peds nclex

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and avoids which of the following?

*1. Keeping the child uncovered to assist in reducing the fever*

A nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which of the following?

*4. Dysfunction in the cerebral hemisphere*

A nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation?

*1. Level of consciousness*

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which of the following will be prescribed initially?

*2. Insertion of a Foley catheter*

A nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which of the following that is indicative of this common complication?

*2. Nuchal rigidity*

A nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which of the following is the priority for the child?

*3. Promoting bedrest*

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse assists with developing a plan of care. The nurse questions which intervention that is written in the plan of care?

*1. Palpating the abdomen for a mass*

A nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which of the following?

*2. An elevated thyroid-stimulating hormone (TSH) level*

A nurse is developing a plan of care for a child with autism. The nurse identifies which of the following as the priority problem for this child?

*2. Risk for injury*

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which of the following that is a sign of this disorder?

*3. Evidence of soiled clothing*

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which of the following is the priority nursing action?

*3. Notify the registered nurse.*

A nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which of the following as the reliable method of determining fluid loss?

*4. Body weight*

A nursing student is assigned to care for an infant with a diagnosis of congestive heart failure (CHF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by:

*4. Weighing the diapers*

A nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?

*2. Projectile vomiting*

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further instruction?

*1. "The cast will feel warm when it is dried."*

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

*1. "When picking up your infant, support the infant's neck and head with the open palm of your hand."*

A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains a copy of an x-ray report of the child's:

*1. Cervical spine*

A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further instruction?

*2. "I will apply lotion under the brace to prevent skin breakdown."*

A nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which of the following items should the nurse place at the bedside?

*2. A suction apparatus and oxygen*

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. The nurse responds by telling the mother that surgery will probably be performed:

*2. Before the child is 3 years old*

A nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation should the nurse expect to note documented in the health record?

*2. Profuse watery diarrhea and vomiting*

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would do which of the following in order to protect the child from injury? *SELECT ALL THAT APPLY.*

*2. Remove toys that have bright, blinking lights on them.* *3. Keep side rails and other hard objects padded.* *4. Turn the client to the side during a seizure.*

When instructing the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver states:

*3. "I will allow my child to put cotton balls inside the cast to relieve pressure."*

A nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further instruction?

*3. "Lesions are most often located on the arms and chest."*

The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse makes which response to the mother?

*3. "This is not an emergency. I will speak to the health care provider and call you right back."*

A nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year-old consumes approximately:

*3. 175 mL per feeding*

A nurse is observing a student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes to:

*3. Apply continuous suction when inserting the catheter.*

A nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for signs of:

*3. Congestive heart failure (CHF)*

A nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is appropriate?

*3. Consult with the registered nurse to verify the prescription.*

A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate?

*3. Exercise intolerance*

A nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse monitors the child for central nervous system (CNS) involvement by checking which of the following?

*3. Level of consciousness (LOC)*

A nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing that in this disorder:

*3. There is no communication from the right atrium to the right ventricle.*

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further information?

*4. "The infectious period ranges from 10 days before symptoms start to 15 days after the rash appears."*

A nurse is teaching cardiopulmonary resuscitation to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands the reason if the student makes which statement?

*4. "The object may be forced back further into the throat."*

A sweat test is performed on a child with a suspected diagnosis of cystic fibrosis (CF). Which test result is suggestive of cystic fibrosis and will require further assessment and investigation?

*4. Chloride level of 40 mEq/L*

A nurse is caring for an infant with congenital heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the early development of congestive heart failure (CHF)?

*4. Diaphoresis during feeding*

A nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate?

*4. Document the findings.*

A nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which of the following symptoms led the mother to seek health care for the infant?

*4. Foul-smelling, ribbon-like stools*

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the primary health care provider regarding necessary follow-up because this infection can be associated with:

*4. Possible sexual abuse*

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which of the following is the priority nursing intervention?

*4. Providing a quiet atmosphere with dimmed lights*

A nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further instructions?

