NUR 234: Peds PrepU
A parent phones the healthcare provider's office stating that a 13-month-old infant has had diarrhea for 3 days and the parent is unsure what fluids to offer. Which suggestions would the nurse provide? Select all that apply.
Pedialyte & Water
A hospitalized infant, age 10 months, begins to choke while eating and quickly becomes unconscious. A foreign object isn't visible in the infant's airway, but respirations are absent and the pulse is 50 beats/minute and thready. The nurse attempts rescue breathing, but the ventilations are unsuccessful. What should the nurse do next?
Perform chest compressions
An experienced nurse is teaching a new nurse how to care for an infant undergoing phototherapy for hyperbilirubinemia. For which intervention should the experienced nurse provide further education to the new nurse?
Performing frequent visual assessment of jaundice
During a well-baby visit, a parent asks the nurse when the infant should start receiving solid foods. The nurse should instruct the parent to introduce which solid food first?
Rice cereal
Family members and friends stage an intervention for an alcoholic adolescent. The intervention is successful when the adolescent:
is motivated to enter an alcohol rehabilitation program.
The nurse is teaching a group of parents about the risk of airway obstruction in young children. What information is most appropriate for the nurse to share regarding the risk of airway obstruction?
"A small airway makes it easier for foreign objects to cause obstruction."
A nurse is teaching the parents of an infant with cystic fibrosis about chest percussion therapy. Which statement by the nurse is most accurate in explaining the rationale for using chest percussion on infants with cystic fibrosis?
"Chest percussion helps clear secretions out of the lungs."
A parent is concerned about spoiling a 2-month-old child by picking up the child each time the child cries. Which suggestion should the nurse offer?
"Continue to pick up the crying baby because young infants need cuddling and holding to meet their needs."
A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. What is most important for the nurse to ask the family about the baby's symptoms?
"Do you give the baby a bottle to take to bed?"
A client fell and broke an arm and had a cast applied. Which of these statements by the client indicates an immediate risk for compartment syndrome?
"I can't wiggle my fingers."
A nurse is teaching a caregiver how to administer antibiotics at home to a client with acute otitis media. Which statement by the caregiver indicates that teaching has been successful?
"I'll give the antibiotics for the full 10-day course of treatment."
The caregiver of a hospitalized 3-year-old client expresses concern because the client is wetting the bed. What should the nurse say?
"It's common for a child to exhibit regressive behavior when anxious or stressed."
A teenage mother brings her 1-year-old child to the pediatrician's office for a well-baby checkup. The mother says that her infant can't sit alone.
"Let's see about further developmental testing."
A 15-year-old client with a urinary tract infection is admitted to the facility. The adolescent tells the nurse she hopes she's pregnant. How should the nurse respond?
"Tell me what being pregnant would mean to you."
During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal?
"The baby's stools are bright yellow and soft."
A nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?
"You seem upset. Tell me about it."
The nurse receives a report on four infants (see graphic). Which infant should the nurse see first?
30 minutes, 40 weeks
A high-risk adolescent is given a tuberculin intradermal skin test to detect tuberculosis infection. How long after the test is administered should the results be evaluated?
48-72 hours
A physician prescribes 150 mg of ibuprofen for a toddler whose temperature did not decrease after receiving acetaminophen. The oral suspension available contains 100 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using one decimal place.
7.5 mL
When discharging a 5-month-old infant from the hospital, the nurse checks to see whether the parent's car restraint system for the infant is appropriate. Which restraint system would be safest?
A rear-facing infant safety seat in the middle of the back seat
A nurse is caring for a group of toddlers in a large urban hospital. When considering providing care, which clients require contact precautions? Select all that apply.
A toddler with scabies A toddler with a multidrug-resistant organism
A nurse discussing injury prevention with a group of workers at a daycare center is focusing on toddlers. When discussing this age-group, the nurse should stress that
Accidents are the leading cause of death among toddlers
The nurse is caring for a child with cystic fibrosis who is admitted to the floor with an upper respiratory tract infection. The child has labored breathing and a congested, nonproductive cough. What is the immediate priority for the nurse?
Airway
A 2-year-old client is brought to the emergency department with suspected croup. The client appears frightened and cries as the nurse approaches him. The nurse needs to assess the client's breath sounds. The best way to approach the client is to
Allow the client to handle the stethoscope before the nurse listens to the client's lungs
A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's
Apical pulse
An adolescent client reports right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. A physical examination reveals rebound tenderness and a positive psoas sign. Based on these findings, what should the nurse suspect?
Appendicitis
To establish a good interview relationship with an adolescent, which strategy is most appropriate?
Asking open-ended questions
A parent brings an infant to the health clinic for a well-baby checkup. During the assessment, the nurse measures the head circumference of the child and notes that there has been a rapid increase in size. What action should the nurse take next?
Assess for signs of increased intracranial pressure
The nurse is caring for a 9-month-old infant with severe diarrhea that has lasted 3 days and who displays evidence of severe dehydration with increased heart rate and decreased blood pressure. What nursing assessment is a priority?
Capillary refill time
The nurse provides care to a client with anogenital warts (HPV). The nurse teaches that anogenital warts increase an adolescent female's risk of which condition?
Cervical cancer
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first?
Clamp the catheter
A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study?
Colonoscopy with biopsy
An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care?
Determine whether the adolescent has developed a plan for committing suicide
A 13-year-old with anorexia nervosa is admitted to the facility for I.V. fluid therapy and nutritional management. The client is worried that the I.V. fluids will cause weight gain. Which nursing diagnosis is most appropriate?
