Peds Final NCLEX Questions

The nurse is assessing a 6-month-old healthy infant who weighed 3.2 kg at birth. The nurse should expect the infant to now weigh approximately how many kilograms?

6.3-Birth weight doubles at about ages 5 to 6 months.

What do morbidity rates measure?

Prevalence of a specific illness in a population- Morbidity measures prevalence of a specific illness in a population over a specific period. Life span statistics are included in mortality data. Acute illness, chronic disease, and disability are factors that give morbidity statistics.

Hypospadias refers to which of the following?

Urethral opening along ventral surface of penis-Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present but not at the glans. Hypospadias refers to the urethral opening, not to the size of the penis. When the urethral opening is located along the dorsal surface of the penis, this is known as epispadias.

Meconium aspiration syndrome causes which of the following?

airway obstruction-After the passage of meconium into the amniotic fluid, the infant may inhale or swallow the fluid. Any gasping that occurs can cause the sticky meconium to become aspirated into the lower airways, causing a partial airway obstruction.

Which of the following is the most appropriate nursing action when intermittently gavage feeding a preterm infant?

allow formula to flow by gravity

Chromosome analysis of the fetus is usually accomplished through the testing of which of the following?

amniotic fluid- Currently, fluid obtained by amniocentesis forms the basis for diagnostic prenatal testing.

In terms of fine motor development, what should an infant of 7 months be able to do?

transfer objects from one hand to the other- The ability to transfer objects from one hand to another occurs at about age 7 months. The infant can use one hand for grasping and hold a cube in the other at the same time. A crude pincer grasp develops by ages 8 to 9 months. The ability to hold a crayon and mark on a piece of paper develops between ages 12 and 15 months. Infants can release a cube into a cup at ages 9 to 12 months.

According to Erikson, infancy is concerned with acquiring a sense of which of the following?

trust-During the first year of life, the infant focuses on the task of developing a sense of trust of self, of others, and of the world. This presents challenges for infants who are separated from parents or consistent caregivers. Industry is the focus of school-age children. Preschoolers are engaged in acquiring initiative. Autonomy is a developmental task during the toddler years.

A parent has a 2-year-old child in the clinic for a well-child checkup. Which of the following statements by the parent would indicate to the nurse that the parent needs more instruction regarding accident prevention?

"We stopped using the car seat now that our child is older." -Convertible car seats are necessary until the child is at least 18 kg (40 lb). Booster seats are required until the child is 36.2 kg (80 lb).

Neonates are predisposed to problems with thermoregulation because of which of the following factors?

A large body surface area favors heat loss to the environment. - Newborns have a large surface area relative to their weight, which facilitates heat loss to the environment. The neonate kidney cannot concentrate urine, but this does not affect thermoregulation. Maintenance of a flexed position helps retain heat and partially compensates for the heat loss secondary to the large surface area. Newborns have a thin layer of subcutaneous fat, which allows for heat transfer from higher to lower temperature areas (the newborn to the environment).

Which of the following genetic terms refers to a recognized pattern of malformations with a single specific cause?

A syndrome is a collection of primary malformations or defects with a single underlying cause.

Preschoolers' fears can best be dealt with by which of the following interventions?

Actively involving them in finding practical methods to deal with the frightening experience-Actively involving preschoolers in finding methods to deal with frightening experiences is the best way to deal with fears. Forcing a child to confront fears may make the child more afraid. Preconceptual thought prevents logical understanding. Ridiculing fears does not make them go away.

Which of the following behaviors indicates that an infant has developed object permanence?

Actively searches for a hidden object -During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows an object exists even when it is not visible. The ability to understand cause and effect is part of secondary schema development, which is a later developmental task. Between ages 8 and 12 weeks, infants begin to respond differentially to their mothers. They cry, smile, vocalize, and show distinct preference for the mother.

Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which of the following?

Avoid using any latex product-Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment.

A couple has given birth to their first child, a boy with a recessive disorder. The genetic counselor tells them that the risk of recurrence is one in four. Which of the following statements is a correct interpretation of this information?

Because each pregnancy is an independent event, each child has the same one in four risk of receiving the two genes required for a recessive trait to be apparent. The odds ratio does not change.

Which of the following is a characteristic of children with depression?

