NURA 403 peds quiz 1 study
Mary comes to a community parenting group complaining about the terrible twos. "My child says NO to everything I ask!". What should the nurse respond with? A. "Give them choices between two things like "do you want your milk in the red cup or blue cup", or let them decide on things that don't matter" B. "Tell your friends your child has an attitude, maybe they have ideas" C. "Make your spouse be the bad guy and enforce the rules" D. "Maybe they don't understand what NO means yet"
A. "Give them choices between two things like "do you want your milk in the red cup or blue cup", or let them decide on things that don't matter" This will allow the toddler to have the independence they seek in appropriate contexts
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will lock my medications in the medicine cabinet." B. "I will keep my child's crib mattress at the highest level." C. "I will turn pot handles to the side of my stove while cooking." D. "I will give my child syrup of ipecac if she swallows something poisonous."
A. "I will lock my medications in the medicine cabinet."
A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? A. Begin after the extrusion reflex has diminished. B. Introduce solids between 2 and 3 months of age. C. Wait until the infant's first tooth erupts. D. Add a sweetener such as light corn syrup to bland foods.
A. Begin after the extrusion reflex has diminished. The nurse should explain that the extrusion reflex results in food being pushed out of the mouth instead of being swallowed. The tongue extrusion reflex diminishes after 4 months of age.
A nurse goes to her daughter's preschool class for a Christmas party. She notices one of the children seems developmentally behind. Which example is evidence of a possible delay? A. The child tries to eat ice cream with their hands and does not respond to gentle correction B. The child talks about their food likes and dislikes C. The child switches feet when going up and down stairs D. The child asks many questions about Christmas and joins peers in making tree ornaments without being told
A. The child tries to eat ice cream with their hands and does not respond to gentle correction A preschooler should be able to use utensils at this stage. Other examples demonstrate age-appropriate behavior.
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to the body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.
A. The child views death as similar to sleep. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. Preschool-age children may think of death like sleep. Preschool-age children also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. Finally, preschool-age children sometimes believe that death is the result of guilt or a punishment for something they did, said, or thought.
A nurse is performing a physical assessment on a 12-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight. B. The infant's posterior fontanel is closed. C. The infant is unable to walk without support. D. A total of 6 teeth are present.
A. The infant's current weight is double his birth weight. The nurse should expect a 12-month-old infant's weight to be triple his birth weight; therefore, the nurse should report this finding to the provider.
A nurse is assessing an 18-month-old toddler during a well-child examination. Which of the following findings should the nurse report to the provider? A. The toddler is unable to remove his shoes B. The toddler is unable to draw a plus sign C. The toddler is unable to jump off a step D. The toddler is unable to turn 1 page of a book at a time
A. The toddler is unable to remove his shoes An 18-month-old toddler should be able to remove his or her own shoes, socks, and gloves. The nurse should report this finding to the provider.
A nurse is providing teaching to the guardian of an adolescent. The guardian reports that the adolescent sleeps about 10 hr on weekend nights. Which of the following responses should the nurse provide? A. "Your child should have a blood test to check for anemia." B. "Adolescents need more sleep due to rapid growth." C. "Your child should not be staying up so late at night." D. "If your child eats properly, this should not happen."
B. "Adolescents need more sleep due to rapid growth." The nurse should identify that sleeping 10 hours on weekend nights is an expected finding in adolescents, who need more sleep time than other age groups. Common reasons for the increased need for sleep include stress, busy schedules (e.g. extracurricular activities), and rapid physical growth.
A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? A. "Does your child wear a hat outdoors in cold weather?" B. "Does anyone smoke around or in the same house as your child?" C. "Have you given your child any aspirin recently?" D. "Is your child's diet high in gluten?"
B. "Does anyone smoke around or in the same house as your child?" Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space and prolongs the inflammation and impedes drainage from the ear.
A nurse is providing teaching to the guardian of a 9-month-old infant who has a new prescription for an oral liquid medication. Which of the following points should the nurse include in the teaching? A. "Mix the medication into a small amount of your infant's formula to disguise the taste." B. "Use an oral syringe to measure your infant's medicine accurately." C. "Position your infant supine when administering the medication." D. "Assist your infant with drinking the medicine from a small paper cup."
B. "Use an oral syringe to measure your infant's medicine accurately." An oral syringe is the best method for accurately measuring small amounts of liquid medications. Additionally, the syringe allows the caregiver to deposit small amounts of the medication along the side of the infant's tongue to decrease the risk of aspiration.
