pediatrics HESI practice

which education would the nurse provide to a mother of a newborn regarding the safe use of breast milk? select all that apply. one, some, or all responses may be correct. - "do not thaw the breast milk in the microwave." - "expressed breast milk must be stored in a glass container." - "breast milk can be stored for up to 6 months in the freezer." - "breast milk may be thawed by mixing it with lukewarm water." - "expressed breast milk must be used within 72 hours after refrigeration."

- "do not thaw the breast milk in the microwave." - "breast milk can be stored for up to 6 months in the freezer."

the clinic nurse is reviewing information with parents whose child was recently diagnosed with autism spectrum disorder. which statements by the parents indicate to the nurse that they understand the teaching? (select all that apply.) - "repetitive movements are common" - "loves to interact with same age children" - "non verbal communication is limited" - "frequently reaches out to be comforted" - "maintain a daily routine whenever possible"

- "repetitive movements are common" - "non verbal communication is limited" - "maintain a daily routine whenever possible"

which of these statements about language development in children ages 12 to 36 months are true? select all that apply. one, some, or all responses may be correct - 24 month old children use pronouns - 18 month old children use approximately 25 words - 24 month old children speak in four word sentences - 24 month old children have a vocabulary of up to 500 words - 36 month old children learn to use five or six new words each day

- 24 month old children use pronouns - 36 month old children learn to use five or six new words each day

a 10-month-old is admitted for a tetralogy of fallot repair. which postoperative finding indicates that the repair is successful? (select all that apply.) - absence of cyanosis when feeding - presence of a heart murmur - lips are pink when crying - heart rate is 120 beats/min - respiratory rate is 32 breaths/min

- absence of cyanosis when feeding - lips are pink when crying - heart rate is 120 beats/min - respiratory rate is 32 breaths/min (rationale: the heart murmur associated with tetralogy of fallot should be resolved after the repair. the cyanosis with feeding, crying, and defecation should resolve. vital signs are normal as there is no need to compensate for the congenital defect)

which actions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (select all that apply.) - provide a low fiber diet - administer mineral oil daily - decrease the daily fluids - eliminate dairy products - initiate consistent toileting routine

- administer mineral oil daily - eliminate dairy products - initiate consistent toileting routine

the nurse is providing care to a child with a white blood cell count of 1.025 cell/mm³. what measures will the nurse take to decrease the risk for infection? (select all that apply.) - assist with daily hygiene with an antimicrobial soap - include fresh strawberries in the lunch menu - replace the water in the pitcher every 4 hours - encourage the addition of a green leafy salad with supper - offer a toothbrush and toothpaste after every meal and at bedtime

- assist with daily hygiene with an antimicrobial soap - replace the water in the pitcher every 4 hours - offer a toothbrush and toothpaste after every meal and at bedtime

a child who recently returned from a 3-day camping trip over spring vacation is brought to the clinic after a rash, chills, and low-grade fever develop. what are the most important data for the nurse to assess when taking the child's history? select all that apply - date of return to school - sports played on camping trip - history of allergic reactions - recent exposure to poison oak or ivy - number of children on trip

- history of allergic reactions - recent exposure to poison oak or ivy

the nurse is conducting meal planning for a child scheduled for discharged after treatment for acute glomerulonephritis. what foods are appropriate for this child? (select all that apply.) - lean beef - chicken without the skin - brown rice - movie style popcorn - regular canned green beans - carrots

- lean beef - chicken without the skin - brown rice - carrots (rationale: because of the fluid retention associated with this diagnosis, foods need to be low in sodium)

the nurse comes upon a hospitalized child having tonic-colonic movements. the child has a history of seizure activity. what actions will the nurse take for this child? (select all that apply.) - place a pillow under the child's head - place an airway while the child continues to seize - hold the child down during the seizure - unbutton the top button of the child's shirt - place the child on the side after the seizure is over - leave the child to get help from the unit across the hall

- place a pillow under the child's head - unbutton the top button of the child's shirt - place the child on the side after the seizure is over

what assessment findings will the nurse expect to see in a 9-month-old with cerebral palsy? (select all that apply.) - absence of the moro reflex - presence of the babinski reflex - presence of the tonic neck reflex - irritability and excessive crying - rigidity of the arms and legs - coordinated suck-swallow when feeding

