NCLEX Pediatrics questions

A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or an unexplained fever within the past 2 months?

" 4 *Rationale:* Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse tells the mother that she should: 1. Keep the child in a room with dim lights. 2. Give the child warm baths to help prevent itching. 3. Allow the child to play outdoors, because sunlight will help the rash. 4. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever

. 1 *Rationale:* A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome. Warm baths and the sun will aggravate itching. In addition, the child needs to rest.

A nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder? 1. A child of Mexican descent 2. A child of Mediterranean descent 3. A child whose intake of iron is extremely poor 4. A child breast-fed by a mother with chronic anemia

2 *Rationale:* Beta-thalassemia is an autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations. Options 1, 3, and 4 are not risk factors for this disorder.

A nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which of the following items should the nurse place at the bedside? 1. Oxygen and a tongue depressor 2. A suction apparatus and oxygen 3. An airway and a tracheotomy set 4. An emergency cart and an oxygen mask

2 *Rationale:* Seizures cause a tightening of all body muscles that is followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after the seizure. Suctioning and oxygen are helpful to prevent choking and cyanosis. Option 1 is incorrect; a tongue depressor is not needed and nothing is placed into the client's mouth during a seizure because of the risk for injury. Option 3 is incorrect, because inserting a tracheostomy is not done. Option 4 is incorrect, because an emergency cart would not be left at the bedside; however, it would be available in the treatment room or on the nursing unit.

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease? 1. Platelet count 2. Hematocrit level 3. Hemoglobin level 4. Reticulocyte count

4 *Rationale:* A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells (RBCs) in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin and hematocrit levels and a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Increased reticulocyte counts occur in children with SCD because the life span of their sickled RBCs is shortened.

The primary goal to be included in the plan of care for a child who has cerebral palsy is to: 1. Eliminate the cause of the disease. 2. Improve muscle control and coordination. 3. Prevent the occurrence of emotional disturbances. 4. Maximize the child's assets and minimize the limitations.

4 *Rationale:* The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.

A child has a basilar skull fracture. Which of the following health care provider's prescriptions should the nurse question? 1. Restrict fluid intake. 2. Insert an indwelling urinary catheter. 3. Keep an intravenous (IV) line patent. 4. Suction via the nasotracheal route as needed

.*4 *Rationale:* Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary.

A nurse is assisting in developing a plan of care for a diagnosed with acute glomerulonephritis. The nurse includes which intervention in the plan of care? 1. Encourage limited activity and provide safety measures. 2. Force intake of oral fluids to prevent hypovolemic shock. 3. Catheterize the child to strictly monitor intake and output. 4. Encourage classmates to visit and to keep the child informed of school events.

1 *Rationale:* Activity is limited and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause a risk of infection. Fluids should not be forced. Visitors should be limited to allow for adequate rest.

After a tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child? 1. Yellow Jell-O 2. Cold ginger ale 3. Vanilla pudding 4. Cherry Popsicle

1 *Rationale:* After a tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided, because they may irritate the throat. Milk and milk products (pudding) are avoided, because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided, because they give the appearance of blood if the child vomits.

After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to: 1. Turn the child to the side. 2. Notify the RN or health care provider (HCP). 3. Administer the prescribed antiemetic. 4. Maintain nothing-by-mouth (NPO) status.

1 *Rationale:* After a tonsillectomy, if bleeding occurs, the child is turned to the side, and the RN or HCP is notified. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. The nurse tells the child to: 1. Drink a half a cup of orange juice before soccer practice. 2. Eat twice the amount that is normally eaten at lunchtime. 3. Take half of the amount of prescribed insulin on practice days. 4. Take the prescribed insulin at noontime rather than in the morning.

1 *Rationale:* An extra snack of 10 g to 15 g of carbohydrates eaten before activities and for every 30 to 45 minutes of activity will prevent hypoglycemia. A half cup of orange juice will provide the needed carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration, and meal amounts should not be doubled.

A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. "I will give my child cough syrup if a cough develops." 2. "During an attack, I will take my child to a cool location." 3. "I will give acetaminophen (Tylenol) if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

1 *Rationale:* Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

A nurse reinforces home-care instructions to the parents of a child with celiac disease. Which of the following food items would the nurse advise the parents to include in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

1 *Rationale:* Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which of the following is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication.

1 *Rationale:* Digoxin is effective within a narrow therapeutic range (0.5 to 2 ng/mL). Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats per minute in an infant, the nurse would withhold the dose and notify the registered nurse and health care provider. Options 2, 3, and 4 are incorrect actions.

