Peds I: Module 1-3 Quiz
A 3-month-old infant is admitted for ALTE (apparent life-threatening event). The mother describes the infant turning blue then going limp at home after drinking a bottle. The infant is currently alert and appropriate. What is the most important nursing intervention? Taking the child's blood pressure Providing emotional support for the parents Assessing the child during and post feeding Administering oxygen
Assessing the child during and post feeding Rationale: There are multiple causes of ALTE, but in this description, gastroesophageal reflux is most likely. Assessing the child during and post feeding will allow the nurse to see how the parents feed the child, too fast, burping, sitting up, etc. and see how the child reacts. The nurse can then provide input, such as sitting the baby up to feed and keeping upright after feedings. All the interventions listed are important (oxygen only if needed and ordered) but assessing the child eating is the most important in this scenario, given that the child is currently alert.
A nurse is caring for a 6-year-old post-op tonsillectomy patient. Which action should cause the nurse to intervene and not allow the child to do? Blowing his nose forcefully Drinking water from a cup Playing video games with the head of bed elevated Eating ice chips
Blowing his nose forcefully Rationale: Blowing the nose can disrupt the surgical site and cause bleeding. Eating ice chips, drinking clear fluids from a cup- not a using a straw, and having the head of bed elevated while awake are all appropriate actions post-op (ATI, p.92).
A 3-year-old is newly diagnosed with asthma. The nurse is teaching the caregiver about symptoms of an acute episode. Which should be included? Select all that apply. Fever Coughing Nasal Flaring Increased energy Anxiety
Coughing Nasal Flaring Anxiety Rationale: A child with asthma will have increasing anxiety as the episode progresses. They get anxious because they cannot breathe (ATI, p. 99, textbook, p. 1168). There will be coughing, nasal flaring, possibly head bobbing, decreased air movement- which can have wheezing or may not, respirations are increased and labored, and the child will be fatigued from the effort to breathe.
The mother of a toddler-age patient states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate? "The younger child's airways are smaller and more easily occluded." "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." "Toddlers do not breathe as deeply as do older children." "You are incorrect in your assessment."
"The younger child's airways are smaller and more easily occluded." Rationale: The mother is correct in her statement. Airways are smaller in the younger child and are more easily occluded when mucus is produced. Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent. Depth of breathing is not age dependent.
Which statement should the nurse include when teaching parents of an infant about normal growth and development regarding weight gain? "Your baby's weight should triple by 6 months of age." Your baby's weight should double by 1 year of age." "Your baby's weight should double by 6 months of age." "Your baby's weight should triple by 9 months of age."
"Your baby's weight should double by 6 months of age." Rationale, page 758: It is expected that the infant would double in weight by 5 to 6 months of age. A child whose weight triples by 6 months of age has gained weight too rapidly. The normal infant's birth weight triples by 1 year of age. If not, this child may not be growing adequately. Module 1
A child with a history of being premature, weighing 1.5 kg at birth, is admitted with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). The child is dehydrated, not taking in fluids, and having difficulty breathing. No bacterial infection is suspected. What prescriber order should the nurse question? Applying humidified oxygen IV normal saline replacement fluids Nasal suction prior to feeding Administer antibiotics
Administer antibiotics Rationale: Antibiotics are only given when a bacterial infection is suspected either along with, or in place of a virus. All the other interventions are appropriate, as the child has difficulty breathing- needing suctioned before feedings is typical of bronchiolitis, as is humidified oxygen if the saturations are low. The child is also dehydrated so replacement fluids is important.
A child is admitted to the pediatric medical unit with a diagnosis of Kawasaki disease. Which provider order should the nurse question? Oral aspirin every 8 hours Echocardiogram Contact isolation Vital signs every 4 hours
Contact isolation Rationale: The child is not contagious so contact isolation is not appropriate. Aspirin is used as an anti-inflammatory and is prescribed around the clock. This is appropriate. An echocardiogram will be used as a baseline to compare against as the child recovers to assist in monitoring for cardiac lesions. The child will need close monitoring during the early period of the disease with more frequent vital signs.
