Exam 3

An infant is prescribed digoxin. What should the nurse explain to the parents regarding the action of this medication?

Slows and strengthens the heartbeat

The nurse is presenting nutritional information at a community health fair. Which suggestion should the nurse prioritize when illustrating proper nutrition for preschoolers?

Snacks throughout the day help the child meet nutritional requirements

A 4-year-old is going to finger paint for the first time. What is the best action for the adult supervisor of this activity?

Support whatever the child paints.

During a wellness care visit, the parents of a 2-year-old toddler report that they are struggling to deal with their toddler's daily and increasing number of tantrums. What information should be provided to the parents? Select all that apply.

Tantrums are a common occurrence for a toddler of this age. Maintaining a consistent daily routine can help to reduce tantrums. Ignoring the behavior is often helpful in reducing the duration of the tantrum.

A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following?

Teach parents about "back to sleep."

The nurse is caring for a couple who have just learned that their infant has a genetic disorder. Which of the following would be least appropriate for the nurse to do at this time?

Teaching the parents about the child's medical needs

The nurse is caring for a 4-week-old girl and her mother. Which of the following is the most appropriate subject for anticipatory guidance?

Telling how and when to introduce rice cereal

The 18-month-old has most likely attained which of the following gross motor skills?

The ability to walk independently.

What is the best explanation of Erikson's theory of psychosocial development during adolescence?

The adolescent faces many different decisions during the teen years concerning the future and the adult world.

The nurse is admitting a 15-year-old adolescent to the hospital pediatric unit. What does the nurse recognize as a priority for this adolescent?

The adolescent's need for privacy should be respected.

The nurse is assessing a 4-month-old boy during a scheduled visit. Which of the following findings might suggest a developmental problem?

The child does not babble or laugh.

The nurse is assessing a healthy 2-year-old client. Which assessment finding most concerns the nurse?

The child speaks in one-word sentences

The nurse caring for a 6-year-old patient enters the room to administer an oral medication in the form of a pill. The dad at the bedside looks at the pill and tells the nurse that his daughter has a hard time swallowing pills. Which of the following is the best response by the nurse?

The father is the best source of knowledge on medication administration for the child. The pharmacy should be called to determine if the pill might be crushed.

A mother asks the nurse if there is any way to prevent acute otitis media. What would the nurse state to the mother?

The frequency of otitis media is reduced in breast-fed infants.

The nurse is teaching a new mother about the development of sensory skills in her newborn. Which of the following would alert the mother to a sensory deficit in her child?

The newborn does not respond to a loud noise.

In teaching caregivers of preschool children, the nurse would reinforce that which activity would be most important for this age group?

The preschool child should be properly restrained when riding in a vehicle.

The physician has made a notation in the medical record of a 17-year-old that the teen is not demonstrating successful completion of Erikson's stages of development. What behavior would be consistent with this assessment?

The teen is uncertain and frequently unable to make decisions.

The nurse is teaching the parents of a 1-month-old girl with Down syndrome how to maintain good health for the child. Which instruction would the nurse be least likely to include?

Adhering to the special dietary needs of the child

The nurse is caring for a 20-month-old girl with equivocal bacterial otitis media, a severe earache, and a temperature of 39°C (102.2°F). Which intervention would the nurse expect to implement?

Administering antibiotics as soon as they're available

In working with the toddler, which of the following statements would be most appropriate to say to the toddler to decrease the behavior known as negativism?

"It is time for lunch, I am going to put your bib on."

A mother is concerned about her infant's spitting up. Which suggestion would be most appropriate?

"Keep the baby sitting up for about 30 minutes afterward."

The nurse is caring for a 3-year-old at a well-child checkup. The parent states that her child still has an afternoon nap but she has a friend whose toddler no longer naps in the afternoon. She is seeking advice on what do to. When providing anticipatory guidance to the parent about sleep patterns, what is the most appropriate response by the nurse?

"Often, the afternoon nap will be no longer needed after 4 years."

A child with attention deficit/hyperactivity disorder is prescribed long-actingmethylphenidate. Which of the following would the nurse include when teaching thechild and his parents about this drug?

