Ped's I Quiz I & II

Infant hypothyroidism s/s

- Tongue sticking out -hypoactive bowel sounds/constipation -"floppy" when handled

Milwaukee brace

- Worn for scoliosis 16-23 hours a day

Hypothyroidism

- must be diagnosed and treated soon so that growth is not slowed/mental retardation does not develop/no failure to thrive

Coarction (Stenosis/narrowing) of the aorta manifestation

-Blood pressure difference of 20 mmHg between upper and lower extremities -Flushing of face -bounding upper extremity pulses -epistaxis -cool lower extremities -leg cramps -weak femoral pulses -exercise intolerance

- Child with DMT1 has football practice, how do you prevent hypoglycemic episode after practice?

-Half cup of orange juice every 35-40 minutes (15-20g carb) -NO decreased dose of insulin, NO double meals

Highest risk of iron deficiency anemia

-Infants -adolescents when growth occurs the most rapidly.

Rheumatic fever Manifestations:

-Migratory polyarthritis -skin eruptions/subcutaneous nodules -Chorea/St. Vitus dance, rheumatic carditis (involuntary, purposeless movements of the muscles) -abdominal pain(commonly confused with appendicitis)

Types of Child Abuse

-Physical -Emotional or mental -Sexual -Neglect

epistaxis interventions

-apply pressure 10 minutes -lean forward -apply ice pack or cotton

Iron supplements

-given with citrus fruit to increase absorption -spread throughout the day (not in one dose)

nursing care for sickle cell crisis

-hydration ( 8 glasses a day) -pain management -blood transfusion -emotional support

sickle cell no-nos

-meperidine/Demerol -cold compress for pain

Digoxin

-never repeat doses if child vomits -don't give the dose if more than 4 hours has passed since administration time -don't mix with food -notify if more than one dose missed

Skin disorders nursing interventions

-short nails (avoid scratching) -avoid wool or stuffed animals -loose clothing -wash in mild detergent (no fabric softener) -bathe in tepid water without soap or bubbles

Iron supplements administration

-take with straw to avoid staining teeth -IM use Z-track method to avoid staining

A positive diagnosis of rheumatic fever cannot be made without the presence of

-two major criteria Carditis Polyarthritis Erythema marginatum Chorea Subcutaneous nodules -one major and two minor criteria, plus a history of streptococcal infection. Fever Arthralgia Previous history of rheumatic heart disease Elevated erythrocyte sedimentation rate Leukocytosis Abnormal electrocardiogram (altered P-R interval) Positive test for C-reactive protein (CRP)

diaper rash (intertrigo)

-use moisture barriers to prevent further breakdown of skin -change diaper frequently and expose skin to air (not hot air) DO NOT: -use cloth diapers (bc they aren't as absorbent) -use talcum powder bc causes respiratory problems

rheumatic fever treatment

1. Penicillin 10 days 2. Erythromycin for penicillin sensitive 3. Aspirin (salicylates) to control inflammation 4, Prophylactic treatment against recurrence monthly IM injections of benzathine penicillin. susceptible to recurrence should be monitored for 5 years Phenobarbital for CNS symptoms

A nurse is reinforcing teaching with the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicate 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 make sure 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. "My child will likely be irritable for the next few weeks." C. "I will make sure 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." A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. Clients with this condition receive high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. The temperature of a child with Kawasaki disease should be recorded until she has been afebrile for several days. Incorrect Answers: B. Peeling of the skin of the hands and feet is expected for a child who has Kawasaki disease. The peeling does not cause any pain and usually occurs between the second and third week. There is no need to report this manifestation to the child's provider. E. A child with Kawasaki disease will likely have joint stiffness and arthritis-related symptoms for several weeks. The joint stiffness is typically worse during cold weather and in the mornings.

How to check circulation of extremities?

Cap refill feeling sensation

Tetralogy of fallot expected findings

Increased RBC's (polycythemia vera) -treat with hydration

treat juvenile arthritis

Methotrexate kidney toxic - dink 2-3L fluid daily

Compartment syndrome

Pain that does not resolve with medication

Nursing care for Tay-Sachs Disease

Palliative care

Bacterial endocarditis

an inflammation of the lining or valves of the heart caused by the presence of bacteria in the bloodstream can occur as a result of dental/other procedures teach the need for antibiotic prophylactic therapy

Neuromuscular assessments

conducted to ensure adequate tissue perfusion is imperative to perform on clients with fractures in casts or traction

sickle cell crisis triggers

dehydration exposure to cold stress

Thalassemia

enlarged mandible because of the bone marrow overgrowth

Compartment syndrome treatment

fasciotomy

Thalassemia manifestations

fever pallor listlessness

nauseated client

give cool, clear, liquids (favorite foods when nauseated can associate that food with a bad experience)

anemia can result in

growth retardation -treat with iron supplements (after 6 month old)

Impetigo

honey colored crusts - highly contageous

Joint most affected for children

knee

Tetralogy of Fallot intervention

knee chest position

Hemophilia A (85% of cases)

missing factor 8 (VIII) Treatment is Desmopressin A classic symptom of hemophilia is bleeding into the joints (hemarthrosis). *do not give aspirin*

Hemophilia B

missing factor 9(IX)

Sunscreen

most effective 30 minutes before sun exposure

Digoxin toxicity s/s

nausea vomiting dysrhythmias vision changes

Discharge teaching for parents with children after cardiac surgery:

o Mix of bed rest/activity o No lotions or powders to the skin incision

wound healing in burn injuries

proteins and Vitamin C

Rheumatic fever can cause

scarring of the mitral valve -very destructive to the heart

mandatory reporting

spiral fractures

Candidiasis treatment

swish with Nystatin 4x daily (newborn swab it in mouth)

aplastic anemia can be caused by

toxic chemicals or radiation -all formed elements of blood do not form -decreased bone marrow production

A nurse is reinforcing teaching with 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 be certain to put on 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 will prevent the harness straps from rubbing against and irritating the infant's skin. Incorrect Answers: B. Putting on the infant's diaper over the harness will cause soiling of the harness and direct contact of the harness with the skin, which can lead to skin irritation and breakdown. C. The parent should return to the clinic for harness adjustments. Parents should not make any adjustments to the harness without the supervision of a health care professional. D. Lotions and powders should not be applied due to the possibility of irritating the skin around the buckles.

A nurse is applying EMLA cream to a child's hand prior to the insertion of an intravenous catheter. Which of the following interventions should the nurse perform? A. Apply the EMLA cream 60 minutes prior to the procedure B. Cleanse the site with alcohol prior to applying the cream C. Rub the cream into the skin using firm pressure in a circular motion D. Choose another site if the skin area becomes reddened or blanched

✔ A. Apply the EMLA cream 60 minutes prior to the procedure EMLA cream is a topical anesthetic that should be applied at least 60 minutes prior to a procedure. Procedures requiring deeper penetration such as a bone marrow aspiration may require application 2 to 3 hours prior to the scheduled procedure. Incorrect Answers: B. The site should only be cleaned with soap and water prior to the application of the EMLA cream. The medication requires the presence of alcohol on the skin to activate the anesthetic action. C. The cream should be placed over the intended area, and an occlusive dressing should be applied. The nurse should not rub the cream into the skin. D. Reddened or blanched skin is an expected finding when the anesthetic medication has effectively penetrated the skin.

A nurse is caring for a child who has electrical burns on her lower arms and hands. Which of the following findings indicates the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain

✔ A. Dark urine Dark urine can be an indication of myoglobinuria. It results from elimination of waste products from muscle damage and can cause renal failure. Incorrect Answers: B. Radial pulses of +2 are within the expected reference range. They are a reflection of circulatory status, not burn complications. C. A respiratory rate of 20/min is within the expected reference range. It reflects respiratory status, not burn complications. D. Electrical injuries can cause major, full-thickness burns that destroy the nerve endings in the skin, thus reducing the amount of pain the client feels.

A nurse is collecting developmental data from a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Fasten buttons on a shirt B. Tie shoelaces C. Part and comb hair D. Cut meat at dinner

✔ A. Fasten buttons on a shirt The nurse should expect a 4-year-old child to be able to fasten simple buttons on a shirt; however, the child may have difficulty if the buttons are complicated. Incorrect Answers: B. The nurse should expect a 4-year-old child to be able to lace shoes; however, tying the shoelaces is a fine motor skill expected of a 5-year-old child. C. The nurse should expect a 7-year-old child to be able to part and comb his/her hair without needing assistance. D. The nurse should expect a 7-year-old child to be able to cut tender pieces of meat with a table knife.

A nurse is collecting data from an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. High-pitched cry B. Sunken fontanel C. Tachycardia D. Increased awake time

✔ A. High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping. Incorrect Answers: B. The nurse should identify that a firm and bulging fontanel is an indication of increased ICP. C. The nurse should identify bradycardia as an indication of increased ICP. D. The nurse should identify increased sleep time as an indication of increased ICP.

A nurse is reinforcing teaching with 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. Incorrect Answers: B. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the upper arms during basketball competitions. C. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the thighs during basketball competitions. D. The lower leg is not a recommended injection site for insulin. Insulin is administered subcutaneously into adipose or fat tissue over a muscle. Recommended injection sites for insulin are the abdomen, hips, buttocks, upper arms and thighs. When participating in vigorous exercise, the nurse should instruct the client to select an injection site that is not on an extremity involved in the activity.

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 influenza 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 months and 18 months of age. Incorrect Answers: B. The nurse should verify that the child received the Hib vaccine at 2, 4, and 6 months as well as at 12 to 15 months. This immunization is not routinely administered at 6 years of age. C. The nurse should verify that the child received the pneumococcal conjugate vaccine at 2, 4, 6, and 12 to 15 months. This immunization is not routinely administered at 6 years of age. D. The nurse should verify that the child received the HBV vaccine within 12 hours after birth with additional doses at 1 to 2 months and 6 to 18 months of age. This immunization is not routinely administered at 6 years of age.

A nurse is planning to perform chest physiotherapy (CPT) for an infant who has cystic fibrosis. Which of the following techniques should the nurse plan to include? A. Repeatedly strike the infant's chest using a cupped hand B. Administer the CPT 30 minutes after each C. Position the infant prone to drain the apical segment of the left upper lobe D. Hyperoxygenate the infant before initiating CPT

✔ A. Repeatedly strike the infant's chest using a cupped hand Percussion involves striking a cupped or curved palm against the infant's chest to produce an audible thumping noise. This technique loosens the mucus in the airway for expectoration and should not produce discomfort. Incorrect Answers: B. CPT is best scheduled before meals or at least 1 hour after a meal so the subsequent coughing does not cause vomiting. C. When draining the apical segment of the left upper lobe, the nurse should position the infant on the nurse's lap. D. Hyperoxygenation is not necessary prior to CPT. It should be used prior to suctioning an infant.

A nurse is collecting data from a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? A. Stacking 10 blocks B. Printing 1 letter C. Tying shoelaces D. Using 7-word sentences

✔ A. Stacking 10 blocks The nurse should expect a 3-year-old preschooler to have the fine motor ability to stack 10 blocks. Incorrect Answers: B. The nurse should expect a 3-year-old preschooler to have the ability to draw a circle but not print letters until age 5. C. The nurse should expect a 3-year-old preschooler to have the fine motor ability to put on shoes but not tie shoelaces until age 5. D. The nurse should expect a 3-year-old preschooler to have the language ability to use 3- to 4-word sentences. Seven-word sentences are not expected until age 5.

A nurse is collecting developmental data on a 4-year-old child. Which of the following findings should the nurse expect? A. The child is able to hop on 1 foot. B. The child is able to build a tower of up to 6 blocks. C. The child is able to name the days of the week. D. The child is able to identify left and right.

✔ A. The child is able to hop on 1 foot. The nurse should expect a 4-year-old child to have the gross motor ability to hop on 1 foot. Incorrect Answers: B. The nurse should expect a 3-year-old child to have the fine motor ability to build a tower of 9 to 10 blocks. C. The nurse should expect a 5-year-old child to have the language ability to identify time-related words such as the days of the week. D. The nurse should expect a 6-year-old child to have the cognitive ability to identify left and right.

A nurse on a pediatric unit is assisting with the care of a preschooler who is prescribed an IV medication. Which of the following techniques should the nurse use to assist with preparing the child for the procedure? A. Use role-play activities with the child B. Provide the child with a detailed explanation of the procedure C. Implement interactive sessions of 30 min each with the child D. Give the child identical IV supplies to play with

✔ A. Use role-play activities with the child The nurse should use role-play activities to decrease the child's anxiety about the procedure. This approach will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Incorrect Answers: B. The nurse should avoid giving a detailed explanation of the procedure because this likely will increase the child's anxiety. The nurse should explain the procedure to the preschooler using simple words and phrases. C. To maintain the child's attention, the nurse should limit interactive sessions for a preschooler to 10 to 15 minutes each. D. The nurse should allow the child to see, hold, and ask questions about needleless IV supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Giving the child identical IV supplies to play with is a major safety risk because the child will likely be injured by the needle.

A nurse is collecting data from an adolescent who takes insulin for the treatment of type 1 diabetes mellitus. The nurse should identify that which of the following findings indicates effective management of the client's diabetes mellitus? A. Blood glucose value before each meal of 80 mg/dL B. Blood glucose value at bedtime of 140 mg/dL C. HbA1c of 9% D. 24-hr urine glucose of 400 mg

✔ B. Blood glucose value at bedtime of 140 mg/dL The nurse should identify that a blood glucose value of 140 mg/dL at bedtime is within the expected reference range for an adolescent. This finding indicates the effectiveness of the client's insulin treatment and management of diabetes mellitus. Incorrect Answers: A. The nurse should identify that a blood glucose value of 80 mg/dL before meals is below the expected reference range for an adolescent. A decreased blood glucose level before meals can indicate a need for the provider to adjust the dosage, frequency, or type of insulin in order to prevent hypoglycemia. C. The nurse should identify that an HbA1c of 9% is greater than the expected reference range for an adolescent. An elevated HbA1c level can indicate a need for the provider to adjust the insulin dosage, frequency, or type in order to prevent hyperglycemia. D. The nurse should identify that a 24-hour urine glucose level of 400 mg is above the expected reference range for an adolescent. Glycosuria might indicate a need for the provider to adjust the client's insulin dosage, frequency, or type.