Disturbed body image
A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate?
Elevating the foot of the bed
According to Erikson, the psychosocial task of adolescence is the development of a sense of identity. A nurse can best promote the development of a hospitalized adolescent by:
Encouraging peer visitation
The nurse is caring for two children in the same room. The parents of one child ask the nurse about the condition of the other child. What is the most appropriate response by the nurse?
Explain that giving information would violate confidentiality.
An infant is having a 2-month checkup at the pediatrician's office. The physician tells the parents that the infant is being assessed for Ortolani's sign (Clunk sound). The nurse explains that the presence of Ortolani's sign indicates dislocation of the:
Hip
The nurse is caring for a 10-year-old child who is newly diagnosed with type 1 diabetes mellitus. The nurse is teaching the parents how to recognize signs and symptoms of hyperglycemia. Which of the following is most important for the nurse to include as an initial symptom of hyperglycemia?
Increased thirst
At the health clinic, a sexually active 15-year-old girl tells a nurse she's worried that her parents may find out about her sexual activity. "They would never approve," she says. The nurse should formulate which nursing diagnosis?
Ineffective sexuality patterns related to parent's expectations
The nurse is teaching an adolescent how to self-administer insulin. Which of the following is a priority for the nurse to emphasize about insulin administration?
Insulin injections are administered in subcutaneous tissue
The nurse is assessing a 4-month-old client. For what finding will the nurse take immediate action?
Intercostal retractions on inspiration
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position?
Knee-to-chest
A nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements about infant development are true? Select all that apply.
Lack of visual coordination usually resolves by age 6 months A 6-month-old infant can usually roll from prone to spine and supine to prone positions A teething ring is appropriate for a 6 month old infant
A 2-year-old child has just been admitted to the floor and is displaying fear related to separation from the parents. What additional measures should the nurse implement to alleviate fear?
Leave a small light on at night
A caller asks the pediatric nurse about a child's status. This caller does not know the predetermined code word that would positively identify the caller as a person who could receive information about the child. The nurse should inform the caller that:
Nurses are not permitted to divulge information to a caller who doesn't know the code word for identification.
The best way for a nurse to assess pain in an 18-month-old client is to
Observe for behavioral changes
For a child with hemophilia, what is the most important nursing goal?
Prevent bleeding episodes
A child's physician orders a drug for home use. Before the child is discharged, the nurse should:
Provide the family with the drug's name, dosage, route, and frequency of administration
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit?
Sunken fontanel
The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal?
The client will reach his/her optimal level of functioning.
The nurse is caring for the following infant after surgery. Which short term goal is the priority?
The infant will remain infection free in the postoperative period
A mother who is visibly upset carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse's first action should be:
To take the infant and mother back to a treatment room
A parent calls the pediatric clinic to express concern over the child's eating habits. The parent says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of:
Toddlers
Which situation violates a hospitalized adolescent's right to confidentiality?
Two nurses talk about the adolescent on an elevator on their way to lunch
A nurse manager is reviewing charts of several toddlers on a pediatric unit. The manager notices that the weight of the toddlers has not been documented and decides to address the issue with the staff. Which is the most critical information for the nurse manager to share with the staff regarding this situation?
Undocumented weights could result in medication errors
A 10-month-old infant is admitted with a harsh, barking cough and respiratory stridor. What are the most appropriate precautions for the nurse to follow when caring for the child?
Use an isolation gown and gloves in the room
The nurse is caring for a child hospitalized with epiglottitis. What will the nurse assign as the highest priority nursing diagnosis?
ineffective airway clearance related to swelling of the epiglottis
A nurse is administering I.V. fluids to an infant. Infants receiving I.V. therapy are particularly vulnerable to:
Fluid overload
The nurse is caring for an infant with severe diarrhea that has lasted 3 days. The child has poor skin turgor and dry mucous membranes. What is the priority nursing diagnosis for the nurse to use when planning care for this child?
Fluid volume deficit
A mother brings her 4-month-old infant to the clinic for a wellness checkup. Which immunizations should the infant receive? Select all that apply.
Haemophilus influenzae type B (Hib) diphtheria, tetanus, and pertussis (DTaP) inactivated polio virus (IPV) rotavirus (RV) pneumococcal (PCV)
When examining school-age and adolescent clients, the nurse routinely screens for scoliosis. Which statement accurately summarizes how to perform this screening?
Have the client stand firmly on both feet and bend forward at the hips, with the trunk exposed
A nurse is teaching bicycle safety to a child and parents. What protective device should the nurse tell the parents is most important in preventing or lessening the severity of injury related to bicycle crashes?
Helmet
A nurse is assessing an 8-month-old infant during a wellness checkup. Which action is a normal developmental task for an infant this age?
Sitting without support
A caregiver tells the nurse that the 22-month-old client says no to everything. When scolded, the client gets angry and starts crying loudly but then immediately wants to be held. What is the best interpretation of this behavior?
This behavior is normal in a 2 year old
A 2-month-old infant is seen in the emergency department for symptoms of infection. The healthcare provider has prescribed an antibiotic via the IM route. In which location should the nurse administer the injection?
Vastus lateralis
A toddler is hospitalized for evaluation and management of congenital heart disease (CHD). During discharge preparation, the nurse should discuss which topic with the parents?
When to administer prophylactic antibiotics
The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider?
Potassium level of 6.5 mEq/L (6.5 mmol/L)
A school-age client begins to have a seizure while walking to the bathroom after an appendectomy. The nearby staff do not have the client's medical history. What is the nurse's first action?
Position the client on the side