- presence of the babinski reflex - presence of the tonic neck reflex - irritability and excessive crying - rigidity of the arms and legs (rationale: for the infant with cerebral palsy (CP) infantile reflexes remain after 6 months. the nurse may observe both the moro and the tonic neck reflexes in these infants. the babinski reflex does not disappear until approximately 1 year of age. infants with CP are often irritable, cry for no apparent reason. muscle tone of the arms and legs is altered and displayed as rigid. because of the abnormal motor development and coordination, feeding can be challenging)

the nurse is performing discharge teaching to the parents after the birth of their child with a cleft palate. when planning for the timing of the cleft palate repair, what developmental milestones will the infant exhibit? (select all that apply.) - sitting up with props - walks holding onto furniture - rolling over from front to back - knows familiar faces - finds hidden objects

- sitting up with props - rolling over from front to back - knows familiar faces

upon initial assessment of a newborn, the nurse palpates the infant's mouth and feels an incomplete closure of the soft palate. what other focused assessments will the nurse include in the newborns plan of care? (select all that apply.) - suck - swallow - calorie intake - daily weight - moro reflex - plantar creases

- suck - swallow - calorie intake - daily weight

a 3-month-old infant returns from surgery with elbow restraints and a logan bow over a cleft lip suture line. which action should the nurse take to maintain suture line integrity during the initial postoperative period? - place the infant upright in an infant seat position - provide matters with the use of elbow restraints - use soft rubber catheters for nasal suctioning - apply water soluble lubricant to the suture line

provide matters with the use of elbow restraints (rationale: the use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. prone positioning should be avoided to prevent disruption of the protective logan bow and prevent the infant from rubbing the face on the bed surface. mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding)

a child comes to the school nurse complaining of itching. further assessment reveals that the child has impetigo. what action should the nurse take? - send the child home with the parents to see the health care provider before returning to school - send the child home with the parents and report this to the health department - cover the lesion with a dry gauze dressing and send the child back to class - wash the lesion with antimicrobial soap, air-dry, and send the child back to class

send the child home with the parents to see the health care provider before returning to school (rationale: impetigo is a staphylococcal infection and is transmitted by person-to-person contact. the child should be sent home with a note to the parents explaining the condition)

which preoperative nursing action should be included in the plan of care for an infant with pyloric stenosis? - monitor for signs of metabolic acidosis - estimate the quantity of diarrhea stools - place in a supine position after feeding - observe for projectile vomiting

observe for projectile vomiting (rationale: projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis)

at which stage of development would the nurse anticipate that pediatric clients will begin to show differences in play activities that are related to gender? - preschool - adolescence - late school age - early school age

late school age

a 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. which statement by the parent warrants immediate intervention by the nurse? - "my son often chokes while I am feeding him" - "is it normal for my child's legs to cross each other?" - "he gets stiff when I pull him up to a sitting position?" - "my 4 year old son is jealous of his little brother"

"my son often chokes while I am feeding him"

a 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 99.6°F. how many calories per day will the nurse include in the infant's plan of care? - 400 calories/day - 500 calories/day - 600 calories/day - 700 calories/day

600 calories/day (rationale: an infant requires 108 calories/kg/day. the first step is to change 10 lb 15 oz to 10.9 lb. then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). however, this infant requires 10% more calories because of the 1°F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. this infant will require approximately 600 calories/day)

in a child with lead poisoning, where is lead stored while remaining inert? - liver - blood - bones - soft tissues

bones

according to erikson's theory of psychosocial development, which task does the nurse recognize as the chief psychosocial task of preschoolers? - control over bodily functions - development of a sense of initiative - toleration of separation from parents - ability to interact with others in a less egocentric manner

development of a sense of initiative

which nursing intervention would the nurse provide an infant exhibiting signs of increased intracranial pressure (icp)? - initiating clear fluid diet - elevating the infant's head higher than the hips - checking the reflexes every 15 minutes - stimulating the infant frequently while assessing level of consciousness

elevating the infant's head higher than the hips

the nurse checks the fluid from the nose of the client newly admitted to the emergency room after a motor vehicle accident. which positive finding would be most concerning to the nurse? - protein - glucose - blood - pH 7.4

glucose (rationale: the presence of glucose in drainage from the ear or nose after a head injury is indicative of cerebral spinal fluid)

the parents and two siblings of a 6-week-old infant are grieving the infant's death as a result of sudden infant death syndrome (sids). which short-term goal would the nurse have for this family? - identifying the problems that they will be facing as a result of the loss of the infant - accepting that there was nothing that they could have done to prevent the infant's death - including the infant's siblings in the events and grieving in the wake of the infant's death - seeking out other families who have lost infants to SIDS and obtaining support from them