A nurse is reinforcing teaching with 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 minutes C. Soak combs and brushes for 5 min in boiling water D. Seal non-washable items in a bag for 7 days

✔ B. Dry clothing in a hot dryer for at least 20 minutes The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes. Incorrect Answers: A. The nurse should instruct the parent to machine-wash the child's clothing and bed linens in hot water. C. The nurse should instruct the parent to soak the child's combs and brushes for 10 minutes in boiling water. D. The nurse should instruct the parent to seal the child's non-washable items in a bag for 14 days.

A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? A. Playing a simple game with another child B. Engaging in play near other children C. Sharing crayons with another toddler D. Jumping on 1 foot without help

✔ B. Engaging in play near other children A toddler is expected to play in parallel with other children. As socialization begins, the child plays alongside other children, not with them. Incorrect Answers: A. Play becomes associative at about 5 years of age. At this age, the child attempts to follow rules but might cheat to prevent losing. C. The nurse should not expect a child to understand the concept of sharing until around 3 years of age. D. The nurse should not expect a child to have the gross motor ability to skip and hop on 1 foot until about 4 years of age.

A nurse is contributing to the plan of care for a 6-month-old infant who has respiratory syncytial virus (RSV). Which of the following interventions should the nurse plan to include? A. Thicken feeding with 5 mL of rice cereal per 30 mL of formula B. Implement droplet and contact precautions C. Administer bronchodilator therapy via blow-by technique D. Use a cool mist vaporizer

✔ B. Implement droplet and contact precautions Respiratory syncytial virus is a highly contagious virus that is spread through contact with respiratory secretions and via large droplets. Therefore, both forms of isolation are indicated for a client with this infection. Incorrect Answers: A. Thickening feedings is an appropriate intervention for an infant with gastroesophageal reflux disease who is not gaining weight appropriately. It is not an appropriate intervention for an infant with bronchiolitis. Infants with bronchiolitis have difficulty sucking and swallowing due to copious secretions and tachypnea. These clients are typically NPO. C. Bronchodilator therapy should be administered using a small mask that fits over the infant's mouth and nose. Blow-by technique does not ensure full delivery of the prescribed medication to the infant. D. A cool mist vaporizer in the home is therapeutic for a child with acute spasmodic laryngitis to relieve laryngeal edema. It is not an appropriate action for an infant hospitalized with an RSV infection.

A nurse is obtaining a temperature reading from an 18-month-old infant. Which of the following methods should the nurse use? A. Pull the pinna upward and insert the tympanic thermometer probe into the ear canal B. Insert the lubricated tip of the thermometer 2.5 cm (1 in) into the toddler's rectum C. Obtain an axillary temperature and add 1°C (1.8°F) to the reading D. Place the tip of the thermometer in the left or right posterior sublingual pocket

✔ B. Insert the lubricated tip of the thermometer 2.5 cm (1 in) into the toddler's rectum The nurse should lubricate the tip of the thermometer with a water-soluble lubricant and gently insert the thermometer into the rectum. The nurse should hold the thermometer firmly in place while obtaining the reading. Incorrect Answers: A. Tympanic temperature readings are not accurate when performed on children younger than 2 years of age. C. The nurse should not add 1°C to an obtained axillary reading. D. Oral temperatures should be performed on children who are 5 years of age or older.

A nurse is caring for a 7-year-old child who has Kawasaki disease. Which of the following interventions should the nurse perform? A. Apply warm soaks to irritated skin areas B. Monitor for signs of fluid retention C. Urge socialization with other children in the playroom D. Encourage the child to perform active range of motion exercises

✔ B. Monitor for signs of fluid retention Children with Kawasaki disease are at a high risk for developing heart failure due to the disorder causing inflammation of the small and medium blood vessels throughout the body. This can lead to coronary aneurysms and myocarditis. The nurse should monitor daily weights, intake and output, and the development of tachycardia and respiratory distress. Incorrect Answers: A. Cold soaks would be an appropriate intervention. Children with Kawasaki disease typically present with a pruritic rash over their trunk and extremities. This rash often results in peeling of the skin. C. Children with Kawasaki disease should be kept in a quiet environment with minimal stimulation to allow adequate rest. These children experience significant irritability throughout the acute and convalescent phase of the disease. D. The nurse should perform passive range of motion exercises for a child who develops arthritic joint pain due to the disorder. These exercises are best tolerated after the child's bath.

A nurse is assisting with the plan of 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 hours 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 hours 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 cool 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. Incorrect Answers: A. Hyperthermia is caused by external conditions that create more heat than the body can eliminate. The body temperature exceeds the set point, which differs from the elevation of the body's actual setpoint associated with hyperpyrexia. Because of this, antipyretics are not effective in treating hyperthermia. C. The child should be placed in a warm bath. The nurse should gradually add cool water until the water temperature is 1°C (33°F) less than the child's body temperature. Placing the child in water that is too cool will result in vasoconstriction of the blood vessels on the surface, which will not allow the visceral heat to dissipate to the cooler outside air. D. The nurse should assess the child's temperature every 30 to 60 minutes or continually during the cooling process to prevent hypothermia.

A nurse is caring for a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelet count 500,000/mm^3 B. RBC 2.5 million/uL C. WBC 4,000/mm^3 D. Hct 60%

✔ B. RBC 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. Incorrect Answers: A. A platelet count of 500,000/mm^3 is above the expected reference range. A child who has acute lymphocytic leukemia has a low platelet count. C. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC. D. An Hct of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level.

A nurse is reinforcing teaching about otic medication administration with the guardian of an 18-month-old toddler. Which of the following statements should the nurse make? A. "Administer the drops immediately after removing the medication from the refrigerator." B. "Place the child in a seated position with the head tilted to the side for administration." C. "Gently pull the ear cartilage down and back when administering the medication." D. "Position the medication bottle so the drops do not touch the side of the ear canal."

✔ C. "Gently pull the ear cartilage down and back when administering the medication." The nurse should instruct the guardian to pull the pinna gently down and back to straighten the eustachian tube when administering the medication. Incorrect Answers: A. The nurse should instruct the guardian that the medication should be at room temperature or slightly warmer to prevent pain and vertigo during administration. B. The nurse should instruct the guardian to place the child prone or supine, with the head turned to the side to administer the drops. The child should remain in this position for 2 to 3 minutes following administration so the medication can fully enter the ear canal. D. The nurse should instruct the guardian to position the bottle so the ear drops fall against the side of the ear canal to avoid placing the drops directly onto the tympanic membrane.

A nurse is reinforcing discharge teaching with the parent of a newborn who has been 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. Incorrect Answers: A. The parent should avoid using powder and lotion because they can accumulate in the skin folds and cause irritation. B. The parent should never adjust the length of the straps on the harness. The straps should only be adjusted by the health care provider to ensure prevention of hip extension and adduction. D. The diaper should be placed under the harness to maintain cleanliness.

A nurse is reinforcing teaching with a school-aged child who has just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse reinforce with the child and his parents about care during the first 48 hours? A. "Use a toothbrush to scratch under the cast if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the cast with soapy water."

✔ C. "Keep the cast above the level of your heart." Immediately following the injury and for at least the first 48 hours, the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return. Incorrect Answers: A. The nurse should tell the child not to insert any objects between the cast and the skin. Any scratches or abrasions could lead to infection. B. The child should rest and avoid strenuous activities but should use the muscles of the leg and the joints above and below the cast. D. Fiberglass casts do not deteriorate as much as plaster casts do when wet, but the child should keep the cast dry. Wet cotton batting and stocking net inside the cast will absorb water and could lead to skin breakdown.

A nurse is assisting with a nutritional screening for a 12-year-old client who weighs 41 kg (90 lb) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index (BMI)? A. 1.5 B. 3.6 C. 18.2 D. 27.3

✔ C. 18.2 To calculate the client's BMI, the nurse should divide the client's weight in kilograms by the square of the client's height in meters. Therefore, 41 kg divided by the square of 1.5 m gives a correct BMI of 18.2. Incorrect Answers: A. A value of 1.5 comes from dividing 90 lb by 60 inches, which is an incorrect calculation for BMI. B. A value of 3.6 comes from dividing 90 lb by the square of 5 feet, which is an incorrect calculation for BMI. D. A value of 27.3 comes from dividing 41 kg by 1.5 m, which is an incorrect calculation for BMI.

A charge nurse is reinforcing teaching about child maltreatment with 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 nonbiological 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 has increased care needs, which increases the risk of caregiver fatigue and can lead to a higher potential for maltreatment. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have additional stressors and restricted access to available support systems.

A nurse is collecting the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform? A. Use a cuff to auscultate blood pressure B. Determine heart rate by taking the radial pulse C. Count respirations before taking other vital signs D. Measure temperature by placing the thermometer in the infant's ear

✔ C. Count respirations before taking other vital signs It is best to count the infant's respirations while the infant is calm and before being disturbed. The pulse should be taken next, followed by the temperature, which is the most disruptive assessment to an infant. Incorrect Answers: A. Automated devices are preferred over manual cuffs for measuring an infant's blood pressure because it is difficult to auscultate the beat. B. Apical heart rates, which are heard through a stethoscope held at the apex of the heart, are the most reliable method of determining heart rates. D. Tympanic temperatures do not provide a precise measurement of an infant's body temperature. A rectal temperature is the most consistent with an infant's core temperature.

A nurse is preparing to collect data from an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 15 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms

✔ C. Examine the infant's throat at the end of the examination The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult. Incorrect Answers: A. The nurse should pull the infant's pinna downward and toward the back of the head when examining the ears. The ear canal is curved upward until approximately 3 years of age. Pulling the pinna down and back straightens the ear canal and allows easier visualization of the tympanic membrane. B. The nurse should assess the infant's heart rate by auscultating the apical pulse for 1 min. D. The nurse should not measure the blood pressure in an 11-month-old infant. Blood pressure is routinely measured starting at 3 years of age.

A nurse is contributing to the plan of care for an infant who has 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. Incorrect Answers: A. The nurse should not place a diaper on the infant until after the defect has been repaired and healed due to the risk of tearing the sac. The nurse should place padding under the infant to absorb urine and stool and provide frequent skin care. B. Povidone-iodine is neurotoxic and should not come in contact with the spinal malformation. D. The nurse should keep the meningocele sac from drying by applying sterile nonadherent dressings that are moistened with 0.9% sodium chloride every 2 to 4 hours. A dry dressing might stick to the sac and cause tearing.

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. Incorrect Answers: A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication to the newborn. B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an extended position would be uncomfortable for the newborn and would likely increase pain because it is not a natural position at this age.

A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse, "My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take? A. Evaluate the infant's sucking reflex B. Suction the infant's airway before trying to administer a bottle feeding C. Prepare to administer intravenous fluids D. Place the infant in a negative-pressure isolation room

✔ C. Prepare to administer intravenous fluids The nurse should prepare to assist with the administration of intravenous fluids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to finish a bottle of formula. Also, fluids will help loosen congestion, which typically occurs with RSV. Incorrect Answers: A. The infant's inability to finish a bottle of formula does not indicate the need to assess the infant's sucking reflex. The sucking reflex begins to diminish at about 6 months of age. A weak or nonexistent sucking reflex would have been identified much earlier than 6 months of age because it would have impeded feeding. B. The infant might require suctioning to clear secretions; however, suctioning should only be performed when necessary and not as a prophylactic treatment because it can cause tissue damage. D. There is no indication that the nurse should place the infant in a negative-pressure isolation room. This type of isolation is used for clients who have tuberculosis.

A nurse is contributing to the preoperative teaching plan for a school-aged child who is scheduled for cardiac surgery. Which of the following recommendations should the nurse make? A. Limit education sessions to 10 min B. Use simple, concrete terms when giving explanations C. Use photographs to help explain the procedure D. Schedule education session 2 days prior to the procedure

✔ C. Use photographs to help explain the procedure The nurse should recognize the school-aged 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. Incorrect Answers: A. The nurse should recommend limiting education sessions to 10 to 15 minutes for a preschooler but can recommend extending sessions for a school-aged child to about 20 minutes. B. The nurse should recognize the school-aged child's increased language ability and desire for knowledge; therefore, the nurse should use correct medical terminology when reinforcing preoperative teaching. D. The nurse should recommend scheduling the preoperative education sessions for a school-aged child no more than a day prior to the procedure.

A nurse in a pediatric clinic is preparing to assist with a sweat chloride test for a toddler who is suspected to have cystic fibrosis. Which of the following actions should the nurse plan to take? A. Verify the toddler has been NPO for 6 hours prior to the test B. Document the toddler's food intake for the past 72 hours C. Warm the temperature of the toddler's examination room D. Expose the toddler's back for the application of electrodes

✔ C. Warm the temperature of the toddler's examination room The nurse should ensure that the examination room is warm. A warm environment promotes the toddler's ability to produce sweat for the sweat chloride test. To further promote sweating, the nurse should apply blankets to maintain the toddler's body heat during the test. Incorrect Answers: A. The nurse should ensure that the toddler has adequate fluid intake prior to the sweat chloride test. If the toddler is dehydrated, the test results can be inaccurate due to a decreased ability to produce sweat and an increased concentration of electrolytes. B. The nurse should review and document the toddler's food intake for 72 hours if the toddler is having a stool analysis for the diagnosis of cystic fibrosis. A 72-hour stool test analyzes the amounts of fat and enzymes in the stool samples. D. The nurse should expose the thigh of an infant and the forearm of an older child for application of electrodes during a sweat chloride test. The nurse should keep other areas of the toddler's body covered with blankets to maintain body heat during the test.

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. Monitor the child's blood pressure twice per day B. Maintain the child on bed rest for 3 days C. Weigh the child once each day D. Increase the child's daily intake of sodium

✔ C. Weigh the child once each day The nurse should weigh the child at the same time each day to monitor fluid balance. Incorrect Answers: A. Glomerulonephritis can cause hypertension that can lead to cerebral ischemia. Therefore, the nurse should monitor the child's blood pressure every 4 hours. B. The child should participate in activities as tolerated. Bed rest is not required. D. The nurse should offer the child a regular diet with moderate sodium restriction and ensure no salt is added to foods.

A nurse in a pediatric clinic is reinforcing teaching with the parent of a school-aged child who has type 1 diabetes mellitus and an upper respiratory infection. Which of the following statements by the parent indicates an understanding of the instructions? A. "I will give my child half of the usual insulin dose until the infection is clear." B. "I will monitor my child's urine for ketones once a day." C. "I will notify the provider if my child's random glucose level is greater than 140." D. "I will check my child's blood glucose level every 3 hours."

✔ D. "I will check my child's blood glucose level every 3 hours." The nurse should identify that a child who has type 1 diabetes mellitus has an increased risk of diabetic ketoacidosis during an illness. Therefore, the nurse should instruct the parent to monitor the child's blood glucose level every 3 hours. Incorrect Answers: A. A child who has type 1 diabetes mellitus is at increased risk for hyperglycemia during an illness. Therefore, the nurse should inform the parent that the child should continue to receive the prescribed amount of insulin to maintain blood glucose levels. B. A child who has type 1 diabetes mellitus is at increased risk for diabetic ketoacidosis during an illness. Therefore, the nurse should instruct the parent to check the child's urine for ketones every 3 hours. C. The nurse should instruct the parent to notify the provider if the child's random blood glucose level is greater than 240 mg/dL. Other manifestations the parent should report include vomiting and ketones in the child's urine.

A nurse is reinforcing teaching about exercise with an adolescent client who has type 1 diabetes mellitus. Which of the following points should the nurse reinforce? A. "Before engaging in physical activity, you should inject insulin into a muscle group that you will be using during the activity." B. "You should plan to alternate days of vigorous physical exercise with days of increased rest." C. "Plan to avoid participation in team sports." D. "You might need to decrease your routine insulin dosage before exercise."

✔ D. "You might need to decrease your routine insulin dosage before exercise." Eating additional carbohydrates or decreasing the regular insulin injection according to an established protocol before exercise is sometimes necessary to prevent hypoglycemia. Incorrect Answers: A. Exercising a muscle group increases circulation and insulin absorption from that area. Injecting insulin into a muscle that will not be used during the exercise can decrease the chances of hypoglycemia occurring during the physical activity. B. An adolescent who has type 1 diabetes mellitus should design a consistent daily exercise program. Once a daily program is established, the client needs to continue this type of exercise every day, including weekends, to avoid becoming hyperglycemic. C. Exercise is an important component of care for type 1 diabetes mellitus because it uses carbohydrates and helps reduce hyperglycemia. No type of exercise is restricted for adolescents or children who have diabetes mellitus.

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 When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of lowering the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.

A nurse is preparing for the insertion of an intravenous peripheral catheter into an 8-year-old child. Which of the following interventions should the nurse plan to take? A. Cover the insertion site with a firmly fastened opaque dressing B. Immobilize the extremity with a padded board after the insertion of the catheter C. Choose an 18- or 20-gauge catheter for insertion D. Apply an anesthetic cream to the intended site 60 minutes prior to the procedure

✔ D. Apply an anesthetic cream to the intended site 60 minutes prior to the procedure The application of lidocaine anesthetic cream at least 30 to 60 minutes prior to the procedure will prevent discomfort and reduce future fear of such procedures. Incorrect Answers: A. The insertion site should be covered with a transparent occlusive dressing to allow frequent close observation of the insertion site. B. The use of immobilization boards is not recommended for school-aged children. Immobilizing the extremity with a padded board can increase the risk of tissue excoriation and joint contractures and restrict the child's ability to use the extremity. C. The nurse should plan to insert the smallest gauge catheter in an effort to decrease the child's discomfort level. A 25- to 27-gauge catheter, which is 1.25 cm (0.5 inch) in length, is recommended for a school-aged child.

A school nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range-of-motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint

✔ D. Apply an ice pack to the joint Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint. Incorrect Answers: A. The nurse should avoid giving clients with hemophilia aspirin or NSAIDs because these medications can interfere with the action of platelets. B. Passive range-of-motion exercises should never be performed on a client with hemophilia. Over-stretching and tearing could inadvertently occur, resulting in further joint bleeding. C. Cryoprecipitate is no longer used to treat clients with hemophilia due to the inability to remove hepatitis and HIV from the product. Hemophilia is currently treated with factor VIII replacement products or a synthetic form of vasopressin.

A nurse in an acute pediatric unit is contributing to the plan of care for a preschooler. Which of the following recommendations should the nurse make? A. Request that a laboratory technician obtains blood specimens in the preschooler's room B. Encourage the preschooler to rest quietly for 30 minutes following traumatic procedures C. Use the terminology "quick stick" when preparing to administer an injection D. Ask the parent if she would like to hold the preschooler during an assessment by the respiratory therapist

✔ D. Ask the parent if she would like to hold the preschooler during an assessment by the respiratory therapist The respiratory therapist can assess the preschooler's respiratory status while the child is being held by the parent. This is often a useful technique to keep the preschooler calm and quiet. Incorrect Answers: A. Whenever possible, procedures that can be painful or traumatic should be done in a treatment area so that the child does not come to fear the room or bed, which is a designated safe area. B. The nurse should encourage and plan play activities following traumatic experiences. These activities allow the preschooler to express feelings and emotions related to the experience. C. The nurse should avoid using terminology such as "shot" or "stick" that the preschooler might find confusing or perceive as threatening.

A nurse is reinforcing preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure B. Provide the child with diagrams and pictures while explaining the procedure C. Use correct medical terminology during the teaching session D. Explain the procedure in terms of what the child will feel, see, hear, and taste

✔ D. Explain the procedure in terms of what the child will feel, see, hear, and taste Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure. Incorrect Answers: A. Preschoolers are unable to think abstractly or understand concepts that will occur far in the future. B.The nurse should use dolls or stuffed animals to explain the procedure and allow the child to handle equipment if possible. C. Teaching for a preschooler should be done using simple, familiar terms.

A nurse is checking the gross motor development of a 3-year-old child. Which of the following 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. Incorrect Answers: A. Skipping is a developmental task expected of a 4-year-old child. B. Hopping on 1 foot is a developmental task expected of a 4-year-old child. C. Throwing a ball overhead is a developmental task expected of a 4-year-old child.

A school nurse is reinforcing dietary teaching with 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 2 hours 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 minutes before my baseball games start." E. "I should have a 16-ounce sports drink if I start feeling weak or shaky."

A. "I should eat extra food on busy days when I am more active." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 minutes before my baseball games start." The nurse should instruct the adolescent to boost 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. 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. The nurse should instruct the adolescent to eat a recommended snack 30 minutes prior to a planned activity such as a baseball game. If the game is prolonged, a snack should be consumed every 45 minutes to 1 hour. If, for some reason, the extra food cannot be tolerated, the next intervention is to decrease the adolescent's insulin dose before baseball games. Incorrect Answers: B. The adolescent should exercise within 2 hours of eating because exercise requires more carbohydrates in the system. Waiting 2 hours after eating before exercise increases the likelihood of a hypoglycemic episode. A carbohydrate snack will most likely be needed during and a few hours following prolonged activity or exercise. E. The adolescent should consume 8 oz of a sports drink if feeling hypoglycemic. Manifestations of hypoglycemia include dizziness, a headache, irritability, weakness, shakiness, and confusion. An 8-oz sports drink contains 15 g of carbohydrate. If the adolescent consumes a 16 oz drink, it would contain a minimum of 30 g of carbohydrate, which could cause hyperglycemia and require a dose of insulin.

A school nurse is assisting 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. Nausea D. Urticaria E. Stridor Nausea and hives are common responses to excessive histamine release. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents with dyspnea and stridor. Incorrect Answer: A. C. Histamine is a potent vasodilator; therefore, a client who is going into anaphylaxis will exhibit tachycardia and hypotension.

A nurse is reinforcing teaching with the guardian of an infant who has tetralogy of Fallot. Which of the following guardian responses indicates an understanding of the teaching? A. "I should bring the baby's knees toward her chest for cyanotic episodes." B. "I will expect my baby's cyanotic episodes to occur most often during the evening." C. "I should limit my baby's total fluid intake to decrease the frequency of cyanotic episodes." D. "I will give my baby oxygen through a nasal cannula during cyanotic episodes."

✔ A. "I should bring the baby's knees toward her chest for cyanotic episodes." Placing the infant in a knee-chest position during hypercyanotic spells traps blood in the lower extremities and reduces manifestations by diverting more blood pressure into the pulmonary artery. Incorrect Answers: B. The majority of cyanotic spells occur during the morning hours and after feedings, bowel movements, and crying episodes. C. Infants who have episodes of hypoxemia should maintain an adequate level of hydration to reduce the risk of stroke due to increased blood viscosity. D. During cyanotic episodes, the infant should receive 100% oxygen via face mask.

A nurse is collecting data on a 6-month-old infant. Which of the following findings should the nurse identify as unexpected and report to the provider? A. Head lag when pulled to a sitting position B. Weight that has doubled since birth C. Absence of a pincer grasp D. Respiratory rate 30/min

✔ A. Head lag when pulled to a sitting position At 3 months of age, an infant should demonstrate only slight head lag when pulled to a sitting position. This lag should no longer be present at 5 months of age. Head lag in a 6-month-old infant is not an expected finding and should be reported to the provider. Incorrect Answers: B. An infant's weight is expected to be double the birth weight by 4 to 6 months of age and triple the birth weight by 1 year of age. C. This is an expected finding. The ability to pick up a small object between the thumb and forefinger does not typically develop until the infant is 9 months old. D. This is an expected finding. An infant's respiratory rate slows during the first year of life, decreasing from 30 to 60 as a newborn to 20 to 30 at 1 year of age.

A nurse is caring for a school-aged child who has terminal cancer and is receiving palliative care. The child's family asks about possible interventions. Which of the following statements should the nurse include in the teaching? A. "Nonpharmacological interventions have a place in managing your child's palliative care." B. "Palliative chemotherapy is meant to lengthen your child's life and might be curative." C. "We should limit the amount of opioids your child uses to prevent addiction." D. "It is best for your child to receive medications via intramuscular injection."

✔ A. "Nonpharmacological interventions have a place in managing your child's palliative care." Nonpharmacological interventions such as relaxation breathing are important adjunctive therapies and should be used along with pharmacological interventions. Incorrect Answers: B. Palliative chemotherapy and palliative radiation are designed to increase comfort by slowing the growth of cancer. However, these interventions do not offer the potential to be curative or to lengthen the child's life. C. For children who are receiving palliative care for a terminal illness, addiction to opioids is not a concern. They should receive an appropriate dose to manage their pain. D. Children potentially underreport their pain to avoid additional pain or discomfort as a result of how medications might be administered. Oral, sublingual, and transdermal routes should be used to provide pain relief without the trauma of injections whenever possible.

A nurse is collecting data from a school-aged child who had 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 to be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus. Incorrect Answers: B. This complication can occur following a cardiac catheterization. It is not associated with the insertion of a VP shunt. C. The inability of the shunt to drain due to a blockage will increase intracranial pressure. This can result in pressure on the oculomotor nerve, which causes dilation of the pupils. D. Frontal bossing can be observed in infants with hydrocephalus. Open cranial sutures allow excess cerebral spinal fluid to cause head enlargement. Frontal bossing describes the protruding frontal skull bones that can occur in severe cases of hydrocephalus.

A nurse is reinforcing teaching about nutritional needs with the parents of a 2-year-old toddler. Which of the following pieces of information should the nurse include? A. An appropriate serving size of a solid food is 2 tablespoons B. Discourage the toddler from eating with the fingers C. Appetite increases dramatically throughout the toddler years D. Toddlers like to try foods with new tastes and smells

✔ A. An appropriate serving size of a solid food is 2 tablespoons A general guide to appropriate serving sizes during toddlerhood is to serve 1 tablespoon of solid food for each year the child is old. If the plate is filled with too much food, a toddler is likely to be overwhelmed and reject the food. Incorrect Answers: B. Toddlers are typically picky, fussy eaters who prefer to eat with their fingers and prefer foods of interesting colors and shapes. Serving meals with these preferences in mind will increase oral intake to meet nutritional needs. C. Nutritional needs typically decrease during the second year of life, and toddlers will respond with a decreased appetite known as physiological anorexia. D. Toddlers prefer rituals during this developmental age. Toddlers respond best to the predictability of scheduled meal times and the same foods served in the same dishes.

A nurse is assisting with the admission of a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After the child's admission history is complete, which of the following actions should the nurse recommend? 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 for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex when caring for this client. Incorrect Answers: B. A UTI is a common complication of myelomeningocele. However, neither myelomeningocele nor a UTI requires contact precautions. C. Straining urine is essential for urolithiasis (urinary calculi) or stones in the urinary system, not for myelomeningocele or UTI. D. Women should take folic acid during pregnancy to reduce the risk of neural tube defects such as myelomeningocele.