Change in appetite, resulting in weight loss or gain-Physiologic characteristics of children with depression include a change in appetite resulting in weight loss or gain, nonspecific complaints of not feeling well, alterations in sleeping pattern (insomnia or hypersomnia), and constipation. Children who are depressed have sad facial expressions with an absence or diminished range of affective response. Children who are depressed lack interest in doing homework or achieving in school, resulting in lower grades. These children withdraw from previously enjoyed activities and engage in solitary play or work. Schoolwork is not replaced by play.

Which of the following interventions should the nurse implement to maintain the skin integrity of a preterm infant born at 30 weeks?

Cleanse skin with sterile water only-A preterm infant is bathed no more than two or three times per week with a neutral pH solution such as sterile water. The eyes, oral and diaper areas, and pressure points should be cleansed daily.

The nurse is using a bulb syringe to suction a neonate after delivery. Which of the following is an important consideration?

Clear the pharynx before the nasal passages-Clearing the mouth and pharynx first will help prevent aspiration of amniotic fluid. Compress the bulb syringe before insertion. If it is compressed afterward, the secretions will be forced into the neonate's lungs. Only one bulb syringe is indicated. Mechanical suction can be used if more forceful removal of secretions is required.

Several types of seizures can occur in neonates. Which of the following is characteristic of clonic seizures?

Clonic seizures are characterized by slow, rhythmic, jerking movements that cannot be stopped by flexion of the affected limb. Apnea is a common manifestation of subtle seizures. Tremors are not characteristic of seizure activity. They may be indicative of hypoglycemia or hypocalcemia. A clonic seizure would have extension and contraction of the extremities, not just extension.

Myelination of the spinal cord is almost complete by 2 years of age. As a result of this, which of the following can gradually be achieved?

Control of anal and urethral sphincters-With complete myelination of the spinal column, voluntary control of elimination occurs. Control of anal and urethral sphincters is gradually achieved. Visual acuity is acceptable at 20/40. Throwing a ball without falling is achieved by 18 months of age

The nurse is assessing a 6-month-old infant who has head lag. The nurse should recognize which of the following?

Developmental-neurologic evaluation is needed.-Most infants have only slight head lag when pulled from a lying to a sitting position at 4 months of age. By 6 months, head control should be well established. Developmental-neurologic evaluation is indicated to determine why the child is not achieving an expected milestone. The head lag is suggestive of a developmental delay.

Neonates are highly susceptible to infection as a result of which of the following?

Diminished nonspecific and specific immunity-Neonates have diminished inflammatory (nonspecific) and humoral (specific) immunity. They are unable to mount a local inflammatory reaction at the portal of entry to signal infection, and the resulting symptoms are vague and nonspecific, delaying diagnosis and treatment.

In terms of fine motor development, what could a 3-year-old child be expected to do?

Draw single-line shapes such as circles-Three-year-old children are able to draw single-line shapes such as circles. A 5-year-old child's fine motor skills include the ability to tie shoelaces, use scissors or a pencil, and draw a person with seven to nine parts.

Which of the following statements best represents the risk of recurrence in autosomal dominant inheritance?

Each child of a heterozygous affected parent has a 50% chance of inheriting the mutated allele. C

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be which of the following?

Encourage her to express her feelings-For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must emphasize not only the infant's physical needs but also the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a precious human being. The child's normalcy is emphasized, and the mother is assisted in recognizing the child's uniqueness.

The nurse assesses the neonate immediately after birth. Esophageal atresia or tracheoesophageal fistula is suspected if which of the following is present?

Excessive amount of frothy saliva in the mouth-Frothy saliva in the mouth and nose, drooling, choking, and coughing in a newborn are associated with esophageal atresia and tracheoesophageal fistula.

The American Academy of Pediatrics recommends that the best form of infant nutrition is what?

Exclusive breastfeeding until 1 year of age-The American Academy of Pediatrics has reaffirmed its position that an infant should be breastfed exclusively for the first year of life. This group also supports programs that enable women to return to work and continue breastfeeding. Breastfeeding until 6 months of age is too short a period. The recommendation is for breastfeeding, not commercial formula. If the mother has stopped breastfeeding, then commercial formula, rather than whole milk, should be used until age 1 year.

The nurse is assessing a 3-day-old breastfed newborn who weighed 3400 g (7 lb, 8 oz) at birth. The infant's mother is now concerned because the infant weighs 3147 g (6 lb, 15 oz). The most appropriate nursing intervention is which of the following?

Explain that this weight loss is within normal limits. -A neonate normally loses about 10% of the birth weight by age 3 to 4 days. The birth weight is usually regained by the tenth day of life. Because this is an expected occurrence, no further action is needed. The mother should be taught about normal infant feeding and growth patterns.