A 5-year-old child is hospitalized with a fractured femur. Which tool should the nurse use to assess this child's pain? PIPP scale Faces Pain Rating Scale CRIES scale NIPS scale
Faces Pain Rating Scale Rationale: A 5-year-old child should be able to use the Faces Scale to choose which face best matches the child's pain level. The CRIES Scale was developed for preterm and full-term neonates. The NIPS Scale was developed for use in newborns. The PIPP Scale was developed for premature infants. Module 1
A patient presents in the ED with tachypnea (without cyanosis), tachycardia, murmur, CHF, poor weight gain, and a history of frequent respiratory infections. Which category of cardiac defects do you expect to find in the patient's history? Increased pulmonary blood flow Mixed defect Obstruction to systemic blood flow Decreased pulmonary blood flow
Increased pulmonary blood flow Rationale: Patients with a cardiac disorder resulting in increased pulmonary blood flow have the above symptoms. They do not have cyanosis since the pulmonary system is not deficient in blood flow (p.1191). The patient could have PDA, ASD, or VSD. Defects with increased pulmonary blood flow also create a medium for respiratory infections. The other categories typically have cyanosis due to the lack of blood available to the pulmonary system or cyanotic blood being shunted to the peripheral system - resulting in decreased systemic oxygenation.
Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 10-year-old child? Recognizing that food jags are common Encouraging the use of a highchair with a safety strap Involving the child in snack selection and preparation Recommending the child consumes high-fat foods
Involving the child in snack selection and preparation Rationale, page 872: A 10-year-old child should be involved in snack selection and preparation. Food jags are more common in preschool age children. The use of a highchair with a safety strap is not information that should be included for a 4-year-old child during a health maintenance visit. This is more appropriate for a toddler-age child. Low-fat, not high-fat, foods should be encouraged during the health maintenance visit. Module 2
An infant is in the hospital for post-op VSD repair. What would the nurse need to teach the parents about post-operative care? Select all that apply. Give the infant pain medication only if they are fussy and inconsolable Lift the infant without lifting under the arms to reduce stress on the incision The child will only need PRN pain medication Place a thin blanket over the incision in car seats to prevent rubbing Give Tylenol or Ibuprofen (if age appropriate or approved by provider) for pain
Lift the infant without lifting under the arms to reduce stress on the incision Place a thin blanket over the incision in car seats to prevent rubbing Give Tylenol or Ibuprofen (if age appropriate or approved by provider) for pain Rationale: Lifting under the back with head and leg support will decrease stress on the incision, therefore decreasing pain. Lifting under the arms can create stress, and sometimes rubbing if the caregiver's hands touch the incision while lifting. (p.1199) The child will need around the clock pain medication for the first few days, or longer, not solely PRNs. A thin blanket will prevent rubbing, therefore reducing the risk of pain- though make sure the infant fits in the car seat safely. Tylenol and/or ibuprofen are often given for pain- but check with the physician for approval for ibuprofen if under 6 months.