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro
B. Babinski The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits. Incorrect Answers:A. The stepping reflex, in which the infant takes reflexive steps when placed on his or her feet in an upright position, disappears by the age of 4 weeks. C. The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months. D. The Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.
A nurse is caring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? A. Discuss placement options for the newborn B. Encourage the parents to touch and care for the newborn C. Reassure the parents that everything will be fine D. Avoid talking about the newborn's defect until the parents bring up the subject
B. Encourage the parents to touch and care for the newborn Touching and caretaking will help the parents bond with the newborn.
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine B. Give the medication at the side of the infant's mouth C. Add the medication to a full bottle of the infant's formula D. Administer the medication slowly while holding the nares closed
B. Give the medication at the side of the infant's mouth When administering medications to an infant, a needleless oral syringe or medicine dropper is placed in the side of the mouth (i.e. in the buccal cavity alongside the tongue) to prevent gagging and aspiration.
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeping on hands and knees B. Inability to vocalize vowel sounds C. Using a crude pincer grasp D. Standing by holding onto a support
B. Inability to vocalize vowel sounds The infant should begin vocalizing vowel sounds at the age of 7 months. By the age of 10 months, the infant should be able to say at least 1 word like "mama".
A nurse is assessing a 6-month-old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infant's visual acuity? A. Shine a penlight briefly into the left eye and then the right eye B. Move a brightly colored toy from side to side in front of the infant's face C. Ask the guardian to sit in front of the infant and nod his head up and down D. Observe the infant's ability to grasp the feet and pull them to the mouth
B. Move a brightly colored toy from side to side in front of the infant's face The nurse should check the infant's ability to see by positioning the infant upright and holding a brightly colored toy or object in front of the infant's face and moving it from side to side. The nurse should observe the infant's ability to fixate on the toy and track its movement. The nurse can also perform this assessment using the human face as a visual target.
A nurse is assessing the dynamics of a family in which child maltreatment is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.
B. The child has several unexplained scars and bruises. The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider.
A nurse cringes when she sees a BCBA at the autism clinic working with a 4 year old on sorting and classification of flashcards by type. The child has had this as part of their programming, without mastery, for 6 months. The nurse knows it has not been mastered because... A. The BCBA offers skittles for correct answers, which aren't a potent enough reinforcer for the child B. The child must reach Piaget's concrete operational stage to complete this task, which occurs at 6-12 years of age C. The child just hasn't had enough teaching trials yet D. The BCBA hasn't captured the child's attention well enough during teaching
B. The child must reach Piaget's concrete operational stage to complete this task, which occurs at 6-12 years of age
A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? A. "A 7-year-old child prefers to play with children of a different gender." B. "A 6-year-old child should understand the concept of cause and effect." C. "A 6-year-old child should be able to count 13 coins." D. "An 8-year-old child should be able to wash his or her own hair independently."
C. "A 6-year-old child should be able to count 13 coins." A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands. Incorrect Answers: A. A 7-year-old child prefers playing with groups of friends of the same gender. B. A child who is 8 to 9 years old understands the concept of cause and effect. D. A child who is 10 to 12 years old should be able to wash his or her hair independently. An 8-year-old child should be able to brush his or her own hair.
A nurse is assessing a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and has a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A. 7 B. 8 C. 9 D. 10
C. 9 Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reflexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence of acrocyanosis.
A nurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. C. Call the poison control center. D. Induce vomiting.
C. Call the poison control center. According to evidence-based practice, the nurse should instruct the parents to call the poison control center, which will then identify what further actions the parents should take.
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should reply that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism
C. Object permanence Object permanence refers to the cognitive skill of knowing an object still exists even when out of sight. By discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.
A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position
C. Prepare concentrated sucrose for oral administration The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non-nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as an indicator for further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.
C. The child complains daily about going to school. Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children at this stage want to learn and master new concepts. If the child complains daily about going to school, further evaluation is warranted.
According to Erikson, during which phase of life does a child lean on their peer group as a bridge, and focus on independence? A) Preschool B) Toddlerhood C) School age D) Adolescence
D) Adolescence
A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. "My child has frequent mood swings." B. "My child has a very messy bedroom." C. "My child takes 1 to 2 showers per day." D. "My child spends 4 hours per day using online chat rooms." (LOL)
D. "My child spends 4 hours per day using online chat rooms." Adolescents may spend time using a computer, but parents should know what they are doing and who they are communicating with and limit the time. The American Academy of Pediatrics guidelines recommends 2 hours of screen time daily.
