PEDS FINAL STUDY

A nurse is assiting with the care of a child with spina bifida. Which of the folloing precations should nurse take while caring for this child?

Precautions for Spina Bifida -- Latex Precautions

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?

"Did the child have a sore throat or an unexplained fever within the past 2 months?"

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?

"I am so pleased that I won't have to eliminate oatmeal from my child's diet."

A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which response by the adolescent indicates an understanding of the teaching?

"I can take my brace off for about an hour daily to shower"

A nurse provides information to the mother of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the mother indicates the need for further instruction regarding this disorder?

"I need to bring my child back to the clinic in 1 month for a new cast."

A nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further instruction?

"I need to provide a well-balanced, high-fat diet to my child."

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?

"I will give my child a dose of albendazole today and again in 2 weeks"

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?

"If my baby has a high-pitched cry, I should call the doctor."

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?

"If my child vomits after medication administration, I will repeat the dose."

A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. The appropriate nursing response is which of the following?

"It is the inability to tolerate sugar found in dairy products."

A nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease?

"The child does not experience pain at the primary tumor site."

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?

"The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."

A nurse is teaching cardiopulmonary resuscitation to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands the reason if the student makes which statement?

"The object may be forced back further into the throat."

A nurse is preparing to obtain an ASO titer from a child who has acute glomerulonephritis. The parent asks the nurse to explain what the purpose of the test is. Which response should the nurse make?

"The test shows us if your child had a recent strep infection"

A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need to further research this disorder?

"This disease is twice as likely to occur in boys rather than girls."

A nurse is reviewing the lab 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?

1.035

A parent of an 11-month-old child tells the nurse in the providers office that she is concerned about the amount of sleep her daughter is getting. The nurse should explain that by the end of the first year infant should get about how many hours of sleep each night?

14 hr

A nurse is preparing to administer diphenhydramine 5mg/kg/day PO divided equally every 8 hr to a school-age child who weighs 50 lb. Diphenhydramine oral solution 12.5 mg/5 mL is available. How many mL should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

15

A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Elevate the extremity 2. Notify the provider 3. Remove the IV line 4. Stop the infusion

4, 1, 2, 3

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is/are the result of chronic vaso-occlusive phenomena? (Select all that apply.) A.Enlarged heart B.Enuresis C.Leg ulcers D.Extrahepatic cholestasis E.Retinal detachment

A, B, C, E

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness? (Select all that apply.) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

A, B, E (Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on teaching the child's parents about topical application of an antibacterial ointment. The parents should wash their hands before and after contact with the affected area and wash the child's bed linens daily in hot water to decrease the risk of reinfection or transmission.)

A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply.) A."My child will likely be irritable for the next few weeks." B."I will notify my child's doctor if the skin on her hands or feet begins to peel." C."I will ensure my child does not receive any live vaccines for at least 18 months." D."I will keep a record of my child's temperature until she has no fever for several days." E."My child will have joint stiffness primarily at the end of the day."

A, C, D

A school nurse is providing dietary teaching for an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (Select all that apply.) A. "I should eat extra food on busy days when I am more active." B. "I should wait for 2 hr after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 min before my baseball games start." E. "I should have a 16 oz sports drink if I start feeling weak or shaky."

A, C, D (The nurse should instruct the adolescent to increase the intake of allowable foods when the level of activity is increased. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. Additionally, the nurse should instruct the adolescent to increase the intake of sugar-free fluids when sick because fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids such as water, broth, and tea. The adolescent should continue with the usual intake at mealtimes and follow the recommended meal plan as much as possible.)

A nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods increase the risk of choking in toddlers? (Select all that apply.) A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers

A,B,C,D (Foods that are shaped like a tube, such as hot dogs and grapes, place toddlers at risk for choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew, such as bagels and marshmallows, place toddlers at risk for choking; if swallowed before they are adequately chewed, they can block the airway.)

A nurse is collecting data from an infant who has Gastroesophageal reflux (GERD) . Which of the following findings should the nurse expect? ( select all that apply) A. Vomiting B. WeightLoss C. Rigid Abdomen D. Wheezing E. Pallor

A,B,D

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? (Select all that apply.) A.The child views death as similar to sleep. B.The child is interested in what happens to the body after death. C.The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.

A,D,E

A nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? (Select all that apply.) A.Yellow sclerae B.Rapid weight gain C.Tar-colored stools D.Abdominal distention E. Dark urine

A,D,E (Biliary atresia is a progressive process that leads to the destruction of the biliary tree. Yellow sclerae are an early manifestation of biliary atresia caused by obstruction of the biliary tree, resulting in cholestasis. Abdominal distention is a clinical manifestation of biliary atresia due to hepatomegaly. Dark urine is a clinical manifestation of biliary atresia due to conjugated bilirubin escaping from the liver and being excreted in the urine.)

A nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse perform? (Select all that apply.) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Perform immediate gastric lavage D. Insert an IV for morphine administration E. Apply a pulse oximeter

A,D,E (The nurse should ask the parent or guardian about the size of the container, its contents prior to ingestion, and its contents remaining following ingestion. This information provides an estimate of the amount of cleaner the child ingested and can assist the provider in directing treatment. A child who ingests a corrosive agent is likely to have intense pain due to burns in the gastrointestinal system. The nurse should administer morphine as prescribed via IV to provide pain relief. The child is also at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level will help the nurse recognize if the child's airway is becoming obscured.)

The nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should ignore the stuttering and not interrupt her." B. "I should finish my child's sentence if she is stuck on a word." C. "I should reward my child when she doesn't stutter." D. "I should tell my child to slow down when she starts stuttering."

A. "I should ignore the stuttering and not interrupt her." (Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged.)

A nurse is teaching the parent of a preschool-aged child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A."I will give my child a dose of albendazole today and again in 2 weeks." B."I will collect specimens immediately after my child has a bowel movement." C."I will give my child a tub bath twice each day." D."I will place my child's bed linens in a sealed plastic bag for 7 days."

A. "I will give my child a dose of albendazole today and again in 2 weeks." (The nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to eradicate the parasite and prevent reinfection)

A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A."Initial vaccines should be administered between birth and 2 weeks of age." B."Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C."An allergic reaction to a vaccine is due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5°F and head congestion."

A. "Initial vaccines should be administered between birth and 2 weeks of age." (The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBsAg) negative.)

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? A."My child should consume 1,000 calories per day." B."My child should have 4 oz of protein per day." C."I should give my child 32 oz (4 cups) of milk per day." D."I should feed my child 4 oz (1/2 cup) of vegetables per day."

A. "My child should consume 1,000 calories per day."

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A."The infant might be dehydrated." B."The infant might be anemic." C."The infant might have received too much fluid." D. "The infant might have leukemia."

A. "The infant might be dehydrated." (An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration.)

A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

A. Abdominal distention (A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus.)

A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A.Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion B.Give potassium as a rapid IV bolus C.Administer 3 units of ultralente insulin subcutaneously D.Obtain an HbA1c level stat

A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion (When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur.)

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A.Administer ibuprofen B.Limit daily fluid intake C.Apply cold compresses to painful joints D.Withhold live virus immunizations

A. Administer ibuprofen (The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic.)

A nurse is reinforcing teaching with a parent of a child who has eczema. Which of th following instructions should the nurse include in the teaching A. Apply a cool wet compress to the affected area B. Launder clothing with fabric softener C. Give bubble baths everyday D. Use a wool gloves in the winter time

A. Apply a cool wet compress to the affected area

A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the client's bathroom to strain the client's urine D. Administer folic acid with meals

A. Attach a latex allergy alert identification band (Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as latex gloves for this client.)

A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A.Burp the infant at least 2 to 3 times during the feeding B.Remove the nipple from the infant's mouth if swallowing becomes audible C.Stop the feeding if formula appears in the nasal cavity of the infant D.Discourage the parents from participating in the feeding prior to a surgical repair

A. Burp the infant at least 2 to 3 times during the feeding (Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed.)

A nurse is collecting data from a 2 year old toddler who has AIDS. The nurse should inspect inside the toddler mouth for which of the following opportunistic infections (fungus infections is usually opportunistic infections)? A. Candidiasis B. Gingivitis C. Canker sores D. Koplik spots

A. Candidiasis

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A.Celiac disease B.Ulcerative colitis C.Hirschsprung's disease D.Crohn's disease

A. Celiac disease (The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short-bowel syndrome, lactose intolerance, and congenital enzyme deficiency.)