The nurse is planning care for an overweight adolescent. Which topic may also be appropriate for the nurse to include in the adolescent's plan of care? Negative self-esteem Substance abuse Spiritual distress School Phobia
Negative self-esteem Rationale: Self-esteem is tied closely to body image, a common source of distress among obese adolescents. Therefore, the nurse will monitor the adolescent for issues with self-esteem. Substance abuse is not the major mental health issue associated with obesity. While the adolescent may dislike attending school, this is not the mental health problem the nurse should be evaluating. Adolescents may have issues related to spirituality, but this is not associated with obesity. Module 2
Two 3-year-old patients are playing together in a hospital playroom. One is working on a puzzle, while the other is stacking blocks. Which type of play are these children participating in based on this scenario? Associative Play Solitary Play Parallel Play Cooperative Play
Parallel Play Rationale, page 765: Parallel play is when two or more children play together, each engaging in his or her own activities. Cooperative play is when children demonstrate the ability to cooperate with others and to play a part in order to contribute to a unified whole. Theschool-age child participates in cooperative play. Solitary play is when a child plays alone. Infants' play style is described as solitary. Associative play is characterized by children interacting in groups and participating in similar activities. Preschoolers' play style is associative. Module 1
At a primary care well visit, the nurse is teaching a new mother about risk factors for SIDS and prevention. What should be included in the teaching? Select all that apply. Recommend a pacifier for nap and bedtime Do not allow pillows, stuffed animals, blankets in crib Avoid second hand smoke It's ok to have the baby sleep on the parent's chest as long as you don't fall asleep Always place the child to sleep on his/her back in own crib- not sharing a bed
Recommend a pacifier for nap and bedtime Do not allow pillows, stuffed animals, blankets in crib Avoid second hand smoke Always place the child to sleep on his/her back in own crib- not sharing a bed
The nurse is teaching the parents of a 6-month-old infant about the introduction of solid foods. Which foods will the nurse include in the teaching session? Select all that apply. Rice Cereal Ice Cream Meats Fruits Vegetables
Rice Cereal Fruits Vegetables Rationale: Rice cereal is typically the first solid food that is introduced at 6 months of age. It is appropriate to include this food in the teaching session. Fruits and vegetables are introduced at 6 to 8 months of age. It is appropriate to include these foods in the teaching session. Meats are not introduced until 8 to 10 months of age. Module 2
Which data collected during the respiratory assessment would indicate the pediatric patient is compromised? Select all that apply. Stridor (high pitch wheezing) Strong Cry Substernal retractions Nasal Flaring Lung Sounds clear to auscultation
Stridor Substernal retractions Nasal Flaring Rationale: Stridor is an adventitious breath sound that may indicate respiratory compromise. Substernal retractions may indicate respiratory compromise. Nasal flaring may indicate respiratory compromise. Lung sounds that are clear to auscultation do not indicate respiratory compromise. A weak, not strong, cry may indicate respiratory compromise.
The nurse is teaching the parents of a 4-month-old infant about good feeding habits. Which is the rationale for not letting the baby go to sleep with a bottle? To decrease the risk for dental caries To decrease the risk for sleeping disorders To decrease the risk for obesity To decrease the risk of malocclusion problems
To decrease the risk for dental caries Rationale: The primary concerns related to putting an infant to bed with a bottle are dental caries and otitis media. Malocclusion, poor dental alignment, is not a significant problem. Sleeping disorders have not been found to be related to letting an infant go to sleep with a bottle. Module 2
A child has Hypoplastic Left Heart Syndrome. Why is it essential for the patient to receive prostaglandin E1? To close the patent ductus arteriosus To increase heart rate To increase respiratory rate To maintain a patent ductus arteriosus
To maintain a patent ductus arteriosus Rationale: Prostaglandin E1 is immediately given to maintain a patent ductus arteriosus until surgery/heart transplant can be performed (p.1210-1211). Without a patent ductus arteriosus, CHF develops, leading to shock, and death. A patent ductus arteriosus will allow blood flow, decreasing CHF symptoms (therefore decreasing heart rate and respiratory rate) until other interventions are available.
A registered nurse is delegating to an unlicensed assistive person (that has been verified in skills) to monitor strict I & O and provide care for a cardiac patient with fluid retention concerns. What interventions would the nurse delegate? Select all that apply. Weighing the child at the same time every day in a gown Assess for areas of edema Document all fluid/food intake, every 2 hours. Weighing diapers before and after use Turn the patient every 2 hours
Weighing the child at the same time every day in a gown Document all fluid/food intake, every 2 hours. Weighing diapers before and after use Turn the patient every 2 hours Rationale: All of the above are essential when monitoring strict I & O and caring for a patient with fluid concerns. Children with fluid concerns can have skin breakdown so turning is important. The nurse will also need to assess for skin breakdown, edema, etc. but assessments cannot be delegated to a UAP.
The mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. Which response by the nurse to the mother is appropriate? "Pick up and cuddle your child now, please." "What do you usually do or say during a temper tantrum?" "Let's ignore this behavior. It will stop sooner." "This is definitely a temper tantrum. I know exactly what you are feeling right now."