Mr. and Mrs. Wilson have a newborn with ambiguous genitalia. Tests are being done to assist in gender assignment. The parents tell the nurse that family and friends are asking what caused the baby to be this way. The nurse's intervention should include which of the following?

Explain the disorder so they can explain it to others-Although ambiguous genitalia may appear as one entity, there are many causes. It is essential that the parents understand the complex issues that are involved in gender assignment as they work with the multidisciplinary team. Depending on the etiology, this can be a lifelong problem. Gender assignment should be a slow, deliberative process.

Which of the following self-report pain rating scales can be used in children as young as 3 years of age?

FACES Pain Rating Scale-The Poker Chip Tool has been validated for children 4 years of age who have been determined to have the cognitive ability to identify the larger of two numbers. The Visual Analog Scale can be used for children older than 4 years of age but is most appropriate for ages 7 and older. The FACES Pain Rating Scale is for children as young as 3 years of age. The Word-Graphic Rating Scale uses descriptive words and is recommended for children 4 to 17 years of age.

Which of the following is the most consistent and commonly used indicator of pain in infants?

Facial expression of discomfort

Which of the following is a major long-term problem for a child with a cleft lip and palate?

Faulty dentition -A comprehensive team approach is used for children with a cleft lip and palate. Extensive orthodontics and prosthodontics are usually required to correct the malposition of the teeth and other bony structures. The child can be adequately nourished before and after surgical repair takes place.

What information should the nurse give a mother regarding the introduction of solid foods during infancy?

Foods should be introduced one at a time at intervals of 5 to 7 days-One food item is introduced at intervals of 5 to 7 days to allow the identification of food allergies. Iron-fortified cereal should be the first solid food introduced into the infant's diet. Mixing solid foods in a bottle has no effect on the transition to solid food. Solid foods can be introduced earlier than 8 to 10 months. The extrusion reflex usually disappears by age 6 months.

Elevation of triple marker screening results indicates the need for which of the following?

Further diagnostic testing- Further diagnostic testing is indicated for unexplained results outside the expected limits. Termination of the pregnancy is not indicated based on the results of the screening test. Definitive testing is done after unexplained positive screening results.

A child who has been receiving morphine intravenously will now start receiving it orally. The nurse should anticipate that to achieve equianalgesia (equal analgesic effect), the oral dose will be which of the following?

Greater than the intravenous dose-Oral morphine undergoes significant metabolism from the first-pass effect. For this reason, a higher oral dose is necessary to achieve the same effect as parenteral morphine. The same dose given orally will provide less pain relief. A dose larger than the intravenous dose must be given to achieve an equianalgesic effect.

Which of the following is characteristic of infants whose mothers smoked during pregnancy?

Growth restriction in weight, length, and chest and head circumference-Infants born to mothers who smoke have growth failure in weight, length, and chest circumference compared with infants of mothers who do not smoke. A dose-effect relation exists. Infants have significant growth failure, which is related to the number of cigarettes smoked.

A young child is being treated for giardiasis. Which of the following should the nurse recommend to the child's parent?

Handwashing will be important to prevent transmission to other family members.-Proper handwashing technique is important to prevent transmission of the parasite to other family members. If a child with giardiasis is in a pool, contamination of the entire pool is a possibility. Treatment may be indicated for up to 1 month to treat parasites that have hatched since treatment began. It is imperative to promote fluid intake to prevent dehydration in the child, so withholding fluids is not an appropriate recommendation.

Which of the following vaccines is recommended for administration at birth?

Hep B-Hepatitis B immunization is recommended early. Hepatitis B virus infections that occur during childhood can lead to fatal consequences from cirrhosis or liver cancer during adulthood. MMR is recommended for children ages 12 to 15 months. The hepatitis A series should begin between 12 and 23 months. Hib is administered beginning at age 2 months.

Which of the following is the causative agent for erythema infectiosum (fifth disease)?

Human parvovirus B19-The human parvovirus B19 is the causative agent. Mumps is caused by paramyxovirus organisms. The human herpesvirus type 6 is the virus responsible for exanthema subitum (roseola). Group A α-hemolytic streptococci infection causes scarlet fever.

The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. Nursing considerations regarding infiltration include which of the following?