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (select all that apply) A. Elbow B. Mummy C. Wrist D. Jacket

A. Elbow

A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Fastening buttons on a shirt B. Tying shoelaces C. Parting and combing hair D. Cutting the meat at dinner

A. Fastening buttons on a shirt (The nurse should expect a 4-year-old child to have the fine motor ability to fasten buttons on a shirt; however, the child may have difficulty if the buttons are small.)

A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include? A.Higher body fat content is associated with earlier onset of menarche B.Pubic hair is typically present prior to breast development C.Ovulation begins after sexual maturation is complete D.Menarche signals the beginning of puberty

A. Higher body fat content is associated with earlier onset of menarche (The nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche.)

A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg

A. Hip (Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site.)

A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? A. Hypertension B. Abdominal obesity C. Bradycardia D. Loose stools

A. Hypertension (The nurse should expect a child who has pheochromocytoma to exhibit hypertension due to the increased production of catecholamines. Other manifestations include sweating, weight loss, and polyuria.)

A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A.Inactivated poliovirus vaccine (IPV) B.Haemophilus influenzae type B vaccine (Hib) C.Pneumococcal conjugate vaccine (PCV) D.Hepatitis B vaccine (HBV)

A. Inactivated poliovirus vaccine (IPV) (The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 and 18 months of age.)

A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations ? A. Influenza (TIV) B. Inactivated poliovirus (IPV) C. Haemophilus Influenza tybe B (HiB) D. Hepatitis B (Hep B)

A. Influenza (TIV)

A nurse is creating a plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse include? A.Initiate protective-environment isolation for the child B.Apply pressure for 1-2 min at the puncture site following blood specimen collection C.Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D.Check the child's blood glucose level every 4 hr

A. Initiate protective-environment isolation for the child (The nurse should suggest protective-environment isolation for the child, which consists of a private room with positive air pressure and no live flowers; nurses must don a respirator mask, gloves, and gown prior to entering the child's room. A child who has aplastic anemia has decreased RBCs, platelets, and WBCs, causing immune suppression and increasing susceptibility to infection.)

A nurse is caring for a school age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35mL of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe? A. Lowsodium,fluid restricted B. Regular diet no added salt C. Low carbohydrate ,low protein diet D. Low protein. Low potassium diet

A. Lowsodium,fluid restricted

A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority? A.Measure the client's weight daily B.Check for tears C.Palpate the fontanel D. Assess skin turgor

A. Measure the client's weight daily (When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages. Daily weight measurements are especially critical for infants and children because fluid accounts for a greater portion of body weight.)

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A.Monitor the child's oxygen saturation level B.Administer prescribed antibiotics to the child C.Increase the child's fluid intake D.Apply warm compresses to the child's affected joints

A. Monitor the child's oxygen saturation level

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.) A.Observe the parents' actions when feeding the child B.Maintain a detailed record of food and fluid intake C.Follow the child's cues to time food and fluids D. Sit beside the child's high chair for feedings E. Play music videos during scheduled meal times

A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake (Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for this child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.)

A nurse is caring for a child who Is postoperative following the insertion of a ventriculorperitoneal shunt. The nurse should place the child in which of the following positions? A. On the nonoperative side B. A 45 deg head elevation C. Prone D. Supine

A. On the nonoperative side

A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death? A.People can come back to life after they die. B.Death eventually occurs for all people. C.Death is a scary monster that causes people to die. D.People are unable to be anything but alive.

A. People can come back to life after they die. (A preschooler typically views death as temporary and interchangeable with life.)

A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints

A. Potential for sustaining abdominal trauma (An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen.)

A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take? A.Provide thorough skin care B.Test for blood type and cross-match C.Allow ample hydrating fluids D.Maintain a low-carbohydrate diet

A. Provide thorough skin care (The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection.)

A nurse is preparing to administer vaccines to a 4 month old infant. Which of the following vaccines should the nurse to administer? A. Rotavirus B. Influenza C. MMR(measles, mumps, rubella) D. Varicella(VAR)

A. Rotavirus

A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B.Verify the prescribed medication regimen C.Determine if the infant has been exposed to others who are ill D.Ask the guardian about the infant's urinary output

A. Tell the guardian that a repeat dose of medication should not be given (The greatest risk to this infant is an injury from digoxin toxicity. Therefore, the priority action for the nurse to take is to instruct the guardian not to administer another dose of medication. The nurse should follow-up with the guardian frequently to determine if the child has further episodes of vomiting. If so, the nurse should notify the provider immediately because vomiting is a possible indication of digoxin toxicity.)

A nurse is preparing to assess a 3-month-old infant during a well-child visit. Which of the following observations should the nurse expect? A.The infant looks at his hands B.The infant has a pincer grasp C.The infant has no head lag when pulled to a sitting position D.The infant can independently roll from his back to his abdomen

A. The infant looks at his hands (Infants usually start to look at their hands while lying down or sitting between 12 to 20 weeks of age. Convergence on near objects is usually well established by 3 months of age.)

An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV positive. B. The infant's ELISA test result is probably a false positive for HIV. C. Antiretroviral medications are inappropriate for infants and children who have HIV. D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.

A. The infant's mother is likely HIV positive. (Transmission of HIV from a woman to her infant can occur during pregnancy, in delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants.)

A nurse is assessing an 18-month-old toddler during a well-child examination. Which of the following findings should the nurse report to the provider? A. The toddler is unable to remove his shoes B. The toddler is unable to draw a plus sign C. The toddler is unable to jump off a step D. The toddler is unable to turn 1 page of a book at a time

A. The toddler is unable to remove his shoes (An 18-month-old toddler should be able to remove his or her own shoes, socks, and gloves. The nurse should report this finding to the provider.)

A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. They provide direct stimulation of auditory nerve fiber. B. They conduct sound waves through the mastoid bone to the cochlea. C. They process digital sound to amplify several sound frequencies. D. They convert vibrations in the ear's structures to electrical signals.

A. They provide direct stimulation of auditory nerve fiber. (Cochlear implants work by directly stimulating nerve fibers in the cochlea.)

A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta D. Patent ductus arteriosus

A. Transposition of the great arteries (An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without)

A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect? A. WBC 17,000/mm3 B. Left lower quadrant abdominal pain C. Hyperactive bowel sounds D. Bradycardia

A. WBC 17,000/mm3

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? A.Weight gain of 1.8 kg (4 lb) B.Heart rate of 125/min C.Soft, flat fontanel D.Systemic murmur

A. Weight gain of 1.8 kg (4 lb) (A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.)

A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant response to therapy by performing which of the following actions? A. weighing the infants at the same time everyday B. Taking the infants vitals signs every 2hr. C. Measuring the infants head circumference twice per day D.Counting the number of wet diapers every shift

A. weighing the infants at the same time everyday

A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. Which of the following parent statements indicates an understanding of the teaching? A."I will apply the harness over a t-shirt and knee socks." B. "I will put my baby's diaper over the harness." C. "I will make the required harness adjustments as my baby grows." D."I will apply powder around the harness buckles each day."

A."I will apply the harness over a t-shirt and knee socks." (Applying the harness over a t-shirt and knee socks indicates that the parent understands the instructions. This step will prevent the harness straps from rubbing against and causing irritation to the infant's skin.)

A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A."My child may take aspirin for his joint pain." B."My child will need a blood transfusion prior to discharge." C."I will need to wear a gown when I'm in my child's room." D."I will apply lotion to my child's peeling hands."

A."My child may take aspirin for his joint pain." (Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints.)

A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A.Bulky stools B.Weakened rectal sphincter C.Elevated pancreatic enzymes D.Decreased intra-abdominal pressure

A.Bulky stools (The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools.)

A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first? A.Percuss the upper posterior chest B.Perform vibration while the client exhales slowly through the nose C.Instruct the client to cough

A.Percuss the upper posterior chest

A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A.Provide a high-fat diet for the toddler B.Limit the toddler's daily intake of sodium C.Increase the toddler's intake of foods high in folic acid D.Allow the toddler to skip meals when he is not hungry

A.Provide a high-fat diet for the toddler (Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat.)

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.Schedule the child for a preoperative visit to the facility (A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure.)

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?

An abdominal ultrasound, x-Ray, or CT, will confirm the pocket in the intestine.

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:

An elevated temperature

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?