"What do you usually do or say during a temper tantrum?" Rationale, page 875: Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. Ignoring the behavior is not an effective way to problem solve for temper tantrums. Sympathizing with the mother may make the mother feel better at that moment but does not help the mother improve her child's behavior. Cuddling the child will provide positive reinforcement to the child to continue that behavior and providing a direct instruction to the mother in this manner is unlikely to elicit the mother's trust in the nurse. Module 2
At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process? 2 years 4 years 12 months 18 months
2 years Rationale, page 870: BMI is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that can reduce the incidence of obesity. While the nurse will plot a child's growth at 12 and 18 months of age, a BMI is not included in the physical assessment at these times. The nurse will not initiate BMI calculation for a 4 year old; this action should be implemented into the nursing assessment prior to 4 years of age. Module 2
Which instruction from the nurse is appropriate when conducting teaching to new parents regarding infant care and feeding? Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age. Delay supplemental foods until the infant is 4 to 6 months old. Begin diluted fruit juice at 2 months of age but wait 3 to 5 days before trying a new food. Delay supplemental foods until the infant reaches 15 pounds or greater.
Delay supplemental foods until the infant is 4 to 6 months old. Rationale: Age 4 to 6 months is the optimal age to begin supplemental feedings. The infant does not need supplemental foods earlier and introducing supplemental foods earlier does not promote sleep. Fruit juice and rice cereal are not well tolerated by infants at 2 months of age as they lack the digestive enzymes to take in and metabolize many food products. Introducing cereal at this stage will not help promote sleep. Earlier feeding of non-formula foods, regardless of the infant's weight, is more likely to cause the development of food allergies. Module 2
During a scheduled health maintenance visit for a 6-month-old infant the nurse asks, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? Health Promotion Health Maintenance Developmental Surveillance Disease Surveillance
Developmental Surveillance Rationale, page 855: The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. While health promotion and health maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones. This question is not classified as a disease surveillance question. Module 2
A patient with a cardiac defect causing increased pulmonary blood flow is admitted and needs medication. What cardiac medication slows the heart rate, increases cardiac filling time, and increases cardiac output ACEi-angiotensin-converting enzyme inhibitor (Enalapril) Spironolactone (Aldactone) Furosemide (Lasix) Digoxin (Lanoxin)
Digoxin (Lanoxin) Rationale: Digoxin provides the actions listed above. Furosemide provides rapid diuresis, spironolactone maintains diuresis, and ACEi promotes vascular relaxation and reduced peripheral vascular resistance (p. 1213).
An adolescent is admitted to the eating disorders unit with a 2-year history of anorexia nervosa. Assessment data indicate that the adolescent has recently sustained additional weight loss and electrolyte imbalances. Which is the priority when planning care for this patient? Regulation of antidepressant drugs Individual Counseling Nutritional Support Family Therapy
Nutritional Support Rationale, page 887: Hospitalization usually is in response to the weight loss and electrolyte imbalances, so nutritional support becomes the priority intervention. While family therapy is important, it is not the priority intervention at this time. Antidepressant drugs may be used as a component of the treatment, but this is not the priority intervention. All other activities can be managed as outpatient therapies. Module 2
In addition to separation anxiety, which is a common fear for the hospitalized pediatric patient between the ages of 6 and 18 months? Stranger Anxiety Bodily Injury Disfigurement Death
Stranger Anxiety Rationale, page 941 (Table 39-1): In addition to separation anxiety, infants between 6 and 18 months of age might display stranger anxiety when confronted with strangers such as healthcare providers. Infants do not fear disfigurement. Infants and toddlers do not fear death. Infants and toddlers do not fear bodily injury. Module 1
The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child? Hypothermia related to decreased metabolic state Acute pain related to the effects of a congenital heart defect Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect
Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow Rationale: VSDs are left to right shunts, which increases pulmonary blood flow without cyanosis. Because of the increased pulmonary congestion, impaired gas exchange would be an appropriate nursing diagnosis. Ventricular septal defects do not cause hypothermia, pain, fever, or deficient fluid volume.