Hypertonic solutions can cause severe tissue damage if infiltration occurs-Hypertonic fluids can damage cells if the fluid leaks from the vein. Careful monitoring is required to prevent severe tissue damage. Infiltrations occur for many reasons, not only activity. The vein, catheter, and fluid used all contribute to the possibility of infiltration. The continuous infusion pump may alarm when the pressure increases, but this does not alert the nurse to all infiltrations. Infusion rates and sites should be checked hourly to prevent tissue damage from extravasations, fluid overload, and dehydration.

The nurse is caring for a neonate whose mother has diabetes. Which of the following clinical manifestations would the nurse expect to see?

Hypoglycemic and large for gestational age-The clinical manifestations of an infant born to a mother with diabetes include being large for gestational age, plump, and full faced; having abundant vernix caseosa; being listless and lethargic; and having hypoglycemia, which appears a short time after birth. The infant is hypoglycemic from increased fetal production of insulin and being large for gestational age.

An infant has just been born with a symptomatic congenital diaphragmatic hernia. Care of the infant in the preoperative period should include which of the following?

Immediate endotracheal intubation-Many infants with symptomatic congenital diaphragmatic hernias require immediate ventilatory assistance after birth. Endotracheal intubation is essential. The child is not fed. Gastric decompression is indicated.

A mother calls the school nurse saying that her daughter has developed school phobia. She has been out of school for 3 days. The nurse's recommendations should include which of the following?

Immediately return the child to school-The primary goal is to return the child to school. Parents must be convinced gently, but firmly, that immediate return is essential and that it is their responsibility to insist on school attendance. The longer the child is permitted to stay out of school, the more difficult it will be for the child to reenter. This will only delay the return to school and inhibit the child's ability to cope. Professional counseling is recommended if the problem persists, but the child's return to school should not wait for the counseling.

An intravenous line is needed in a school-age child. The most appropriate action to provide analgesia during this procedure is to apply

LMX (4% liposomal lidocaine cream) 30 minutes before the procedure- LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on the wound for suturing. It is not useful for intact skin. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximum effectiveness, EMLA must be applied approximately 60 minutes in advance.

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care should include which of the following?

Monitor closely for signs of infection-Infection is the greatest hazard in the postoperative period. The nurse is vigilant for signs of cerebrospinal fluid infection, including elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child is placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir, when placed, is used for access to the ventricular system. It should not be pumped.

What is the leading cause of death from unintentional injuries in children?

Motor vehicle-related injuries are responsible for more than half of the injury-related deaths in children. Half of all poisonings occur in children younger than the age of 4 years, and it is the third leading cause of injury in those 15 to 24 years of age. Drowning and burns are among the top three causes of death for boys and girls throughout childhood.

Which of the following tools would be most useful to assess maternal and newborn attachment behaviors?

NCAST (Nursing Child Assessment Satellite Training) Feeding Scale- The NCAST Feeding Scale is a systematic tool to describe parent and newborn behaviors during feedings. Observations include the interaction between parent and infant.

A young woman who has recently become engaged to be married asks the nurse when genetic counseling is advisable. The couple does not plan to have children for several years. Which of the following should be the nurse's recommendation?

Now if they are members of a population at risk for certain diseases-Couples who are both members of a group that is at risk for certain diseases or who have concerns about a disorder in one of their families should be advised about the availability of genetic counseling. This should be done at the earliest possible time. When possible, counseling should precede pregnancy.

Which of the following is the most critical physiologic change required of newborns at birth?

Onset of breathing- The onset of breathing is the most immediate and critical physiologic change required for the transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. Body temperature maintenance, stabilization of fluid and electrolytes, and closure of fetal shunts in the heart are important changes that must occur in the transition to extrauterine life, but breathing and the exchange of oxygen for carbon dioxide must come first.

Which of the following clinical manifestations of developmental dysplasia of the hip would be seen in a newborn?

Ortolani sign-In the newborn period, the dysplasia usually appears as hip joint laxity. During the Ortolani test, the examiner places forward and then backward pressure on the trochanter. If the femoral head is felt to slip, dysplasia may be present. This test is most reliable from birth to 2 to 3 months.

When preparing parents to teach their children about human sexuality, the nurse should emphasize which of the following?

Parents should determine exactly what the child knows and wants to know before answering a question about sex.-Parents should be told that there are two rules that should be followed: find out what the child knows and be honest. Parents should model sexual behavior that is consistent with what they are teaching their children. Anatomic terms, although sometimes difficult to pronounce, will lay the groundwork for honest discussions later.

The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. Which of the following is an important consideration in managing the child's pain?

