longer need to use a booster seat."

"We signed up for swim lessons at the local community center." Children should know how to swim, as drowning is a significant cause of morbidity and mortality in children. The nurse should encourage families to enroll their school-age children in swim lessons.

A nurse in a pediatric clinic is caring for an adolescent. Which of the following actions should the nurse take to establish a rapport with the adolescent? Discuss topics related to alcohol use at the beginning of the interview. Use close-ended questions to promote communication. Complete the social history with the adolescent's parent present. Ask the adolescent what pronouns they use.

Ask the adolescent what pronouns they use. The nurse should ask the adolescent what pronouns they use at the start of the interaction. This establishes respect for the adolescent as an individual.

A nurse is caring for a 4-year-old preschooler who is postoperative. Which of the following methods should the nurse use to assess the child's pain? Ask the child to mark a line on a scale from 'no pain' to 'pain as bad as it can be.' Ask the child to point to the picture of the face that represents how they feel. Ask the child to rate their pain on a scale of 0 to 10. Rate pain based on the child's facial expression, cry, breathing pattern, motor activity of arms and legs, and state of arousal.

Ask the child to point to the picture of the face that represents how they feel. The FACES pain scale is a self-report pain scale used in children ages 3 to 8 years of age. When using this scale, the nurse should provide the child with pictures of faces then ask the child to point to the picture that most closely relates to how they feel. This is an appropriate method of measuring pain for a preschooler.

A nurse is preparing a presentation on infant gross motor skills for a group of newly hired pediatric nurses. Which of the following statements should the nurse include in the presentation? (Select All that Apply.) At 2 months, infants hold their head up in the prone position. At 3 months, infants roll from supine to prone to back again. At 6 months, infants pull to stand up. At 9 months, infants sit unsupported. At 12 months, infants walk independently.

At 2 months, infants hold their head up in the prone position is correct. The nurse should include that an infant will hold their head up when in the prone position and move all extremities well at 2 months of age. At 9 months, infants sit unsupported is correct. The nurse should include that an infant will sit unsupported, get to a sitting position independently, and roll from a supine to a prone position at 9 months of age.

A nurse is caring for a toddler on a pediatric unit. Which of the following methods should the nurse use to assess the toddler's temperature? Axillary thermometer Oral thermometer Glass thermometer Strip thermometer

Axillary thermometer An axillary thermometer can be used to measure the temperature of any child. This is an appropriate method of measuring the temperature of a toddler.

A nurse is assessing a newborn while they are being held upright in their parent's arms. The nurse notes that the newborn's anterior fontanel is sunken. The nurse should identify this finding as a possible manifestation of which of the following conditions? Dehydration Neural tube defect Traumatic brain injury Meningitis

Dehydration The nurse should recognize a sunken fontanel as an unexpected finding. A sunken fontanel can indicate the newborn is dehydrated.

A nurse is assessing a 5-year-old preschooler during a well-child examination. Which of the following findings should the nurse expect? Bruises on the upper arm Round, protuberant abdomen Enlarged tonsils without exudate Sway-backed posture when standing

Enlarged tonsils without exudate This is an expected finding. The nurse should expect the tonsils of a preschooler to appear enlarged. Findings such as tonsillar exudate are associated with infection.

A nurse is assessing a 5-year-old preschooler who has Down syndrome. Which of the following findings should the nurse expect when assessing the child's neck? A webbed neck Anterior neck folds Lax skin A short neck

Lax skin This is an expected finding in children who have Down syndrome.

A nurse is preparing a presentation for a group of newly hired pediatric nurses on expected pubertal changes during adolescence. Which of the following statements should the nurse include in the presentation? Males begin puberty earlier than females. Enlargement of the penis is the first pubertal change in males. Menarche begins about 2 years after breast budding in females. Pubic hair is the first pubertal change in females.

Menarche begins about 2 years after breast budding in females. Menarche, the first menstrual period, typically begins approximately 2 years after the presence of breast budding in females.

A nurse is assessing a toddler in a pediatric clinic. Which of the following findings requires further evaluation? Pinna is below the outer canthus of the eye. Toddler gained 1.8 kg (4 lb) of weight in the past year. Heart rate is 100/min. Abdomen is soft and protuberant.

Pinna is below the outer canthus of the eye. This is an unexpected finding that requires further evaluation. Low-set ears can be an indication of a genetic condition. The nurse should expect the pinna to be in line with the outer canthus of the eye.

A nurse is caring for a 6-week-old infant who is postoperative following a pyloromyotomy. The nurse measures the infant's facial expression, body movement, sleep, verbal or vocal ability, ability to be consoled, and response to movements and touch. Which of the following behavioral assessment tools is the nurse using? Riley Infant Pain Scale Modified Behavioral Pain Scale (MBPS) Neonatal Infant Pain Scale (NIPS) FACES Pain Scale

Riley Infant Pain Scale The Riley Infant Pain Scale measures six parameters: facial expression, body movement, sleep, verbal or vocal ability, consolability, and response to movements and touch.

A nurse is assessing the sensory development of a 2-month-old infant. Which of the following findings should alert the nurse to a possible sensory deficit in the infant? The infant's eyes wander and occasionally are crossed. The infant does not respond to a loud noise. The infant's eyes focus on near objects. The infant does not make 'ahh' sounds.

The infant does not respond to a loud noise. This is an unexpected sensory finding and might be an indication of a sensory deficit. Hearing is typically fully developed at birth, so the infant should respond to noises.

A nurse is performing a physical assessment on a newborn who is sleeping. Which of the following body areas should the nurse assess last? Abdomen Heart Lungs Throat

Throat The nurse should systematically assess the newborn, proceeding from head to toe, saving the more intrusive portions, such as the throat, for last.

A nurse is performing a physical assessment on an infant. Which of the following actions should the nurse take when performing a respiratory assessment? Perform the respiratory assessment last. Listen closely to breath sounds during cries. Use a stethoscope with a small diaphragm. Document abdominal breathing as an unexpected finding.

Use a stethoscope with a small diaphragm. The nurse should use a stethoscope with a small diaphragm when auscultating lung sounds on an infant because this helps differentiate the anatomy being examined.