*1. "I need to use a nipple with a small hole to prevent choking."*

A nurse has provided discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further instruction?

*1. "I should carry my child by straddling the child on my hip."*

A child has epistaxis. The nurse understands that an appropriate treatment for epistaxis is which of the following?

*1. Have the child sit up and lean forward.*

A nurse is providing home care instructions to the mother of a child with bacterial conjunctivitis. The nurse should tell the mother:

*3. That the child's towels and washcloths should not be used by other members of the household*

The primary goal to be included in the plan of care for a child who has cerebral palsy is to:

*4. Maximize the child's assets and minimize the limitations.*

The health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?

*4. p24 antigen assay*

A nurse reinforces home-care instructions to the parents of a child with celiac disease. Which of the following food items would the nurse advise the parents to include in the child's diet?

*1. Rice*

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

*3. DTaP, Hib, IPV, pneumococcal vaccine (PCV)*

A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by:

*4. Covering the bladder with a nonadhering plastic wrap*

A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. The appropriate nursing action would be to:

*4. Let the mother hold the child and direct a cool mist over the child's face*

A nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by a parent would indicate a need for further teaching?

*1. "Our child sleeps in our bedroom at night."*

A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?

*1. Pain*

A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, the nurse plans to inform the mother of the child that:

*1. The child will need to be hospitalized for observation.*

A nurse is caring for an 18-month-old child who has been vomiting. The appropriate position in which to place the child during naps and sleep time is:

*2. A side-lying position*

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which of the following during this episode of nausea?

*2. Cool, clear liquids*

A nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which of the following is the appropriate nursing intervention?

*2. Document the findings.*

A nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?

*3. "When I'm feeling better, I'm returning to the soccer team."*

A nurse provides home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further instruction?

*4. "I need to give frequent, small, nutritious meals if my child starts to vomit."*

Which test would the nurse anticipate for a teenage client who has been treated for vaginal candida repeatedly in the last 6 months to assist in the identification of the underlying chronic pathology?

*4. Blood glucose level*

A mother of a 6-year-old-child calls a nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. The nurse should tell the mother to immediately:

*4. Call the poison control center.*

A nurse is caring for a newborn with a diagnosis of spina bifida (myelomeningocele). To monitor for a major symptom associated with this disorder, the nurse:

*4. Checks for responses to painful stimuli from the torso downward*

A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which of the following is a characteristic of this disorder?

*4. Invagination of a section of the intestine into the distal bowel*

An adolescent is admitted to the hospital with complaints of lower right abdominal pain. The health care provider prescribes laboratory tests to rule out ectopic pregnancy rather than appendicitis. Which of the following is most significant in ruling out an ectopic pregnancy?

*4. Serum human chorionic gonadotropin*

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? *SELECT ALL THAT APPLY.*

*1. Pallor* *2. Edema* *3. Anorexia* *4. Proteinuria*

A nurse is providing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further instructions?

*2. "I can use a warm mist humidifier to keep the secretions loose."*

A nurse is assigned to care for a child with a diagnosis of Wilms' tumor. In planning care for the child, the nurse understands that this tumor is:

*2. A renal tumor*

A nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which of the following?

*2. Bacteriuria*

A nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which of the following is the priority concern?

*2. Infection*

The appropriate child position after a tonsillectomy is which of the following?

*2. Side-lying position*

Following a cleft lip repair, the nurse provides instructions to the parents regarding cleaning of the lip repair site. Which of the following solutions would the nurse use in demonstrating this procedure to the parents?

*2. Sterile water*

A nurse provides instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin (Nix) has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further instructions?

*3. "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours."*

A nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?

*1. Immune globulin*

A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which of the following interventions would the nurse include in the plan of care?

*1. Perform oral hygiene four times a day.*

A nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which of the following actions would the nurse take?

*2. Document the findings.*

A nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate will be prescribed? *SELECT ALL THAT APPLY.*

*2. Initiate an intravenous line.* *3. Maintain nothing-by-mouth status.* *4. Administer intravenous antibiotics.* *5. Administer preoperative medications.*

A nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure:

*2. Safety with activities*

A health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child would check which highest-priority item before administration of the potassium?