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4 oz of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 qt of skim milk each day."
D. "My infant drinks at least 2 qt of skim milk each day." As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect the child's intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids, which are needed for growth and development.
A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following replies should the nurse provide? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."
D. "Toddlers do not have well-developed abdominal muscles." The abdominal muscles are immature and minimally developed at this stage. Therefore, many toddlers have a "potbellied" appearance.
A nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make? A. "This amount of weight gain could likely indicate a serious problem." B. "This weight change seems to be the result of poor eating habits." C. "Your child should have gained double this amount in a year." D. "Your child's weight change is expected for this age group."
D. "Your child's weight change is expected for this age group." A preschooler should gain about 2 to 3 kg (4.4 to 6.6 lb) each year. Therefore, the nurse should reassure the parent that this child's weight gain is an expected finding for the age group.
A nurse is providing anticipatory nutritional guidance for the caregivers of a 5-month-old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low-fat cow's milk at 6 months of age. B. Heat fruit juice before offering it to the infant. C. Introduce a new food every other day. D. Allow the infant to try finger foods, such as crackers, after 6 months of age.
D. Allow the infant to try finger foods, such as crackers, after 6 months of age. The nurse should instruct the caregivers that infants will acquire the coordination to begin self-feeding finger foods at around 6 months of age.
A nurse is providing teaching to the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods in the infant's diet? A. After the rooting reflex disappears B. At 2 to 3 months of age C. After the infant's first tooth erupts D. At 4 to 6 months of age
D. At 4 to 6 months of age The nurse should identify that infants are developmentally ready for solid foods at 4 to 6 months of age. Incorrect Answers: A. The disappearance of the extrusion reflex, rather than the rooting reflex, is an indicator of the infant's developmental readiness for solid foods. B. Infants between 2 and 3 months of age still have the extrusion reflex and are not developmentally ready for solid foods. C. The timing of the eruption of the infant's first tooth varies greatly and t is not an appropriate indicator for introducing solid foods.
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers with blocks
D. Building towers with blocks Building towers with blocks is an appropriate activity for a 2-year-old child. and promotes fine-motor development. Also, knocking blocks down provides a means of dealing with the stress of hospitalization.
A nurse is caring for a 12-month-old infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? A. Spoon B. Straw C. Firm nipple D. Cup
D. Cup The infant should be fed clear liquids using a cup for 7 to 10 days following a cleft palate repair to prevent trauma and injury to the suture line. Incorrect Answers: A. Feeding the infant using a spoon is contraindicated following a cleft palate repair because placing objects in the mouth could rub or disturb the suture line. B. Feeding the infant using a straw is contraindicated following a cleft palate repair because placing objects in the mouth could rub or disturb the suture line. C. Feeding the infant using a firm nipple is contraindicated following a cleft palate repair because placing objects in the mouth could rub or disturb the suture line.
A nurse is planning preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure. B. Provide diagrams and pictures while explaining the procedure. C. Use correct medical terminology during the teaching session. D. Explain the procedure in terms of what the child will feel, see, hear, and taste.
D. Explain the procedure in terms of what the child will feel, see, hear, and taste. Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure.
A nurse is assessing the development of a 3-year-old child. Which of the following gross motor skills should the nurse expect the child to be able to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot
D. Standing on 1 foot The nurse should expect a 3-year-old child to have the gross motor ability to stand on 1 foot for a few seconds. Incorrect Answers:A. Skipping is a developmental task expected of a 4-year-old child. B. Hopping on 1 foot is a developmental task expected of a 4-year-old child. C. Throwing a ball overhead is a developmental task expected of a 4-year-old child.
A nurse is assessing a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open D. The infant needs assistance to sit up
D. The infant needs assistance to sit up An infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine is due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5°F and head congestion."
A. "Initial vaccines should be administered between birth and 2 weeks of age." The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBsAg) negative.
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include as an expected finding for this age group? A. Copying a circle B. Cutting foods using a table knife C. Beginning to write in cursive D. Printing the first and last name clearly
A. Copying a circle The nurse should explain that copying a circle is a skill achieved by the age of 4 years. Incorrect Answers: B. Cutting food using a table knife is a fine motor skill expected of 7-year-old children. C. The initial use of cursive writing is an expected skill for an 8- to 9-year-old child. D. Children will print their first name around the age of 5 years.
A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring the child's stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 times per day D. Provide a shared room with another child his age
A. Encourage the parents to bring the child's stuffed animal Encouraging parents to bring in a child's favorite stuffed animal may lessen the disruptiveness of hospitalization.