including the infant's siblings in the events and grieving in the wake of the infant's death

which psychosocial developmental skill would the nurse anticipate in a 4-year-old child? - self evaluation - logical thinking - increased curiosity - understanding of others

increased curiosity

which age group would the nurse recommend that children be taught to swim under guided supervision? - toddlers - adolescents - preschoolers - school age children

preschoolers

a parent of a newborn states to the nurse, "my baby is constantly crying and irritable. I just cannot take this much longer." which information would the nurse discuss with the parent? - limit setting - shaken baby syndrome - developmental milestones - sudden infant death syndrome

shaken baby syndrome

a mother is carrying in her 3-year-old to the emergency department (ED) screaming, "I think my baby swallowed a bottle of Tylenol." what is the nurse's next action? - notify the hcp in the ED - take the child's vital signs - start an IV - ask the mother for the bottle containing the tylenol

take the child's vital signs (rationale: assessment first. know the child's baseline, unless the child is lifeless, then start CPR. since there is no data indicating lifelessness and no option of CPR, then taking the vital sign assessment is correct)

which step would the nurse follow when taking a toddler's blood pressure? - use an ultrasonic stethoscope - choose a cuff labeled "toddler" - use a pediatric stethoscope bell to hear korotkoff sounds - place the stethoscope firmly on the antecubital fossa for good auscultation

use a pediatric stethoscope bell to hear korotkoff sounds

to which client would the nurse provide education regarding the pubertal growth spurt? - an 8 year old school age male client - a 16 year old adolescent male client - a 12 year old school age female - an 18 year old adolescent female client

a 12 year old school age female

the nurse is preparing to assess several clients at a pediatric clinic. which client would require a developmental screening versus developmental surveillance during a scheduled health maintenance visit? - a 9 month old infant - a 2 week old newborn - a 15 month old toddler - a 4 year old preschooler

a 9 month old infant

which statement correctly describes the initiative versus guilt stage? - individuals like to pretend and try out new roles - individuals are more accomplished in some basic self-care activities - individuals show marked preoccupation with appearance and body image - individuals are eager to apply themselves to learning socially productive skills and tools

individuals like to pretend and try out new roles

the nurse is reviewing the laboratory results for a child admitted to rule out cystic fibrosis. which test result should the nurse bring to the immediate attention of the health care provider? - serum sodium of 135 - serum sodium of 145 - sweat chloride of 20 - sweat chloride of 80

sweat chloride of 80 (rationale: a weat chloride concentration of greater than 60 mEq/L is a positive result for cystic fibrosis. the remaining values are within the normal range)

ampicillin, 75 mg/kg, is prescribed for a 22-lb child. it is available in a solution that contains 250 mg/5 mL. how many milliliters should the nurse administer in one dose? _____

15mL (rationale: 2.2 lb/1 kg = 22 lb/x kgx = 10 kg1 kg/75 mg = 10 kg/x mgx = 750 mg250 mg/5 mL = 750 mg/x mLx = 15 mL)

which is the reason for calculating a body mass index (BMI)-for-age during a health maintenance assessment for school-age clients? - assessing for bulimia - monitoring for failure to thrive - monitoring for anorexia - assessing for obesity or overweight

assessing for obesity or overweight

which nutrients would the nurse teach the parents of a child with celiac disease to avoid? - saturated oils and fats - milk and hard cheeses - corn and rice products - wheat and oat products

wheat and oat products

a child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. during the initial nursing assessment, which symptoms will this child most likely exhibit? (select all that apply.) - bone pain - tremors - nystagmus - abdominal distention - pallor

- bone pain - pallor

which symptom would the nurse recognize as a late sign of acute aspirin poisoning in children? - nausea - tinnitus - vomiting - confusion

confusion

the nurse is preparing to administer eardrops to a 2-year-old. what is the proper procedure for administering this medication? - pull the pinna up and back - pull the pinna down and back - pull the pinna up and forward - pull the pinna down and forward

pull the pinna down and back (rationale: up until a child is 3-year-old, the proper procedure for administering eardrops is by pulling the pinna down and back to straighten the ear canal)

a 2-year-old child is placed in an oxygen tent. what clothes will the nurse recommend the parents bring from home for the child? - an all cotton sleeper - a synthetic shirt and baggy shorts - a polyester play outfit - a lightly woven wool sweater

an all cotton sleeper (rationale: the child will be in an environment of cool, moist air. cotton is a breathable fabric appropriate for this environment. polyester and synthetic fibers will trap the cool moisture. wool will make the child feel cold when it gets moist)