Plan a preventive schedule of pain medication around the clock.

What nursing intervention is most descriptive of atraumatic care of children?

Preparing a child before any unfamiliar treatment or procedure

Which of the following findings would the nurse consider normal in assessing the anterior fontanel of a neonate?

Pulsating anterior fontanel- The fontanel should feel flat, firm, and well demarcated. Pulsations are frequently visible at the anterior fontanel. A closed anterior fontanel is a potential sign of a major abnormality. A sunken or bulging fontanel (when the infant is quiet) may be indicative of distress or a major abnormality.

Which of the following is characteristic of a neonate's vision?

Pupils react to light- Although at birth the eye is still structurally incomplete, the pupils do react to light. The tear glands do not begin to function until age 2 to 4 weeks. The blink reflex is responsive to minimum stimulus. The ciliary muscles are immature, limiting the eye's ability to focus on an object for any length of time.

Which of the following is descriptive of toddlers' cognitive development at age 20 months?

Realize that "out of sight" is not out of reach.-At this age, children are in the final sensorimotor stage. They will now search for an object in several potential places even though they saw only the original hiding place. Children have a more developed sense of objective permanence. They will search for objects even if they have not seen them hidden. When a child is able to put objects into a container but cannot take them out, this is indicative of tertiary circular reactions, which appear between the ages of 13 and 18 months.

The parent of a 10-week-old infant tells the nurse, "She cries sometimes when nothing is wrong—for example, when she is dry and has recently been fed." The most appropriate nursing intervention is which of the following?

Reassure the parent that periods of "unexplained fussiness" are normal-A crying infant can be a source of great distress for parents. There is great variability in the amount of crying that can be expected from an infant. Parents should be reassured that some crying without apparent cause is normal. Persistent and inconsolable crying may need further attention. Reassuring the parent that nothing is wrong negates the parent's concern about the child. The parent is responding to cues from the infant by feeding and changing diapers.

A toddler's parent asks the nurse for suggestions on dealing with temper tantrums. Which one of the following is the most appropriate recommendation?

Remain close by the child but ignore the behaviors-The best way to deal with temper tantrums is to ignore the behaviors, provided that the actions are not dangerous to the child. Tantrums are common during this age group as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The presence of the parent is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.

Which of the following refers to an infant whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

SGA- A small-for-gestational-age, or small-for-date, infant is any child whose intrauterine growth rate was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves.

The parents of a 3-month-old girl complain to the nurse that they are exhausted because she still wakes up as often as every 1 to 2 hours during the night. When she awakens, they change her diaper, and her mother nurses her back to sleep. Which of the following should the nurse suggest to help them deal with this problem?

Start putting her to bed while still awake and while the parent is present-Current research suggests that parents be present at bedtime until the child is drowsy. The child should then be allowed to fall asleep alone. This encourages self-soothing behaviors. Children who learn to fall asleep on their own have longer sustained sleep periods than those who fall asleep with parents present. Letting the child cry herself back to sleep is difficult to implement for many parent

Which of the following is an important consideration when the nurse is discussing enuresis with the parents of a young child?

The child should be encouraged to take charge of treatment interventions. -Because any treatment involves and requires the child's active participation, the child is in charge of the interventions, and the parents should learn to support the child rather than intervene. Enuresis is more common in boys than in girls, and it has a strong family tendency. Psychogenic factors may influence enuresis, but it is doubtful that they are causative.

Which of the following is most suggestive that a nurse has a nontherapeutic relationship with a patient or family?

The concern of other staff members may indicate that the nurse is exhibiting negative behaviors and may be involved in a nontherapeutic relationship. Consistent staff assignments are important to provide continuity of care and contribute to therapeutic relationships. Using teaching skills to instruct the patient or family rather than doing everything for them empowers the family and facilitates their caring for the child. In therapeutic relationships, the nurse must recognize and maintain professional boundaries. The ability to recognize when these are being eroded is essential.

Which of the following is an important consideration in understanding the reactions of parents when their infant is born with physical defects?

The psychologic reaction is similar to that with the death of an infant- Parents need to grieve for the loss of the expected child. They also must adapt to the needs of a child with physical defects and the additional demands this will place on the family. The grief usually consists of several stages, including shock, frustration, and anger. The grief response may last for years. Denial and disbelief during the shock phase are not maladaptive. They can serve to protect the parents as they begin to deal with the impact of the initial stress. Parents are sensitive and responsive to the behaviors of others. Health professionals' interactions with the infant and parents provide cues to the parents that can greatly influence their reaction to the infant.