Which screening is appropriate for the school nurse to perform on all adolescent students? Hepatitis B profile Scoliosis Chest x-ray Respiratory rate
Scoliosis Rationale, page 841: Routine screening for adolescents includes checking for scoliosis, height, weight, and blood pressure measurements. A respiratory rate is not a screening examination for all adolescents. It is done throughout childhood at each health supervision visit. The hepatitis B profile is needed only once, prior to administration of the hepatitis B vaccine; however, this is not a required screening for all adolescents. A chest x-ray is not a routine screening test for adolescents. Module 1
Which nursing actions are developmentally appropriate when providing care to a hospitalized toddler-age child? Select all that apply. Assessing drawings to determine concerns Showing equipment that will be used during the exam Allowing self-feeding opportunities Using a crib mobile for distraction during a procedure Having a potty-chair available
Showing equipment that will be used during the exam Allowing self-feeding opportunities Having a potty-chair available Rationale, page 940: Many toddlers are potty training; therefore, it is appropriate for the nurse to have a potty-chair available for the child. It is appropriate for the nurse to allow for self-feeding opportunities as this is developmentally appropriate for a toddler-age child. Showing equipment that will be used during a scheduled exam may be helpful for a toddler-age child. A crib mobile would be more developmentally appropriate for the infant, not the toddler-age, child. This is more appropriate for the preschool-age child. Assessing drawing to determine concerns is developmentally appropriate for the preschool, not the toddler-age, child. Module 2
Which distraction techniques should the nurse use for an early school-age child during a painful procedure? Select all that apply. Blowing bubbles Music therapy Sucrose solution Guided imagery
Blowing bubbles Music therapy Guided imagery Rationale: Blowing bubbles or popping bubbles can be a distraction for a young school-age child. Listening to music or singing can be used as distraction for this age group. Guided imagery is a means of encouraging relaxation and mental images to manage pain. Sucrose solution is used for infants up to 12 months of age. This is a complementary therapy but not a method of distraction. Module 1
A premature infant is admitted with the diagnosis of PDA (not surgically repaired). What intervention is most likely to be ordered? Administer IV Indomethacin Administer Prostaglandin E1 Administer Valium Administer IV Tylenol
Administer IV Indomethacin Rationale: IV Indomethacin is used in premature infants to attempt to close the PDA without surgery (p.1195). IV ibuprofen may also be used to attempt closure (though note that ibuprofen is not usually used in infants under 6 months unless it is cardiac related- also not used if it is a term infant). Prostaglandin E1 is used for Transposition of the Great Arteries, Aortic Stenosis/Coarctation, and Hypoplastic Left Heart Syndrome, but not PDA). Valium may be used for sedation (also often used for seizure patients), but does not repair a PDA.
An infant with Tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. Draw blood for a serum hemoglobin Administer Oxygen Obtain vital signs and O2 saturation Administer diphenhydramine (Benadryl) as ordered Place the child in knee-chest position
Administer Oxygen Obtain vital signs and O2 saturation Place the child in knee-chest position Rationale: When an infant with TOF has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the infant in knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance). The nurse would not draw blood until the episode had subsided because unpleasant procedures are postponed. Benadryl is not appropriate for this child.
The parents of a child who is critically injured wish to stay in the room while the child is receiving emergency care. Which nursing action is most appropriate in this situation? Escorting the parents to the waiting room and assuring them that they can see their child soon Asking the healthcare provider if the parents can stay with the child Allowing the parents to stay with the child Telling the parents that they do not need to stay with the child
Allowing the parents to stay with the child Rationale, page : Parents should be allowed to stay with their child if they wish instead of going to the waiting room where they lack privacy. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care. The physician does not make the decision whether the parents stay with the child; the parents make the decision. Module 1
Which heart defect should the nurse suspect for an infant whose upper extremities have stronger pulses than the lower extremities and blood pressure is higher in the arms than in the legs? Patent ductus arteriosus Atrial septal defect Transposition of the great vessels Coarctation of the aorta
Coarctation of the aorta Rationale: Coarctation of the aorta can present with stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs because of obstruction of circulation to the lower extremities. Atrial septal defect, transposition of the great vessels, and patent ductus arteriosus are not associated with blood pressures that are different in upper and lower extremities.