Antistreptolysin O titer

A nursing student caring for a 6-month-old infant is asked to collect a urine specimen from the infant. The student collects the specimen by:

Attaching a urinary collection device to the infant's perineum for collection

A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A.Offer the infant a feeding every 2 hr B.Allow 30 min to complete each feeding C.Gradually increase the caloric density of the formula D.Position the infant semi-upright during feedings E.Provide gavage feeding if respiratory rate exceeds 80/min

B, C, D, E (The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress.)

A nurse is conducting a health assessment for a 24-month-old toddler at the local health department. The nurse should expect which of the following findings? (Select all that apply.) A.8 deciduous teeth B.Ability to build a tower of 6 blocks C.Vocabulary of 10-20 words D.Slightly bowed or curved leg appearance E.Head circumference greater than chest circumference

B, D (The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. Additionally, a 24-month-old toddler will have a "pot-bellied" appearance; the legs should be slightly bowed to support the weight of the comparatively large trunk.)

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor

B, D, E

A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse perform? (Select all that apply.) A.Place the child in a supine position B.Apply pressure to the child's nose using the thumb and forefinger C.Have the child tilt his head back D.Apply a warm cloth to the bridge of the child's nose E.Keep the child calm

B, E (Applying pressure continuously for 10 minutes to the nose with the thumb and forefinger helps control the bleeding. Most bleeding comes from the front portion of the nasal septum, so pressure on this area is generally effective. If bleeding persists, placing ice or a cold cloth on the bridge of the nose and inserting cotton or tissue into the nostril might help. The nurse should keep the child calm to help slow the bleeding. Agitation can raise blood pressure, which will increase the bleeding.)

A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."

B. "I will continue to take my medication when my peak flow rate is in the green zone." (This statement by the adolescent indicates an understanding of the teaching. A peak flow rate in the green zone indicates the current treatment has been effective; therefore, the adolescent should continue with their current medication regimen.)

A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."

B. "Keep hair off your forehead." (Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne.)

A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "You baby can start the measles, mumps, and rubella vaccine now."

B. "Your baby can start the pneumococcal vaccine now." (The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age.)

A nurse in the emergency department 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. 12 months old (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 receiving hand off report for a toddler who has a fractured right femur and is in 90 degree /90 degree traction. The nurse should expect to observe which of the following? A. Skin straps maintaining the affected leg in an extended positon B. A skeletal pin in the distal end of the femur C.Apadded sling under the knee of the affected leg D. The buttocks elevated slightly off of the bed

B. A skeletal pin in the distal end of the femur

A nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises C. Use humidified oxygen to thin secretions D. Initiate seizure precautions

B. Administer oral analgesics prior to exercises (Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause the child discomfort.)

A nurse is assessing the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? A.Position each child with their heels at a line that is 6 m (20 ft) away from the Snellen chart B.Allow each child to wear his or her glasses during the exam C.Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart

B. Allow each child to wear his or her glasses during the exam

A nurse is caring for a child who has tinea pedis. The childs parents ask the nurse what this infection is commonly called. The nurse should respond with which of the following common names A. Shingles B. Athletic foot C. Fever blisters D. Pinworms

B. Athletic foot

A nurse is collecting data from an 8 month old infant who has increased intracranial pressure (ICP) which of the following manifestations should the nurse expect? A. Insomnia B. Bulging fontanel C. Low pitched cry D. Positive babinski reflex

B. Bulging fontanel

A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? A.Decreased skin turgor B.Capillary refill 5 seconds C.Heart rate 150/min D.Dry mucous membranes

B. Capillary refill 5 seconds (When using the urgent vs nonurgent approach to client care, the nurse should identify that the priority finding is a capillary refill of 5 seconds. A capillary refill above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock.)

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A.Maintain the child on strict bed rest B.Check the child's blood pressure every 4 hr C.Administer albumin to the child every 8 hr D.Provide the child with a low-carbohydrate diet

B. Check the child's blood pressure every 4 hr (The nurse should check the child's blood pressure every 4 to 6 hours to monitor for hypertension.)

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. Development of the superego (This is the development of a conscience. Preschoolers begin to develop an understanding of right from wrong. While they might be unable 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 assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing from 1 hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting

B. Dropping a cube when passing from 1 hand to the other (The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider.)

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent

B. Inactivity and thumb sucking (A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.)

A nurse is caring for a toddler who has gastroenteritis caused by Salmonella. Which of the following is the priority action for the nurse? A.Weigh the child B.Initiate contact precautions C.Establish a skin care routine D.Obtain a recent food history

B. Initiate contact precautions (Salmonella is a type of bacteria that is transmitted via contaminated feces, making contact precautions essential for preventing transmission. This client is at greatest risk for transmission of Salmonella to others; therefore, contact precautions are the nurse's priority.)

A nurse is planning care for a preschooler who is immediately postoperative following the placement of a ventriculoperitoneal shunt. Which of the following interventions should the nurse include in the plan? A.Monitor the preschooler's pupils every 8 hours B.Lay the preschooler on the nonoperative side C.Keep the head of the bed elevated to 30° D.Check bowel sounds once per day

B. Lay the preschooler on the nonoperative side (The preschooler should not be positioned on the shunt side postoperatively to avoid putting pressure on the shunt or surgical site.)

A nurse is teaching 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? A. Chill the medication prior to administration B. Massage the anterior area of the infant's ear following administration C.Hyperextend the infant's neck during administration D. Pull the auricle up and back during medication administration

B. Massage the anterior area of the infant's ear following administration (The nurse should instruct the parents to massage the anterior area of the ear following the administration of ear drops to facilitate instillation of the medication.)

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A.Diastolic murmur B.Murmur at the left sternal border C.Cyanosis that increases with crying D.Widened pulse pressure

B. Murmur at the left sternal border (A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.)

A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A.Bradycardia B.Muscle weakness C.Diarrhea D.Dry skin

B. Muscle weakness (Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea.)

A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching. A. Fractures in a child take longer to heal than fractures in an adult B. Normal bone growth can be affected by the fracture C. Bone marrow can be lost through the fracture D. Your child will need to increase his calcium intake to 3,000 milligrams daily

B. Normal bone growth can be affected by the fracture

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take? A.Place the infant in a lateral position B.Perform oropharyngeal suctioning C.Administer ranitidine orally D.Thicken the infant's formula

B. Perform oropharyngeal suctioning (When caring for an infant who has a tracheoesophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease the infant's risk of aspiration.)

A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist, warm pack on the adolescent's lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the adolescent's puncture site

B. Place the adolescent in a supine position (The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache.)

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hr B. Position the child on a cooling blanket and cover her with a sheet C. Place the child in a tub filled with water cooled to 26.7° to 29.4°C (80° to 85°F) D. Assess the child's temperature every 2 hr during the cooling process

B. Position the child on a cooling blanket and cover her with a sheet (A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cooler blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface.)

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelets 500,000 mm^3 B. RBCs 2.5 million/uL C. WBCs 4,000/mm^3 D. Hct 60%

B. RBCs 2.5 million/uL (An RBC count of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC count.)

A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect? A. Nonpruritic erythematous papulse B. Rash with thick skin C. Maculopapular lesions between fingers and toes D. Inflamed area with white exudate

B. Rash with thick skin

A nurse in a pediatric clinic is collecting data from a preschool age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection? A. Scaly patches that have clear centers (ring worm) B. Red macule with honey colored crusts C. Firm brown papules with a roughened, finely papillomatous texture D. Reddened areas with white exudate

B. Red macule with honey colored crusts

A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A.Supine B. Semi-Fowler's C. Sims' D. Orthopneic

B. Semi-Fowler's (Maintaining a semi-Fowler's position promotes adequate ventilation. Flexing the knees slightly will likely be the most comfortable position for the child. Additionally, this promotes drainage of the cecum downward into the pelvis instead of upward toward the lungs.)

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? A.Bottle formula with added protein B.Small, frequent bottle feedings of electrolyte solution C.Continuous nasoduodenal tube feedings D.Bolus feedings via gastrostomy tube

B. Small, frequent bottle feedings of electrolyte solution (Feedings begin 4 to 6 hours after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water.)