A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. Your explanation to the parents should include

The pump allows for a continuous basal rate and delivers a constant amount of medication to control pain-The PCA prescription can be set for a basal rate for a continued infusion of pain medication to prevent pain from returning during sleep and when the patient cannot control the infusion. Although the goal of PCA is to have effective pain relief, a pain-free state may not be possible. With a child who is 5 years old, the parents and nurse must assess the child to ensure that adequate medication is being given. A child who is 5 years old may not be able to understand the concept of pushing a button. Evidence suggests that effective analgesia can be obtained with the parents and nurse giving boluses as necessary. The prescription for the PCA includes how much medication can be given in a defined period. Monitoring every 1 to 2 hours for patient response is sufficient.

In the newborn, intramuscular vitamin K is administered into which muscle?

The vastus lateralis is the traditionally recommended injection site. The ventrogluteal site may be used as an alternative site. The deltoid and dorsogluteal sites are not recommended for vitamin K administration. The rectus femoris is not used for intramuscular injections.

Which of the following is descriptive of nursing diagnoses?

They provide the basis for the selection of nursing interventions. - The nursing diagnosis is the clinical judgment about the client's response to actual or potential health problems. The outcome statement guides the necessary interventions. Nursing diagnoses do not describe all areas of nursing practice. An actual problem may not exist. There may be risk factors that predispose a child or family to dysfunctional health patterns. There may not be a direct cause-and-effect relationship expressed in the diagnostic statement.

Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. Which of the following is the best interpretation of this behavior?

This is typical behavior because toddlers are egocentric-Play develops from the solitary play of infancy to the parallel play of toddlers. A toddler plays alongside other children, not with them. When a child grabs a toy from another child, it is typical behavior of the toddler and is not intentionally aggressive. Shared play is not within their cognitive development. Toddlers do not conceptualize shared play. Because a toddler cannot view the situation from the perspective of the other child, it is okay to take the toy. Therefore, no right or wrong is associated with taking a toy.

In 1935 Title V of the Social Security Act was passed. This was significant in the evolution of child health care in the United States because it established what?

This legislation provided for federal grants to be given to states for three major programs, Maternal Child Health, Crippled Children's Services, and Child Welfare Services.

The nurses caring for a child are concerned about the child's frequent requests for pain medication. During a team conference, a nurse suggests they consider administering a placebo instead of the usual pain medication. The decision should be based on knowledge of which of the following?

This practice is unjustified and unethical.- Use of placebos without the patient's consent is unethical. Use of placebos does not provide information about the presence or severity of the pain. Individuals may have a positive response to a placebo despite a significant organic cause for their pain.

The nurse is assessing a child with herpetic gingivostomatitis. In determining whether to wear gloves, the nurse bases the decision on which of the following?

This virus easily enters breaks in the skin.-The herpes simplex virus is highly contagious and can easily enter breaks in the skin of the hands. Although the nurse can decide not to wear gloves, this is a violation of universal precautions because contact with the oral mucosa may take place. Herpetic gingivostomatitis is present in the lesions and is easily spread.

Trisomy 13, trisomy 18, and trisomy 21 have which of the following in common?

Trisomy 13, trisomy 18, and trisomy 21 have distinctive clinical manifestations that often allow presumptive diagnosis soon after birth.

The health promotion interventions that have the greatest impact on injury prevention are which of the following?

Using a developmental approach to safety counseling-Utilizing a developmental approach to safety counseling will ensure that the parents are taught risks associated with developmental age and increased risk factors for that population. Family members may have different learning styles, so the nurse should include several strategies in the health promotion teaching session. Although nutritional counseling is important, it is not an injury prevention health promotion priority for preventing injury. Maslow's hierarchy of needs is a theoretical model to assist in assuring all the needs of an individual are met, but it is not the theoretical model of choice in this scenario.

After 8 weeks in the neonatal intensive care unit, Chris will be soon discharged. His parents seem apprehensive and worry that he may still be in danger. The nurse should recognize this as which of the following?

a common parental reaction-Parents become apprehensive and excited as the time for discharge approaches. They have many concerns and insecurities regarding the care of their infant. A major concern is that they may be unable to recognize signs of illness or distress in their infant. This is a normal adaptive response. The neonatal intensive care unit nurses should facilitate discharge by involving the parents in care as soon as possible. Preparation for discharge should begin early and include helping the parents acquire the skills necessary for care.

