family hesi

The nursing instructor asks the nursing student to describe the fine motor skills of a 3-year-old child. Which statement by the student indicates the need for further learning?

"A child of 3 years can skip on alternate feet, jump rope, and skate."

A nursing student is learning about expected postpartum anatomical and physiological changes. Which statement made by the nursing student indicates a need for further learning?

"After birth, the vagina gradually decreases in size and returns to its pre-pregnancy state."

The mother of a 10-year-old boy with mild scoliosis asks the nurse, "How long will my son have to continue his exercises before he's better?" How should the nurse respond?

"Even if he keeps doing the exercises, we won't know how much he's improved until he's fully grown."

Which parental statement indicates an understanding of the prevention of motor vehicle injury for a 5-year-old child?

"My child is not able to cross the street safely."

The parents of a child with recently diagnosed leukemia ask the nurse why their child has too many white blood cells. Which is the nurse's best response?

"The bone marrow is not controlling your child's white blood cell production as it should."

Which parent education would the nurse provide the mother of a 5-month-old boy who is concerned that her son no longer turns his head toward her breast when she touches his cheek?

"Usually this reflex disappears around 4 months."

The nurse is in the process of discharging a 9-year-old boy with recently diagnosed type 1 diabetes. Which parental statement would indicate a potential issue in future family dynamics?

"We know that our child is special, so we'll go easy on the discipline."

The father of a child who is dying of cancer asks the nurse whether he should tell his 7-year-old son that his sister is dying. What is the most appropriate response by the nurse?

"Your son probably doesn't understand death as we do but fears it just the same. He should be told the truth to let him prepare for his sister's death."

A 2-day-old infant who weighs 6 lb (2722 g) is fed formula every 4 hours. Newborns require about 73 mL of fluid per pound (454 g) of body weight each day. In light of this information, approximately how much formula would the infant receive at each feeding?

2 to 3 oz (60-90 mL)

The nurse is planning to teach a 9-year-old child with type 1 diabetes to perform blood glucose monitoring. Which information would the nurse use as a basis for the teaching?

A child this age can maintain the glucose level in the normal range by changing insulin needs accordingly.

A breast-feeding teenage mother is diagnosed with syphilis. Which would be the medication of choice for this client?

Benzathine penicillin

Which assessment would the nurse prioritize for a newborn with Down syndrome?

Cardiac irregularities for congenital heart disease

Which topics will the school nurse include in adolescent education on sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct.

Condom use Types of contraception Number of sexual partners

A child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure, but that the anemia can be treated with frequent blood transfusions. How do blood transfusions treat children with the diagnosis of thalassemia major?

Correct the anemia, but they may cause other problems

Which change in laboratory values and/or intake and output would the nurse expect after corticosteroid therapy for a 4-year-old child with nephrotic syndrome?

Decrease in proteinuria

An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. Which nursing intervention would be included to promote parent-infant attachment?

Demonstrating positive acceptance of the infant

The school nurse identifies an adolescent at risk for smoking due to peer pressure. Which interventions would be appropriate? Select all that apply. One, some, or all responses may be correct.

Discuss alternatives to smoking. Mention immediate physiological consequences. Suggest effective arguments to deal with peer pressure

Which is the most appropriate nursing action when caring for a 19-month-old boy who has been in the hospital for 2 weeks and becomes increasingly withdrawn and mute?

Encouraging the parents to stay with him as much as possible

Two siblings who live in a camp for migrant workers have contracted measles. The nurse, trying to determine which individuals had contact with the children, identifies those with immunity and assesses the probability of containing the measles to the camp. Which technique has the nurse used in managing this situation?

Epidemiological process

Which intervention would the nurse prioritize when planning a teaching program for a child who was recently diagnosed with type 1 diabetes?

Exploring the child's feelings about diabetes

The nurse is inspecting the abdomen of an 18-month-old child. Which methods would the nurse adopt to inspect for inguinal hernia? Select all that apply. One, some, or all responses may be correct.

Have the child blow a bubble. Get the child to laugh so as to raise the intra-abdominal pressure

Which action would the nurse take for a 4-year-old child who is called to the operating room for a planned myringotomy?

Having the parents accompany the child to the operating suite

A parent of a child asks the nurse how to tell the difference between measles (rubeola) and German measles (rubella). Which would the nurse tell the parent differentiates rubeola from rubella?

High fever and Koplik spots

A client measuring at 18 weeks' gestation visits the prenatal clinic stating that she is still very nauseated and vomits frequently. Physical examination reveals a brown vaginal discharge and a blood pressure of 148/90 mm Hg. There are absent fetal heart tones. Which condition does the nurse suspect the client is experiencing?