A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents to 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. The child is withdrawn and refuses to talk. (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 discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique? A.The guardian explains to the child why her behavior is unacceptable B.The guardian places the child in time-out after misbehaving C.The guardian allows the child to choose the consequence of her misbehavior D.The guardian assigns an extra chore for the child's misbehavior

B. The guardian places the child in time-out after misbehaving (The nurse should encourage the guardian to continue to use time-out as a form of discipline. This technique is effective with a preschooler if carried out correctly. The nurse should review the process of using time-outs with the guardian (e.g. ensuring the time-out takes place in a safe and quiet location) and recommend that the length of the time-out is 1 minute for each year of the child's age.)

A nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. Which of the following reactions by the infant should the nurse expect? A. The infant gives the nurse a social smile. B. The infant turns away when the nurse approaches. C. The infant reaches out to the nurse to be held. D. The infant is responsive and alert as the nurse comes closer.

B. The infant turns away when the nurse approaches. (The nurse should expect an 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger.)

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding? A. Prone B. Upright C. Leftside D. Right side

B. Upright

A nurse is providing education for a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color

B. Vocabulary of 10 or more words (At 18 months, children typically have a vocabulary of 10 or more words.)

A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A.Machine-wash clothing in cold water B.Dry clothing in a hot dryer for at least 20 min C.Soak combs and brushes for 5 min in boiling water D.Seal nonwashable items in a bag for 7 days

B.Dry clothing in a hot dryer for at least 20 min (The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes.)

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? A.Age 10 years B.Frequent hospitalizations C.Parent bonding with child D.Calm, quiet demeanor

B.Frequent hospitalizations (Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization.)

A nurse is assessing a 6-year-old child who began treatment for pneumococcal pneumonia 4 days ago. Which of the following findings should the nurse identify as an indication the treatment is effective? A.Dullness with chest percussion B.Heart rate 118/min C.Conjunctival discharge D.Respiratory rate 28/min

B.Heart rate 118/min (The nurse should identify that a heart rate of 118/min is within the expected reference range for a 6-year-old child. A child who has an acute pneumococcal pneumonia infection will exhibit tachycardia.)

A nurse is caring for a toddler who's parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse's priority? A. Schedule the child for an abdominal ultrasound B.Instruct the parent to avoid pressing on the abdominal area C.Determine if the child is having pain D. Obtain a urine specimen for a urinalysis

B.Instruct the parent to avoid pressing on the abdominal area

A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A.Measure the infant's intake and output B.Measure the infant's head circumference C.Check the infant's lower-extremity function D.Monitor the infant's blood pressure

B.Measure the infant's head circumference (Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements.)

A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.5 mEq/L Which of the following findings should the nurse expect?( 9- 10.5 = Normal Calcium level ) A.Diarrhea B.Muscle Hypotonicity C. Tachycardia D.Positive Chvostek's sign

B.Muscle Hypotonicity

A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take? A.Feed the infant through an BG tube B.Place the infant in prone position C. Cover the infants lesion with a dry cloth D.Perform range of motion exercises to the infant's hips

B.Place the infant in prone position

A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? A.Obtain a throat culture B.Prepare the child for a neck radiograph C.initiate airborne precaution D. visualize the epiglottitis using a tongue depressor

B.Prepare the child for a neck radiograph

A nurse reinforcing teaching the parents of a pre-schooler who has atopic dermatitis. Which of the following information should the nurse include? A.You'll need to take the entire prescription of antibiotics even if your symptoms improved. B.The doctors may recommend antihistamines to help control symptoms. C.You can relieve your child's discomfort by applying warm compression of the lesion D.The doctor will remove the lesions with the liquid nitrogen

B.The doctors may recommend antihistamines to help control symptoms.

A nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which of the following?

Bacteriuria

A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which findings should the nurse include in the teaching?

Barking cough, stridor, wheezing, cyanosis, apnea

A nurse is teaching the parent of an infant about home safety. Which of the following pieces of information should the nurse include? (Select all that apply.) A.Use a wheeled infant walker. B.Place soft pillows around the edge of the infant's crib. C.Position the car seat so it is rear-facing. D.Secure a safety gate at the top and bottom of the stairs. E.Maintain the water heater temperature at 49°C (120°F).

C,D,E

A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A."Children commonly begin having imaginary friends when they reach school age." B."Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals." Check Answer Question Feedback Show Explanation Grade Pause Previous

C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." (The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions.)

A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in 1-piece outfits." B."I need to buy diapers that are tighter than those my infant usually wears." C."I need to apply paste to the back of the wafer on my child's appliance." D."I will not need to toilet train my child."

C. "I need to apply paste to the back of the wafer on my child's appliance." (The parent should apply stoma paste to the back of the wafer on the appliance and around the stoma. This paste will act as a sealant to prevent skin breakdown.)

A nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. "I should apply powder to the folds of skin on my baby's knees and thighs." B."I should adjust the straps on the harness once a week as my baby grows." C."I should lightly massage my baby underneath the straps once a day." D."I should place my baby's diaper over the straps of the harness."

C. "I should lightly massage my baby underneath the straps once a day." (The parent should lightly massage the skin under the harness daily to promote circulation.)

A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons." D. "I should ensure the crib slats are no more than 3 inches apart."

C. "I should make sure my baby's clothing does not have buttons." (The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration.)

A nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? A."Impetigo is caused by a virus." B."Impetigo is contagious for 48 hours after vesicles rupture." C."I will wash my child's clothes in hot water." D."My child now has immunity against impetigo."

C. "I will wash my child's clothes in hot water." (The parent should wash the child's clothes in hot water to kill bacteria. The parent should also keep the child's towels and washcloths separate from those of other members of the household.)

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? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."

C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." (The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury.)

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A."During this phase, feed your child anything that she will eat." B."Increase the amount of calories and water your child consumes." C."Keep a diary of the foods your child eats each day." D."Provide a large variety of fruit juices for your child to choose from."

C. "Keep a diary of the foods your child eats each day." (The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack.)

A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make? A."The nursing staff will bathe your child and take care of his daily needs." B."Your child will be most comfortable in a low-stimulation environment." C."Would you like assistance in planning where your child will die?" D."Would you like hospice to continue providing curative care in your home?"

C. "Would you like assistance in planning where your child will die?" (The nurse should inform the parents that they can choose to keep the child in a hospital setting or take the child home to die. The nurse should be aware that active participation in planning for the location of the child's death promotes positive bereavement outcomes. The nurse should provide assistance to the parents in making and implementing this plan.)

A nurse is assessing a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A. 7 B. 8 C.9 D.10

C. 9 (Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reflexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence of acrocyanosis.)

A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers

C. A blue coloring of the sclera (This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding.)

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL

C. A child who has sickle cell anemia and a urine specific gravity of 1.030 (The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration could cause sickle cell crisis that can occlude the child's circulation.)

A nurse is caring for a 4-month-old child who is hospitalized. Which of the following toys should the nurse provide for the child? A. A board book with large pictures B. A toy with movable parts C. A plastic mirror D. Push-pull toy

C. A plastic mirror (A 4-month-old infant can recognize herself and will also attempt to play with "the baby in the mirror." A mirror is a bright object that provides appropriate visual stimulation for this age group. For the infant's safety, however, the mirror must be unbreakable.)

A nurse is collecting data from a 1 year old child who has Wilms tumor. Which of the following findings should the nurse expect? A. Jaundice B. Swollen joints C. Abdominal mass D. Diarrhea

C. Abdominal mass

A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately? A. A school-age child with a urine specific gravity of 1.035 B. A toddler with a BUN of 25 mg/dL and a creatinine of 0.5 mg/dL C. An infant with a WBC count of 24,000/mm3 D. An adolescent with a positive beta human chorionic gonadotropin test Check Answer

C. An infant with a WBC count of 24,000/mm3 (WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy.)

A nurse is assisting with the admission of an infant who has resp. Syncytial Virus (RSV) which of the following rooms should the nurse assign the infant? A. A semi-private room with an infant who has a croup B. Asemi-private room with a toddler who has pneumonia C. Aprivate room with contact/droplet precautions D. A private room with protective isolation

C. Aprivate room with contact/droplet precautions

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A.Avoid laying the infant on his abdomen B. Avoid tucking the appliance into the infant's diaper C. Check the bag for stool every 4 hours D. Replace the appliance every 3 days

C. Check the bag for stool every 4 hours (The nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin.)

A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment. B. In single-parent families, the parent's non-biological partner is typically the abuser of the child. C. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally across all socioeconomic groups.

C. Children who were born prematurely are more likely to be maltreated. (Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment.)