which choice is not part of a low-residue diet? - apples - spaghetti - ice cream - ripe bananas

apples (rationale: most raw fruits, such as apples, are high-residue foods that contribute to the development of bulk; the child's overdistended colon cannot tolerate an increase in residue. a low-residue diet prevents irritating the bowel further. spaghetti is a low-residue food. ice cream is a low-residue food. although ripe bananas are raw fruit, they are not classified as high residue)

how will the nurse plan to position a child with left sided pneumonia? - on the child's right side - on the child's left side - head of the bed up at a 90 degree angle - prone, with pillows placed bilaterally

on the child's left side (rationale: placing the child on the affected side decreases discomfort in the pleural area)

a mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. further questioning by the nurse reveals that the cough is nonproductive. what is the nurse's best instruction to the mother? - watch the boy for a few more days and see if the cough begins to produce sputum - the full 10 day course of antibiotics must be completed before effectiveness can be evaluated - give the child plenty of fluids and an OTC cough suppressant - bring the child to the clinic today for an examination

bring the child to the clinic today for an examination

a nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? - communicate the result to the oncoming nurse and document - tell the oncoming nurse that the level is dangerously high - ask the laboratory to redo the test because the result is faulty - hold the next dose of theophylline based on this finding

communicate the result to the oncoming nurse and document (rationale: the therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. this information evaluates the prescribed therapy and should be communicated in the nurse's report)

the health care provider prescribes digoxin 0.05 mg/kg/day in two equally divided doses. the child' weight is 18 pounds. how many mg will the nurse administer in one dose? _____ (round to the nearest tenth.)

0.2 mg/dose (rationale: Xmg/dose = 0.05mg/1kg/day x 1kg/2.2lbs x 18 lb x 1day/2 doses = 0.9/4.4 = 0.2 mg per dose)

at which age does the anterior fontanel of the skull close? - 12 to 18 months - 20 to 24 months - 26 to 30 months - 32 to 36 months

12 to 18 months

the nurse is planning care for a newborn. what is the best time to draw the newborn's phenylketonuria (PKU)? - within 1 hour of birth - within 4 hours of birth - around 24 hours after birth - around 48 hours after birth

around 48 hours after birth (rationale: screening of newborns for PKU needs to occur after the baby has injected either formula or breast milk. If screening is conducted before 48 hours after birth, the screening should be repeated by 14 days after birth)

which instruction would the nurse give to the parent of a child who has had one episode of diarrhea according to evidence-based practice for this situation? - limit the child's activities, withhold oral feedings, and call the clinic in 4 hours - wrap the child snugly, offer sugar water, and bring the child to the clinic immediately - allow the child to continue activities, withhold oral feedings for 24 hours, and call the clinic tomorrow - continue the child's feedings as usual, observe the frequency of stools, and bring the child to the clinic tomorrow if the diarrhea continues

continue the child's feedings as usual, observe the frequency of stools, and bring the child to the clinic tomorrow if the diarrhea continues

which action would the nurse take to promote the social development of a 9-month-old infant? - engaging in peek a boo - offering soft clay to manipulate - providing a pegboard for pounding - demonstrating how to speak words

engaging in peek a boo

parents whose child has cystic fibrosis (CF) have no history of CF in their family and ask how their child inherited this disorder. how would the nurse clarify the way in which the disease was inherited? - it is a mutated gene - it involves an x-linked gene - the inheritance is autosomal recessive - the inheritance is autosomal dominant

the inheritance is autosomal recessive

how would the nurse describe pulmonic stenosis to the parent of a 4-year-old child who was recently diagnosed? - narrowing of the valve between the left atrium and left ventricle - hardening of the valve between the right atrium and right ventricle - hardening of the valve between the right ventricle and the arch of aorta - narrowing of the valve between the right ventricle and the pulmonary artery

narrowing of the valve between the right ventricle and the pulmonary artery

the nurse is educating parents about the changes to expect when their child enters toddlerhood. which information would the nurse include? - the toddler's body appears slender - the toddler has a protruded abdomen - the toddler's feet are severely everted - the toddler has inconspicuous cervical curves

the toddler has a protruded abdomen

which education would the nurse provide the parent of a 4-year-old child? - they are easy to please with food - they master the ability to draw diamond shapes - they double their birth length at this age - they have an average weight of 32 pounds

they double their birth length at this age

following the administration of immunizations to a 6-month-old infant, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? - "I will give my baby a baby aspirin every 4 hours as needed for fever." - "I will call the clinic if my baby's cry becomes high-pitched or unusual." - "I know I can expect my baby to be irritable over the next 2 days." - "I will exercise my baby's legs regularly to decrease the soreness."