A nurse working on a maternal-newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. The nurse should include which of the following infant conditions as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism
A. Galactosemia An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes.
A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include? A. Higher body fat content is associated with earlier onset of menarche B. Pubic hair is typically present prior to breast development C. Ovulation begins after sexual maturation is complete D. Menarche signals the beginning of puberty
A. Higher body fat content is associated with earlier onset of menarche The nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche.
A nurse is assessing the gross motor skills of a 4-year-old preschooler. The nurse should expect the preschooler to perform which of the following activities? A. Hopping on 1 foot B. Skipping on alternate feet C. Jumping rope D. Roller skating
A. Hopping on 1 foot The nurse should expect a 4-year-old preschooler to hop on 1 foot. Incorrect Answers: B. A 5-year-old preschooler should be able to skip on alternate feet. C. A 5-year-old preschooler should be able to jump rope. D. A 5-year-old preschooler should be able to roller skate.
A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A. Inactivated poliovirus vaccine (IPV) B. Haemophilus influenzae type B vaccine (Hib) C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B vaccine (HBV)
A. Inactivated poliovirus vaccine (IPV) The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 and 18 months of age. Very DIM for 4-6 yrs VERY Varicella (1 & 4 years) D DTaP (2,4,6,12 mo. & 4-6 yrs) I Influenza & IPV "polio" (2,4,6 mo. & 4-6 yrs) M MMR (1 & 4 years
A nurse is providing teaching about home safety to the parent of a 2-month-old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water heater to 60°C (140°F)
A. Remove bibs before the infant goes to sleep The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation.
A nurse is preparing to assess a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age
A. The child prefers to sit on the parent's lap during the examination Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination.
A hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? A. Toddlers will react to the parents' anxiety and sadness. B. Toddlers view death as punishment for bad behavior. C. Toddlers view death as permanent and irreversible. D. Toddlers have a realistic concept of death.
A. Toddlers will react to the parents' anxiety and sadness The nurse should identify that toddlers have little understanding of death. Their reaction is related to changes in routine and the parents' emotions.
A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Abdomen 5 cm (2 in) from the umbilicus
A. Vastus lateralis The vastus lateralis is a large developed muscle, even in an infant. The muscle can tolerate the volume of the injection, and there are no important nerves or blood vessels in this muscle.
A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During the assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child? A. 6 months old B. 12 months old C. 18 months old D. 24 months old
B. 12 months old The nurse should know that this infant must be less than 18 months old because her anterior fontanel is still open. The infant is approximately 12 months old due to the presence of 6 teeth. Her skills—sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say 2 words (12 months)—should also help the nurse estimate the infant's age as 12 months.
A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer which of the following benefits? A. Decrease the child's fear of the dark B. Allow the child to manipulate toy medical equipment C. Provide an opportunity to analyze the child's emotions D. Encourage parents to engage with their child
B. Allow the child to manipulate toy medical equipment A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse is helping decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.
A nurse is performing a well-child assessment on a 7-year-old client who takes great pride in bringing school papers home. The nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs. inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doubt
B. Industry vs. inferiority The developmental task of industry vs. inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years (ages 6 to 12 years).
A nurse is planning to teach a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-age children are attempting to master which of the following developmental tasks? A. Initiative vs. guilt B. Industry vs. inferiority C. Trust vs. mistrust D. Identity vs. role confusion
B. Industry vs. inferiority When planning to teach, the nurse should identify that school-age children are attempting to master the developmental task of industry vs. inferiority. During this stage, children enjoy learning new skills and experiencing the sense of accomplishment that comes with mastery of the skill.
A nurse is providing education for a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18-month-old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Following simple directional commands D. Naming a single color
B. Vocabulary of 10 or more words At 18 months, children typically have a vocabulary of 10 or more words. Incorrect Answers: A. A 2-year-old child can state his/her name and typically refers to self by name as opposed to using the correct pronoun. C. A 2-year-old child is typically able to follow and complete simple commands. D. Toddlers typically cannot name a color until they have reached 30 months of age.
During early adolescence, the school nurse knows to discuss what task with students in a health class? A) How cool Bruce Willis movies used to be and to put 12 Monkeys on their netflix list B) Switching from a sippy cup to an open cup C) Increased need for washing the face and use of deodorant D) How to safely ride a balance bike
C) Increased need for washing the face and use of deodorant Due to hormonal changes and increase in activity of acropine sweat glands and sebaceous glands, the teen may notice more body odor and facial oils
A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals."