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider? A.BUN 8 mg/dL B.Uric acid 3.0 mg/dL C.Creatinine 0.9 mg/dL D.Urine specific gravity 1.010

C. Creatinine 0.9 mg/dL (The expected reference range for a toddler is a creatinine level of 0.3 to 0.7 mg/dL. This child's level is above the expected reference range and should be reported to the provider.)

A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production

C. Deep, rapid respirations (This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia.)

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A.FACES B.CRIES C.FLACC D.PIPP

C. FLACC (The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age.)

A nurse is collecting data from a child who has (beta) B-thalassemia. Which of the following findings should the nurse expect? A. Hyperactivity B. Increased appetite C. Fever D. Flushed of skin

C. Fever

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione

C. Give the child flavored popsicles (Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles as a source of fluid.)

A nurse is reinforcing teaching with the mother of a 2-month old infant whose provider applied a Paylik Harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements. Which of the following statements by the mother indicates an understanding of the teaching? A. I will adjust the harness straps every day." B.I will place the diaper over the harness." C. I will check my baby's skin three times each day. D.I will gently massage lotion on his skin around the harness clasps."

C. I will check my baby's skin three times each day.

A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take? A. Initiate a protective environment B. Initiate air borne precautuons C. Initiate droplet precautions D. Initiate contact precautions

C. Initiate droplet precautions

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? A.Apply cold compresses to the child's extremities B.Administer meperidine every 4 hr until the crisis has resolved C.Maintain the child on bed rest D.Decrease the child's fluid intake for 8 hr

C. Maintain the child on bed rest (The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.)

A nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis. Which of the following instructions should the nurse include? A. Clean secretions from the infected eye by wiping from the outer canthus toward the inner canthus and upward B. Keep the infected eye covered with warm compresses for the first 24 to 48 hr C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for 1 min after administering the eye drops

C. Notify the provider immediately if the sclera becomes inflamed (Although the conjunctiva becomes inflamed during this infection, the sclera should remain clear and white. If the sclera becomes inflamed, it can indicate the presence of a serious conjunctival infection, and the child should be assessed immediately by an ophthalmologist.)

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A.Fasten the diaper loosely B.Cleanse the meningeal sac with povidone-iodine daily C.Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

C. Palpate the abdomen for bladder distension (A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder.)

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D.Place the newborn in an extended position

C. Prepare concentrated sucrose for oral administration (The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non-nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture.)

A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's

C. Prone (When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac.)

A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect? A.BUN 5 mg/dL B.Creatinine 0.2 mg/dL C.Sodium 125 mEq/L D.Potassium 4.2 mEq/L

C. Sodium 125 mEq/L (The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEq/L is below the expected reference range for an infant.)

A nurse is caring for a 6 month old child. The childs provider has ordered a diphtheria, tetanus, and pertussis (DTAP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine? A. Febrile otitis media B.Evidence of sensitivity to egg antigens C. Temp of 40.5 C(104.9F) after last DTAPD. D.New onset of seizure disorder in the child's sibling

C. Temp of 40.5 C(104.9F) after last DTAPD.

A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider? A.The child wets the bed when sleeping B.The child cannot catch a ball C.The child cannot walk on tiptoe D.The child builds a tower of 10 cubes

C. The child cannot walk on tiptoe (The nurse should identify that a child should be able to take a few steps on tiptoe by 30 months of age. Therefore, the nurse should report this finding to the provider.)

A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A.The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.

C. The child complains daily about going to school. (Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted.)

A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak

C. The child reports tightness at the wrist (The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome.)

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? A. Primary dentition is complete. B. The toddler is unable to hop on 1 foot. C. The toddler's birth weight is tripled. D. The toddler is able to state her first and last name.

C. The toddler's birth weight is tripled. (The toddler's birth weight should triple by 12 months of age. By 30 months of age, the toddler's birth weight should be quadrupled.)

A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A.Bruising of the right elbow B.Dislocated left shoulder revealed by X-ray C.Thin, frail extremities D.Abrasions on both wrists

C. Thin, frail extremities (The nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this finding further and report the results to the provider.)

A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A.Use a mobile walker for the toddler B.Discourage activities involving repetitive joint movement C.Use manual jaw control when feeding the toddler D.Discourage the use of wrist splints

C. Use manual jaw control when feeding the toddler (The nurse should encourage the parent to include the use of manual jaw control during feedings. Children diagnosed with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to the jaws during feeding.)

A nurse is planning preoperative teaching for a school-age child who is scheduled for cardiac surgery. Which of the following actions should the nurse plan to take when teaching the child? A. Limit teaching sessions to 10 min B. Use simple, concrete terms when giving explanations C. Use photographs to help explain the procedure D. Conduct the teaching session 2 days before the procedure

C. Use photographs to help explain the procedure (The nurse should recognize the school-age child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand.)

A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Heart rate 130/min B. respiratory 24/min C. urine specific gravity 1.015

C. urine specific gravity 1.015

A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? A. "A 7-year-old child prefers to play with children of a different gender." B."A 6-year-old child should understand the concept of cause and effect." C."A 6-year-old child should be able to count 13 coins." D.An 8-year-old child should be able to wash his or her own hair independently."

C."A 6-year-old child should be able to count 13 coins." (A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands.)

A nurse is providing teaching to an adolescent client who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? A."Apply cold compresses to relieve your joint pain." B."Take opioids routinely." C."Attend school regularly." D."Adhere to an arthritis diet."

C."Attend school regularly." (The nurse should encourage this adolescent with idiopathic arthritis to attend school. The adolescent should attend school even on days when joint pain or stiffness occurs.)

A nurse is caring for a school age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take? A.Position the casted arm in a dependent position B.Place a warm moist heat pack on the cast C.Administer diphenhydramine to relieve itching D.Move the casted arm with a firm grip

C.Administer diphenhydramine to relieve itching

A nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C.Barking cough D. Projectile vomiting Check AnswerCorrect

C.Barking cough (Infants who have tracheomalacia have a weakened trachea, which can lead to collapse. Clinical manifestations of tracheomalacia include a barking cough, stridor, wheezing, cyanosis, and apnea.)

A nurse is caring for a toddler who has laryngotracheobronchitis ( LTB ) For which of the following findings should the nurse monitor to detect airway obstruction? A.Decreased Stridor B.DecreasedRestlessness C.Increased Heart rate D.Decreased Temperature

C.Increased Heart rate

A nurse is contributing to the plan of care for a 2month old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the clients plan of care? A. Feed the infant half strength formula for the first 48hr. B. Remove elbow restraints while the infant is sleeping C.Keep the infant in a side lying position D.Administer pain medication PRN for the first 48 hr.

C.Keep the infant in a side lying position

A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actoons should the nurse take? A. Ask another nurse to assist with holding the toddler in a prone position B. Restrain the toddler for 1 hr after the procedure C.Place the toddler in a side lying knee chest position D. Swaddle the toddler in a warm blanket

C.Place the toddler in a side lying knee chest position

A nurse is a collecting data from an infant which of the following is a clinical manifestation of pyloric stenosis?" A. Absent Bowel sounds B. Increased Sodium Level C.Projectile Vomiting after feedings D. Golf- ball size over the left quadrant

C.Projectile Vomiting after feedings

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:

Checks for responses to painful stimuli from the torso downward

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?

Chloride level of 40 mEq/L

A nurse has reviewed the health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to:

Collect a 24-hour urine sample.

Adolescents' cognitive abilities differ from those of children primarily in that, unlike children, an adolescent's thinking is not necessarily tied to

Concrete events

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 instrument?

Cup - 7-10 days to prevent trauma and injury to suture line.

A nurse reinforces teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? A " administer a bronchodilator to the child after chest percussion therapy ." B. "a pigeon-shaped chase might become evident as the disease progressing." C. "Bradycardia is an early indicator of pneumothorax." D. "Engage the child in daily aerobic exercise".

D. "Engage the child in daily aerobic exercise".

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? A."I will give you an antibiotic before your procedure." B."I will place you on your side during the procedure." C."You might have a headache following the procedure." D."I will place a pressure dressing over the area following the procedure."

D. "I will place a pressure dressing over the area following the procedure." (Applying a pressure dressing over the area following the procedure helps prevent bleeding from the site.)

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? A. "I can give my baby 4 oz of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 qt of skim milk each day."

D. "My infant drinks at least 2 qt of skim milk each day." (As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect the child's intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids, which are needed for growth and development.)