"Take this drug every day in the morning when you wake up."

The nurse is providing anticipatory guidance to a mother of a 5-month-old boy about introducing solid foods. Which statement by the mother indicates that effective teaching has occurred?

"The cereal should be a fairly thin consistency at first."

The mother of a child having myringotomy tubes placed asks, "Will my son lose his hearing while the tubes are in place?" What is the nurse's best answer?

"The tubes are inserted into a section of eardrum in which the hearing is not affected."

A child having myringotomy tubes placed asks, "How and when will the tubes be removed?" What is your best response?

"The tubes remain in place for 6 to 12 months until they come out by themselves."

A new mother shows the nurse that her baby grasps her finger when she touches the baby's palm. How might the nurse respond to this information?

"This is a primitive reflex known as the palmar grasp."

The parent of a 6-month old infant asks the nurse for advice about his son's thumb sucking. What would be the nurse's best response to this parent?

"Thumb sucking is a healthy self-comforting activity."

A parent brings an 18-month-old child to the pediatrician's office for a well-child visit. The child has mild cerebral palsy that affects the child's gait. The nurse wants to assess the child's neuromuscular system. What is the best way for the nurse to make that assessment?

quietly observe the child at play while interviewing the parent

Parents of a 12-year-old child ask the clinic nurse, "How many hours of sleep should our child get?' The nurse should respond that 12-year-old children need how many hours of sleep at night?

9-10 hours

The nurse is preparing to administer ear drops to a 6-year-old. To ensure that the medication is instilled properly, the nurse does which of the following?

Pulls the pinna upward and back

The nurse is helping a new mother prepare for breastfeeding her infant. During which of the following newborn states of consciousness would the nurse recommended attempting the feeding?

Quiet alert state

The nurse has brought a group of preschoolers to the playroom to play. Which activity would the nurse predict the children to become involved in?

Pretending to be mommies and daddies in the playhouse

The nurse is examining a 5-year-old boy. Which of the following signs or symptoms is are liable first indication of respiratory illness in children?

Rapid, shallow breathing

Parents of a toddler describe how they handled their child's temper tantrum in a shopping mall. What action of the parents indicates need for additional teaching?

Reasoned with the child to stop the behavior

The nurse is caring for a preschool-aged child diagnosed with acute otitis media. Which intervention should be a priority for the nurse?

Relieving pain

The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which nursing diagnosis should the nurse use to guide care during the immediate postoperative period?

Risk for infection of incision line, related to disruption of skin barrier during surgery

The school nurse has been asked to begin teaching sex education in the 5th grade. The nurse should recognize that:

Sex can be presented as a normal part of growth and development

The nurse is caring for a 10-year-old girl in traction. The girl is experiencing muscle spasms associated with the traction. What would the nurse expect to administer if ordered?

diazepam

The nurse is talking to the parent of a 19-month-old toddler about setting limits and supervising activities. In which situation will the nurse recommend letting the toddler do as he or she pleases?

exploring one's body

The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal?

falls when bending over to touch toes

When providing guidance to the parents of a child with Down syndrome, which of the following would be most appropriate?

high fiber diet

According to Erikson, the adolescent develops his or her own sense of being an independent person with individual thoughts and goals. This stage is referred to as:

identity vs. role confusion.

A nurse is describing growth and development during the preschool period. What would the nurse identify as a predominant and heightened characteristic for this age group?

imagination

Which characteristic is true of cerebral palsy?

it appears at birth or during the first 2 years of life

A nurse is reading a journal article about adolescents and major causes of injuries in this age group. The nurse demonstrates understanding of this information by identifying which situation as the major cause of adolescent injuries?

motor vehicle crash

A father and his 4-year-old son are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the boy doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?

opening drawers in the room, pulling out supplies, and examining them

When teaching the parents of a child with phenylketonuria, the nurse would instruct them to include which of the following foods in the child's diet?

oranges

The nurse is conducting a well-child assessment of a 4-year-old. Which assessment finding warrants further investigation?

presence of 10 deciduous teeth (should have 20 at this age)

A nurse is conducting a physical exam of a 9 month old infant with a suspected neuromuscular disorder. Which finding would warrant further evaluation?

presence of moro reflex

The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurseanticipates which of the following as most helpful in determining the extent of thechild's hypoxia?

pulse ox

The nurse is speaking with the parent of a 4-year-old child. Which statement by the parent would suggest a need for further investigation?