"I will give my baby a baby aspirin every 4 hours as needed for fever." (rationale: although fever may occur, non-aspirin-containing medications should be used because of the risk of reye syndrome)

an infant is admitted with the medical diagnosis of coarctation of the aorta. what findings from the child's initial assessment support this medical diagnosis? (select all that apply.) - dilated scalp veins - separated cranial suture lines - bulging anterior fontanels - bounding pulses in the arms - cool lower extremities

- bounding pulses in the arms - cool lower extremities (rationale: coarctation of the aorta includes a narrowing of the aorta near is ductus arteriosus. there is a decrease in the blood pressure to the lower body)

which assessment data would cause the nurse to suspect that a toddler-age child is experiencing physical neglect? - abdominal distention - bloody underclothing - recurrent urinary tract infections - bruises in various stages of healing

abdominal distention

the in-patient nurse is caring for a child with leukemia. the parents are asking for help with meal selection for their child. what items will the nurse recommend? (select all that apply.) - scrambled eggs - creamed corn - spaghetti and meatballs - macaroni and cheese - honey based granola bars

- scrambled eggs - creamed corn - macaroni and cheese (rationale: children with leukemia need food that is nutritious and requires little chewing. meatballs and granola bars, though high in protein, are too difficult to chew. the remaining foods have both nutritive value and are easy to eat)

which parent teaching would the nurse provide about signs of shunt failure in a 4-month-old infant with a ventroperitoneal shunt? select all that apply. one, some, or all responses may be correct - vomiting - dehydration - sunken eyeballs - distended fontanels - abdominal distention

- vomiting - distended fontanels

which age would a child be able to drink from a cup? - 5 months - 7 months - 12 months - 15 months

12 months

at which age would the nurse anticipate that the preschool-aged client will overcome many fears? - 2 years - 3 years - 4 years - 5 years

5 years

the health care provider orders ampicillin 10 mL three times a day for a 16.5 pound infant. the label on the ampicillin bottle reads 125 mg per 5 mL. how many milligrams will the infant receive in 1 day?

750 mL (rationale: Xmg/day = 125 mg/5mL x 10 mL/dose x 3 doses/day = 3750/5 = 750 mg/day)

a 6-month-old infant is admitted to the postanesthesia care unit with elbow restraints in place. an endotracheal tube is in place connected to a ventilator, but the child will be extubated soon following recovery from anesthesia. which action should the nurse include in the child's postoperative care? - keep restraints on at all times to prevent unplanned extubation - remove restrains one at a time and provide ROM exercises - remove all restrains simultaneously and provide play activities - document the reason for application of the restraints for every 72 hours

remove restrains one at a time and provide ROM exercises

a child is recovering from a splenectomy secondary to a diagnosis of β-thalassemia major. What is the most important instruction the nurse must include in the child's discharge plan? - parental genetic counseling - include the pneumococcal vaccine - weekly hemoglobin levels - report signs of infection

report signs of infection (rationale: the child is at risk for sepsis after a splenectomy. report to the child's health care provider any signs and symptoms of infection)

how do toddlers learn self-protection? - through trial and error strategies - by imitating playmates and siblings - by obeying orders from mother and father - by playing with age appropriate toys and puzzles

through trial and error strategies

the nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. which action is most important for the nurse to take first? - assess the child's mucus membranes and skin turgor - contact food services about needed menu restrictions - determine the child's food likes and dislikes - ask the parents about the child's recent dietary intake

assess the child's mucus membranes and skin turgor

the nurse is providing care for a child newly admitted in a sickle cell crisis. in reviewing the admission prescriptions, which prescription is concerning and the nurse needs to confirm with the health care provider? - meperidine 15 mg IV every 4 hours, around the clock for pain - hydrate with 2000 mL of oral fluids over the next 6 hours - place cold compresses to affected joints for 15 minutes every 4 hours - raise the head of the bed 20 to 30 degrees and dim the lights

meperidine 15 mg IV every 4 hours, around the clock for pain (meperidine (demerol) can have severe neurologic effects in clients with sickle cell disease. Start with other analgesics such as morphine or hydromorphone)

a parent reports that his or her child just ate several multivitamins with iron. which statement would the nurse say to the parent? - "give your child orange juice" - "call the poison control center" - "iron-fortified multivitamins are safe for your child" - "administer an emetic - syrup or ipecac, if you have it"