The apnea monitor alarm sounds on a neonate for the third time during this shift. The nurse's first action should be which of the following?

asses infant for color and presence of respirations-The first action is to assess the infant for color and respirations. Only if these are the expected findings for the infant would other actions be taken. If the infant does have an apneic episode, then tactile stimulation is indicated. This occurs after the assessment. Administering the flow of 100% oxygen is not indicated until after respiratory status is assessed. After the nurse determines that the infant is not in distress, then possible causes of a false alarm are investigated.

An infant who was born yesterday is scheduled for surgery tomorrow. Which of the following interventions in the preoperative period will be the most helpful in assessing postoperative pain in this neonate?

asses the neonate's behavior-A preoperative assessment of the infant's behavior is essential. This provides a baseline against which to measure postoperative behavior. Changes may indicate pain or an unstable condition.

Which of the following is descriptive of a preschooler's concept of time?

associates time with events-In a preschooler's understanding, time has a relation with events such as: "We'll go outside after lunch." Preschoolers develop an abstract sense of time at age 3 years. Children can tell time on a clock at age 7 years. Children do not fully understand use of time-oriented words until age 6 years.

Imaginary playmates are beneficial to the preschool child because they do which of the following?

become friends in times of loneliness- one purpose of an imaginary friend is to be a friend in times of loneliness. Imaginary friends do not take the place of social interaction but may encourage conversation.

Which of the following is a nursing responsibility in caring for an infant suspected of having necrotizing enterocolitis (NEC)?

closely monitor abdominal distention-Monitoring the abdomen for signs of distention can aid in the prompt recognition of NEC. Feedings are held. Gastric residuals are checked before feedings. With NEC the bowel wall is edematous and breaking down. Rectal temperatures are contraindicated.

A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. The nurse should recommend that the infant be given

commercial iron-fortified formula-For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If breastfeeding has been discontinued, then iron-fortified commercial formula should be used. Cow's milk should not be used in children younger than 12 months. Maternal iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron-deficiency anemia.

A school-age child with cancer is being prepared for a procedure. The child says, "I have had one of these. They hurt." The nurse's response should be based on knowledge that children

commonly experience treatment-related moderate to severe pain when they have cancer.-Pain is reported by approximately 84% of children with cancer. Of these, most report it as moderate to severe, and half report the pain as highly distressing. There are no data to support that children misrepresent pain experiences. Pain tolerance is a complex phenomenon that is not based on age. Children do not become accustomed to painful procedures.

A significant common side effect that occurs with opioid administration is

constipation

The nurse is caring for a neonate born with an omphalocele. Initial management after delivery includes

covering the omphalocele with saline-soaked gauze and a plastic drape-The sac is covered to prevent drying and excessive fluid loss from the neonate. The child will not be fed. With the abdominal contents outside of the infant, the stomach is decompressed and the infant is maintained with parenteral nutrition. A neutral thermal environment is desired, but the sac is not allowed to dry.

Where would nonpathologic cyanosis normally be present in the newborn shortly after birth?

feet and hands-Cyanosis of the feet and hands is termed acrocyanosis and is a usual finding in newborns. Cyanosis of the bridge of nose, circumoral area, and mucous membranes are signs of general cyanosis, which is a potential sign of distress or major abnormality.

Which statement characterizes toddlers' eating behavior?

food fads are common-Appetite and food preferences are sporadic during the toddler years. The child may enjoy the same food several days in a row and then refuse to eat it. It is difficult to change the food fad. At approximately 18 months of age, toddlers have decreased nutritional needs. This is labeled physiologic anorexia. Toddlers have distinct food preferences that may not be consistent or predictable.

The nurse is guiding parents in selecting a daycare facility for their child. Which of the following is especially important to consider when making the selection?

health practices of the facility-Health practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when hand washing and other hygienic measures are not consistently used.

The mother of an infant who was born at 30 weeks of gestation tells the nurse that she wants to be able to breastfeed. The nurse should explain that

human milk is preferred over other types of nutrition-Human milk is the preferred food for infants. The mother should pump her breasts to provide milk for the infant. This can be given if the child is receiving enteral feedings. She will be able to breastfeed when the infant is able to coordinate breathing, sucking, and swallowing. Human milk has the essential ingredients that are necessary for the infant's stage of growth. Preterm infants fed commercial formula had longer hospital stays than those fed fortified human milk. Commercial formulas are available for preterm infants

Which of the following problems is most often associated with myelomeningocele?

hydrocephalus- Hydrocephalus is a frequently associated anomaly in 80% to 90% of children.