A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately? 1. Temperature 100.9° F 2. Pulse 78 beats per minute 3. Blood pressure 110/70 mm Hg 4. Respirations 22 breaths per minute

1 *Rationale:* Fever may be an indication of an infection of the shunt, which is the primary concern in the postoperative period, related to a shunt insertion. All of the other vital signs are normal findings for this child.

A nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse plans to: 1. Restrict fluids, as prescribed. 2. Administer analgesics, as prescribed. 3. Care for the arteriovenous (AV) fistula. 4. Encourage the intake of foods that are high in potassium.

1 *Rationale:* HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be on fluid restrictions. Pain is not associated with HUS, and potassium would be restricted rather than encouraged if the child was anuric. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle accident for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP? 1. Nausea 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size

1 *Rationale:* Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

A nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by a parent would indicate a need for further teaching? 1. "Our child sleeps in our bedroom at night." 2. "We worry about injuries when our child has a seizure." 3. "Our child is involved in a swim program with neighbors and friends." 4. "Our babysitter just completed cardiopulmonary resuscitation (CPR) training."

1 *Rationale:* Parents are especially concerned about seizures that might go undetected at night. The nurse should suggest a baby monitor. Reassurance by the nurse should ensure parental confidence and decrease parental overprotection. Option 2 is a common concern. Options 3 and 4 demonstrate the parents' ability to choose respite care and activities appropriately. The parents need to be reminded that, as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care are appropriate to minimize complications.

A child has been diagnosed with Reye's syndrome. The nurse understands that a major symptom associated with Reye's syndrome is:+ 1. Persistent vomiting 2. Protein in the urine 3. Symptoms of hyperglycemia 4. A history of a Staphylococcus infection

1 *Rationale:* Persistent vomiting is a major symptom that is associated with increased intracranial pressure (ICP). Options 2, 3, and 4 are incorrect. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.

A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1. Rectal 2. Axillary 3. Electronic 4. Tympanic

1 *Rationale:* Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which of the following in the plan of care? 1. Initiating seizure precautions 2. Using a wheelchair for out-of-bed activities 3. Assisting the child with ambulation at all times 4. Avoiding contact with other children on the nursing unit

1 *Rationale:* Safety of the child is the nursing priority. Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. A thorough neurological assessment should be performed on the child, and the child's safety should be assessed before allowing the child to get out of bed without help. Assessment of the child's gait should be assessed daily. However, options 2 and 3 are not required unless functional deficits exist. Isolating the child, option 4, is not necessary.

A nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further instruction? 1. "I will place a steam vaporizer in my child's room." 2. "I will take my child out into the cool, humid night air." 3. "I will place a cool-mist humidifier in my child's room." 4. "I will place my child in a closed bathroom and allow my child to inhale steam from the running water."

1 *Rationale:* Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended as compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the cool, humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

An infant with congestive heart failure (CHF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output (I&O). Which is the best method for the nurse to use to monitor the urine output? 1. Weighing the diapers 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

1 *Rationale:* The best method to monitor urine output in an infant on diuretic therapy is to weigh the diapers. The weight of dry diapers is subtracted from the weight of wet diapers to determine the amount of urine excreted: 1 g is equivalent to 1 mL of urine. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the best method and places the infant at risk for infection.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position? 1. Prone 2. Supine 3. Trendelenburg's 4. High Fowler's

1 *Rationale:* The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action? 1. Notify the registered nurse of the finding. 2. Assess for other associated anomalies and document carefully. 3. Tell the mother and father that this may indicate spina bifida. 4. Recognize that this is normal in the neonate and continue the bath.

1 *Rationale:* The legal role of the LPN is to practice under the supervision of the registered nurse. In this instance, the tuft of hair may be indicative of a spinal anomaly, and the registered nurse should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this is the responsibility of the health care provider, if an anomaly is suspected or diagnosed. The LPN should take the priority intervention of notifying the registered nurse before documenting in the chart.

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse give to the mother to prevent the transmission of the disease? 1. "Disease transmission is unknown." 2. "The disease is transmitted through the urine and feces, so the other children should use a separate bathroom." 3. "The disease is transmitted through the respiratory tract, so the child should be isolated from the other children as much as possible." 4. "The disease is transmitted by contact with body fluids, so any items contaminated with body fluids need to discarded in a separate receptacle."