"call the poison control center" (rationale: the poison control center will provide the best guidance for treatment of excess ingestion of a substance; enemas, lavage, or chelation therapy with deferoxamine, a heavy metal antagonist, may be recommended, depending on the amount ingested and the child's age and response. orange juice will enhance absorption of the iron and will create a greater risk for toxicity. iron is the most toxic substance in multivitamins. although signs and symptoms may not be evident for several hours, treatment should be initiated before a problem develops. emetics are not used for poisonings; they are not effective in removing the toxic substance and causing the child to vomit creates a risk for aspiration)

the nurse is evaluating the teaching given to the parents of a child with glomerulonephritis. which parent statement will the nurse need to correct? (select all that apply.) - weight at the same time every day - use the same scale for daily weights - wait 2 to 3 days to report rusty-brown urine - see the hcp if a sore throat develops - report facial edema that occurs in the evening

- wait 2 to 3 days to report rusty-brown urine - report facial edema that occurs in the evening (rationale: the presence of frothy, rust colored urine is a sign of nephrotic syndrome. with nephrotic syndrome, facial edema occurs in the morning. measurement of fluid balance is accurate if weights occur at the same time each day, on the same scale, with the same clothing. all infections, especially sore throats need to be reported to evaluate for β-hemolytic streptococcal infections)

which strategy would the nurse use to soothe a 2-month-old infant who is crying? - offering the infant a bottle of diluted juice - holding and rocking the infant in a quiet room - changing the diaper before returning the infant to the crib - wrapping a blanket around the infant and placing him or her in a supine position

holding and rocking the infant in a quiet room

a 1-year-old infant has been admitted with a tentative diagnosis of bacterial meningitis. which cerebrospinal fluid (csf) laboratory finding would support this diagnosis? - decreased cell count - increased protein level - increased glucose level - low spinal fluid pressure

increased protein level

after a 3-day hospitalization for croup, secondary to mycoplasma pneumonia, the nurse is working with the parents to discharge the child home. the parents state to the nurse, "we do not have the money to purchase the right kind of vaporizer." what is the nurse's best action? - give the parents $30 cash from a personal fund - ask, "do you have a freezer with your refrigerator?" - ask, "do you have any relatives nearby that could purchase the vaporizer?" - give the parents an old hospital vaporizer with warm, moist heat

ask, "do you have a freezer with your refrigerator?" (rationale: an alternative to cool mist is breathing in cool air from a freezer, cool night air, or cool air from a basement)

which clinical finding of an 8-year-old child with a history of asthma requires immediate intervention? - barrel chest - audible wheezing - HR of 105 beats/min - RR of 30 breaths/min

audible wheezing

in which stage of erikson's theory does the child initiate self-care activities? - initiative vs guilt - integrity vs despair - autonomy vs sense of shame and doubt - generatively vs self absorption and stagnation

autonomy vs sense of shame and doubt

which feeding education would the nurse provide the parent of a 2-month-old infant with the diagnosis of heart failure? - use double strength formula - avoid using a preemie nipple - refrain from feeding until crying from hunger pains - feed slowly awhile allowing time for adequate periods of rest

feed slowly awhile allowing time for adequate periods of rest

the nurse is caring for a toddler who has undergone bone marrow transplantation. which clinical finding would the nurse anticipate if an infection develops? - fever and lethargy - positive blood antibody titers - a delay in the growth of bone - neutropenia and lymphocytopenia

fever and lethargy

which type of fracture is common in preschool children? - greenstick - transverse - compound - comminuted

greenstick (rationale: ossification of the long bones is incomplete in childhood; children's bones can flex to about a 45-degree angle before breaking. when the bone is angulated beyond 45 degrees, the compressed side bends and the torsion side breaks (greenstick fracture)

according to erikson's theory, in which stage would the nurse expect a preschooler to start to pretend? - initiative vs guilt stage - integrity vs despair stage - autonomy vs a sense of shame and doubt stage - generatively vs self absorption and stagnation stage

initiative vs guilt stage

in which position would the nurse place an infant who just underwent surgery for a cleft lip? - prone - low fowler - left side lying - caregiver's shoulder

low fowler (rationale: the low fowler or supine position prevents the incision from coming into contact with the mattress and is the preferred position for infants)