A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A."Have your parent stretch and move your legs for you." B."Apply heat to joints that become painful, stiff, and swollen." C."Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."

D. "You will be able to participate in physical exercises." (Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided.)

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A.Small plastic doll with clothes and accessories B.Alphabet flash cards C.Handheld video game D. 10-piece wooden puzzle

D. 10-piece wooden puzzle (Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow manipulation and exploration and meet the child's developmental and diversional activity needs.)

A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non corrosive substance that has no recommended antitode. The nurse should recommend to perform gastric lavage with which of the following substances? A.0.9% sodium chloride B. Syrup of Ipecac C. Osmotic Diarrheal agents D. Activated Charcoal

D. Activated Charcoal

A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A.Reduce the temperature of the child's room B.Redress the child in minimal clothing C.Apply cool compresses to the child's forehead D. Administer an antipyretic to the child

D. Administer an antipyretic to the child

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? A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine B. Single injection of tetanus immune globulin (TIG) mixed with pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)

D. Adult tetanus booster (Td) (Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age.)

A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH) which of the following findings should the nurse expect? A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Inwardly turned foot on the affected side D. Asymmetric thigh folds

D. Asymmetric thigh folds

A nurse is collecting data from a 7 month old infant which of the following findings should indicate to the nurse a need for further evaluation? A. Usees a unidextrous grasp B. Has a fear of strangers C. Sits leaning forward on both hands D. Babbles one syllable sounds

D. Babbles one syllable sounds

A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination? A. Lie prone on the examination table B. Touch your chin to your chest and then look up at the ceiling C. Turn to the side and remain in a relaxed position D. Bend forward from the waist with your head and arms downward

D. Bend forward from the waist with your head and arms downward

A nurse is caring for a 7-year-old child who is in skeletal traction following a complete fracture of the femur. Which of the following diversional activities should the nurse offer the child? A.Puzzle with large pieces B.Building blocks C.Finger paints D.Chapter books

D. Chapter books (The nurse should offer chapter books as an appropriate diversional activity for a school-age child who has limited movement due to skeletal traction.)

A nurse is assessing a preschooler who has HIV. Which of the following manifestations should the nurse expect? A.Generalized petechiae B.Jaundice C.Obesity D.Chronic diarrhea

D. Chronic diarrhea (Chronic diarrhea is an expected finding for a preschooler who has HIV.)

A nurse is caring for a 12-month-old infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? A.Spoon B.Straw C.Firm nipple D.Cup

D. 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 collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect? A. Hip dislocation B. Flaccid paralysis of lower extremities C. Hydrocephalus D. Dimple in sacral area

D. Dimple in sacral area

A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience

D. Encourage the child to focus on a recent pleasurable experience (The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the non-pharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques.)

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A.Perform passive range of motion for unaffected joints B.Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

D. Encourage the child to use an incentive spirometer

A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short

D. Ensure that staff visits with the child are kept short (Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible.)

A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A.Hypotension B.Elevated serum lipid levels C.Decreased serum potassium levels D.Hematuria

D. Hematuria (Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis.)

A nurse is preparing to administer an enema to a 10-month-old infant. Which of the following actions should the nurse plan to take? A.Administer the enema using room-temperature tap water B.Insert the tubing 7.5 cm (3 in) into the rectum C.Position the infant sitting upright on a bedpan while administering the enema D.Hold the infant's buttocks together after administering the fluid

D. Hold the infant's buttocks together after administering the fluid (Because the infant is incontinent, the nurse should hold the buttocks together for a short time to maintain retention of the enema.)

A nurse is reinforcing teaching about preventing disease tansmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include? A.Ill continue to encourage him to drink lots of fluids." B. Ill take his temp .Q4 hours" C. Ill give him acetaminophen for the pain D. Ill discard his toothbrush and buy another "

D. Ill discard his toothbrush and buy another "

A nurse is caring for a newly admitted adolescents who has anorexia nervosa. Which of the findings should the nurse expect A. Diarrhea B. Hypertension C. Tachycardia D. Lanugo

D. Lanugo

A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the following instructions should the nurse include in the teaching? A.Apply aluminum acetate solution compresses to the lesions B.Apply hydrocortisone cream to the lesions twice daily C.Seal nonwashable toys in a plastic bag for 2 weeks D. Leave the medicated shampoo on the scalp for 5 to 10 minutes

D. Leave the medicated shampoo on the scalp for 5 to 10 minutes (The nurse should instruct the parent to use a shampoo made of 2% ketoconazole or 1% selenium sulfide for the treatment of tinea capitis. For the shampoo to be effective, the parent should leave it on the child's scalp for 5 to 10 minutes prior to rinsing.)

A nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? A.Assess for edema of the extremities B.Apply warm compresses to the neck area C.Initiate airborne precautions D.Maintain a cardiorespiratory monitor

D. Maintain a cardiorespiratory monitor (Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidified oxygen and suction equipment should be used as needed.)

A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis

D. Metabolic acidosis (Metabolic acidosis is an expected finding for clients who have acute renal failure.)

A nurse is caring for a toddlet who has intusussepction. Which of the following manifestations should the nurse expect? A. Drooping B. Increased Appetite C. Jaundice D. Mucus in Stools

D. Mucus in Stools

A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler in a supine position D. Pad the rails of the toddler's bed

D. Pad the rails of the toddler's bed (When caring for a toddler who has manifestations of bacterial meningitis, the nurse should implement seizure precautions, which includes padding the side rails of the bed.)

A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A.Dilated pupils B.Tremors C.Yawning D.Pruritus

D. Pruritus (Pruritus is an adverse effect of opioids. Constipation, respiratory depression, nausea, vomiting, agitation, orthostatic hypotension, and hallucinations are also adverse effects of opioids.)

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL

D. RBC 6.8 million/uL (A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.)

A nurse is teaching an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the nonpharmacological strategy of thought-stopping? A. Assemble a puzzle B.Discuss a recent pleasurable event C.Tighten and then relax each body part D.Repeat memorized facts about the painful event

D. Repeat memorized facts about the painful event

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? A. Ask the child to hold a breath and blow it out slowly B. Ask the child to describe a pleasurable event C. Bounce the child gently while holding him upright D. Rock the child using long, rhythmic movements

D. Rock the child using long, rhythmic movements (The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest and rocking or swaying back and forth in long, wide movements.)

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

D. Serum cholesterol 700 mg/dL (A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids.)

A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A.Excessively prolonged expiration B.Increased diaphoresis C.Increased production of frothy sputum D. Sudden decrease in wheezing

D. Sudden decrease in wheezing (When applying the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority because they pose a larger risk to the client. A sudden decrease in wheezing can indicate 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, and/or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilatory failure and imminent respiratory arrest.)

A nurse is caring for a preschool age child who has croup. Which of the following findings should the nurse report to the provider? A. Barky cough B.Paroxysmal attacks of laryngeal spasm at night C.Hoarseness D. drooling

D. drooling

A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A.Reposition the sensor to a new site once every 24 hr B.Secure the oximetry sensor to the infant's wrist C.Apply conduction gel to the skin before attaching the sensor D.Cover the oximetry sensor with clothing

D.Cover the oximetry sensor with clothing (The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading.)

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A.Provide foods high in iron B.Avoid people who have infections C.Administer PRN oxygen D.Encourage quiet play

D.Encourage quiet play (A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing the chance of hemorrhage.)

A nurse is caring for a child who has nosebleed. Which of the following actions should the nurse take? A. Place the child in a sitting position and tilt her head back B. Apply ice at the opening of the nares for 5 min and then re-check for bleeding C.Place the child In a supine position with a pillow under her head D.Have the child sit with her head tilted forward and hold pressure on her nose for 10 mins

D.Have the child sit with her head tilted forward and hold pressure on her nose for 10 mins

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? A. Restrict the child's potassium intake B. Administer acetaminophen to the child twice daily C. Weigh the child once each week D. Keep the child away from people who have an infection

D.Keep the child away from people who have an infection (Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.)

a nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A. Remove the window and view the incision B. Turn the client so the cast will dry on all sides C. Medicate the client for pain D.Perform neurovascular checks of the affected extremity

D.Perform neurovascular checks of the affected extremity

A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A.Skipping around the room B.Hopping on 1 foot C.Throwing a ball overhead D.Standing on 1 foot

D.Standing on 1 foot (The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds.)