*2. Urine output*

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse makes which response to the mother?

*3. "Have the child perform simple isometric exercises during this time."*

A nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which of the following, if stated by the mother, would indicate the need for further instructions?

*3. "It is OK to share towels and washcloths."*

A nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further instructions?

*3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."*

A nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand these measures if they state which of the following?

*3. "We will provide comfort measures to reduce any crying periods by our child."*

A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse would expect to find:

*3. An erythrocyte (red blood cell [RBC]) count of 2 cells in 1 mL of peripheral blood*

A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which of the following laboratory tests would rule out a past streptococcal infection in the child?

*3. Antistreptolysin titer*

A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which of the following nursing interventions would be most appropriate to alleviate the child's fears and the mother's anxiety?

*3. Ask the mother if she would like to stay overnight with the child.*

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron:

*3. Between meals*

A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?

*3. Decreased wheezing*

A mother brings her 15-month-old child to the health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, the nurse might suspect that the child has:

*3. Fifth disease*

A nurse is providing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which of the following instructions?

*4. "Call the health care provider if the infant has a high-pitched cry."*

A nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

*4. "Did the child have a sore throat or an unexplained fever within the past 2 months?"*

Permethrin 5% (Elimite) is prescribed for a 4-year-old child with a diagnosis of scabies. The nurse instructs the mother regarding the use of this treatment. Which instruction is appropriate?

*4. Apply the lotion to cool, dry skin at least half an hour after bathing.*

A nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?

*4. Checking the child's ability to perform range of motion to the shoulder area of the affected extremity*

A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which of the following on the handout?*SELECT ALL THAT APPLY.*

*1. It is a disease that causes mucus formation to be abnormally thick.* *2. It is a chronic multisystem disorder affecting the exocrine glands.* *3. It is transmitted as an autosomal recessive trait.*

The school nurse notes that the child has a rash and suspects that it is caused by erythema infectiosum (fifth disease). The nurse bases this determination on the observation that the rash results in:

*4. A "slapped-face" appearance*

A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

*1. Rectal*

A nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is:

*1. Temperature 100.9° F*

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? *SELECT ALL THAT APPLY.*

*1. Tuck pant legs into socks.* *2. Wear closed shoes when hiking.* *3. Apply insect repellent containing DEET.* *4. Cover the ground with a blanket when sitting.*

Which of the following are characteristics of scabies? *SELECT ALL THAT APPLY.*

*2. It appears as burrows or fine, grayish-red lines.* *3. It is transmitted by close personal contact with an infected person.* *4. It is endemic among schoolchildren and institutionalized populations.* *6. Household members and contacts of the infected child need to be treated at the same time that the child is being treated.*

A nurse is reinforcing discharge instructions to the mother of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which of the following statements, if made by the mother of the child, indicates that further teaching is necessary?

*3. "I'll let him decide when to return to his play activities."*

A nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume, knowing that:

*2. Each gram of diaper weight is equivalent to 1 mL of urine.*

A nurse is providing instructions to a mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother?

*4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."*

A nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The nurse interprets that the client has not fully understood the information presented if the child makes which statement?

*4. "This brace will correct my curve."*

A nurse is assisting in preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which dietary intervention is most appropriate for this child?

*4. Encourage the child to eat in the playroom.*

A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. The appropriate nursing response is which of the following?

*2. "It is the inability to tolerate sugar found in dairy products."*

A nurse is reviewing the record of a child scheduled for a health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which of the following when collecting data?

*2. Bladder function*

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which of the following is noted?

*3. A decrease in urine output to 0.5 mL/kg/hr*

A nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse tells the mother that which of the following supplements will be required as a result of the need to avoid lactose in the diet?

*3. Calcium*

A nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3 and the platelet count is 150,000 cells/mm3. Which of the following nursing interventions will the nurse incorporate into the plan of care?