when caring for a child with congenital heart disease and polycythemia, which nursing action has the highest priority? - administer oxygen therapy continuously - restricting fluids as ordered - maintaining adequate hydration - maintaining digoxin levels

maintaining adequate hydration

an 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. which action will the nurse include when teaching the parents about immediate post-procedure care? - teach the parents how to ambulate the child in the room safely - show the parents how to hold the child with the extremity extended - restrain the child's lower extremities for a minimum of 4 hours - place the child in a prone position to apply pressure to the site

show the parents how to hold the child with the extremity extended (rationale: the extremity should be extended to prevent trauma to the femoral catheterization site. options A and D increase the risk for complications and are contraindicated. option C is not necessary. only the extremity that was catheterized requires immobilization)

a 9-month-old infant is admitted to the pediatric unit. twelve hours later, the nurse determines that the previous blood pressures were taken using a neonate-size cuff. which is the best action for the nurse to take? - removing all neonate size cuffs from the unit - using the neonate size cuff for future measurement - taking the next measurement with both a neonate and a child size cuff - notifying the health care provider that the results were obtained with a neonate-size cuff

taking the next measurement with both a neonate and a child size cuff

the nurse is teaching a class about keeping medications and household cleaning supplies out of the reach of toddlers. the nurse explains that this is necessary because of which characteristic of toddlers? - they have increased appetites - they are developing a sense of taste - they have a high level of oral activity - they are rebelling against parental authority

they have a high level of oral activity

which is the priority nursing responsibility when caring for a toddler after a circumcision? - limiting oral fluids - monitoring IV fluid intake - applying ice packs to the genital area - watching for bleeding around the penis

watching for bleeding around the penis

during which stage of development would the nurse anticipate sibling relationships that fluctuate between open bickering and supportive relationships? - preschool - early school age - late adolescence - middle school age

middle school age

a parent asks the nurse what to do when the toddler has temper tantrums. which play materials would the nurse suggest that the child be offered as another means of expressing anger? - ball and bat - wad of clay - punching bag - pegs and pounding board

pegs and pounding board (rationale: a pounding board with pegs to hammer into holes is a safe toy for toddlers because it is fairly large, easy to manipulate, and sturdy. it also provides an acceptable way for anger to be expressed)

the parent of a 7-month-old boy states, "you know, my son doesn't sit up by himself yet. shouldn't he be able to do this by now?" how would the nurse respond? - "he may need a little encouragement" - "most babies do sit up by this time" - "don't worry that he's not sitting up yet" - "many babies don't sit up until they're 8 months old"

"many babies don't sit up until they're 8 months old"

the nurse is reviewing the discharge instructions of the parents of a 2-year-old who just underwent a myringotomy. what instructions will the nurse include in the parent's teaching? (select all that apply.) - do not immerse the child's head in water when bathing - administer the Tylenol as prescribed - do not substitute aspirin for the prescribed tylenol - purchase earplugs and place them during bathtime - change the bandage on the ear three times a day

- do not immerse the child's head in water when bathing - administer the Tylenol as prescribed - do not substitute aspirin for the prescribed tylenol - purchase earplugs and place them during bathtime

which foods will the nurse include in the meal plan for iron deficiency anemia? (select all that apply.) - dried fruits - nuts - cheese - spinach salad - cod - red meat

- dried fruits - nuts - spinach salad - red meat (rationale: cheese and cod fish are not high sources. the remaining selections are iron-rich food selections along with egg yolks, kidney beans, legumes, liver, prune juice, seeds, shellfish, tofu, and whole grains)

which areas are sources of stress in 4-year-old children? select all that apply. one, some, or all responses may be correct - school - attention - insecurity - activity level - separation anxiety

- attention - insecurity - activity level

a child presents to the school nurse with a bloody nose, which occurred spontaneously. what actions will the nurse take for this child? (select all that apply.) - assist the child to a lying position on a school cot - have the child pinch the nose closed tightly - prepare a warm compress to apply to the nose - set the timer for 10 minutes. - locate the water-soluble jelly in the clinic

- have the child pinch the nose closed tightly - set the timer for 10 minutes. - locate the water-soluble jelly in the clinic (rationale: the child must be in an upright position to prevent aspiration. cool compresses or ice packs can help constrict the area and decrease the flow of blood. the remaining steps are appropriate for a bloody nose. the nurse must remain calm. if the child senses the nurse is agitated, then the child might become agitated and then become uncooperative)

the nurse is teaching a group of new first-time parents about sudden infant death syndrome (SIDS). what will the nurse include in the teaching plan? (select all that apply.) - boys are at higher risk for SIDS than girls - the high risk period is after 9 months of age - do not place the baby to sleep on its tummy - napping on the sofa is acceptable - sleeping with your newborn is encouraged