Sara, age 4 months, was born at 35 weeks of gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was full term. The nurse should explain that

infants become less difficult if they are kept on scheduled feedings and structured routines-Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in routines. Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infant's unique temperament. Sara's temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to Sara's temperament.

Which of the following is the earliest clinical manifestation of biliary atresia?

jaundice-Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera and may be present at birth, but it is usually not apparent until ages 2 to 3 weeks.

Which of the following findings on physical assessment of a neonate would indicate the need for further evaluation?

low set ears-The top of the pinnae of the ear should be on a horizontal line with the outer canthus of the eye. Placement below this level is indicative of major abnormalities and must be referred for further evaluation. Nystagmus is an involuntary movement of the eyes. This is a common variation in newborns. Epstein pearls are small, white, epithelial cysts along both sides of the midline of the hard palate. They are insignificant and disappear in several weeks. A positive Babinski reflex is expected until 1 year of age.

Nonpharmacologic strategies for pain management

may reduce pain perception-Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. Nonpharmacologic techniques should be learned before the pain occurs. It is best to use both pharmacologic and nonpharmacologic measures for pain control. The nonpharmacologic strategy should be matched with the child's pain severity and taught to the child before the onset of the painful experience. Some of the nonpharmacologic techniques may mitigate the child's experience with mild pain, but the child will still know the discomfort was present.

The clinic is loaning a federally approved car seat to a 10-lb (4.5-kg) infant's family. The nurse should explain that the safest place to put the car seat is in the

middle of the back seat facing rearward-The rear-facing car seat provides the best protection for an infant's disproportionately heavy head and weak neck in the event of an accident. The middle of the back seat is the safest position for the child. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.

The nurse is caring for a male infant who was born 24 hours ago to a mother who received no prenatal care. The infant is a poor feeder but sucks avidly on his hands. Clinical manifestations also include hyperactive reflexes; tremors; sneezing; and a high-pitched, shrill cry. The nurse should suspect which of the following?

narcotic withdrawal-Infants exposed to drugs in utero usually show no untoward effects until 12 to 24 hours after birth for heroin or much longer for methadone. The infant usually has nonspecific signs that may coexist with other conditions such as hypocalcemia and hypoglycemia. In addition, these infants may have loose stools; tachycardia; fever; projectile vomiting; sneezing; and generalized sweating, which is uncommon in newborns.

Physiologic measurements in children's pain assessment are

not useful as the sole indicator for pain- Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used.

Which of the following reflexes appear at about 7 to 9 months of age?

parachute-The parachute reflex appears at 7 to 9 months of age and persists indefinitely. The Moro reflex is one of the primitive reflexes present at birth. Neck righting appears at 3 months of age and persists until 24 to 36 months. Labyrinth righting appears at 2 months and is strongest at 10 months.

Which of the following is important in providing a neutral thermal environment for an LBW infant in an incubator?

prevent heat loss-Prevention of heat loss in the distressed infant is essential for survival. Cotton blankets should be used.

A thorough systemic physical assessment is necessary in the extremely low-birth-weight (ELBW) infant to detect

subtle changes that may be indicative of an underlying problem-An ELBW infant is not able to handle prolonged physiologic stress. These infants manifest stress with subtle changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Weight should be monitored as a reflection of genitourinary function. Usually one or two times per day is adequate. Although maternal-child attachment difficulties are a concern in ELBW infants, these observations are done with parental visits. The child's physiologic status is a priority.

Recommendations for parents of toddlers to meet fluoride requirements include all of the following except

supervise the use of fluoride rinses-Fluoride rinses are only suggested for children at high risk for cavities or over the age of 6 years. Toothpaste supervision, storage of fluoride products out of reach, and administration of fluoride supplements if water fluoride content is low are all recommended for toddlers.

An infant is born with anencephaly. When discussing this condition with the parents, the nurse should know that

the condition is incompatible with life- Anencephaly is the most serious neural tube defect. Both hemispheres of the brain are absent. Anencephaly is incompatible with life. Some infants with mature brainstem function can maintain vital functions for a short period. Currently, there are no medical or surgical treatment options.

A newborn with congenital clubfoot is being treated with successive casts. The parents ask why so many casts are required. The nurse should explain that

they allow for gradual stretching of tight structures-Serial casting is begun shortly after birth and before discharge from the nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy.