ATI Nursing Care of Children Practice A, RN Nursing Care of Children Practice 2019 A ATI

A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a preschooler. The nurse should recognize which of the following statements by the parent as a contraindication to receiving the immunization?

"My child received an immunoglobulin last month." The nurse should identify that a preschooler who received an immunoglobulin less than 1 month ago should not receive the MMR vaccine on this day. The nurse should instruct the parent to reschedule the immunization after 3 months have elapsed, since the child received passive immunity via administration of an immunoglobulin.

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching?

Apples The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.

A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions should the nurse take?

Apply pressure to the lacrimal punctum for 1 min following administration. The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

Apply topical analgesic cream to the site 1 hr prior to the procedure. The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.

A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development?

Birth weight doubled The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is collecting data from a toddler who has gastroesophageal reflex disease (GERD). Which of the following findings should the nurse expect?

Chronic cough The nurse should identify that a chronic cough is an expected finding in a child who has GERD.

A nurse in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take?

Cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings in an indication of early septic shock?

Temperature 39.1° C (102.4° F) The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.

A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider?

Vomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider.

A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent.

Determine if the child is breathing. Empty the child's mouth of remaining pills and residue. Identify the medication and dosage strength. Call a poison control center. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary. Then, the child's mouth should be emptied of pills and residue to prevent additional exposure to the medication. Next, the parent should identify the medication and dosage strength by looking at the medication container. Lastly, the parent should contact a poison control center for advice on the next course of action.

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death?

"At this age, your child likely believes his thoughts can cause another person's death." The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.

A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?

"I should keep my child indoors when I mow the yard." The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks.

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?

"I should secure the car seat using lower anchors and tethers instead of the seat belt." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following instructions should the nurse include?

"Keep your child away from crowded areas." The nurse should instruct the guardian to keep the child away from crowds and visitors who have an illness to decrease the risk for infection.

A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on her religious beliefs, she cannot receive a blood transfusion. Which of the following responses should the nurse make?

"Let's discuss the possibility of you needing a blood transfusion with your parents." The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?

"Let's talk about some of the ways you have handled previous stressors in your life." This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

A nurse is reinforcing teaching regarding the immunization schedule of a newborn. Which of the following statements made by the parent should the nurse recognize as an understanding of the newborn's immunization schedule?

"My baby will receive his next immunization when he is 2 months old." Newborns should receive the next scheduled immunization 2 months after birth.

A nurse is caring for a school-age girl who is being treated for frequent, severe UTI's. The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTI's?

"My daughter has bowel movements every 4 to 5 days." The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

"Put your child's finger under warm, running water prior to collecting blood." The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.

A nurse is reinforcing teaching with the guardian of a child who has scabies and a new prescription for permethrin 5% cream. Which of the following information should the nurse include?

"The medication will eliminate your child's itching within 2 to 3 weeks." The nurse should instruct the guardian that, although the medication kills the mites, itching can continue for 2 to 3 weeks following application of the medication.

A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching?

"We will turn the pot handles toward the back of the stove." The nurse should instruct the parents to turn pot handles toward the back of the stove to prevent the toddler from pulling a pot off the stove, resulting in a burn.

A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make?

"You can sign the consent form because you are married." The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age.

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and a new prescription for isotretinoin. Which of the following information should the nurse include?

"You will need to have two negative pregnancy tests prior to starting this medication." The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?

"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.)

-Ankle clonus -Exaggerated stretch reflexes -Contractures

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?

1 capsule

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in mL?

690 mL 1 oz = 30 mL

A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first?

A child who has a fever and nuchal rigidity A client who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

A unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point?

A. The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.

A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?

Absence of peristalsis The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning.

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?

Cuts an outlined shape using scissors. The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?

Denies discomfort during assessment of injuries. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?

First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.

A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider?

Hgb 8.5 g/dL A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan?

Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child.

A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis?

Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Mental confusion A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.

A nurse is reinforcing teaching with the parent of a child who has a new prescription for ferrous sulfate. The nurse should reinforce that the parent should administer the medication with which of the following fluids to enhance the medication absorption?

Orange juice The nurse should reinforce with the parent that administering ferrous sulfate with orange juice will enhance medication absorption.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?

Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

Place the child in a side-lying position. The nurse should place the child in a side-lying position to prevent aspiration.

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?

Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider?

Report of tingling in the right foot The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?

Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.

A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child?

Speak at the child's eye level. The nurse should instruct the guardian to speak at the child's eye level and ensure that there is adequate lighting on the speaker's face to facilitate lipreading and communication.

The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral?

Speech therapist The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.

A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding?

Stands on one foot for several seconds Standing on one foot for several seconds is an expected behavior for a toddler.

A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestations of splenic sequestration?

The nurse should observe the location over the infant's spleen (LUQ of abdomen) when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood.

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection?

Trim the child's fingernails short. The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under her nails and prevent reinfection.

A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye?

Urticaria The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer?

"A decrease in urine protein indicates that treatment is effective." The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.

A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first?

Administer pain medication to the client. According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?

Administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences.

A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack?

Albuterol The nurse should inform the parent to administer albuterol, a short-acting beta2 agonist, to the preschooler for acute asthma attacks.

A nurse is collecting data from a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?

BP 115/70 mm Hg The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider.

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening?

Bending forward with back parallel to the floor The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis?

Dry cough The nurse should identify that a dry cough is an early manifestation of pertussis.

A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?

Dry, hacking cough The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.

A nurse is reinforcing teaching about tracheostomy care with the parent of a toddler who has a temporary tracheostomy. Which of the following instructions should the nurse include in the teaching?

Ensure one finger fits between the ties and the neck. The nurse should instruct the parent that one finger should fit between the ties and the neck to ensure the tube is held securely in place.

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?

Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching?

Eye patch Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye.

A nurse is contributing to the plan of care for an adolescent client who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care?

Inform the client regarding routes of transmission. The nurse should inform the client about the transmission of HIV and how to prevent its spread.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?

Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

A nurse is reinforcing teaching with the parent of a child who has hemophilia and is experiencing acute hemarthrosis. Which of the following instructions should the nurse include in the teaching?

Keep the affected joints immobilized The nurse should reinforce with the parent to keep the child's affected joints elevated and immobilized to minimize bleeding. After the acute episode, the child should begin active range-of-motion exercises.

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider?

Lead 14 mcg/dL This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?

Loud, harsh murmur The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take?

Place the infant in semi-Fowler's position for 1 hr after the feeding. The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.

A nurse is reviewing the laboratory report of a preschooler who has a Wilm's tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider?

Platelet count 70,000/mm3 This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan?

Promote oxygen utilization The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue.

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer?

Tetanus, diphtheria toxoids, and acellular pertussis (Tdap) The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.

A nurse is collecting data about the dietary habits of an adolescent client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits?

The client skips eating dinner for track practice three times per week. The nurse should identify that adolescents are often at risk for developing poor eating habits. Skipping dinner twice each week puts this client at risk for nutritional deficits.

A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?

Weight loss of 10% The nurse should expect an infant who has severe dehydration to experience weight loss of 10% or greater.

A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.

A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

White rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet?

White rice The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats, fish, and dried beans.

A nurse is auscultating heart sounds on an infant. The nurse should identify this sound as which of the following? (Audio clip)

Sinus rhythm The nurse should identify this heart sound as sinus rhythm. The nurse should auscultate heart sounds at the apical impulse, which is at the left midclavicular line and fifth intercostal space. The expected heart sounds include S1, which is the closure of the atrioventricular valves, and S2, which is the closure of the semilunar valves.

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider?

Sodium 150 mEq/L Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.

A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching?

Spends a lot of time by herself Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age.

A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?

Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?

Tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?

Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.

A nurse is reinforcing teaching about injury prevention with the guardian of an infant. Which of the following statements by the guardian indicates an understanding of the teaching?

"I should make sure my baby's clothing does not have buttons on it." The nurse should instruct the guardian to avoid dressing the infant in clothing with buttons to reduce the risk of choking and aspiration.

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the parent indicates an understanding of the teaching?

"I will have my child sleep in knee, wrist, and hand splints." The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will make sure that electrical devices in the house are grounded." This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark.

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicates an understanding of the teaching?

"I will place a screen in front of the fireplace." The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?

"I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.

A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child's parents that the therapeutic effects of this medication can be evaluated by which of the following?

Amount and consistency of stools Recording the amount and consistency of the child's stools will help determine the effectiveness of pancrelipase, which is taken to decrease the bulk of feces.

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take?

Confirm that the pH of the stomach contents is 5 or less. The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?

Give morphine 0.05mg/kg IV A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occured?

Green, tarry stools Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?

Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take?

Have a suction canister and tubing available in the room. The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.

A nurse is assisting with the care of an infant who has spina bifida and recently had a ventriculoperitoneal shunt placed for hydrocephalus. Which of the following findings should the nurse identify as an indication of increased ICP?

High-pitched cry The nurse should identify that a high-pitched cry is an indication of increased intracranial pressure.

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect to observe first?

Hives The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.

A nurse is collecting data about a 4-year-old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities?

Hopping on one foot The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk factor for this disorder? (Select all that apply.)

Hypothyroidism The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. Cannabis use The nurse should identify that cannabis use is a risk factor for primary amenorrhea. Oral contraceptive use The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. Emotional stress The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment?

Laceration on the side of the torso A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.

A nurse is assisting with the care of a 3-year-old child who is prescribed a lumbar puncture. Which of the following actions should the nurse take to prevent complications?

Maintain the child in a flat position after the procedure. After a lumbar puncture, the optimal position for the client is flat and supine to prevent headaches.