- boys are at higher risk for SIDS than girls - do not place the baby to sleep on its tummy

the nurse in the emergency room is reviewing the prescriptions for a child admitted with diabetic ketoacidosis. which prescriptions will the nurse question as they are concerning? (select all that apply.) - IV of 0.9% normal saline - regular insulin - clear liquid diet - glasgow coma scale assessment - restrict parents from visiting

- clear liquid diet - restrict parents from visiting (rationale: the child should be NPO until the condition stabilizes and the blood glucose readings approach the acceptable range. parents can be a source of comfort and support. Increased anxiety can make the child's condition worse. the remaining are acceptable treatments for DKA)

the parents of a 2-year-old child are watching the nurse administer the denver II developmental screening test to their child. they ask, "why did you make our child draw on paper? we don't let our child draw at home." which is the best response by the nurse? - "I should have asked you about drawing first" - "these drawings help us determine your child's intelligence" - "it lets us test the child's ability to perform tasks requiring the hands" - "I don't understand why drawing is forbidden in your home"

"it lets us test the child's ability to perform tasks requiring the hands"

a child is being sent home with a prescription for liquid iron. which statements indicate to the nurse that the mother understands the discharge instructions? (select all that apply.) - "this medication will work in about a week" - "I will have my child drink this with a straw" - "teeth brushing will follow the administration" - "I will watch for green, liquid stools" - "I will give this on an empty stomach"

- "I will have my child drink this with a straw" - "teeth brushing will follow the administration" - "I will give this on an empty stomach" (rationale: iron supplements can take 4 to 6 weeks to start making a difference in the h/h. stools may turn tarry/black with iron supplementation and constipation may occur. drinking through a straw will help decrease the staining of the teeth as does brushing teeth after administration. administering on an empty stomach helps increase absorption)

the nurse is reviewing meal planning with a mother whose child is on furosemide. what high potassium selections will the nurse encourage the mother to include in the child's diet? (select all that apply.) - bananas - mandarin oranges - strawberries - green peas - raisins - blueberries

- bananas - mandarin oranges - raisins

a mother reports to the clinic nurse persistent nighttime bed wetting for her 6-year-old child. what focused assessments will the nurse include in the child's initial evaluation? (select all that apply.) - have the mother conduct a 48 hour diet recall - determine the amount of fluid intake after 1800 mL - ask if the child urinates just before bedtime - ask about the onset of the bedwetting - obtain a clean catch urine sample - ask if the child has started riding a bicycle

- determine the amount of fluid intake after 1800 mL - ask if the child urinates just before bedtime - ask about the onset of the bedwetting - obtain a clean catch urine sample

a burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. when calculating the percentage of burn, which parts of the child's body are proportionally larger than an adult's body? (select all that apply.) - head - arms - legs - back - neck - chest

- head - neck

the nurse is reviewing a list of allowable immunizations which was developed by the parents of a child with leukemia. which immunizations will the nurse to correct from the parents' lists? (select all that apply.) - measles - mumps - rubella - varicella - hepatitis b

- measles - mumps - rubella - varicella (rationale: the child must not receive any live virus vaccines. hepatitis B is the only immunization from the list that is not a live virus)

which complication would the nurse recognize as the most serious in an infant with meningitis? - epilepsy - blindness - peripheral circulatory collapse - communicating hydrocephalus

peripheral circulatory collapse

the nurse is helping a family prepare to send their 7-year-old child to school for the first time. the child is wheel-chair bound, and has a permanent tracheostomy. what information must the nurse include in the teaching plan for the child? - cover the tracheostomy site with clothing so that other children will not notice - apply suction for 30 seconds when inserting a catheter into stoma - discourage the child coughing deeply to remove mucus secretions - place suctioning supplies on the back of the wheelchair when transporting

place suctioning supplies on the back of the wheelchair when transporting

a parent is worried about the infant's excessive dependence on nonnutritive sucking. which intervention will help decrease this dependence? - prolonging the feeding time - using infant formulas frequently - offering pacifier as soon as the crying begins - wrapping the infant snugly most of the time

prolonging the feeding time

when a parent asks about a sudden issue with bedwetting, which would the nurse document in the child's health record? - primary enuresis - secondary enuresis - primary encopresis - secondary encopresis

secondary enuresis