A nurse is caring for a toddler in the immediate postoperative period following the placement of a ventriculoperitoneal (VP) shunt. Which of the following interventions should the nurse perform? A. Check for abdominal distention B. Keep the head of the bed elevated 60 to 90° C. Palpate the anterior fontanel for bulging or tenseness D. Position the child to keep pressure on the operative side

✔ A. Check for abdominal distention Intracranial fluid draining into the abdominal cavity may cause peritonitis or an ileus. The nurse should monitor the abdomen for distention and bowel sounds. Incorrect Answers: B. The child should be positioned flat during the immediate postoperative period to prevent the intracranial fluid from draining too rapidly, which could cause complications. C. While bulging or tenseness are signs of increased intracranial pressure in an infant, a toddler's anterior fontanel is closed. The anterior fontanel typically closes by 12 to 18 months of age. D. The child should be positioned with the operative side up to keep pressure off the shunt valve.

A nurse is collecting data from a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

✔ A. Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify that the child is having a hemolytic reaction. Incorrect Answers: B. Pruritus and flushing are findings that indicate a response to allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction. C. Rales and cyanosis are findings that indicate the blood product might have been administered too quickly. The nurse should identify these findings as an indication the child is experiencing fluid overload. D. Bradycardia and diarrhea are findings that indicate a complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication the child is experiencing an electrolyte imbalance.

A nurse is assisting with the development of 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. Incorrect Answers: B. The nurse should inform the parents that breast development usually begins around 8 to 12 years of age, followed 2 to 6 months later by the appearance of pubic hair. C. The nurse should inform the parents that ovulation is stimulated by the increasing amount of estrogen that develops after the onset of menarche. This increased level of estrogen promotes further sexual maturation. D. The nurse should inform the parents that menarche is an indication of late puberty. The onset of menstrual periods is preceded by an increase in height, breast development, and the appearance of pubic hair.

A nurse is contributing to the plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse suggest? A. Initiate protective environment isolation for the child B. Apply pressure for 1 to 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. Evaluate 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 this child, which consists of a private room with positive air pressure, no live flowers, and nurses donning 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. Incorrect Answers: B. Decreased platelets increase the child's risk of bleeding. The nurse should apply pressure to peripheral puncture sites for a minimum of 5 minutes to prevent bleeding following blood specimen collection. C. Ferrous sulfate is a required medication to administer for a child who has iron-deficiency anemia; it is not a necessary intervention for this client. Furthermore, the nurse should avoid mixing medications into liquids because if the child fails to drink the entire glass, the dosage received is not complete. D. Aplastic anemia does not affect the child's blood glucose level. Therefore, this is not a necessary intervention.

A nurse is assisting with the immediate postoperative care of an 8-month-old infant who had a cleft palate repair. Which of the following actions should the nurse perform? A. Maintain the infant in a side-lying position B. Provide non-pharmacological pain relief with a pacifier C. Offer pureed solid foods once the infant is awake and alert D. Assess the infant's pain level using the FACES Pain Rating Scale

✔ A. Maintain the infant in a side-lying position Following a cleft palate repair, infants should be positioned side-lying to allow the drainage of blood and secretions and to minimize the risk of aspiration. Incorrect Answers: B. No rigid objects such as straws, spoons, pacifiers or suction catheters should be placed in the mouth of a child who had a cleft palate repair. These objects could damage the suture line of the repair. C. Infants who have a cleft palate repair are typically fed only clear liquids for the first 24 hours postoperatively. Only liquids are allowed for the first 2 weeks following the repair. D. The FACES Pain Rating Scale is appropriate for children who are 3 years old and above. This scale uses a picture with 6 faces graduating from happy to sad. The child is instructed to point to the picture that shows how they are feeling. Infants should be assessed for pain using a behavioral scale such as the FLACC Pain Assessment Scale.

A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the child under a radiant warmer D. Tape a piece of plastic over the protruding membranes

✔ A. Monitor the infant's head circumference Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference can help determine any increase. Incorrect Answer: B. The nurse should place a child who has myelomeningocele in a prone position to minimize the risk of trauma or tension to the sac. C. The nurse should not place a child who has myelomeningocele under a radiant warmer due to the risk of drying out the lesion and causing cracking. D. Placing a piece of plastic over the protruding membranes will exert pressure on the area. Instead, the nurse can place wet gauze over the lesion to help provide moisture.

A nurse is contributing to the plan of care for a toddler who has acute gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child? A. Oral rehydration solution B. Bananas or applesauce C. Chicken or beef broth D. Hypertonic IV solution

✔ A. Oral rehydration solution The nurse should plan to provide an oral rehydration solution (ORS) to this child who has acute gastroenteritis. ORS promotes the body's reabsorption of water and sodium and is more effective and less traumatic than the administration of IV fluids for the treatment of dehydration due to diarrhea and emesis. Incorrect Answers: B. The nurse should understand that providing a BRAT (bananas, rice, applesauce, and toast or tea) diet is contraindicated for the treatment of acute gastroenteritis because it does not provide sufficient nutrition and electrolytes. C. The nurse should be aware that providing chicken or beef broth is not recommended for the treatment of acute gastroenteritis because broth does not provide the child with adequate carbohydrates and contains high amounts of sodium. D. The nurse should understand that while providing IV fluids can be effective in the treatment of dehydration caused by acute gastroenteritis, oral treatment is more effective, costs less, and is less traumatic for the child.

A nurse is collecting data from a 12-month-old infant during a well-child checkup. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight. B. The infant's posterior fontanel is closed. C. The child is unable to walk without support. D. A total of 6 teeth are present.

✔ A. The infant's current weight is double his birth weight. The nurse should expect a 12-month-old infant's weight to be triple his birth weight; therefore, the nurse should report this finding to the provider. Incorrect Answers: B. The nurse should expect the infant's posterior fontanel to be closed at about 2 months of age. C. Although the ability to walk independently varies among infants, the nurse should not expect this gross motor skill until the infant is 13 to 15 months of age. D. The nurse should expect a 12-month-old infant to have 6 to 8 teeth present.

A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take? A. Place the infant in knee-chest position B. Begin CPR C. Prepare to intubate the infant D. Administer IV adenosine

✔ A. Place the infant in knee-chest position The nurse should identify that a hypercyanotic spell occurs when a vascular spasm reduces pulmonary blood flow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery. Incorrect Answers: B. The nurse should identify that a hypercyanotic spell is a temporary period of hypoxia that can occur in response to crying, feeding, or straining during a bowel movement. The nurse should not initiate CPR because the infant is still breathing and has a pulse. C. The nurse should administer 100% oxygen via facemask to treat the hypoxia that occurs during a hypercyanotic spell. D. The nurse should not administer adenosine to an infant experiencing a hypercyanotic spell. Adenosine is an antiarrhythmic used in the treatment of supraventricular tachycardia.

A nurse is reinforcing dietary teaching with 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. Incorrect Answers: B. The parent does not need to restrict the toddler's intake of sodium. C. The parent should increase the toddler's daily caloric intake. An increase in foods high in folic acid is not required for children who have cystic fibrosis. D. The parent should increase the toddler's daily caloric intake by 110% to 200% to meet increased nutritional needs. Therefore, the toddler should not skip meals.

A nurse is talking with the parent of an infant during a well-child visit. The parent states, "My 6-year-old son started wetting the bed after we brought his baby sister home. He hasn't done that in over a year." The nurse should recognize that this behavior by the sibling is an indication of which of the following defense mechanisms? A. Regression B. Repression C. Rationalization D. Identification

✔ A. Regression The 6-year-old sibling's behavior is an indication of regression. With this defense mechanism, the individual reverts to a prior stage of development as a means of coping with stress. Incorrect Answers: B. Repression is a defense mechanism in which the individual involuntarily blocks awareness of a stressor. The 6-year-old sibling's behavior is not an indication of repression. C. Rationalization is a defense mechanism in which the individual attempts to explain unacceptable behavior or feelings with logical reasoning. The 6-year-old sibling's behavior is not an indication of rationalization. D. Identification is a defense mechanism in which individuals attempt to boost their self-esteem by behaving like or portraying qualities of someone that they hold in high regard. The 6-year-old sibling's behavior is not an indication of identification.

A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Restrain the toddler's arms at the elbows B. Feed the toddler with a spoon C. Monitor the toddler's oral temperature D. Weigh the toddler every 48 hours

✔ A. Restrain the toddler's arms at the elbows When caring for a toddler who is postoperative following a cleft palate repair, the nurse should apply elbow restraints (unless prescribed otherwise) to prevent the toddler from rubbing or disrupting the sutured area. Incorrect Answers: B. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should avoid the use of hard utensils due to the risk of injury to the repair. C. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should avoid placing rigid objects in the mouth such as a thermometer due to the risk of injury to the repair. D. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should weigh the infant at the same time of each day using the same scale in order to check nutritional status.

A nurse is caring for a 2-year-old child who has a history of frequent urinary tract infections. When reinforcing teaching with the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include? A. Teach the child to wipe from front to back B. Give the child frequent bubble baths C. Urge the child to urinate every 6 hours D. Administer oxybutynin daily

✔ A. Teach the child to wipe from front to back The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra. Incorrect Answers: B. The child should avoid bubble baths because they can cause urethral irritation. C. The child should urinate at least every 4 hours to prevent stasis of urine in the bladder, which can cause bacteria growth. D. Oxybutynin is an antispasmodic used for clients ages 6 and older who have neurogenic bladders.

A nurse is preparing to assist with the physical assessment of a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age

✔ A. The child prefers to sit on the parent's lap during the examination Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination. Incorrect Answers: B. Preschool and school-aged children are typically interested in a demonstration of how the examination equipment works. Toddlers might want to inspect the equipment before use but are not usually interested in how it functions. C. School-aged children are typically interested in how the body works and are open to instructions. Toddlers can understand the names and basic actions that body parts can perform, but they do not usually ask specific questions about body functions. D. Adolescents are typically concerned about comparing their development to the development of peers. Toddlers are just beginning to understand their existence as a separate person from their mother and are not concerned with how their development compares to other toddlers.

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. Incorrect Answers: B. The nurse should identify that a 30-month-old toddler should be able to draw a plus sign. C. The nurse should identify that a 30-month-old toddler should be able to jump off a step or small chair. D. The nurse should identify that an 18-month-old toddler should be able to turn 2 to 3 pages in a book. The child should be able to turn a single page in a book at 24 months of age.

A school nurse is collecting data from an adolescent child 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. To reduce the potential of sustaining abdominal trauma B. To mitigate a deficient dietary intake C. To avoid exposing peers to the illness D. To avoid straining sore joints

✔ A. To reduce the potential of 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, he must avoid activities that might result in trauma to the enlarged spleen. Incorrect Answers: B. Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, upon his return to school, he should not have deficient dietary intake. C. The Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. D. An adolescent who has mononucleosis will not have joint inflammation.

A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Abdomen 5 cm (2 in) from the umbilicus

✔ A. Vastus lateralis The vastus lateralis is a large, developed muscle, even in an infant. It can tolerate the volume of the injection, and there are no important nerves or blood vessels in this muscle. Incorrect Answers: B. The infant receiving an injection at the dorsogluteal site is contraindicated because the muscle is poorly developed. C. The deltoid has a small muscle mass, and the proximity of the radial and axillary nerves make it suitable for use only after the age of 18 months. D. The abdomen is used for subcutaneous injections.

A nurse is reinforcing teaching with the guardian of an adolescent. The guardian reports that the adolescent sleeps for about 10 hours on weekend nights. Which of the following responses should the nurse make? A. "Your child should have a blood test to check for anemia." B. "Adolescents need more sleep due to rapid growth." C. "Your child should not be staying up so late at night." D. "If your child is eating properly, this should not happen."

✔ B. "Adolescents need more sleep due to rapid growth." The nurse should identify that sleeping for 10 hours on weekend nights is an expected finding because adolescents need more sleep time than other age groups. Common reasons for the increased need for sleep include stress; busy schedules, including extracurricular activities; and rapid physical growth. Incorrect Answers: A. This is an expected finding for an adolescent and does not indicate a need to check for anemia. C. This is an expected finding for an adolescent and does not indicate the need to go to sleep earlier. D. This is an expected finding for an adolescent and does not indicate a nutritional deficiency.

A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? A. "Does your child wear a hat outdoors in cold weather?" B. "Does anyone smoke around or in the same house as your child?" C. "Have you given your child any aspirin recently?" D. "Is your child's diet high in gluten?"

✔ B. "Does anyone smoke around or in the same house as your child?" Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear, prolongs inflammation, and impedes drainage from the ear. Incorrect Answers: A. Exposure to cold weather does not cause otitis media. C. Although aspirin has some implications for Reye's syndrome if taken during a viral illness, aspirin itself does not cause otitis media. D. Although gluten has some association with a variety of gastrointestinal and allergic disorders, it does not cause otitis media.

A nurse is reinforcing teaching with the parent of an 8-year-old child who has AIDS. Which of the following instructions should the nurse highlight? A. "You should plan low-calorie, high-fiber meals for your child." B. "Everyone in the home should practice good hand hygiene." C. "You should plan to homeschool your child." D. "Avoid routine immunizations."

✔ B. "Everyone in the home should practice good hand hygiene." Children who have AIDS and their families must maintain strict personal hygiene measures such as frequent handwashing and avoiding close contact between the child and anyone who is ill. These precautions will help prevent the child from contracting dangerous opportunistic infections. Incorrect Answers: A. Children who have AIDS typically exhibit nutritional deficiencies and significant failure to thrive due to recurrent illnesses and diarrhea. Therefore, the parent should provide low-fiber, high-calorie meals and closely monitor the child for slowing of growth or weight-gain patterns. C. Daily interaction with schoolmates is very important for the social development of school-aged children. The risk of transmission of AIDS is very low in the school setting. Reinforcing handwashing and avoiding contact with other children who are ill will decrease the risk of infection transmission to the child. D. A child who has AIDS should receive routine immunizations at the scheduled times. Live attenuated vaccines such as the varicella vaccine and the measles, mumps, and rubella vaccine can be withheld if the child is showing signs of severe immunocompromise.