1 *Rationale:* The method of transmission of roseola is unknown. Options 2, 3, and 4 are not correct transmission routes of roseola.

A nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger and it returns to its original color in 2 seconds. Which action should be taken by the nurse? 1. Document the findings. 2. Notify the registered nurse (RN). 3. Prepare the child for bivalving the cast. 4. Elevate the extremity and recheck the capillary refill immediately.

1 *Rationale:* When checking capillary refill, the nurse would expect to note that a compressed nail bed will return to its original color in less than 3 seconds. Options 2, 3, and 4 are unnecessary actions.

A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? *Select all that apply.* 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child.

1 3 5 6. Insert a padded tongue blade into the child's mouth. *Rationale:* During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration, because saliva will drain out of the corner of the child's mouth. The child is not restrained, because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? *Select all that apply.* 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids

1,2,3,4 *Rationale:* Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

The nurse should implement which of the following in the care of a child who is having a seizure? *Select all that apply.* 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Insert an oral airway. 5. Place the child in a supine position. 6. Loosen clothing around the child's neck.

1,3,6 *Rationale:* During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

A nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? *Select all that apply.* 1. Restrict fluid intake. 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply nasal oxygen at 2 L per minute. 5. Provide a high-calorie, high-protein diet. 6. Administer meperidine (Demerol) 25 mg for pain.

1,6 *Rationale:* Sickle cell anemia is one of a group of diseases called hemoglobinopathies in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell, and insufficient oxygen causes the cells to assume a sickle shape; the cells become rigid and clumped together, thus obstructing capillary blood flow. Oral and intravenous fluids are important parts of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, which is a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Therefore, the nurse would question the prescriptions for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, high-protein diet are important parts of the treatment plan.

A nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

2 *Rationale:* Clinical manifestations of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse tells the mother to: 1. Use aspirin for pain relief. 2. Pad crib rails and table corners. 3. Use a soft toothbrush for dental hygiene. 4. Use a generous amount of lubricant when taking a temperature rectally.

2 *Rationale:* Establishment of an age-appropriate safe environment is of paramount importance for hemophiliac clients. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra "joint" padding on clothes, observing a mobile infant at all times, and keeping items that can be pulled down onto the infant out of reach. Use of a soft toothbrush is an appropriate measure for a child with hemophilia, but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophiliac individuals because of the risk of bleeding.

A nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis? 1. Hypotension 2. Red-brown urine 3. Low urinary specific gravity 4. A low blood urea nitrogen (BUN) level

2 *Rationale:* Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, and hypertension is also common. A mid to high urinary specific gravity is associated with glomerulonephritis. BUN levels may be elevated.

A nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care, knowing that this type of fracture involves: 1. The entire bone fractured straight across 2. A greater risk of infection than a simple fracture 3. One side of the bone being broken and the other side being bent 4. The bone being fractured but not producing a break in the skin

2 *Rationale:* In a compound (open) fracture, a wound in the skin leads to the broken bone, and there is an added danger of infection. Option 1 describes a transverse fracture. Option 3 describes a greenstick fracture. Option 4 describes a closed or simple fracture.

A nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse appropriately responds by saying: 1. The entire bone fractured straight across 2. A greater risk of infection than a simple fracture 3. One side of the bone being broken and the other side being bent 4. The bone being fractured but not producing a break in the skin

2 *Rationale:* It is important to give the mother information that addresses the issue that is the parent's concern. Most children experience remission with treatment. Options 1 and 3 are nontherapeutic and may add to the mother's guilt. Option 4 does not acknowledge the concern and is a stereotypical response.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child? 1. Nausea 2. Bradycardia 3. Bulging fontanel 4. Dilated scalp veins

2 *Rationale:* Late signs of increased ICP include a significant decrease in the level of consciousness, bradycardia, and fixed and dilated pupils. Nausea is an early sign of increased ICP. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant rather than in a 5-year-old child.

A nurse is assisting with performing admission data collection on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is: 1. Hypotension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2 *Rationale:* Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased, and the blood pressure is normal or slightly decreased.

A nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child? 1. Observing for nonverbal signs of pain 2. Using pillows to elevate the head and shoulders 3. Checking neurovascular status of the extremities 4. Placing the child on a stretcher and bringing the child to the playroom

2 *Rationale:* Pillows should not be used to elevate the head or shoulders of a child in a body cast because the pillows will thrust the child's chest against the cast and cause discomfort and respiratory difficulty. Neurovascular checks are a critical component of care to ensure that the cast is not causing circulatory compromise. The nurse should observe for nonverbal signs of pain and ask the older child if pain is experienced. A ride on a stretcher to the playroom or around the hospital provides changes of position and scenery.