C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions.
A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."
C. "Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack.
A nurse on a pediatric unit is caring for a child who is not eating well. Which of the following suggestions should the nurse offer to the parents to promote the child's food intake? A. "Make dietary selections for your child." B. "Offer foods that have strong flavors or smells." C. "Let your child eat with others when possible." D. "Make sure your child eats most of the food on his plate."
C. "Let your child eat with others when possible." Socialization with others promotes nutrition by making the child feel more comfortable in his surroundings and enhancing the enjoyment of meal times.
A nurse is assessing a 1-week-old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. A blue coloring of the sclera D. A patchy, red rash with raised centers
C. A blue coloring of the sclera This discoloration is associated with osteogenesis imperfecta, a genetic disorder that results in bone fragility. The nurse should notify the provider of this finding. Incorrect Answers: A. This discoloration is known as a nevus simplex, or stork bite. It typically blanches with pressure and becomes more prominent with crying. This finding does not require notification of the provider. B. This discoloration is known as a Mongolian spot. It is typically observed in infants who have increased skin pigmentation (e.g., those of African, Asian, or Hispanic descent) and does not require notification of the provider. D. This discoloration is known as erythema toxicum, or newborn rash. It is a benign, transient finding and does not require notification of the provider.
A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature 37.5°C (99.5°F) B. Apical pulse rate 140/min C. BP 86/40 mmHg D. Respiratory rate 32/min
C. BP 86/40 mmHg A BP of 86/40 mmHg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.
A nurse is assessing the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform? A. Use a cuff to auscultate blood pressure B. Determine heart rate by taking the radial pulse C. Count respirations before taking other vital signs D. Measure temperature by placing the thermometer in the infant's ear
C. Count respirations before taking other vital signs It is best to count the infant's respirations while the infant is calm and before being disturbed. The pulse should be taken next, followed by the temperature, which is the most disruptive assessment to an infant.
A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy B. Give the child a thorough explanation before providing care C. Encourage rooming-in D. Tell the child you will help fix her
C. Encourage rooming-in Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope with an unfamiliar environment.
A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 15 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms
C. Examine the infant's throat at the end of the examination The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale
C. FACES pain rating scale The FACES scale includes various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels.
A nurse is assessing a 24-month-old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse expect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand on 1 foot
C. Impaired language skills The nurse should expect a 24-month-old toddler who has ASD to exhibit impaired language skills (e.g. failing to respond to his or her name, pointing to objects instead of speaking, dragging the parent's hand to desired items).
A nurse at a community health department is discussing the nutritional needs of children with a group of parents and guardians. Which of the following pieces of information should the nurse include? A. Infants should be transitioned to low-calorie milk at 12 months. B. Preschoolers need 10-12 g of protein per day. C. Toddlers can be given up to 120-180 mL (4-6 oz) of juice per day. D. School-age children should be encouraged to avoid afternoon snacks.
C. Toddlers can be given up to 120-180 mL (4-6 oz) of juice per day. Parents should limit a toddler's juice intake to 120 to 180 mL per day because juice is high in sugar and should not replace more important nutrients.
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following pieces of information is appropriate for the nurse to include? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero B. Administer a folic acid supplement to the child each day C. Give pancreatic enzymes to the child with meals and snacks D. Ensure the child's dietary intake of calcium and iron is adequate
D. Ensure the child's dietary intake of calcium and iron is adequate A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption of and effects from the lead. Dietary recommendations should include milk as a good source of calcium.
A nurse is assessing the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect? A. The preschooler can draw a stick figure that has 7 parts B. The preschooler can print her first name C. The preschooler can cut out a picture using scissors D. The preschooler builds a tower of 9 cubes
D. The preschooler builds a tower of 9 cubes The nurse should expect a 3-year-old preschooler to have the fine motors skills needed to build a tower of 9 to 10 blocks. Incorrect Answers: A. The nurse should expect a 5-year-old preschooler to draw a stick figure that has 7 to 9 parts B. The nurse should expect a 5-year-old preschooler to write a few letters or numbers such as her first name. C. The nurse should expect a 4-year-old preschooler to cut out a picture using scissors.
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? A. Sitting alone B. Attempting to stack objects C. Picking up small objects with a crude pincer grasp D. Turning from back to stomach
D. Turning from back to stomach A 6-month-old infant should be able to turn over completely, sit momentarily without support, and reach to be picked up