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:

Decorticate posturing

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:

Decreased in the legs and increased in the arms

A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?

Defining a sense of self

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:

Develops stridor

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)?

Diaphoresis during feeding

A nurse is caring for an infant who has HydroCephalus. Which of the following manifestation should the nurse expect to find

Dilated scalp veins

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?

Dipstick the urine for protein every 4 hours.

Most accidents involving adolescents occur when they:

Drive a car or other vehicle

A nurse in the ER 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?

Drooling (inability to swallow saliva)

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?

Encourage the child to drink liquids.

A nurse is caring for a child in skeletal traction. Which of the following actions is the nurses priority?

Encourage the child to use an incentive spirometer

A nurse is collecting data from an adolescent client. Which of the following behaviors should the nurse expect an adolescent who has achieved successful resolution of the developmental tasks of identity vs role confusion to exhibit?

Establishes a close relationship with another person

A nurse is assessing pain in a 3 yr old child following a tonsillectomy. Which rating scales should the nurse use to determine pain level?

FACES rating scale

A nurse is collecting data from 15 year-old adolescent client who had a new diagnosis of diabetes mellitus in order to assist with reinforcing teaching about self-management skills. The nurse should expect the client to be in which of the following phases of cognitive development?

Formal operations phase

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?

Foul-smelling, ribbon-like stools

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurses priority?

Frequent swallowing

A nurse is reviewing the lab report of a toddler who is receiving chemotherapy for leukemia. Which of the following lab values should the nurse report to the provider?

Hgb 6

A nurses caring for an infant who has inadequate motility of part of the intstine resulting in a mechanical obstruction. Which of the following disorders does the infant have?

Hirschsprung disease

A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

His basketball coach committed suicide last month

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?

Hydrocephalus

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?

Increase the child's protein intake

A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which instructions should the nurse include in the plan?

Inspect toys for sharp edges

A nurse is caring for a male infant admitted with a palpable mass in the upper right quadrant and passage of stools mixed with blood and mucus. Which of the following diagnoses are these findings associated with?

Intussusception

A nurse is assigned to care for an infant with cryptorchidism. The nurse anticipates that diagnostic studies will be prescribed to evaluate:

Kidney function

A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect?

Koplik spots

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?

Maintain the child on bed rest.

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:

Moisture of the normal saline dressing on the gibbus area

A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which intervention should the nurse include in the plan?

Monitor child for increased temperature

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?

Mummy restraint

A nurse is assessing a child with VSD. Which findings should the nurse expect?

Murmur at the left sternal border

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?

Oatmeal

A nurse is caring for an infant who has congenital heart defect. Which of the following is associated with increased pulmonary blood flow?

Patent ductus arteriosus

A nurse is caring for an 8 year old who has acute glomerulonephritis. Which of the following findings should the nurse expect?

Periorbital edema

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?

Place a plastic bag over the cast when showering.

A nurse is reviewing lab report of 2 year old child who has diarrhea and has been vomiting for 24 hours. Which findings should be reported to the provider? A. Blood glucose 110 mg/dL B. Potassium2.5mEq/L C. Sodium142mEq/L D. Urine specific gravity 1.025

Potassium 2.5

A nurse is admitting a child who has Wilm's tumor. Which of the following actions should the nurse take?

Put a "no abdominal palpation" sign over the child's bed

A nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The HCP performs the Ortolani maneuver. Which of the following best describes the action/purpose of the Ortolani maneuver?

Reducing the dislocated femoral head back into the acetabulum

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?

Respiratory precautions are indicated during the period of communicability.

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

Restlessness

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?

Reticulocyte count

A nurse is reviewing routine screenings for adolescents. Which of the following screenings should the nurse expect to be included?

Scoliosis

A nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?

Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.

Which statement would have the most positive outcome when the nurse is counseling adolescents on nutrition

Shiny hair and good muscles are linked to good nutrition

A nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which of the following immediate problems as the priority for the infant?

Skin disruption

A nurse is assisting with the development of an education program about nutritional risk among adolescents to a group of parents of adolescents. Which of the following information should the nurse include in the teaching?

Skipping more than three meals per week, eating without family supervision and frequently skipping breakfast

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?

Slight tachypnea

A nurse in an emergency department is assessing a school-age child who is experiencing an azure asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?

Sudden decrease in wheezing

A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which of the following would the nurse anticipate to be a component of the treatment plan?

Supportive treatment

A parent is worried because her 14 year-old son seems to be constantly in the bathroom, shampooing and styling his hair. She worries that her son may be homosexual because he is so concerned with his appearance. What is the most appropriate response to the mother's concern?

Teens are preoccupied with their appearance because of dramatic body changes

A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?

The harness needs to be removed to check the skin and for bathing.

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

There is no communication from the right atrium to the right ventricle.

A nurse is assessing a 2 month old infant who has a ventricular septal defect. Which finding should be reported to the provider?

Weight gain of 1.8 kg (4 lb)

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following is the nurse's priority? a. Administer antibiotics when available b. Reduce environmental stimuli c. Document intake and output d. Maintain seizure precautions

a. Administer antibiotics when available

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate? a. Apical b. Radial c. Carotid d. Femoral

a. Apical (Rationale:a. (The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated atthe fourth intercostal space lateral to the midclavicular line.)

A nurse is caring for a 4 year old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority . (causes icp hydrocephalus) a. lethargy b. lying flat on the unaffected side c. respiratory rate 20/min d. urine output 50 mL in 2hr

a. lethargy

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant a) Wrist b) Great toe c) Index finger d) Heel

b) Great toe

A nurse is collecting data from an infant at well-child visit. The nurse should expect the infant to double his birth weight by which of the following ages? a. 3 months b. 6 months c. 9 months d. 12 months

b. 6 months

A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a) Desmopressin b) Luteinizing hormone-releasing hormone c) Recombinant growth hormone d) Levothyroxine

c) Recombinant growth hormone

A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a) Heart rate 124/min b) Increased tear production c) Sunken anterior fontanel d) Capillary refill 2 seconds

c) Sunken anterior fontanel

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. 1⁄2 cup whole milk b. 1 cup orange juice c. 1⁄2 cup raisins d. 1 cup raw carrots

c. 1⁄2 cup raisins

A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide? a. Availability of firearms b. Family conflict c. Homosexuality d. Active psychiatric disorder

d. Active psychiatric disorder

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? a. Place the child on a no salt added diet b. Check the Childs weight daily c. Educate the parents about potential complications d. Maintain a saline lock (IV access that is attached to any fluids. For emergency)

d. Maintain a saline lock

A clinic nurse is providing teaching to the parent of a 1 month old infant who has GER. Which statement made by the parent indicates an understanding of the teaching?

"I will add rice cereal to my baby's feedings"

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?

"I will inspect my child's mouth everyday for sores."

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 record the highest reading of three attempts"

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching? a) "I should not give my child aspirin for pain or fever." b) "My child will take antibiotic for 6 months." c) "My child might have a period of irregular movement of the extremities." d) "I should expect there to be blood in my child's urine."

"My child might have a period of irregular movement of the extremities."

A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take? A. Administer opioids on a schedule (Nsaids) B. Encourage the child to take day time naps C. Apply cool compresses for 20 mins every hour D. Maintain night splints to the affected joint

D. Maintain night splints to the affected joint

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?

Demonstrate the injection technique on an orange.

A nurse in the ER is caring for a 4 year old child who has burns to the neck and face following a house fire. Which of the following should the nurse take first?

Determine the child's breathing pattern

A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic ear drops. Which of the following instructions should the nurse include?

Massage the anterior area of the infants ear following administration

A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will make sure my child washes her hands before eating" b. "I will restrict the amount of salt in my child's meal" c. "I will put my child in daycare to ensure that she socializes with other children" d. "I will provide low fat meals for my child

a. "I will make sure my child washes her hands before eating"

A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse should expect which of the following findings? a. Tugging on the affected ear lobe b. Bluish green discharge from the ear canal (there's usually no discharge, discharge only comes out if there's opening in the ear drum) c. Increase in appetite (decrease in appetite) Erythema and edema of the affected auricle

a. Tugging on the affected ear lobe

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?

"My child should consume 1000 calories per day" & 2 oz of protein, no more than 3 cups of milk, 1 cup of vegetables per day

A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV. Which of the following statements should the nurse include in the teaching?

"The pneumococcal and influenza vaccines are recommended for your child."