"When we go to the park, my child never wants to play with the other children."

A 6-year-old girl is diagnosed with pulmonary stenosis. The mother asks the nurse what the likely treatment for this condition will involve. What should the nurse tell the mother?

Insertion of a catheter with an uninflated balloon tip into the affected valve, followed by inflation of the balloon to break up adhesions

The nurse is assessing a 4-year-old boy whose mother was 40 years old when he was born. Which of the following findings suggests this child has a genetic disorder?

Inspection reveals low-set ears with lobe creases

The nurse is caring for a pediatric client diagnosed with tetralogy of Fallot. After speaking with the physician, the parents state to the nurse, "The doctor said something about our child having too many red blood cells. We don't understand how that could happen?" What is the best response by the nurse?

"Your child's body is trying to compensate for the low blood oxygen levels from the heart defect by making more red blood cells, but this makes the heart actually work harder."

Frontals must be closed by what age?

2, if not closed by 2 this is concerning

A child diagnosed with acute otitis media has been given a prescription for benzocaine. The nurse is correct when she makes which statement?

"Benzocaine drops should be placed in your ear to numb it and reduce pain."

The nurse is caring for a 3-year-old boy. The parents are concerned that he is exhibitingsigns of cognitive delays. Which statement by the parents would lead the nurse tosuspect autism spectrum disorder rather than possible learning disability?

"He seems to be speaking words less and less frequently."

A 5-year-old develops an otitis media with effusion. Myringotomy tube insertion is scheduled. The mother asks, "Why does this have to be done at the hospital?" What would be your best response?

"He will need to lie still afterward, so he will need to remain at the hospital for a short time."

The nurse has finished teaching the parents of a 10-month-old male ways to prevent another acute otitis media infection. Which statement by the mother indicates she has the correct understanding of the information provided?

"I should continue to breastfeed my son because it lowers the incidence of acute otitis media."

After teaching the parents of a child with attention deficit/hyperactivity disorder about ways to control the child's behavior, the nurse determines a need for additional teaching when the parents state which of the following?

"If he misbehaves, we need to punish him instead of reward him."

A nursing instructor is preparing a class on chronic lung disease. Which of the following would the instructor include when describing this disorder?

It is seen most commonly in premature infants.

A child returns to the clinic after an episode of otitis externa, which has resolved. What would the nurse emphasize as the priority for preventing future episodes?

Keeping ear canals dry,

According to Eric Erikson, the developmental task of the toddler is developing autonomy. Which of the following describes Erikson's psychosocial development task for the toddler?

Learning to act on one's own

A group of students is reviewing material about ways parents can help to foster a child's self-esteem. The students demonstrate a need for additional studying when they identify which method?

Limiting the choices and decisions that the child makes

A nurse is administering digoxin to a 3-year-old. What would be a reason to hold the dose of digoxin?

Nausea and vomiting

A nurse is teaching the parents of a child diagnosed with cystic fibrosis about medication therapy. Which of the following would the nurse instruct the parents to administer orally?

Pancreatic enzymes

A 3-year-old is hospitalized unexpectedly and is frightened about the experience. What action could the nurse take to minimize the anxiety the child is experiencing?

Allow the child to handle the equipment before it is used on the child.

The nurse is assessing a 12-month-old boy with an English-speaking father and a Spanish-speaking mother. The boy does not say mama or dada yet. Which of the following is the priority intervention?

Asking the mother if the child uses Spanish words

The nurse is assessing a 2-year-old boy during a well child visit. The nurse correctly identifies the child's current stage of Erickson's growth and development as:

Autonomy versus shame and doubt

When observing a group of toddlers playing in a child care setting, it is noted that the toddlers are all playing with buckets and shovels but are not playing with each other. This type of play is referred to as:

Parallel play

The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which of the following is a recommended guideline that should be implemented?

Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola.

The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which of the following describes a developmental milestone occurring in infancy?

By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth.

A preschool-age child tells the nurse about an imaginary friend. The parents are concerned because the child refuses to do anything without the friend's help. Which nursing diagnosis is most applicable for the family?

Parental anxiety related to lack of understanding of childhood development (Fantasy play)

The nurse is assessing an infant and notes that the infant's urine has a musty odor.

Phenylketonuria

The nurse is providing anticipatory guidance for violence prevention to a group of parents with adolescents. Which parental action should the nurse include as the most effective in preventing suicide?

Checking for signs of depression or lack of friends

The nurse is preparing a presentation to a local community group about genetic disorders and the types of congenital anomalies that can occur. Which of the following would the nurse include as a major congenital anomaly?

Cleft palate

The nurse is providing anticipatory guidance to a mother to help promote healthy sleep for her 3-week old baby. Which of the following recommended guidelines might be included in the teaching plan?

Place the baby on his or her back when sleeping.

A nurse realizes safety teaching has been successful when the parents identify which action to help prevent the leading cause of death in preschoolers?

Placing the child in an approved car seat

The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level?

Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again.

When performing the physical examination of a child with cystic fibrosis, which of the following would the nurse expect to assess?

Decreased tactile fremitus

A 6-month-old girl weighs 14.7 pounds during a scheduled check-up. Her birth weight was 8 pounds. Which of the following is the priority nursing intervention?

Discussing the child's feeding patterns

The nurse is providing discharge teaching regarding formula preparation for a new mother. Which of the following guidelines would the nurse include in the teaching plan?

Do not add cereal to the formula in the bottle or sweeten the formula with honey.

In children with otitis media, a procedure known as a myringotomy may be performed. Which statement is most accurate regarding this procedure?

During this procedure, small tubes are inserted into the tympanic membrane.

A single mother with three young children is reluctant to leave her crying and upset 16-month-old daughter overnight in the hospital but needs to go home to care for the other children. Which suggestion from the nurse will best address the fears and concerns of both the child and mother?

Encourage the mother to give the child a personal item of the mother's to hold on to until she returns and to tell the child a specific time she will return, such as "when breakfast comes in the morning."

The nurse is assessing 2-year-old twins. The parent states, "My twins will not play together, only alongside each other." Which action will the nurse take first?

Explain that this is normal behavior for toddlers.

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time?

Improving hydration (because they are going to be vomiting alot )

A nurse is conducting a screening program for autism in infants and children. Which ofthe following would the nurse identify as a warning sign?

Inability to say a single word by 16 months

The nurse is planning care for an 8-month-old infant with a ventricular septal defect. Which nursing diagnosis should the nurse use to help guide the care for this patient?

Ineffective tissue perfusion related to inefficiency of the heart as a pump.

What advice should the nurse provide the parent of a toddler, regarding how to handle temper tantrums?

appear to ignore the child

The nurse is assessing a 3-year-old at a well-child visit and the child appears to be progressing well. Which activity will the nurse ask the child to attempt to appropriately assess the fine motor skills of this preschooler?

button clothes

The nurse is watching a 4-year-old child play with another preschool child. The children are playing a game with rules. The nurse notes that the child is demonstrating what type of play?

corporative play

A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and gives him a bottle of water. While he drinks, she notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?

pyloric stenosis

Which gross motor developmental milestone is least likely for a 2 year old?

rides tricycle

It is naptime and the caregiver of a 2-year-old says to her child, "I will help you put all of your stuffed animals in a row next to your bed just like we do every day." This statement is an example of:

ritualism

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as:

spastic

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

step

At a physical examination, a nurse asks the father of a 4-year-old how the boy is developing socially. The father sighs deeply and explains that his son has become increasingly argumentative when playing with his regular group of three friends. The nurse recognizes that this phenomenon is most likely due to:

testing and identification of group role. (Erickson)

A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?

tetralogy of fallot