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen

✔ C. Amoxicillin A child who has acute otitis media should take an antibiotic to help alleviate the infection. Incorrect Answers: A. Diphenhydramine is an antihistamine used for allergic reactions. B. Furosemide is a diuretic used to decrease edema. D. Children younger than 6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.

A nurse is reinforcing teaching with the parents of a 4-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will place my baby on her side when sleeping." B. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." C. "I will decrease the number of feedings my baby receives per day." D. "I will give my baby loperamide with each feeding."

✔ B. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." The parents can give the infant thickened feedings with rice cereal to help decrease the reflux. In addition, the added calories can help infants who are underweight due to the gastroesophageal reflux. Incorrect Answer: A. The American Academy of Pediatrics continues to recommend supine sleeping for infants. Infants who have gastroesophageal reflux should be placed in a supine position with the head elevated. C. Decreasing the number of feedings per day is contraindicated. An infant must eat to gain nutrients and maintain caloric intake for growth and development. D. Loperamide is an antidiarrheal medication that is contraindicated in children younger than 2 years of age. An infant who has gastroesophageal reflux can benefit from an H2 receptor antagonist or proton pump inhibitor.

A nurse is collecting data from 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 to 20 words D. Slightly bowed or curved appearance of the legs E. Head circumference exceeds chest circumference

✔ B. Ability to build a tower of 6 blocks ✔ D. Slightly bowed or curved appearance of the legs The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. A 24-month-old toddler will have a "pot-bellied" appearance, and the client's legs should be slightly bowed in appearance to support the weight of the large trunk. Incorrect Answers: A. The nurse should expect a 24-month-old toddler to have 16 teeth. C. The nurse should expect a 24-month-old toddler to have a vocabulary of about 300 words and be able to speak in 2- to 3-word phrases. E. The nurse should expect a 24-month-old toddler to have a head circumference that is equal to or less than the chest circumference.

A nurse is assisting with the care of 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 discomfort. Incorrect Answers: A. The nurse should implement contact precautions for a client with poliomyelitis. This virus is spread by direct contact with feces and oropharyngeal secretions. C. Respiratory complications from poliomyelitis are due to paralysis of the respiratory muscles. The nurse should assess the child for signs of weak respiratory effort such as difficulty talking, ineffective coughing, and shallow and rapid respirations. D. Seizures are not an expected complication of a poliomyelitis infection.

A nurse is caring for a 5-year-old child who has pneumonia and is experiencing a poor appetite. Which of the following interventions should the nurse take? A. Firmly instruct the child to eat a few bites at each meal B. Allow the child to choose foods with a lower nutritional content C. Provide larger food portions in case the child is hungry D. Serve the main course and dessert together

✔ B. Allow the child to choose foods with a lower nutritional content Allowing the child to consume non-nutritional, empty-calorie foods and liquids will still provide needed calories and fluid during periods of illness. Once the child has recovered from the illness, the child's appetite will typically improve. Incorrect Answers: A. Pressuring a child to eat might cause the child to rebel and then use food consumption as a control mechanism. The nurse should praise the child for what is eaten and avoid using any tactics to force the child to eat. C. Larger portions might overwhelm the child and prompt a refusal to eat. Instead, the nurse should provide smaller, more frequent meals and offer second helpings when food is eaten. D. If both the meal and dessert are offered together, the child will likely fill up on the dessert first and might choose to not eat the other options. Instead, dessert should be offered at the end of the meal.

A nurse in a pediatric clinic is preparing to administer an IM vaccine to a preschooler. Which of the following actions should the nurse take? A. Ask the preschooler's parents to leave the room before administering the vaccine B. Allow the preschooler to hold a needleless syringe during the vaccine C. Give the preschooler a detailed explanation of the purpose of the vaccine D. Reassure the preschooler that the vaccine will just feel like a bee sting

✔ B. Allow the preschooler to hold a needleless syringe during the vaccine The nurse should provide opportunities for distraction during the injection such as holding real medical equipment. Other strategies include allowing the preschooler to hold a stuffed animal, small foam ball, bandages, or unopened alcohol swabs. The nurse should give the preschooler choices when possible but avoid excessive delays. Incorrect Answers: A. The nurse should identify that young children gain support from their parents. The presence of a parent can help the preschooler feel a sense of security and comfort. If the parents prefer to leave the room, the nurse should respect and support their decision. However, the nurse should ask the parents to remain close by to offer necessary support for the preschooler following the administration of the vaccine. C. The nurse should use short, simple, and age-appropriate explanations of what to expect prior to administering the vaccine. A detailed explanation of the purpose of the vaccine will likely confuse the preschooler and increase the child's anxiety level. D. The nurse should discuss the procedure with the preschooler using terminology appropriate for this age group. The preschooler might be scared of bees; therefore, comparing the vaccine to a bee sting could potentially cause the child to become frightened.

A nurse is collecting data from a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggest a possible delay in development? A. Inability to tie shoes B. Adding 3 parts to a stick figure C. Speaking using 2- or 3-word sentences D. Inability to walk backward

✔ C. Speaking using 2- or 3-word sentences A 4-year-old child should be speaking in 4- to 5-word sentences. Speaking in 2- to 3-word sentences is typical for a 2-year-old child. Incorrect Answers: A. Tying shoelaces is a skill expected of a 5-year-old child. B. This is an expected finding in a 4-year-old child. D. Walking backward is a skill expected of a 5-year-old child.

A nurse is caring for an 8-year-old child in the acute care setting. Which of the following actions should the nurse take? A. Reinforce teaching about scheduled procedures several days in advance B. Assign the child the task of checking her blood sugar before meals C. Keep all medical equipment out of sight except when in use D. Apply adhesive bandages after every type of skin puncture

✔ B. Assign the child the task of checking her blood sugar before meals School-aged children are in Erikson's stage of Industry versus Inferiority. They are willing to accept and thrive when assigned the responsibility to perform simple tasks. Incorrect Answers: A. This action would be appropriate for an adolescent. School-aged children should receive teaching up to 1 day before the scheduled procedure to allow adequate time to process the information but not cause undue anxiety. C. This action would be appropriate for a toddler or a preschool-aged child. Children in these age groups typically exhibit animism, which is the belief that inanimate objects can assume life-like characteristics. D. This action would be appropriate when caring for a preschooler. Preschool-aged children are fearful of being injured or losing body parts.

A nurse is reinforcing education with the parent of a toddler who has an acute vomiting illness. Which of the following interventions should the nurse include in the teaching? A. Maintain the child on bed rest in a supine position B. Brush the child's teeth after each emesis C. Keep the child NPO until the vomiting episodes stop D. Avoid carbohydrates when reintroducing solid foods

✔ B. Brush the child's teeth after each emesis The parent should brush the child's teeth or rinse the child's mouth to dilute the amount of hydrochloric acid that contacts the child's teeth. Incorrect Answers: A. The parents should keep the child in a side-lying position to decrease the risk of aspiration while vomiting. C. The parent should offer the child small frequent sips of fluid during the acute vomiting phase to decrease the risk of dehydration. D. Carbohydrates should be included in the fluids and foods offered to limit the breakdown of body protein to meet energy requirements.

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected leg every 4 hours C. Cleanse the pins every 12 hours D. Ask parents to discourage visitors for the child

✔ B. Check for pulses in the affected leg every 4 hours Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours. Incorrect Answers: A. The nurse should not move or adjust the weights to ensure proper alignment and correct healing. C. Buck's traction is skin traction, which works without the use of pins. D. A child who is in Buck's traction is not ill and should be encouraged to continue to socialize through various means.

A nurse is collecting data from a child who has stage I Hodgkin disease. Which of the following findings should the nurse expect? A. Generalized petechiae B. Enlarged lymph nodes C. Chronic vomiting D. Dependent edema

✔ B. Enlarged lymph nodes Manifestations of stage I Hodgkin disease include painless enlargement of lymph nodes. Incorrect Answers: A. Generalized petechiae are not a manifestation of Hodgkin disease. C. Chronic vomiting is not a manifestation of Hodgkin disease. D. Dependent edema is not a manifestation of Hodgkin disease.

A nurse is collecting data from a 12-year-old child during a well-child checkup. Which of the following physical findings should the nurse report to the provider? A. 5 cm (2 in) of growth in the past year B. Hyperopia C. Presence of pubic hair D. Weight gain of 3 kg (6.6 lb) in the last year

✔ B. Hyperopia The nurse should report hyperopia in a 12-year-old child to the provider. Hyperopia (farsightedness) is an unexpected finding after the age of 7. Incorrect Answers: A. The nurse should identify that 5 cm (2 in) of growth per year is an expected finding for school-aged children. C. The development of secondary sex characteristics, including the presence of pubic hair, can be an expected finding for a 12-year-old child. D. A weight gain of 2 to 3 kg (4.4 to 6.6 lb) per year is an expected finding for school-aged children.

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

✔ B. Inactivity and thumb-sucking This 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. Incorrect Answers: A. The protest stage is the first stage of separation anxiety, which includes crying and screaming. C. Denial or detachment is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. The protest stage is the first stage of separation anxiety, which includes the child attempting to escape the area to find the parent.

A nurse is collecting data during a well-child assessment of a 7-year-old child who takes great pride in bringing school papers home. This behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt

✔ B. Industry vs. inferiority The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-aged years (6 to 12 years). Incorrect Answers: A. Initiative vs. guilt is the developmental task of early childhood (3 to 6 years). C. Identity vs. role confusion is the task of the adolescent (13 to 19 years). D. Autonomy vs. shame and doubt is the developmental task of a toddler (12 months to 3 years).

A nurse is collecting data from a school-aged 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 further and report the findings to the provider. Incorrect Answers: A. Bruising of the right elbow is consistent with horseback riding injuries. B. A dislocated shoulder is consistent with horseback riding injuries. D. Abrasions on the wrists are consistent with horseback riding injuries, possibly caused by the reins wrapping around the wrists.

A nurse is caring for a toddler who has gastroenteritis caused by salmonella. Which of the following actions is the priority 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. Due to the safety risks involved, this client is at greatest risk for transmission of salmonella to others; therefore, this is the priority action the nurse should take. Incorrect Answers: A. Throughout the course of gastroenteritis, the nurse should monitor the child's weight so essential nutrition support can be provided. The nurse should weigh the child to evaluate the degree of weight loss; however, another action is the nurse's priority. C. Throughout the course of gastroenteritis, the child's skin must be protected. The nurse should establish a skin-care routine for the child; however, another action is the nurse's priority. D. The nurse should obtain a recent food history to determine how the child acquired the infection and the source of salmonella transmission; however, another action is the nurse's priority.

A nurse is reinforcing discharge teaching with the parents of a school-aged child who has nephrotic syndrome and a prescription for corticosteroid therapy. Which of the following home-care instructions should the nurse include? A. Restrict the child's potassium intake B. Keep the child away from people who have an infection C. Weigh the child once per week using the same scale D. Administer acetaminophen to the child daily

✔ B. Keep the child away from people who have an infection The nurse should instruct the parents to keep the child away from others who have or might have an infection. Children who have nephrotic syndrome are prescribed corticosteroids, which impair the immune system. Therefore, the child is at an increased risk of contracting an infection. Incorrect Answers: A. The nurse should instruct the parents to restrict the child's sodium intake rather than potassium intake. The parents should eliminate high-sodium foods from the child's diet and avoid the addition of salt to the child's food. The parents can resume a regular salt intake for the child after the acute phase of nephrotic syndrome has passed. C. The nurse should instruct the parents to weigh the child daily, at the same time of day, and with the child wearing the same clothing each time. The nurse should also remind the parents to notify the provider if the child's weight increases. D. The nurse should inform the parents that nephrotic syndrome does not cause pain. Therefore, there is no indication for administering acetaminophen on a daily basis, and doing so can cause additional stress to the child's kidneys.

A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A. Increased blood pressure B. Lanugo over the back C. Oily skin with acne D. Elevated body temperature

✔ B. Lanugo over the back The nurse should expect an adolescent who has anorexia nervosa to have lanugo present on the skin as a result of impaired metabolic activity. Other manifestations of anorexia nervosa include hypothermia, hypotension, and dry skin. Incorrect Answers: A. The nurse should expect an adolescent who has anorexia nervosa to have a decreased blood pressure. C. The nurse should expect an adolescent who has anorexia nervosa to have dry skin. D. The nurse should expect an adolescent who has anorexia nervosa to have hypothermia.

A nurse is inspecting the eyes of a 5-day-old infant. Which of the following is the correct technique for the nurse to use? A. Pull the conjunctiva downward and shine a pen-light at the pupil B. Lift the infant's head while the infant is lying in a supine position C. Confirm that light reflects evenly off both pupils using the light of an otoscope D. Pull the eyelids upward individually and slowly bring the index finger toward the infant's nose

✔ B. Lift the infant's head while the infant is lying in a supine position To inspect the eyes of an infant, the nurse should lay the infant in a supine position and lift the head. This maneuver usually causes the infant to open the eyes. Incorrect Answers: A. The nurse should not use this technique to inspect the infant's eyes. Infants can easily be assessed for a red reflex. However, infants cannot follow an object or light across the midline or follow a light into all 6 positions of gaze until they are about 3 months old. C. The Hirschberg test can screen for straight eye alignment and uses the light of an otoscope, which should reflect evenly off both pupils if they are in equal alignment. This is a corneal reflex and screening test that can be used to check whether an infant has strabismus. D. The nurse should not pull the eyelids upward since this could cause the infant discomfort. Checking the infant's ability to focus is done after 3 months of age.

A nurse is caring for a school-aged child who is hospitalized with acute poststreptococcal glomerular nephritis (APSGN). Which of the following interventions should the nurse perform? A. Restrict the child's activity to bed rest only B. Measure the blood pressure every 4 hours C. Encourage oral fluid intake D. Place the child in droplet precautions

✔ B. Measure the blood pressure every 4 hours Children with APSGN have a significant risk of developing acute hypertension. Therefore, the nurse should monitor the child's blood pressure every 4 to 6 hours during the acute phase of the disease. Incorrect Answers: A. Ambulation does not affect the course of APSGN, so the child can determine personal activity levels. Most children with this disorder will not feel well and will limit activities themselves. C. Children with APSGN are placed on fluid restriction due to the edema and exudate that occurs within the kidney in response to the renal disease. D. APSGN in a noninfectious renal disease. No special precautions need to be implemented.

A nurse is assisting with the care of an infant after a myelomeningocele repair. Which of the following is the priority postoperative 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 Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements. Increased head circumference is an indication that the infant is at greatest risk for increased intracranial pressure; therefore, the nurse should identify measuring the infant's head circumference as the priority action. Incorrect Answers: A. Measuring the infant's intake and output is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. C. Checking the infant's lower-extremity function is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. D. Monitoring the infant's blood pressure is an essential component of postoperative care. However, the greatest risk to this client is neurological complications. Therefore, this action is not the nurse's priority.

A nurse is collecting data from a 6-month-old infant. The guardian reports that the infant does not appear interested in the bright-colored mobile hanging above the crib. Which of the following techniques should the nurse use to check the infant's visual acuity? A. Shine a penlight briefly into the left and then the right eye B. Move a brightly colored toy from side to side in front of the infant's face C. Ask the guardian to sit in front of the infant and nod his head up and down D. Observe the infant's ability to grasp her feet and pull them to her mouth

✔ B. Move a brightly colored toy from side to side in front of the infant's face The nurse should check the infant's ability to see by positioning the infant upright, holding a brightly colored toy or object in front of the infant's face, and moving it from side to side. The nurse should observe the infant for the ability to fixate on the toy and track its movement. The nurse can also perform this data-collection technique using a human face as a visual target. Incorrect Answers: A. The nurse should use this technique to check for light perception and pupillary constriction; however, this technique does not check the infant's ability to see. C. The nurse can use the human face to check the infant's vision; however, up and down motions will not provide adequate data about the infant's ability to track movement. D. The nurse should observe the 6-month-old infant's ability to grasp her feet and pull them to her mouth when collecting data about the infant's gross motor development; however, the nurse should use a different technique to check the infant's visual acuity.

A nurse is reinforcing teaching with the guardian of a 10-year-old child whose weight is in the 95th percentile on a growth chart. Which of the following instructions should the nurse include A. Choose an exercise program for the child based on his abilities B. Plan a menu that provides the child with 1,200 calories each day C. Set a goal with the child to plan to lose weight over the next year D. Limit screen time to 3 hours per day

✔ B. Plan a menu that provides the child with 1,200 calories each day The child should take in about 1,200 calories per day to help him lose weight while still providing enough calories to form new body tissue for continued growth. Incorrect Answers: A. Children are much more likely to participate in an exercise program that they have selected and enjoy. C. School-aged children perform better when setting short-term goals rather than long-term goals. The guardian should assist the child in setting a goal of losing a small amount of weight in a shorter time period such as 2.25 kg (5 lb) in 1 month as opposed to 22.5 lb (50 lb) in 1 year. D. Children should limit television and other screen time to 1 to 3 hours per day

A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic spell while crying. Which of the following actions should the nurse take? A. Administer oxygen at 2 L via nasal cannula B. Position the infant in a knee-chest position C. Insert an intravenous catheter D. Instruct the parent to feed the child

✔ B. Position the infant in a knee-chest position Placing an infant with tetralogy of Fallot in a knee-chest position will increase systemic vascular resistance. This action will divert more blood to the pulmonary arteries, which will promote oxygenation in the infant. Incorrect Answers: A. The nurse should administer 100% oxygen via facemask to an infant who is experiencing a hypercyanotic spell. C. This action would not be appropriate during a hypercyanotic spell. Inserting an intravenous catheter would cause further agitation in the infant and prolong the hypercyanotic spell. D. Feeding the child would not be an appropriate action while the infant is experiencing a hypercyanotic spell. The nurse should first calm the infant and increase oxygenation by placing the infant in a knee-chest position and administering 100% oxygen.

A nurse is collecting data from a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed

✔ B. Test the nasal secretions for glucose The nurse should test the nasal secretions for glucose with a reagent strip to determine if the secretions are a leakage of cerebrospinal fluid (CSF). The leakage of CSF is positive for glucose and occurs if the child has a skull fracture. Incorrect Answers: A. The nurse should avoid performing nasotracheal suctioning. This procedure is contraindicated due to the risk of injury to the child's brain if a skull fracture is present. C. The nurse should avoid bright lights due the child's risk of increased intracranial pressure. The nurse should provide an environment with decreased stimulation. D. The nurse should position the child with the head of the bed elevated and the child's head in a midline position to assist with preventing increased intracranial pressure.

A nurse is reviewing the dynamics of a family in which abuse is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.

✔ B. The child has several unexplained scars and bruises. The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider. Incorrect Answers: A. Parents providing emotional support to the child is an expected finding. An unexpected finding would be the parents showing no emotion at all toward the child. C. A fear of health care staff is an expected finding in a child. An unexpected finding would be the child showing indiscriminate friendliness toward strangers such as the health care provider. D. Parents offering consistent stories about the child's injuries is an expected finding. An unexpected finding would be the parents presenting conflicting stories about the injury

A nurse in an acute pediatric unit is caring for a 2-year-old child who has separation anxiety when her parents leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse. B. The child is withdrawn and refuses to talk. C. The child attempts to run away to find her parents. D. The child screams and cries loudly.

✔ B. 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. Incorrect Answers: A. Physical attacks are a manifestation of the stage of protest. C. Attempting to run away to find her parents is a manifestation of the stage of protest. D. Screaming and loud crying are manifestations of the stage of protest.

A nurse in a pediatric clinic is collecting data from a preschooler during a well-child visit. Which of the following findings should the nurse report to the provider? A. The child is sitting on the exam table and talking to a stuffed animal B. The child's blood pressure is 122/80 mmHg C. The child is crying and states, ʺI don't want any medicine." D. The child's respiratory rate is 22/min

✔ B. The child's blood pressure is 122/80 mmHg The nurse should identify that this blood pressure measurement indicates significant hypertension, which requires further assessment to confirm. Therefore, the nurse should report this finding to the provider immediately. Incorrect Answers: A. According to Erikson's developmental theory, preschoolers typically develop a sense of initiative during this age period. Play and imagination are important during this stage of development, and the nurse should expect and encourage the child to continue these activities. C. According to Erikson's developmental theory, preschoolers typically develop a sense of initiative during this age and might exhibit assertive behavior. Preschoolers can associate going to a clinic or seeing a nurse with getting medication. The nurse should encourage the child to express feelings during this stage of development. D. A preschooler should have a respiratory rate between 20/min and 25/min. However, this rate can vary with activity level. The nurse should count a preschooler's respiratory rate for 1 minute.

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. Incorrect Answers: A. The nurse should inform the guardian that a preschooler is in the preoperative stage of cognitive development. Therefore, the child is not yet able to understand fully why an action is wrong. C. The nurse should inform the guardian that a preschooler is in the preoperative stage of cognitive development. Therefore, the child is not yet able to understand how consequences match misbehaviors. The nurse should recommend the guardian decide ahead of time what the consequence should be and then consistently follow through with that consequence if misbehavior occurs. D. The nurse should inform the guardian that assigning an extra chore for misbehavior is an example of an unrelated consequence and should provide the guardian with information about natural and logical consequences. A natural consequence occurs without intervention from the guardian (e.g. getting burned after touching a heater even though the child knows it is dangerous). A logical consequence is directly related to an established rule (e.g. not being allowed to have dessert until the child has eaten vegetables at dinner).

A nurse in a provider's office enters an examination room to collect data from 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 nurse should expect the infant to cling to the parent and turn away when approached by a stranger. Incorrect Answers: A. The nurse should expect social smiles to begin at 6 weeks of age; however, the nurse should not expect this from an 8-month-old infant upon initially entering the room due to the infant's expected fear of strangers. C. The nurse should not expect an 8-month-old infant to reach out to the nurse upon initially entering the room due to the infant's expected fear of strangers. D. The nurse should expect an 8-month-old infant to have a heightened fear of strangers. Once the infant is 12 months old, the nurse should expect an alert and responsive reaction to strangers once again.

A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups? A. Infants B. Toddlers C. Preschoolers D. School-aged children

✔ B. Toddlers Toddlers demonstrate parallel play. Incorrect Answers: A. Infants demonstrate solitary play. C. Preschoolers demonstrate associative play. D. School-aged children demonstrate cooperative play.

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. Incorrect Answers: A. A 7-year-old child prefers playing with groups of friends of the same gender. B. A child who is 8 to 9 years old understands the concept of cause and effect. D. A child who is 10 to 12 years old should be able to wash his or her hair independently. An 8-year-old child should be able to brush his or her own hair.

A nurse is teaching an adolescent client who has juvenile rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply cold compresses to relieve 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 who has idiopathic arthritis to attend school. The adolescent should attend school, even on days when she experiences joint pain or stiffness. Incorrect Answers: A. The nurse should instruct a client who has juvenile idiopathic arthritis to apply moist heat to relieve joint pain and stiffness. B. Opioid pain medications are not routinely prescribed for pain associated with juvenile idiopathic arthritis. The nurse should instruct the client to take NSAIDs on a routine schedule to maintain adequate therapeutic levels. D. There is no "arthritis diet" or certain foods for the adolescent to avoid to decrease symptoms of arthritis. However, to avoid excessive weight gain, the nurse should instruct the client to monitor and match her caloric intake to her individual energy needs.

A nurse is reinforcing teaching with the parent of an infant who has a talipes disorder and a new prescription for casts. Which of the following pieces of information should the nurse reinforce? A. "The casts will need to be changed once each month so your child's legs can grow as expected." B. "After the final casts are removed, no further treatment is needed to correct this disorder." C. "If casts do not correct your child's malformation, surgical correction might be necessary." D. "The casts that are used to correct this deformity decrease the risk of circulation problems."

✔ C. "If casts do not correct your child's malformation, surgical correction might be necessary." The nurse should reinforce with the parent that surgical correction might be recommended if the talipes disorder is not effectively corrected with casting. Incorrect Answers: A. The nurse should reinforce with the parent that the casts will need to be changed every 1 to 2 weeks due to the rapid growth expected during infancy. B. The nurse should reinforce with the parent that after the final casts are removed, the infant might require splints when sleeping or high-top shoes at night for continued treatment of the disorder. D. The nurse should reinforce with the parent that impaired circulation is a risk due to compression from the cast. The nurse should ensure the parents understand how to check the infant's circulation and identify indications of impaired circulation.

A nurse is talking with the parent of a 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further instructions? A. "I need to remind my older kids to keep small objects out of the baby's reach." B. "I let my baby play on her stomach when she is awake and I am watching." C. "My baby loves to play with the pillows in her crib." D. "I put my baby in a rear-facing car seat in the back seat of the car."

✔ C. "My baby loves to play with the pillows in her crib." Parents should never place pillows in an infant's crib since they pose a suffocation hazard. Incorrect Answers: A. This comment relates appropriate information about the fine motor development of 4-month-old infants. At this age, the infant is beginning to reach for and grasp objects and place them in her mouth. It is appropriate anticipatory guidance to start reminding older children at this time to keep small objects away from the infant's reach to keep her safe from a potential choking hazard. B. This comment relates appropriate information about the gross motor development of 4-month-old infants. Parents should encourage these infants to learn to explore their environment by crawling and rolling over. D. This comment relates appropriate information about use of the car seat for a 4-month-old infant. Until the child is 2 years old, she should be in a rear-facing car seat in the back seat of the car.

A nurse is reinforcing teaching with the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." C. "Structuring our daily routine will help our child." D. "Our child probably has this condition as a result of prematurity."

✔ C. "Structuring our daily routine will help our child." Children who have autism spectrum disorder benefit from a structured routine. This can help minimize the anxiety the child might have with sudden schedule changes and socialization requirements, as well as satisfy a preference for ritualistic behavior. Incorrect Answers: A. Donepezil might slow the progression of early onset Alzheimer's disease but is not indicated for autism spectrum disorder. B. Children with autism spectrum disorder demonstrate a limited interest in others and have difficulty with interpersonal interaction; therefore, individual therapy with a consistent caregiver is often preferred. D. There is no evidence that prematurity causes the development of autism spectrum disorder.

A nurse is reinforcing teaching with the guardians of an infant who has mild gastroesophageal reflux (GER). Which of the following instructions about feeding therapies should the nurse recommend? A. "Apply the infant's diaper snugly prior to feedings." B. "Administer nasogastric feedings." C. "Thicken feedings with rice cereal." D. "Place the infant in a lateral position for 1 hour after feedings."

✔ C. "Thicken feedings with rice cereal." The nurse should instruct the guardians about the correct way to thicken feedings with rice cereal. Thickened feedings with rice cereal decrease the infant's manifestations of GER and promote weight gain if needed. Incorrect Answers: A. The nurse should instruct the guardians to keep clothing and diapers loose around the infant's abdomen to decrease pressure on the stomach. Increased abdominal pressure increases the manifestations of GER. B. The nurse should inform the guardians that nasogastric feedings are indicated if GER becomes severe and the infant exhibits manifestations of failure to thrive. D. The nurse should instruct the guardians to hold the infant upright for at least 30 minutes after each feeding. This upright position helps decrease the infant's manifestations of GER.

A nurse in a provider's office is collecting data from an infant who was born at 32 weeks of gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate? A. 2 months B. 4 months C. 6 months D. 8 months

✔ C. 6 months This infant was born 8 weeks prematurely. The nurse should use this data to determine that the infant's setback age is 6 months. Therefore, the nurse should expect the infant to have achieved the developmental milestones of a 6-month-old infant. Incorrect Answers: A. Although the nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old, the nurse should expect this infant to be developmentally older than 2 months. B. Although the nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old, the nurse should expect this infant to be developmentally older than 4 months. D. The nurse should expect the infant to be developmentally younger than a full-term infant who is now 8 months old.

A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL C. A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%

✔ C. A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL The initial goal of therapy for diabetic ketoacidosis (DKA) is reaching a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the client's blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage. Incorrect Answers: A. An elevated WBC count is an expected finding with bacterial pneumonia. B. A low calcium level is an expected finding with chronic kidney disease. D. A decreased hematocrit is an expected finding with leukemia.

A nurse is coordinating care for an adolescent who requires peritoneal dialysis (PD) to treat an acute kidney injury. Which of the following actions should the nurse take? A. Obtain the adolescent's weight and vital signs once per day at the same time B. Immediately stop the PD infusion if the adolescent reports feeling uncomfortably full C. Ask if the adolescent would like to record the amount of solution infused and drained D. Reinforce teaching with the adolescent by emphasizing the right way to do things

✔ C. Ask if the adolescent would like to record the amount of solution infused and drained Allowing the adolescent to be involved in helping with the procedure gives the adolescent a sense of control over what is happening. Recording the amounts is an appropriate action for an adolescent. Incorrect Answers: A. Obtaining the adolescent's weight and vital signs upon admission provides baseline information for the nurse. However, the nurse should check the adolescent's vital signs before and after PD to maintain a precise record of all aspects of the treatment regimen and to help identify any complications that should be reported to the provider. B. The infusion should not be stopped because this is an expected finding during the infusion process. D. This would be appropriate for a school-aged child, but the adolescent needs to be taught how the procedure will be immediately beneficial. When the information being taught only explains how it will affect symptoms at some future date, the adolescent will not remember information as easily.

A nurse is contributing to the plan of care for a school-aged child with cystic fibrosis who is hospitalized. Which of the following should the nurse plan to include? A. Administer pancreatic enzymes 1 hour before each meal B. Offer the child a cough suppressant as needed C. Assist the child with choosing high-protein, high-fat foods for meals D. Provide chest physiotherapy once a day before bedtime

✔ C. Assist the child with choosing high-protein, high-fat foods for meals Children with cystic fibrosis have malabsorption and need to consume a high-protein, high-calorie diet with unlimited fat to promote adequate growth. Incorrect Answers: A. Pancreatic enzymes should be taken with each meal and immediately followed by a generous amount of fluid to promote movement of the medication from the oral cavity and into the digestive tract. B. A child with cystic fibrosis will benefit from coughing and expectorating respiratory secretions. Cough suppressants should be avoided for these children. D. A manifestation of cystic fibrosis is thick respiratory secretions. Chest physiotherapy (CPT) is an important component of care and is typically administered at least twice a day and more often as needed.

A nurse is reinforcing teaching with the guardian of a school-aged child who has diabetes mellitus about how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse describe as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output

✔ C. Deep, rapid respirations The nurse should identify that deep and rapid respirations are Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern results from the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. The child's breath can be sweet-smelling due to the body's attempt to eliminate ketones through the respiratory system. Incorrect Answers: A. A rapid heart rate is a manifestation of DKA. B. Sunken eyeballs are a manifestation of DKA, resulting from dehydration. D. Decreased urinary output is a manifestation of hypoglycemia. Increased urinary output is a manifestation of hyperglycemia, which can lead to DKA.

A nurse is collecting data from 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. Incorrect Answers: A. This finding indicates mild dehydration. A toddler experiencing severe dehydration would exhibit intense thirst. B. This finding indicates mild to moderate dehydration. A toddler experiencing severe dehydration would exhibit a capillary refill of 4 seconds or greater and skin tenting. D. This finding indicates moderate dehydration. A toddler experiencing severe dehydration would exhibit an absence of tears and sunken eyeballs.

A nurse is collecting data on an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? A. Clubbing of the fingernails B. Hypercyanotic spells C. Elevated blood pressure in the arms D. Cyanosis at rest

✔ C. Elevated blood pressure in the arms Coarctation of the aorta is an obstructive defect in which there is constriction of the aorta near the ductus arteriosus. This narrowing causes an increased pressure in the aorta prior to the defect, which causes the blood pressure in the arms to be higher than that of the lower extremities. Incorrect Answers: A. Clubbing of the fingernails is a long-term consequence of hypoxia. It would not be present in an infant. B. Hypercyanotic or TET spells are associated with the cardiac defect tetralogy of Fallot. They are caused by an increased amount of oxygenated blood entering the systemic circulation. Hypercyanotic spells are not associated with coarctation of the aorta. D. Cyanosis at rest is associated with cardiac defects, which interfere with the oxygenation of the blood when circulating through the heart. It is not associated with coarctation of the aorta, which is an obstructive cardiac defect.

A nurse is collecting data from an 18-month-old child 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. Incorrect Answers: A. The nurse should identify that the FACES pain scale is used for children aged 3 years and older. The scale is composed of 6 cartoon faces that range from smiling to crying with tears. B. The nurse should identify that the CRIES pain scale is used for preterm newborns. CRIES is an acronym for crying, requires increased oxygen, increased vital signs, expression, and sleeplessness. D. The nurse should identify that the Premature Infant Pain Profile (PIPP) is used for preterm newborns.

A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's psychosocial stages of development? A. Industry vs. inferiority B. Trust vs. mistrust C. Initiative vs. guilt D. Identity vs. role confusion

✔ C. Initiative vs. guilt A preschooler is in the developmental stage of initiative versus guilt. Preschoolers initiate play activities and experience a feeling of guilt if their efforts at independence receive a negative reaction from caregivers. Incorrect Answers: A. The nurse should identify that a school-aged child is in the developmental stage of industry versus inferiority. In this stage, the child takes initiative for learning and doing things well. Support and positive reinforcement foster the child's sense of pride, while a lack of appreciation can lead to a feeling of inferiority. B. The nurse should identify that an infant is in the developmental stage of trust versus mistrust. In this stage, a caregiver's response to the infant's needs builds trust and reassures the infant that his or her needs are being met. A caregiver who is inconsistent or rejecting can cause a feeling of mistrust. D. The nurse should identify that an adolescent is in the developmental stage of identity versus role confusion. In this stage, the adolescent combines his or her various roles and experiences into a personal identity. Failure to integrate these various images can lead to role confusion or uncertainty of identity or goals.

A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk for electrolyte imbalances compared to an adult client? A. Lower amount of extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

✔ C. Longer intestinal tract Compared to adults or older children, infants have a longer intestinal tract. This results in greater fluid losses, especially through diarrhea. Incorrect Answers: A. Compared with adults or older children, infants have more extracellular fluid. This results in a larger volume and more rapid water loss in this age group. B. Compared to adults or older children, infants have a larger body surface area. This results in greater fluid losses through insensible means. D. Compared to adults or older children, infants have an increased rate of metabolism. This results in more metabolic waste, which must be excreted by the kidneys.

A nurse in a provider's office is reinforcing teaching with the guardian of a preschooler who has cystic fibrosis. Which of the following instructions should the nurse reinforce? A. Ensure the preschooler takes a pancreatic enzyme 1 hour after each meal B. Provide the preschooler with a low-fat, high-fiber diet C. Monitor the preschooler for a decreased activity level D. Limit the preschooler's physical activity to 1 hour each day

✔ C. Monitor the preschooler for a decreased activity level Children who have cystic fibrosis might not exhibit the classic indications of a respiratory infection such as a fever, chest discomfort, or changes in respirations. Monitoring for subtle indications such as a decreased activity level, decreased appetite, and weight loss can ensure respiratory infections are promptly treated. Incorrect Answers: A. A child who has cystic fibrosis should take pancreatic enzymes prior to each meal and snack or within 30 minutes of eating so that the enzymes are available for digestion of the food consumed. B. High-calorie, high-protein diets without a restriction on fat intake are recommended for clients with cystic fibrosis to meet the preschooler's energy needs and support pulmonary function. D. Children who have cystic fibrosis should be encouraged to engage in any physical activity that is safe and enjoyable for the child. Physical activity promotes the child's self-esteem and improves pulmonary function.

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

✔ C. Notify the provider immediately if the sclera becomes inflamed While 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. Incorrect Answers: A. The parent should clean secretions from the eye by wiping from the inner canthus towards the outer canthus and downward. B. Warm compresses can be applied to assist in removing dried secretions. However, the compress should not be left on the eye because it can enhance bacterial growth. D. Applying pressure to the inner canthus of the eye after the medication administration will block the lacrimal punctum. This will prevent the medication from flowing into the nasopharynx, causing an unpleasant taste.

A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procedure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure C. Obtain the adolescent's weight prior to the procedure D. Monitor the adolescent's vital signs every 4 hours during the procedure

✔ C. Obtain the adolescent's weight prior to the procedure The nurse should obtain a baseline weight prior to the initiation of the procedure and again following the procedure. Incorrect Answers: A. The nurse should elevate the head of the adolescent's bed to minimize upward pressure on the diaphragm from the dialysate. B. The nurse should have the adolescent empty his bladder prior to the procedure to allow maximum space in the anterior peritoneal cavity. The adolescent does not need to drink fluids prior to the procedure. D. The nurse should monitor the adolescent's vital signs at least every hour during the procedure.

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

✔ C. Plastic mirror The 4-month-old infant can recognize himself/herself and will also try 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. Incorrect Answers: A. This would be an appropriate choice for a 6- to 12-month-old infant. A 4-month-old infant cannot understand the pictures B. This would be an appropriate choice for a 6- to 12-month-old infant. A 4-month-old infant would not be able to manipulate the movable parts. D. This is an appropriate toy for a 9- to 12-month-old infant. A 4-month-old infant would not be able to perform the actions of pushing and pulling the toy.

A nurse at a community health department is discussing the nutritional needs of children with a group of parents and guardians. Which of the following pieces of information should the nurse include? A. Infants should be transitioned to low-calorie milk at 12 months. B. Preschoolers need 10 to 12 g of protein per day. C. Toddlers can be given up to 120 to 180 mL (4 to 6 oz) of juice per day. D. School-aged children should be encouraged to avoid afternoon snacks.

✔ C. Toddlers can be given up to 120 to 180 mL (4 to 6 oz) of juice per day. Parents should limit a toddler's juice intake to 120 to 180 mL per day because juice is high in sugar and takes the place of more important nutrients. Incorrect Answers: A. Infants and toddlers should avoid low-calorie milk because the dietary fat in milk is essential for the child's growth and development. B. Preschoolers need 13 to 19 g of protein per day to support growth and development. D. School-aged children usually prefer afternoon snacks but should be encouraged to make healthy food choices.

A nurse is reinforcing teaching with a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following statements should the nurse provide? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."

✔ D. "Toddlers do not have well-developed abdominal muscles." The abdominal muscles are immature and not well developed at this stage. Therefore, a toddler will commonly have a "potbellied" appearance. Incorrect Answers: A. Constipation is not the cause of the toddler's protruding abdomen. B. Toddlers are not growing as rapidly as they did in infancy, and weight gain does not cause a protruding abdomen. C. A spinal deformity is not the cause of a toddler's protruding abdomen.

A nurse is reinforcing teaching with the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include? A. "Common sites for an injection of epinephrine are the fatty tissue found in the upper arm and in the lower abdomen." B. "Administer epinephrine prior to giving your child peanut products in the future." C. "No further treatment is needed after injecting the epinephrine." D. "You will need to increase the dosage as your child gains weight."

✔ D. "You will need to increase the dosage as your child gains weight." Epinephrine is a weight-based medication that is available in dosages of 0.15 mg and 0.3 mg. As the child grows, it will be necessary to change the epinephrine dosage that is administered. Incorrect Answers: A. Injectable epinephrine is an intramuscular injection administered into the vastus lateralis muscle of the child's thigh. B. Oral immunotherapy might be attempted with a child who has had an anaphylactic reaction to a food product. This therapy involves the administration of minute amounts of the allergen to increase tolerance to the food. However, this is only done under medical supervision. The parents should avoid administering peanut products to the child and should only use the epinephrine when an allergic reaction occurs. C. The nurse should instruct the parents to notify emergency services following the administration of epinephrine because the child might experience a delayed reaction even if the epinephrine has been administered. This delayed reaction can result in respiratory or cardiac arrest.

A nurse is assisting the provider with a preschooler's annual exam. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make? A. "This amount of weight gain could likely indicate a serious problem." B. "This weight change seems to be the result of poor eating habits." C. "Your child should have gained double this amount in a year." D. "Your child's weight change is expected for this age group."

✔ D. "Your child's weight change is expected for this age group." The preschooler should gain about 2 to 3 kg (4.4 to 6.6 lb) each year. Therefore, the nurse should reassure the parent that this child's weight gain is an expected finding for the age group. Incorrect Answers: A. This weight gain does not indicate a serious problem. It could be a problem if the child had gained twice that amount, or if a child previously of average weight had lost weight. B. The nurse cannot assume inadequate nutrition or poor eating habits without assessing the child's usual intake and overall diet. C. The rate of weight gain typically slows during the preschool years, while the growth in height continues at a steady rate.

A nurse on a pediatric unit is assisting with the admission of 4 children from the emergency department. After receiving a verbal report from the nurse, for which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C. A child who has molluscum contagiosum D. A child who has pertussis

✔ D. A child who has pertussis The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis (whooping cough) is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include a fever, sneezing, and a severe productive cough that generally becomes worse before getting better. Incorrect Answers: A. Rocky Mountain spotted fever is a bacterial infection that is most commonly transmitted via a tick bite. Manifestations include a fever, myalgia, and a maculopapular rash that primarily appears on the wrists and ankles. The rash can spread to the palms of the hands and the soles of the feet. The nurse should plan to use standard precautions when caring for a child who has Rocky Mountain spotted fever. B. Roseola is a viral infection classified in the herpes virus family. Primary manifestations are a rash and a high fever. Other manifestations include lymphadenopathy, a sore throat, and a severe cough. The nurse should plan to use standard precautions when caring for a child who has roseola. C. Molluscum contagiosum is an infection caused by the poxvirus. Clinical manifestations include flesh-colored papules on the face, trunk, and extremities. Molluscum contagiosum is transmitted via direct skin-to-skin contact. Therefore, the nurse should initiate contact precautions when caring for a child who has molluscum contagiosum.

A nurse in the emergency department is assisting with the care of a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A. ​Naloxone B. Diphenhydramine C. Glucagon D. Acetylcysteine

✔ D. Acetylcysteine The nurse should expect to administer acetylcysteine to the child because it is an antidote to acetaminophen. Incorrect Answers: A. The nurse should expect to administer naloxone if the child is experiencing respiratory depression resulting from an opioid; however, naloxone is not indicated as a treatment for an overdose of acetaminophen. B. The nurse should expect to administer diphenhydramine if the child is experiencing an allergic reaction to a medication; however, diphenhydramine is not indicated as a treatment for an overdose of acetaminophen. C. The nurse should expect to administer glucagon if the child is experiencing hypoglycemia; however, glucagon is not indicated as a treatment for an overdose of acetaminophen.

A nurse is preparing to use the Oucher pain-rating scale to determine the pain level of a 3-year-old preschooler who is 24 hours postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Ask the child to choose the cartoon-like face with the expression that best indicates her level of pain B. Ask the child to choose the number from 0 to 10 along a line that best indicates her level of pain C. Ask the child to choose up to 4 large red poker chips to indicate her level of pain D. Ask the child to choose the photograph of a child's face that best indicates her level of pain

✔ D. Ask the child to choose the photograph of a child's face that best indicates her level of pain The Oucher pain rating scale uses 6 photographs of children's faces. The nurse should tell the child that the first photograph shows a child with "no hurt" and the sixth photograph shows a child experiencing "the worst hurt you could ever have." The child should point to the photograph that best indicates how they are feeling. The Oucher scale has several versions, including Hispanic American, African American, and Caucasian. The nurse should use the version that is the closest match to the child's cultural characteristics. Incorrect Answers: A. The FACES pain-rating scale uses cartoonlike facial expressions ranging from happy and smiling to sad and tearful to depict the amount of pain the child is feeling. The nurse should read the words underneath each face for the child to describe the level of pain that each face represents. B. The numeric analog pain scale uses a line with 0 at an end and 10 at the other; the numbers 1 through 9 are evenly marked in between these ends. The nurse should explain to the child that the left end of the line indicates "no pain" or "a little pain" and the right end of the line indicates "a lot of pain" to "the worst pain possible." This scale should be used with older children who can understand the terminology associated with the numbers. C. When using the Poker Chip tool, a nurse places 4 large red poker chips on the bedside table directly in front of the child in a horizontal line. The nurse should explain to the child that the chips are "pieces of hurt," with 1 chip indicating "a little bit of hurt" and all 4 poker chips indicating "the most hurt you could ever have." The nurse should then ask the child, "How many pieces of hurt do you have?"

A nurse is called to stand by at a high-risk delivery. After several pushes, the mother delivers the infant. Which of the following steps should the nurse take first following the delivery of the newborn? A. Complete Ballard scoring B. Obtain the infant's weight C. Place identification bands on the infant's wrist and ankle D. Assess the infant's heartbeat and breathing.

✔ D. Assess the infant's heartbeat and breathing. The first action the nurse should take when using the airway, breathing, circulation framework is to assess the infant's heartbeat and breathing. Any findings outside the expected reference range require action. Incorrect Answers: A. The nurse should complete the Ballard score to determine the gestational age of the infant; however, this is not the first action the nurse should take. B. The nurse should obtain the infant's weight for the birth record and to determine a baseline for future weights, which will help identify any problems with growth and development. However, this is not the first action the nurse should take. C. The nurse should apply identification bands on the infant's wrist and ankle. It serves as a safety mechanism to prevent infant abduction and is used as a form of identification prior to administering medications, treatments or performing assessments. However, it is not the first action the nurse should take.

A nurse is collecting data from a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection? A. Koplik spots B. Peripheral neuropathy C. Chancre D. Candidiasis

✔ D. Candidiasis Candidiasis (oral thrush) results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS. Incorrect Answers: A. Koplik spots are oral lesions that indicate rubeola. They are small, irregular spots with a blue/white center that appear on the buccal mucosa opposite the molars in the prodromal stage of measles. B. Peripheral neuropathy can develop as an adverse effect of medications used to treat AIDS; however, it is not an indication of an opportunistic infection. C. A chancre is a red, circumscribed, crusted oral lesion of the lip that is the primary manifestation of syphilis.

A nurse is reinforcing teaching with the parents of an infant who has a cleft palate. The parents ask the nurse how long they should wait before the infant should have corrective surgery. The nurse explains that the parents should wait no longer than 6 to 12 months to avoid which of the following outcomes? A. Repeated ear infections B. Nutritional deficits C. Immune system deficits D. Difficulty with language acquisition

✔ D. Difficulty with language acquisition Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With a cleft in the palate, these infants could develop poor speech habits. Incorrect Answers: A. Infants who have a cleft palate are at an increased risk for ear infections; however, this can persist even after the repair of the palate. B. Infants who have a cleft palate are at increased risk for poor nutrition due to feeding difficulties. However, there are multiple strategies to help the parents promote nutrition and to help the infant create a seal and generate suction to feed. C. Repair of a cleft palate does not affect the child's immune system. However, repairing the palate too soon can affect the skeletal growth of the mid portion of the child's face.

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 administration of the fluid

✔ D. Hold the infant's buttocks together after administration of the fluid Because the infant is incontinent, the nurse should hold the buttocks together for a short time to maintain retention of the enema. Incorrect Answers: A. Tap water is hypotonic and can cause a rapid fluid shift and fluid overload. An isotonic solution of 0.9% sodium chloride should be used. B. For an infant, the tubing should be inserted 2.5 cm (1 in) into the rectum for administration of the enema. C. The infant should be placed in a supine position with the buttocks over a bedpan and the head and back supported on pillows.

A nurse is caring for a toddler who is hospitalized. Which of the following interventions should the nurse take? A. Ask the toddler to state her name prior to administering the medication B. Secure a safety net to the moveable crib sides C. Brighten the child's room with latex balloon decorations D. Instruct visitors to notify the healthcare team before leaving the room

✔ D. Instruct visitors to notify the healthcare team before leaving the room The nurse needs to know when caregivers are leaving the child unattended so the nurse can ensure the child is safely situated in the bed. Incorrect Answers: A. The nurse should confirm the child's name by looking at an identification band. Toddlers might not know their full name or only answer to a nickname. B. Safety nets are used to prevent the toddler from climbing out of the crib and should be secured to immovable crib parts with a quick-release knot. C. Latex balloons pose a serious choking hazard to all children and should not be permitted.

A nurse is assisting with the care of 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 cardio-respiratory monitor

✔ D. Maintain a cardio-respiratory 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. Incorrect Answers: A. Pertussis causes paroxysms of coughing with frequent vomiting. Therefore, infants who have pertussis are at risk for fluid volume deficit. B. The nurse should apply warm compresses when caring for a child who has a mumps infection, which causes enlarged, painful parotid glands. C. The nurse should initiate standard and droplet precautions when providing care for a client who has pertussis.

A nurse is reinforcing anticipatory nutritional teaching with the caregivers of a 5-month-old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low-fat cow's milk at 6 months of age. B. Heat fruit juice before offering it to the infant. C. Introduce a new food every other day. D. Offer the infant finger foods such as crackers after 6 months of age.

✔ D. Offer the infant finger foods such as crackers after 6 months of age. Infants will acquire the coordination to begin self-feeding finger foods at around 6 months of age. Incorrect Answers: A. The nurse should instruct the caregivers to provide the infant with commercial iron-fortified formula or breast milk until 1 year of age. B. The nurse should instruct the caregivers to offer the infant cold fruit juice. Vitamin C enhances the absorption of iron, but heating the juice will destroy the vitamin C content. C. The nurse should instruct the caregivers to introduce new foods individually every 5 to 7 days to ensure the child does not have an adverse reaction to the food.

A nurse is contributing to the plan of care for a preschool-aged child who has Wilms tumor. Which of the following items should the nurse include in the plan of care prior to surgery? A. Strain the child's urine B. Monitor for postural hypotension prior to allowing the child to ambulate C. Log-roll the child when repositioning D. Place a sign above the bed that states "Do not palpate abdomen"

✔ D. Place a sign above the bed that states "Do not palpate abdomen" Wilms tumor is an encapsulated tumor typically involving only 1 of the child's kidneys. Palpation or pressure on the abdomen could cause the cancerous cells to spread to other parts of the body. The nurse should use extreme care when bathing and handling the child pre-operatively. Incorrect Answers: A. Wilms tumors can cause hematuria but do not cause the formation of renal calculi. B. Children who have Wilms tumor are at risk for hypertension due to an increased secretion of renin by the tumor. C. There is no indication to log roll when repositioning.

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

✔ D. RBC 6.8 million/uL Tetralogy of Fallot causes cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts. Incorrect Answers: A. A platelet count of 20,000/mm^3 is below the expected range. A child who has tetralogy of Fallot will not have a decreased platelet count. B. A WBC count of 4,000/mm^3 is below the expected reference range. A child who has tetralogy of Fallot will not have neutropenia. C. This TSH level is above the expected reference range. A child who has tetralogy of Fallot will not have changes in thyroid function.

A nurse is caring for an adolescent client whose weight is in the 76th percentile on a growth chart. Which of the following recommendations should the nurse make? A. Tell the client not to drink any sugar-sweetened drinks B. Instruct the parents to limit the adolescent's screen time to 30 hours per week C. Recommend that the family eat at restaurants that have salad bars available D. Suggest ways the family can participate in mealtimes together

✔ D. Suggest ways the family can participate in mealtimes together The nurse should recommend having frequent group meals in which everyone in the adolescent's household sits and eats together as an important behavioral modification to prevent obesity. Incorrect Answers: A. The nurse should recommend the client limit, not avoid, sugar-sweetened beverages in an effort to prevent obesity. B. The nurse should recommend that the adolescent's screen time, including television, be limited to 2 hours per day to encourage greater physical activity and to help prevent obesity. C. The nurse should recommend limiting eating at restaurants, regardless of what is offered. Salads can easily be made unhealthy by adding meats and high-fat dressings, so the availability of salad is not a guarantee of healthful eating.

A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? A. Tachypnea B. Dry mouth C. Flushed skin D. Tachycardia

✔ D. Tachycardia A rapid heart rate is a manifestation of hypoglycemia. Other manifestations the nurse should expect the child to exhibit include tremors, difficulty concentrating, dizziness, hunger, and irritability. Incorrect Answers: A. The nurse should identify that deep, rapid respirations are a manifestation of hyperglycemia. A child who is experiencing hypoglycemia will exhibit shallow respirations that are within the expected reference range. B. The nurse should identify that dry mucous membranes are a manifestation of hyperglycemia. A child who is experiencing hypoglycemia will exhibit moist, pink mucus membranes. C. The nurse should identify that flushed skin is a manifestation of hyperglycemia. A child who is experiencing hypoglycemia will exhibit pallor and diaphoresis.

A nurse is collecting data from a 24-month-old child at a well-child visit. Which of the following growth milestones should the nurse expect? A. The child can jump down from a chair independently B. The child walks upstairs alone using each foot after the other on each step C. When given a pencil, the child can make simple lines or strokes for crosses D. The child brings utensils to the mouth without rotating the hand

✔ D. The child brings utensils to the mouth without rotating the hand Around 18 months of age, the child should no longer rotate a spoon when bringing it to the mouth if the fine motor skills are developing as expected. Incorrect Answers: A. At 30 months of age, the child should be able to jump down from a chair unaided. B. At 24 months of age, the child is expected to walk upstairs alone, still using both feet on the same step at the same time. C. Making simple lines or strokes for crosses with a pencil is a fine motor skill that is typically developed at 30 months of age.

A nurse is caring for a child who has a vesicular rash for 6 days. The parents of the child ask the nurse what illness caused this rash. The nurse should explain the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella

✔ D. Varicella Children who have varicella might present with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over. Incorrect Answers: A. A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face. These become more confluent as the rash spreads to the lower areas of the body. B. Fifth disease usually begins with bright red cheeks, producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash. C. A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. Nurses recommend the DTaP immunization to aid in prevention of this disease.

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 take to assist with the child's care? (Select all that apply.) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Gather supplies for gastric lavage D. Assist with the insertion of an IV for morphine administration E. Apply a pulse oximeter

✔A. Identify how much cleaner was in the bottle ✔D. Assist with the insertion of an IV for morphine administration ✔E. Apply a pulse oximeter The nurse should ask the parent or guardian about the size of the container, how much cleaner was in the container prior to ingestion, and how much cleaner was 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 expect the provider to prescribe IV morphine or another strong analgesic to provide pain relief. Additionally, the child is at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level assists the nurse in identifying if the child's airway is becoming obscured. Incorrect Answers: B. Activated charcoal is contraindicated for the treatment of poisoning with a corrosive agent because these substances can burn tissue and allow the charcoal to infiltrate. C. Gastric lavage is contraindicated for the treatment of poisoning with a corrosive agent due to the risk of re-exposure of the upper gastrointestinal system to the corrosive substance, which can result in further injury.