The appropriate child position after a tonsillectomy is which of the following? 1. Supine position 2. Side-lying position 3. High Fowler's position 4. Trendelenburg's position

2 *Rationale:* The child should be placed in a semi-prone or side-lying position after tonsillectomy to facilitate drainage. Options 1, 3, and 4 will not achieve this goal.

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. After an x-ray, it is determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further instructions? 1. "The cast may feel warm as it dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow-dryer set on the cool setting may be used to dry it."

2 *Rationale:* The mother needs to be instructed to not use lotion or powders on the skin around the cast edges or inside the cast, because they can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate instructions.

A nurse has reinforced home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement, if made by the mother, indicates the need for further instructions? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after this surgery."

2 *Rationale:* The mother should be instructed that lotions and powders should not be applied to the incision site because these items can affect the skin integrity and the healing process. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

A nurse provides instruction to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further instructions? 1. "I need to use proper handwashing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions."

2 *Rationale:* The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

A nurse is caring for an 18-month-old child who has been vomiting. The appropriate position in which to place the child during naps and sleep time is: 1. A supine position 2. A side-lying position 3. Prone, with the head elevated 4. Prone, with the face turned to the side

2 *Rationale:* The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, and 4 will place the child at risk for aspiration if vomiting occurs.

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which of the following during this episode of nausea? 1. Low-calorie foods 2. Cool, clear liquids 3. Low-protein foods 4. The child's favorite foods

2 *Rationale:* When the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small amounts because small portions are usually better tolerated. Cool, clear fluids are also soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. It is best to offer small, frequent meals of high-protein and high-calorie content once the nausea has been controlled with medication or has subsided.

A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. *Select all that apply.* 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. 5. Contact the health care provider if the child complains of numbness or tingling in the extremity. 6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

2,5,6 *Rationale:* While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.

A nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is accurate? 1. Ten days after using the antibiotic ointment 2. One week after using the antibiotic ointment 3. Forty-eight hours after using the antibiotic ointment 4. Twenty-four hours after using the antibiotic ointment

3 *Rationale:* The child should not attend school for 24 to 48 hours after the initiation of systemic antibiotics or for 48 hours after the use of the antibiotic ointment. The school should be notified of the diagnosis. Therefore options 1, 2, and 4 are incorrect.

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. *Select all that apply.* 1. Call a code blue. 2. Notify the registered nurse. 3. Place the infant in a prone position. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask.

2456 *Rationale:* The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF? 1. Immunoglobulin 2. Red blood cell count 3. Antistreptolysin O titer 4. White blood cell count

3 *Rationale:* A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 4 will not assist in confirming the diagnosis of RF.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position in which to place this infant at this time is: 1. A flat position 2. A prone position 3. On his or her left side 4. On his or her right side

3 *Rationale:* After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case, it is best to place the infant on his or her left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

3 *Rationale:* Any child who exhibits the "3 Cs"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

A nurse is assigned to care for a child who is in skeletal traction. The nurse avoids which of the following when caring for the child? 1. Keeping the weights hanging freely 2. Ensuring that the ropes are in the pulleys 3. Placing the bed linens on the traction ropes 4. Ensuring that the weights are out of the child's reach

3 *Rationale:* Bed linens should not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, and 4 are appropriate measures when caring for a child who is in skeletal traction.

A nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers? 1. Soccer 2. Basketball 3. Swimming 4. Field hockey

3 *Rationale:* Children with hemophilia need to avoid contact sports and need to take precautions, such as wearing elbow and knee pads and helmets, when participating in other sports. The safest activity that will prevent injury is swimming.

