Maternal Child Online Book Questions Ch. 30
A, B, C
A 3-year-old client had blood drawn for lab work by the nurse. Which documentation would the nurse make for this procedure? (Select all that apply.) A. Procedure performed B. Type of specimen and its appearance C. Child's response D. Parent at bedside E. Client name
C
A 6-year-old client is scheduled for removal of her tonsils and adenoids. She appears anxious and is tearful. Which statement by the nurse would best alleviate her fears? A. "Your throat will be very sore afterward but I will need you to drink anyhow." B. "Someone will be with you when you go to surgery and when you wake up." C. "A special doctor will give you some medicine to make you sleep so you will not know anything that is happening." D. "You look scared. There is nothing to be afraid of."
A
A child is reporting pain where an IV infiltrated his hand earlier in the shift. The doctor orders warm compresses to the right hand every 4 hours. What precautions would the nurse implement for this client? A. Limit treatments to 20 minutes at a time. B. Use hot water on gauze for the warm compress. C. Heat the moistened towels in the microwave to heat them up each time. D. Have the parents apply the warm compress if the nurse is tied up elsewhere.
A
A newly admitted school-aged child has a temperature of 102 F (38.9 C) and the mother reports that she gave her acetaminophen just before coming to the hospital 2 hours ago. What non-pharmacologic intervention could the nurse implement to help bring the temperature down? A. Place the child in a gown or lightweight pajamas. B. Place several blankets on the child to encourage sweating to break the fever. C. Give the child a tepid sponge bath. D. Lower the room temperature to 62 F (16.6 C)
A, C, D, E
A toddler has a peripheral IV and has pulled it out twice on one shift. The nurse decides to apply an elbow restrain on the right arm to prevent the client from pulling the IV out again. What interventions would the nurse implement in caring for a client in elbow restrains? (Select all that apply.) A. Pin the restraint to the child's shirt for stability. B. Remove the restraint if the parent is in the room. C. Tongue depressors can be used to construct the restraint. D. Check the skin under the restraint every 1 to 2 hours. E. Ensure that the restraint does not go too high under the axillae.
A
Colin, age 1, has been admitted for an injury on his head that requires sutures to be placed. He is crying and trying to sit up when he is placed on the examining table. To keep him safe during the procedure, the nurse would choose which method to restrain him? A. Restrain him with a mummy restraint and release it as soon as the procedure is completed. B. Allow his caregiver to hold him during and after the procedure. C. Use a clove hitch restraint to keep his arms still and loosen them every 2 hours. D. Restrain him in a jacket restraint and release it every 15 minutes.
C, D, E
The nurse is preparing a client for an upcoming lumbar puncture (LP). What information would the nurse include in her instructions about the procedure? (Select all that apply.) A. An LP usually takes about 45 minutes to complete. B. The LP will be quite painful when the doctor sticks the needle in the child's back. C. The child has to be still during the procedure and the nurse will help with this. D. The child will feel something cold on his back when the doctor cleans it off. E. The child will need to remain quiet in bad for at least 1 hour following the LP.
B
Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which type of restraints would the nurse most likely use for this child? A. Clove hitch restraint B. Elbow restraint C. jacket restraint D. Mummy restraint
D
For which client would the nurse question the doctor's orders for a throat culture. A. A school-aged child with high fever and enlarged tonsils B. An adolescent with suspected strep infection C. An infant with the diagnosis of "rule out bronchiolitis" and fever D. A toddler suspected to have epiglottitis
A
The floor nurse is making rounds on her clients and discovers that an 8-month-old admitted with pneumonia has an oxygen saturation of 91% on room air. The physician has standing orders to keep saturations at 96% or above. Which oxygen delivery system would the nurse choose for this client? A. Nasal cannula B. Non-rebreather mask C. Face mask D. Oxygen tent
A
The nurse has assisted the provider in performing a spinal tap on a 6-month-old infant. Which of the following should the nurse include in documenting the procedure? A. The nurse documents the child's response to the procedure. B. The nurse documents any questions the caregivers asks. C. The nurse documents how the contaminated linen was disposed of. D. The nurse documents the method used to clean the equipment and procedure room.
C
The nurse needs to transport her preschool client to radiology for a chest x-ray. Which transportation device would be most appropriate? A. Wheelchair B. Stretcher C. Wagon D. Crib
A
The nurse is administering a prescribed bolus gavage feeding. Which action would be incorrect in performing this procedure? A. Verify placement by auscultating for sounds in the stomach when air is inserted. B. Flush the tube with water following the feeding and place the child in the right side. C. Aspirate, measure and return residual stomach contents. D. Elevate the child's head and shoulders during the feeding.
A, B, C
The nurse is reinforcing teaching with a group of caregivers regarding steps that can be taken to lower a child's elevated temperature. Which action would the nurse include in the discussion? (Select all that apply.) A. Encourage fluids B. Administer acetaminophen C. Lower the room temperature D. Dress in pajamas with sleeves and covered feet E. Bathe in warm water.