Hydatidiform mole

A neonate born at 36 weeks' gestation, weighing 4 lb 8 oz (2041 g), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/h. Why is it important for the nurse to check the neonate's voidings for specific gravity?

Infants under open radiant warmers are at risk for dehydration.

During the hourly assessment of an adolescent's intravenous (IV) line the nurse discovers that the IV did not deliver the prescribed amount during the past hour. Which would the nurse complete first?

Inspect the infusion setup.

Which statement is true regarding varicocele?

It causes elongation of the veins of the spermatic cord

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development?

It is where child's identity and roles are learned.

Which would the nurse recommend to a new mother when teaching her about the care of the newborn's umbilical cord area?

Leave the area untouched or clean with soap and water; then pat it dry.

Which assessment findings are suggestive of postpartum depression? Select all that apply. One, some, or all responses may be correct.

Lethargy Ambivalence Emotional lability

Spinal fusion is performed in an adolescent with scoliosis. Which postoperative nursing intervention is specifically related?

Log-rolling every 2 hours

Which clinical condition concerns the nurse the most for an obstetrical client with heart disease? Select all that apply. One, some, or all responses may be correct.

Obesity Anemia Hypertension emotional distress

Which foods increase the risk of aspiration or are choking hazards for toddlers? Select all that apply. One, some, or all responses may be correct.

Peas Nuts Correct

Which instructions would the nurse give to an overweight adolescent to promote weight loss? Select all that apply. One, some, or all responses may be correct.

Perform physical activities regularly. Eat small frequent meals throughout the day. Reduce the intake of sugar and sweetened beverages

Which safety measure would the nurse instruct parents to follow when their child is a toddler?

Place window guards on all windows.

A 10-year-old child who is developmentally delayed to a 3-year-old level is admitted to the hospital for surgery. Which approach to preoperative teaching would the nurse take for the child and parents?

Providing explanations at a preschooler's level of understanding

Which steps would the nurse take to measure the temperature of a 4-year-old child using an electronic infrared thermometer? Select all that apply. One, some, or all responses may be correct.

Pull the pinna up and out Avoid applying pressure to the ejection button Obtain the temperature from client's right ear if the nurse is right-handed.

Which test is used to diagnose trichomoniasis?

Saline wet smear test

In which position would the nurse place an infant while the infant is receiving intermittent nasogastric tube feedings?

Semi-Fowler

Which information would the nurse obtain in a health history for a sexually active 16-year-old to determine the client's risk for sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct.

Sexual practices Barrier protection use Gender of sexual partners Number of sexual partners Use of illicit drugs before sex

Which common concern of most parents of children with sickle cell anemia would the nurse address at a family education conference?

Sharing feelings regarding the transmission of the disorder

A nursing instructor asks a student to outline the factors that predispose adolescents to substance use. Which of these statements are correct? Select all that apply. One, some, or all responses may be correct.

Substance use makes them more mature. Using mood-altering substances creates a sense of well-being. Substance use will help them achieve increased levels of performance.

The nurse palpates a heavy, hard mass on the lateral aspect of the testis. Which treatment is contraindicated for this condition?

Testicular biopsy

Which is included in the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy?

Testing for congenital syphilis

Which is appropriate play for an 8-month-old infant? Select all that apply. One, some, or all responses may be correct.

Textured book Stuffed animal Hanging mobile

The nurse is assessing a female preterm neonate after delivery. Which assessment findings would the nurse document in the hospital electronic medical record of the infant? Select all that apply. One, some, or all responses may be correct.

The infant has a prominent clitoris The hair of the infant is fine and feathery The infant shows no resistance to the heel-to-ear maneuver

Which statements correctly states how toddlers are different from infants?

Toddlers grow at a slower rate.

A newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. How would the nurse remove the electrode?

Twisting the electrode counterclockwise until it is free

Which immunizations would the nurse expect a 5½-month-old infant to have already received if the immunization status is considered up to date?

Two doses of diphtheria, tetanus, and pertussis vaccine

trichomoniasis

an STD caused by a microscopic protozoan that results in infections of the vagina, urethra, and bladder

Which clinical condition is associated with lead poisoning?

anemia

A 10-year-old child sustained burns of the extremities in a house fire. During assessment of the child, which clinical finding would be of concern to the nurse?

burns around the mouth

Which are the leading causes of accidental death in infants under 1 year of age? Select all that apply. One, some, or all responses may be correct.

drowning, suffocation, motor-vehicle related accident

Which assessment finding in a newborn of 33 weeks' gestation alerts the nurse to notify the health care provider?

flaring nares

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching, seizures, cyanosis, abnormal respirations, and a short, shrill cry. Which complication would the nurse suspect?

intracranial hemorrhage

In addition to the regular pregnancy diet and prenatal vitamins and minerals, which supplements may be needed by a pregnant client with rheumatic heart disease? Select all that apply. One, some, or all responses may be correct.

iron folic acid

The nurse suspects that a newborn is experiencing opioid withdrawal. Which assessment finding supports this suspicion?

irritability and nasal congestion

Phenylketonuria

is an inborn error of metabolism that results in decreased metabolism of the amino acid phenylalanine

Which blood hormone level test would the nurse expect to be ordered on the postmenopausal client with galactorrhea?

prolactin

The nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection would the nurse be concerned about?

rubeola

Which is the priority topic when teaching the parents of a toddler-age client regarding the selection of toys?

safety

A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. Which significant adverse outcome during the first 48 hours would the nurse attempt to prevent?

shock

Which behavior would the nurse know is important to avoid in a 5-month-old child who had heart surgery to repair the defects associated with tetralogy of Fallot?

straining at stool

myringotomy

surgical incision into the eardrum, to relieve pressure or drain fluid

A male infant is born at 28 weeks' gestation weighing 2 lb 12 oz (1247 g). Which finding would the nurse expect to note when performing an assessment?

transparent red skin

Which preventable childhood communicable disease may lead to encephalitis?

varicella

Which are sources of lead the nurse would assess for when providing care to a child who is admitted with lead poisoning? Select all that apply. One, some, or all responses may be correct.

water, pottery, stained glass, collectible toys, vinyl miniblinds

The nurse is performing the Ortolani test on a newborn. Which finding indicates a positive result?

an audible click on abduction

Which prophylactic medication would the nurse anticipate administering to a pregnant client who has mitral valve stenosis during the intrapartum period?

antibiotic

During her first prenatal visit a client tells the nurse that she needed an exchange transfusion when she was born because of Rh incompatibility. How would the nurse respond to the client's question asking if her baby will also need a blood transfusion?

"Based on that history you are probably Rh positive and the baby would not be at risk for Rh incompatibility."

The nurse is educating the mother of a 1-year-old baby about an adequate child's diet plan. Which statement made indicates the need for further education?

"I should give low-fat or skimmed milk to the child until he or she is 2 years old."

The parents of a toddler with a right ventriculoperitoneal (VP) shunt for the treatment of hydrocephalus are taught about postoperative positioning. The nurse concludes that they understand the teaching when they state that they will place the toddler in which position?

Flat on the left side with the head and back supported

The nurse is teaching an adolescent female client with irregular menstruation about contraception. Which statements made by the client indicate the need for further education? Select all that apply. One, some, or all responses may be correct.

"The calendar method of oral contraception is most suitable for me." "Condoms do not offer protection against sexually transmitted infections." "Oral contraceptive pills offer protection from sexually transmitted infections."

A mother indicates to the nurse that she is concerned that her 20-month-old child's bedtime thumb-sucking will cause the teeth to protrude. How would the nurse respond?

"There is no reason to be concerned about the teeth protruding unless your child keeps sucking the thumb after the permanent teeth have come in."

A client who is scheduled for an amniocentesis tells the nurse, "I'm glad this test will be able to tell me whether or not my baby is well." How would the nurse respond?

"This test is useful in detecting potential defects caused by chromosomal errors."

The parent of an 18-month-old child reports, "My child is so difficult to please! He has temper tantrums and annoys me by throwing food from the table." Which is the best response by the nurse?

"Toddlers are learning to assert independence, and this behavior is expected at this age."

Which instructions would the nurse give to the parents of a toddler? Select all that apply. One, some, or all responses may be correct.

"You should serve finger foods to your child." "You should give graded independence to your child."

Which would the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)?

A low-phenylalanine diet is required

A multiparous client with a history of gestational hypertension and previous history of abruption is in the transition phase of labor. The electronic fetal monitor shows bradycardia, and a change is seen in the contour of the client's abdomen. Which is the nurse's immediate action?

Alerting staff to the need for immediate cesarean delivery

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. Which intervention would the nurse include in the plan of care?

Checking the child's level of consciousness hourly

A parent tearfully tells the nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." Which is the most appropriate response by the nurse?

Asking for more specific information related to the developmental delay

A 9-year-old child with type 1 diabetes is prone to having hypoglycemic episodes in the morning. Which intervention would be included in the school nurse's plan of care for this child?

Asking the child each day what was eaten for breakfast

Which steps are included in the emergency treatment of poisoning in a toddler? Select all that apply. One, some, or all responses may be correct.

Assess the victim. Identify the poison. Terminate the exposure. Prevent poison absorption.

Which is the appropriate nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?

Assist the client's coach in helping her with the use of breathing techniques.

Where would the nurse look for extra skinfolds when assessing a newborn for developmental dysplasia of the hip (DDH)?

Back of the thigh

Which clinical finding is associated with high-dose lead exposure?

Blindness

A client who is admitted for surgery for a ruptured tubal pregnancy tells the nurse that she has shoulder pain. Which condition is the nurse concerned about based on these manifestations?

Blood accumulation under the diaphragm

Which teaching would the nurse include for parents of an infant with phenylketonuria (PKU)?

Cognitive impairment occurs if PKU is untreated

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, which is the next nursing action?

Feeding the infant

One principle to be followed for children with type 1 diabetes is to provide for the variability of the child's activity. Which would the nurse teach the child about how to compensate for increased physical activity?

Eat more food when planning to exercise more than usual

The nurse is assessing a toddler and the dynamics of the child's family in which abuse is suspected. Which behaviors are expected? Select all that apply. One, some, or all responses may be correct.

The child cringes when approached The parents cannot explain previously healed injuries The child lies still while surveying the environment

A mother tells the nurse that her toddler has been found to have parasites (worms) and that the whole family will need to be treated. Which is the most likely type of worm infestation?

Pinworm (Enterobius)

Which intervention would the nurse include in the plan of care for a toddler-age child whose lead level is 18 mcg/dL?

Repeating laboratory tests at 1 month and then every 3 to 4 months

Which orders would the nurse expect to receive from the primary health care provider for the client at 10 weeks' gestation who has just been diagnosed with syphilis? Select all that apply. One, some, or all responses may be correct.

Screening and testing of sexual partners Intramuscular benzathine penicillin G, 2.4 million units, 1 dose

A 30-month-old toddler is brought to the emergency department in acute respiratory distress, and a diagnosis of laryngotracheobronchitis (viral croup) is made. Which is the most important equipment for the nurse to have available when the child is admitted to the pediatric unit?

Tracheotomy set

Which education would the nurse provide the parents of an infant with phenylketonuria (PKU) about the etiology of the condition?

This autosomal recessive disorder was inherited from parents who are carriers

Ortolani test

To detect hip dislocation or subluxation; Slowly abduct the thigh while maintaining axial pressure; With fingertips on the greater trochanter, exert a lever movement in the opposite direction so that your fingertips press the head of the femur back toward the acetabulum center. If the head of the femur slips back into the acetabulum with a palpable clunk when pressure is exerted, suspect hip subluxation or dislocation.

Which statements would the nurse provide to parents about the sleep patterns of children who range in age from 18 months to 36 months? Select all that apply. One, some, or all responses may be correct.

Total sleep averages 12 hours a day. During this period, the toddler may be unwilling to go to bed at night.

Which steps would the nurse take for managing an adolescent who sustained drug poisoning? Select all that apply. One, some, or all responses may be correct.

Turn the head of the client to the side Empty the mouth to clean the residue of the drug Call local poison control center before any intervention

Which education would the nurse provide the parents of a child with type 1 diabetes who ask why they should test the child's urine for ketones during periods of stress or illness, even though blood glucose testing is being done four times a day?

Urine should be tested for ketones during illness and when the blood glucose level is increased.

Which disease would the nurse suspect in a 16-year-old client with a history of multiple sexual partners who is complaining of increased vaginal discharge, intermittent vaginal bleeding, excessive bleeding during menstruation, and pain in the lower abdomen?

gonorrhea

Which herbal remedies sometimes used by clients of Mexican descent would the nurse include in the assessment process to determine the source of lead poisoning in a toddler? Select all that apply. One, some, or all responses may be correct.

greta, azarcon, tamarindo jellied fruit candy

Which common foods would the nurse expect to cause of an outbreak of Salmonella? Select all that apply. One, some, or all responses may be correct.

hamburgers soft boiled eggs

The nurse is assessing a client who is being admitted for surgical repair of a rectocele. Which signs or symptoms would the nurse expect the client to report? Select all that apply. One, some, or all responses may be correct.

painful intercourse bearing-down sensations

Which is a potential cause of fetal tachycardia when a client is in active labor?

increased maternal metabolism

A toddler is being discharged after myringotomy. Which potential complications would the nurse teach the child's parents to report? Select all that apply. One, some, or all responses may be correct.

increased pain lack of drainage

Which would the nurse consider carefully regarding a preterm infant's kidney function?

large amounts of urine are excreted

Which assessment would the nurse perform first in a child who is brought to the emergency department after sustaining a blow to the head while playing football after school?

level of consciousness

Which nursing intervention would the nurse provide for a 6-month-old infant with bronchiolitis?

Monitoring skin color, anterior fontanel, and vital signs