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant? 1. DTaP (diphtheria, tetanus, acellular pertussis), MMR (measles, mumps, rubella), IPV (inactivated poliovirus vaccine) 2. MMR, Hib (Haemophilus influenzae type b), DTaP 3. DTaP, Hib, IPV, pneumococcal vaccine (PCV) 4. Varicella and hepatitis B vaccines

3 *Rationale:* DTaP, Hib, IPV, and PCV are administered at 4 months of age. DTaP is administered at 2 months, 4 months, 6 months, between 12 and 18 months, and between 4 and 6 years of age. Hib is administered at 2 months, 4 months, 6 months, and between 12 and 15 months of age. IPV is administered at 2 months, 4 months, 6 months, and between 4 and 6 years of age. The first dose of MMR is administered between 12 and 15 months of age; the second dose is administered at 4 to 6 years of age (if the second dose was not given by 4 to 6 years of age, it should be given at the next visit). The first dose of hepatitis B vaccine is administered between birth and 2 months, the second dose is administered between 1 and 4 months, and the third dose is administered between 6 and 18 months of age. Varicella zoster vaccine is administered between 12 and 18 months of age. PCV is administered at 2, 4, and 6 months of age and between 12 and 15 months of age.

A nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing that in this disorder: 1. A single vessel overrides both ventricles. 2. Frequent episodes of hypercyanotic spells occur. 3. There is no communication from the right atrium to the right ventricle. 4. There is no communication from the systemic and pulmonary circulations.

3 *Rationale:* In tricuspid atresia, there is no communication from the right atrium to the right ventricle. Option 1 describes truncus arteriosus. Option 4 describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot.

A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate?1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3 *Rationale:* The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

The nurse assists in planning care for a child who sustained a burn injury based on which of the following accurate statements? 1. Scarring is not as severe in a child as in an adult. 2. Children are at a lower risk of infection than adults because of their strong immune systems. 3. Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. 4. Infants and children are at decreased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

3 *Rationale:* Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. Scarring is more severe in a child; additionally, disturbed body image will be a distinct issue for a child or adolescent, especially as growth continues. An immature immune system presents an increased risk of infection for infants and young children. Infants and children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

The nurse provides instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. Which response by the nurse is accurate? 1. Respiratory isolation is not necessary. 2. Mumps is not transmitted by the respiratory system. 3. Respiratory precautions are indicated during the period of communicability. 4. Respiratory precautions are indicated for 18 days after the onset of parotid swelling.

3 *Rationale:* Mumps is transmitted via direct contact or droplets spread from an infected person and possibly by contact with urine. Respiratory precautions are indicated during the period of communicability. Options 1, 2, and 4 are incorrect.

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply an ice pack to the injection site. 4. Leave the injection site alone, because this always occurs.

3 *Rationale:* Occasionally tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with cool packs for the first 24 hours and followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention, but it is not specific to the subject of the question.

A nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further instructions? 1. "We need to encourage adequate fluid intake." 2. "Coughing spells may be triggered by dust or smoke." 3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." 4. "Good hand-washing techniques need to be instituted to prevent spreading the disease to others."

3 *Rationale:* Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 4 are components of home care instructions.

A nurse who is caring for a child with aplastic anemia reviews the laboratory results and notes a white blood cell (WBC) count of 6000 cells/ mm3 and a platelet count of 27,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care? 1. Encourage naps. 2. Encourage a diet high in iron. 3. Encourage quiet play activities. 4. Maintain strict isolation precautions.

3 *Rationale:* Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

A nurse is performing a neurovascular check on a child with a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should be taken by the nurse? 1. Elevate the extremity. 2. Document the findings. 3. Notify the health care provider (HCP). 4. Ambulate the child with crutches.

3 *Rationale:* Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding should be reported to the registered nurse or HCP. Options 1, 2, and 4 are inappropriate and would delay the required and immediate interventions.

A child is scheduled to receive a measles, mumps, and rubella (MMR) vaccine. The nurse who is preparing to administer the vaccine reviews the child's record. Which finding should make the nurse question the health care provider's prescription? 1. Recent recovery from a cold 2. A history of frequent respiratory infections 3. A history of an anaphylactic reaction to neomycin 4. A local reaction at the site of a previous MMR vaccine injection

3 *Rationale:* The MMR vaccine contains minute amounts of neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to the MMR vaccine. The general contraindication to all immunizations is a severe febrile illness. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is treated with cool packs for the first 24 hours after injection, and this is followed by warm or cool compresses if the inflammation persists.

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which of the following is the priority nursing action? 1. Increase oral fluids. 2. Document the finding. 3. Notify the registered nurse. 4. Place the infant supine in a side-lying position.

3 *Rationale:* The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanel may be a sign of increased ICP within the skull. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions. Although the nurse would document the finding, the first action is to report the finding to the registered nurse, who will then contact the health care provider.

Several children have contracted rubeola (measles) in a local school and the school nurse conducts a teaching session for the parents of the school-children. Which statement, if made by a mother, indicates a need for further teaching regarding this communicable disease? 1. "Small blue-white spots with a red base may appear in the mouth." 2. "The rash usually begins centrally and spreads downward to the limbs." 3. "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears." 4. "Respiratory symptoms such as a very runny nose, cough, and fever occur before the development of a rash.

3 *Rationale:* The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal (catarrhal) stage. Options 1, 2, and 4 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik spots. Option 3 describes the incubation period for rubella, not rubeola.

Which of the following assessment findings may indicate that a child had a tonic-clonic seizure during the night? 1. High-pitched cry 2. Blanched toenails 3. Blood on the pillow 4. Migraine headaches

3 *Rationale:* The complications associated with seizures include airway compromise, extremity and teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on the tongue. Seizures do not cause a high-pitched cry unless a tumor or intracranial pressure is the cause of the seizure diagnosis. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanching does not occur. Migraine headaches are not common in children with seizures.

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse understands that which diagnostic study will confirm this diagnosis? 1. A platelet count 2. A lumbar puncture 3. Bone marrow biopsy 4. White blood cell (WBC) count

3 *Rationale:* The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. The WBC count may be high or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that are indicative of central nervous system disease. An altered platelet count occurs as a result of chemotherapy.

A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse looks for which early sign of CHF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

3 *Rationale:* The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with CHF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with CHF, but it is also not an early sign.

A day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which of the following observations may be indicative of this condition? 1. The child has difficulty hearing. 2. The child does not respond when spoken to. 3. The child consistently tilts his or her head to see. 4. The child consistently turns his or her head to see.

3 *Rationale:* The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Options 1, 2, and 4 are not indicative of this condition.

A nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor that: 1. Hemophilia is a Y-linked hereditary disorder. 2. A splenectomy resolves the bleeding disorders. 3. Hemophilia A results from deficiency of factor VIII. 4. A bone marrow transplant is the treatment of choice.

3 *Rationale:* The term "hemophilia" refers to a group of bleeding disorders. The identification of the specific factor deficiencies allows for definitive treatment with replacement agents. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome, not the Y chromosome. Neither a bone marrow transplant nor splenectomy is used to treat this disorder.

A nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which of the following would be included in the plan? 1. Wear gloves when administering the eardrops. 2. Pull the ear up and back before instilling the eardrops. 3. Pull the earlobe down and back before instilling the ear drops. 4. Hold the child in a sitting position when administering the ear drops.

3 *Rationale:* When administering eardrops to a child who is less than 3 years old, the ear should be pulled down and back. For children who are more than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but handwashing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

A mother of a 6-year-old child with type 1 diabetes mellitus calls the clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it showed positive ketones. Which of the following would the nurse instruct the mother to do? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3 *Rationale:* When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to help with clearing them. The child should be encouraged to drink liquids. It is not necessary to bring the child to the clinic immediately, and insulin doses should not be adjusted or changed.

Choose the interventions for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL. *Select all that apply.* 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3,6 *Rationale:* Hypoglycemia is defined as a blood glucose level less than 70 mg/dL. Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If able, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; the rapid-releasing sugar (such as honey) is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste can be squeezed onto the gums, and the blood glucose level is retested. If the child does not improve within 15 minutes, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. In the hospital setting the nurse should be prepared to administer dextrose intravenously. Encouraging the child to ambulate and administering regular insulin will result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is: 1. Taking the apical pulse 2. Taking the blood pressure 3. Testing the urine for protein 4. Palpating the anterior fontanel

4 *Rationale:* A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

A nursing student is assigned to help administer immunizations to children in a clinic. The nursing instructor asks the student about the contraindications to receiving an immunization. Immunization is contraindicated in the presence of which condition? 1. A cold 2. Otitis media 3. Mild diarrhea 4. A severe febrile illness

4 *Rationale:* A severe febrile illness is a reason to delay immunization, but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea are not contraindications to immunization.

A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and thus to the need to notify the registered nurse? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) 4. A weight gain of 1 lb in 1 day

4 *Rationale:* A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of CHF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities.

A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. Which is the correct response by the nursing student? 1. "Bone marrow depression occurs because of the development of sickled cells." 2. "Sickled cells increase the blood flow through the body and cause a great deal of pain." 3. "The sickled cells mix with the unsickled cells and cause the immune system to become depressed." 4. "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."

4 *Rationale:* All the clinical manifestations of sickle cell disease are a result of the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation, most of the sickled red blood cells resume their normal shape. Options 1, 2, and 3 are inaccurate.

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse would question this prescription if the child had documented evidence of which condition?1. Arthralgia 2. Joint pain 3. Facial edema 4. A viral infection

4 *Rationale:* Anti-inflammatory agents, including aspirin, may be prescribed by the health care provider for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections such as influenza because of the risk of Reye's syndrome. Options 1 and 2 are clinical manifestations of RF. Facial edema may be associated with the development of a cardiac complication.

A child with a fractured femur is placed in Buck's skin traction and the nurse is planning care for the client. Which information about this type of traction is correct? 1. Requires frequent pin care 2. Places the child at risk for infection 3. Uses skeletal traction and weights to provide a counterforce 4. Is a type of skin traction that pulls the hip and leg into extension

4 *Rationale:* Buck's skin traction is a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension. Countertraction is applied by the child's body. Options 1, 2, and 3 describe skeletal traction.

A nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is: 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by a difficulty in controlling the muscles

4 *Rationale:* Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis?1. A veggie salad and a caramel apple 2. A strawberry jelly sandwich and pretzels 3. A plate of nachos and cheese and a cupcake 4. A piece of fried chicken and a loaded baked potato

4 *Rationale:* Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. A piece of fried chicken and a loaded baked potato provides a high-calorie and high-protein meal that includes fat.

A nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which of the following symptoms led the mother to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. The regurgitation of feedings 4. Foul-smelling, ribbon-like stools

4 *Rationale:* Chronic constipation that begins during the first month of life and that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain and distention, and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are incorrect.

A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by: 1. Testing the child's urine for specific gravity 2. Asking the child what happens during a seizure 3. Obtaining a family history of psychiatric illness 4. Obtaining a history regarding factors that may occur beforethe seizure activity

4 *Rationale:* Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test, because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.

A nurse is reviewing the health record of a child who has been recently diagnosed with glomerulonephritis. Which finding noted in the child's record is associated with the diagnosis of glomerulonephritis? 1. The child fell off a bike and onto the handlebars. 2. The child has had nausea and vomiting for the last 24 hours. 3. The child had urticaria and itching for 1 week before diagnosis. 4. The child had a streptococcal throat infection 2 weeks before diagnosis.

4 *Rationale:* Group A β-hemolytic streptococcal infection is a cause of glomerulonephritis. The child often becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The data presented in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

A nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further instruction? 1. "It is extremely contagious." 2. "It is most common during humid weather." 3. "Lesions are most often located on the arms and chest." 4. "It begins in an area of broken skin, such as an insect bite."

4 *Rationale:* Impetigo is most common during the hot and humid summer months. It begins in an area of broken skin, such as an insect bite. It may be caused by Staphylococcus aureus, group A β-hemolytic streptococci, or a combination of these bacteria. It is extremely contagious. Lesions are most often located around the mouth and nose, but they may be present on the extremities.

A child is scheduled for a tonsillectomy. Which of the following would present the highest risk of aspiration during surgery? 1. Difficulty swallowing 2. Bleeding during surgery 3. Exudate in the throat area 4. The presence of loose teeth

4 *Rationale:* In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect. Bleeding during surgery will be controlled via packing and suction as needed.

A nurse is assisting in preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which dietary intervention is most appropriate for this child? 1. Provide a high-salt diet. 2. Provide a high-protein diet. 3. Discourage visitors at mealtimes. 4. Encourage the child to eat in the playroom.

4 *Rationale:* Mealtimes should center on pleasurable socialization. The child should be encouraged to eat meals with other children on the unit. A diet that is normal in protein with a sodium restriction is normally prescribed for a child with nephrotic syndrome. Parents or other family members should be encouraged to be present at mealtimes with a hospitalized child.

A health care provider has prescribed oxygen as needed for a 10-year-old child with congestive heart failure (CHF). In which situation would the nurse administer the oxygen to the child? 1. When the child is sleeping 2. When changing the child's diapers 3. When the mother is holding the child 4. When drawing blood for the measurement of electrolyte levels

4 *Rationale:* Oxygen administration may be prescribed for the infant with CHF for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.

A nurse instructs the mother of a child with sickle cell disease regarding the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

4 *Rationale:* Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. The nurse bases the response on the fact that primary nocturnal enuresis: 1. Does not respond to treatment 2. Is caused by a psychiatric problem 3. Requires surgical intervention to improve the problem 4. Is common and most children will outgrow bed-wetting without therapeutic intervention

4 *Rationale:* Primary nocturnal enuresis is bedwetting and is described as occurring in a child that has never been dry at night for extended periods. It is common in children, most of whom will outgrow bedwetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system (CNS). It is not caused by a psychiatric problem. Behavioral conditioning with use of alarms has been used for treatment in the older child with nocturnal enuresis. A device that contains a moisture-sensitive alarm is worn on the child's pajamas. As the child starts to void, the alarm goes off, awakening the child. The alarm system may need to be used consistently over 15 weeks for resolution.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? 1. Enteric 2. Contact 3. Protective 4. Respiratory

4 *Rationale:* Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory precautions are required, and a mask is worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 2, and 3 are not indicated for rubeola.

A nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother? 1. The synthetic cast takes 24 hours to dry. 2. The synthetic cast is heavier than a plaster cast. 3. The synthetic cast is stronger than a plaster cast. 4. The synthetic cast allows for greater mobility than a plaster cast.

4 *Rationale:* Synthetic casts dry quickly (in less than 30 minutes) and are lighter than plaster casts. Synthetic casts allow for greater mobility than a plaster cast. However, synthetic casts are not as strong as plaster casts and are more expensive.

A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would the nurse expect to note in this child? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Blood and mucus in the stools

4 *Rationale:* The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. Vomiting may be present, but it is not projectile. Bright red blood and mucus are passed through the rectum and commonly described as currant jelly-like stools. Ribbon-like stools are not a manifestation of this disorder.

A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox? 1. The communicable period is unknown. 2. The communicable period ranges from 2 weeks or less up to several months. 3. The communicable period is 10 days before the onset of symptoms to 15 days after the rash appears. 4. The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.

4 *Rationale:* The communicable period for chickenpox is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions. In roseola the communicable period is unknown. Option 2 describes diphtheria. Option 3 describes rubella.

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which of the following is the priority nursing intervention? 1. Monitoring the output 2. Checking for hearing loss 3. Changing the body position every 2 hours 4. Providing a quiet atmosphere with dimmed lights

4 *Rationale:* The major elements of care for a child who has Reye's syndrome are to maintain effective cerebral perfusion and to control intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue and the neuron responses. Cerebral edema is a progressive part of this disease process. Hearing loss and output are not affected. Changing the body position every 2 hours would not directly affect the cerebral edema and intracranial pressure. The child should be in a head-elevated position to decrease the progression of the cerebral edema and to promote the drainage of cerebrospinal fluid.

A nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which of the following is the priority when performing this procedure? 1. Taking the temperature 2. Taking the blood pressure 3. Checking the apical heart rate 4. Checking the peripheral pulse in the affected arm

4 *Rationale:* The neurovascular check for tissue perfusion is performed on the toes or fingers distal to an injury or cast and includes checking peripheral pulse, color, capillary refill time, warmth, motion, and sensation. Options 1, 2, and 3 may be components of care, but they are not the priority in this situation.

A nurse reinforces home-care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further instructions? 1. "I will supervise my child closely." 2. "I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." 4. "I will avoid immunizations and dental hygiene treatments for my child."

4 *Rationale:* The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma (especially trauma that involves the joints), and they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

A nurse provides home care instructions to the parents of a child with congestive heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the health care provider." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."

4 *Rationale:* The parents need to be instructed that, if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed and it is not noticed until 4 hours later, the dose should not be administered.

A child is diagnosed with infectious mononucleosis. The nurse provides home-care instructions to the parents about the care of the child. Which information given by the nurse is accurate? 1. Maintain the child on bedrest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider if the child develops a fever. 4. Notify the HCP if the child develops abdominal or left shoulder pain.

4 *Rationale:* The parents need to be instructed to notify the HCP if abdominal pain (especially in the left upper quadrant) or it left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until the splenomegaly resolves. Bedrest is not necessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol).

A nurse provides home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further instruction? 1. "I need to check for jaundiced skin and eyes every day." 2. "I need to have my child nap during the day to provide rest." 3. "I need to decrease the stimuli at home to prevent intracranial pressure." 4. "I need to give frequent, small, nutritious meals if my child starts to vomit."

4 *Rationale:* The vomiting that occurs in Reye's syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small, frequent meals will not affect the amount of vomiting, and the health care provider is notified if vomiting occurs. Options 1, 2, and 3 are all correct statements. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver complications, which are characteristic of Reye's syndrome.