What gastrointestinal/pancreatic manifestations may you expect from a person with cystic fibrosis Frequent diarrhea adequate absorption of nutrients Loose, watery stools Constipation with greasy, bulky, foul smell stool
Constipation with greasy, bulky, foul smell stool Rationale: People with cystic fibrosis often have constipation issues, not frequent loose stools. They also poorly digest food, causing poor absorption of nutrients (p. 1178)
What would you expect to find upon taking an admission history and initial assessment of an infant with Transposition of the Great Arteries? Select all that apply. Bradycardia Cyanosis Tachypnea An order for Prostaglandin E1 Rapid weight gain
Cyanosis Tachypnea An order for Prostaglandin E1 Rationale: Cyanosis is apparent soon after birth, though may be less noticeable if a large VSD is present. Tachypnea is present, and an order for prostaglandin E1 is ordered to keep a patent ductus arteriosus until surgery can be performed. These children often have problems eating due to respiratory difficulty and fatigue- so growth failure is a possibility- not rapid weight gain (p.1204).
The nurse is assessing a small-for-gestational-age newborn who had an older sibling who died of sudden infant death syndrome (SIDS). Which should the nurse include in the newborn's plan of care based on these data? Encourage the parents to sleep with the newborn for close observation Encourage the parents to place the newborn on the abdomen to sleep Encourage the parents to place the newborn in a crib with a tight-fitting, firm mattress Encourage the parents to place the newborn in a crib with a soft mattress with extra blankets
Encourage the parents to place the newborn in a crib with a tight-fitting, firm mattress Rationale, page : Placing the infant in a crib with a tight-fitting, firm mattress will help keep the infant's mouth free of obstructions. This is the recommended sleeping position and environment for all newborns but is especially important due to the history of SIDS. Co-bedding is not encouraged because it is associated with an increased risk for SIDS. A prone sleeping position is not encouraged because it also is associated with an increased risk for SIDS. Quilts, blankets, and other soft items are not recommended as these increase the risk for SIDS. Put the newborn in a blanket sleeper instead. Module 2
The mother of a 6-year-old boy who has recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. Which defense mechanism will the nurse include when responding to the mother? Fantasy Rationalization Repression Regression
Regression Rationale, page 747: Regression is a return to an earlier behavior and can often occur during a hospital stay. The nurse will include regression in the response to the mother. Repression is the involuntary forgetting of uncomfortable situations. The child is not exhibiting repression. Rationalization is an attempt to make unacceptable feelings acceptable. The child is not exhibiting rationalization. Fantasy is a creation of the mind to help deal with an unacceptable fear. The child is not exhibiting fantasy. Module 1
Which nursing actions are appropriate for the 2-month-old infant during a scheduled health maintenance visit? Select all that apply. Reinforcing the importance of heating bottles with water versus the microwave Recommending that juice be introduced in a sippy cup Reviewing infant fluid needs with the parents Demonstrating proper gum care to the parents Educating the parents to begin introducing solid foods, such as rice cereal
Reinforcing the importance of heating bottles with water versus the microwave Reviewing infant fluid needs with the parents Demonstrating proper gum care to the parents Rationale, page 860: It is appropriate for the nurse to review infant fluid needs with the parents during the 2-month health maintenance visit. It is appropriate for the nurse to reinforce the importance of heating bottles with water versus the microwave with the parents during the 2-month health maintenance visit. It is appropriate for the nurse to demonstrate proper gum care to the parents during the 2-month health maintenance visit. The nurse would not educate the parents to begin introducing solid foods during the 2-month visit. Solid foods are not introduced until 6 months of age. While juice should only be offered in a sippy cup, the nurse would not recommend this during the 2-month health maintenance visit. This subject is appropriate during the 6-month health maintenance visit. Module 2
A toddler-age patient presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data? Throat culture Vital signs Medical history Auscultation of breath sounds
Throat culture Rationale: Throat cultures should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and can cause complete occlusion of the airway. Medical history should be obtained, which assists in diagnosis. Vital signs should always be taken when assessment is done. Assessment of breath sounds is essential for diagnosis.