A nurse working at a clinic speaks on the telephone with a parent of a 2- month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following response by the nurse is appropriate? A. "Bring your infant into the clinic today to be seen" B. "Burp your child more frequently during feedings" C. "Give your infant an oral rehydrating solution" D. "You might want to try switching to different formula"

A. "Bring your infant into the clinic today to be seen"

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infants pain level? A. FLACC B. Oucher C. FACES D. Visual analog scale

A. FLACC

A nurse is caring for a child who has erythema infectiousm. Which of the following findings should the nurse expect? A. Facial erythema B. Koplik spots (measles) C. Parotitis (mumps) D. Pruritus (itchiness. Chicken pox)

A. Facial erythema

A nurse in a clinic is preparing to administer pre-k-kindergarten vaccines to a 5 year old child whose medical record indicates that his immunization are up to date which of the following vaccines should the nurse plan to adminiser? A. Mealsles, mumps, rubella (MMR) B. Haemophilus influenza type B HIB C. Pneumococcal conjugate vaccine(PCV) D. Heptatits B (HBV)

A. Mealsles, mumps, rubella (MMR)

A nurse in a provider's office is reinforcing teaching with a parent of a school age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Wash all bed linens and dry them in a dryer for at least 20 min B. Apply permethrin cream twice daily C. Apply anantifungal treatment ointment once everyday D. Ensure that family pets are treated within 10 days

A. Wash all bed linens and dry them in a dryer for at least 20 min

A nurse is reinforcing reaching with a parent of a 1 month old infant who is to undergo the initial surgery to treat Hirschsprung's disease (a ganglionic megacolon, part of the colon isn't connected to the nerves or not functioning, so there will be an increase size of the colon and stool gets stuck in there). Which of the following statements should indicate to the nurse that the parent understanding the goal of surgery? A."I'm glad that the ostomy is only temporary" B."I'm glad my child will have normal bowel movements now" C."I want to learn how to use the feeding tube as soon as possible" D."the operation will straighten out the kink in the intestine"

A."I'm glad that the ostomy is only temporary"

A nurse is an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler? A.Activated Charcoal B..Acetylcysteine C.A chelating agent (usuallyusedforiron) D. Digoxin immune FAB

A.Activated Charcoal

A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Apply an antibiotic ointment to the suture site B. Clear oral secretions using a bulb syringe C. Feed the infant using a spoon D. Position the infant on her abdomen

B. Clear oral secretions using a bulb syringe

A nurse is caring for a 3 year old client who has persistent otitis media. To help identify contributing factors, the nurse should ask the parents which of the following questions? A. Has your daughter been drinking 6 glasses of water a day B. Does anyone smoke in the house around your daughter. C. Does your daughter get water in her ears when you bathe her? D. Has your daughter had a lot of earwax in her ears over the last month?

B. Does anyone smoke in the house around your daughter.

A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse's priority? A. Schedule the child for an abdominal ultrasound B. Instruct the parent to avoid pressing on the abdominal area C. Determine if the child is having pain D. Obtain a urine specimen for a urinalysis

B. Instruct the parent to avoid pressing on the abdominal area

A nurse is assessing a 6 month old infant following cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature 37.5°C (99.5°F) B. Apical pulse rate 140/min C. BP 86/40 mmHg D. Respiratory rate 32/min

C. BP 86/40 (A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.)

A nurse is assisting with the care of a school age child who has respiratory failure due to pneumonia. Which of the following positons should the nurse encourage to allow maximal lung expansions? A. Prone B. Supine C. Sidelying D. Upright (orthopnic positon, semi fowler, high fowler)

D. Upright (orthopnic positon, semi fowler, high fowler)

A nurse is caring for a 2 week old infant who's mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make? A.SIDS is directly correlated to diphtheria ,tetanus ,and pertussis vaccines B. SIDS rates have been rising over the last 1-years C.Sleep apnea is the main cause of SIDS D. You should place your baby on her back when sleeping to decrease the risk of SIDS

D. You should place your baby on her back when sleeping to decrease the risk of SIDS

A nurse is assisting with a psychosocial assessment of an adolescent client. Which of the following factors indicate to the nurse a potential risk for suicide?

Death of a parent at a young age, recent or impending move, low parental expectations and sudden decline in school performance

A nurse is providing teaching to the parents of a school-age child who has type 1 DM about management of hypoglycemia. Which of the following responses by the parents indicate an understanding of the teaching?

I will make sure my child drinks 240 ml (8 oz) or milk ASAP (15 g simple carb)

A nurse is reinforcing teaching with the parents of an adolescent about expected development. Which of the following developmental tasks should the nurse instruct the parents to expect the adolescent to achieve?

Identity

A nurse is reinforcing teaching with a group of adolescents regarding identifying behavioral indicators of depression. Which of the following manifestations should the nurse include?

Irritability, decreased energy and isolation from peers

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?

Keep child away from people who have an infection

A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend?

Scrambled eggs - no gluten

A nurse is caring for a 6 week old infant following pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hours after the procedure ?

Small, frequent bottle feedings of electrolyte solution

A nurse is caring for an infant following a surgical repair of a cleft lip and palate. Which action should the nurse take?

Suction the infant gently with a bulb syringe PRN.

A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a) Decreased edema b) Increased abdominal girth c) Decreased appetite d) Increased protein in the urine

a) Decreased edema

. A nurse is collecting date from a child during a well- child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse? a) The child is 6 years old. b) The child is male. c) The child was born at 30 weeks of gestation. d) The child was born via cesarean birth.

c) The child was born at 30 weeks of gestation.

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a) "You may bathe your infant in an infant bathtub when you go home." b) "Apply hydrocortisone cream to your infant's penis daily." c) "You should clamp your infant's stent twice daily." d) "Allow the stent to drain directly into your infant's diaper."

d) "Allow the stent to drain directly into your infant's diaper."

A nurse is planning care for a newly admitted school-age child who has a generalized seizure disorder. Which of the following interventions should the nurse plan to include? a) Ensure that a padded tongue blade is at the child's bedside. b) Allow the child to play video games on a tablet computer. c) Allow the child to take a tub bath independently. d) Ensure the oxygen source is functioning in the child's room.

d) Ensure the oxygen source is functioning in the child's room.

A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a) Use sterile scissors to remove the dressing from the site. b) Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. c) Access the site using a non-coring angled needle. d) Use a semipermeable transparent dressing to cover the site.

d) Use a semipermeable transparent dressing to cover the site.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching? a) "Mononucleosisis caused by an infection with the Epstein-Barr virus." b) "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c) "A Monospot is a throat culture used to diagnosis mononucleosis." d) "Children who get mononucleosis will need to refrain from sports for 6 months."

a) "Mononucleosisis caused by an infection with the Epstein-Barr virus."

A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? a) "You should offer your child high-protein meals and snacks through out the day." b) "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c) "You should restrict your child's calorie intake to 1,200 per day." d) "You should give your child a multivitamin once weekly."

a) "You should offer your child high-protein meals and snacks through out the day."

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? a) A toddler who has a concussion and an episode of forceful vomiting b) An adolescent who has infective endocarditis and reports having a headache c) An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 d) A school-age child who has acute glomerulonephritis and brown-colored urine

a) A toddler who has a concussion and an episode of forceful vomiting

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a) Avoid palpating the abdomen when bathing the child before surgery. b) Refrain from auscultating the child's bowel sounds during the postoperative assessment. c) Encourage the child to play with other children on the unit prior to surgery. d) Explain to the child that their pain will be managed after the surgery.

a) Avoid palpating the abdomen when bathing the child before surgery.

A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a) Palpate the dorsum of the child's feet. b) Weigh the child daily using the same scale. c) Assess the child's skin turgor. d) Observe the child for periorbital swelling.

a) Palpate the dorsum of the child's feet.

nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take? a) Place the infant in a knee-chest position. b) Administer a dose of meperidine IV. c) Discontinue administration of IV fluids. d) Apply oxygen at 2 L/min via nasal cannula.

a) Place the infant in a knee-chest position.

a nurse is planning care for a child who has severe diarrhea. which of the following actions is the nurse priority? a. Introduce a regular diet b. Rehydrate c. Maintain fluid therapy d. Assess fluid balance

d. Assess fluid balance (Rationale: Assess first the other three are interventions before u intervene you have to assess how much fluid imbalance. Check for labs results because it will tell you what kind of fluid is to be given and how much fluid to be replaced. Priority is assessment first)