*1. Maintain strict isolation precautions.*

Choose the interventions that a nurse would include when writing a care plan for a child with hepatitis? *SELECT ALL THAT APPLY.*

*1. Providing a low-fat, well-balanced diet* *3. Teaching the child effective hand washing techniques* *5. Instructing the parents about the risks associated with taking medications*

A nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further instruction?

*2. "I need to provide a well-balanced, high-fat diet to my child."*

An emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). The nurse anticipates that the likely initial treatment will be:

*3. The administration of activated charcoal*

A nurse provides home care instructions to the parents of a child with congestive heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction?

*4. "If my child vomits after medication administration, I will repeat the dose."*

A nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?

*1. "If my baby has a high-pitched cry, I should call the doctor."*

Which of the following is the most appropriate location for assessing the pulse of an infant who is less than 1 year old?

*3. Brachial*

A nurse instructs the mother of a child with sickle cell disease regarding the precipitating factors related to pain crisis. Which of the following, if identified by the mother as a precipitating factor, indicates the need for further instructions?

*4. Fluid overload*

A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear?

*1. "This aching and cramping is normal and temporary and will subside."*

A nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than:

*1. 20,000/mm3*

A nursing student caring for a 6-month-old infant is asked to collect a urine specimen from the infant. The student collects the specimen by:

*1. Attaching a urinary collection device to the infant's perineum for collection*

A mother of a 3-year-old child tells the nurse that the child has been continuously scratching the skin and has developed a rash. On data collection, which finding indicates that the child may have scabies?

*1. Fine, grayish-red lines*

A nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the following would be a component of the plan of care? *SELECT ALL THAT APPLY.*

*1. Pad the side rails of the bed with blankets.* *2. Maintain the bed in a low position.* *4. Place the child in a side-lying lateral position if a seizure occurs.* *5. Protect the child's head, body, and extremities if a seizure occurs.*

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. After an x-ray, it is determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further instructions?

*2. "I can use lotion or powder around the cast edges to relieve itching."*

A nurse provides instruction to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further instructions?

*2. "I need to take my child's rectal temperature daily."*

A nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse appropriately responds by saying:

*2. "In most cases, medication and diet will control fluid retention."*

A student nurse examines an Asian-American infant's eyes and notes that the infant's eyes are crossed. Which statement by the student to the nurse indicates an understanding of this finding?

*2. "It probably isn't strabismus but appears that way because of the child's ethnic background."*

A nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease?

*2. "The child does not experience pain at the primary tumor site."*

A nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which of the following items will the nurse place at the bedside in preparation for the child's return from surgery?

*2. A cooling blanket*

A nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care, knowing that this type of fracture involves:

*2. A greater risk of infection than a simple fracture*

A nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding would the nurse expect to note documented in the infant's record regarding this condition?

*2. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table *

A nurse is caring for an infant. A urinalysis has been prescribed, and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen?

*2. Attaches a urinary collection device to the infant's perineum*

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?

*2. Avoid tub baths until the stent has been removed.*

A nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which of the following findings would most likely assist in verifying the suspicion?

*2. Bald spots on the scalp*

A nurse is assisting with performing admission data collection on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is:

*2. Generalized edema*

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. *SELECT ALL THAT APPLY.*

*2. Notify the registered nurse.* *4. Prepare to administer morphine sulfate.* *5. Prepare to administer intravenous fluids.* *6. Prepare to administer 100% oxygen by face mask.*

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? *SELECT ALL THAT APPLY.*

*2. Place the child on a low-bacteria diet.* *3. Change dressings using sterile technique.* *5. Perform meticulous handwashing before caring for the child.*

A male child who had surgery to correct hypospadias is seen in a health care provider's office for a well-baby check-up. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias

*2. Renal anomalies*

A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which of the following in the discussion during the conference?

*2. SIDS usually occurs during sleep and is more common in premature infants.*

A nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests including in the plan to position the infant in a(n):

*2. Side-lying position*

A nurse who is working in the emergency department is caring for a child who has been diagnosed with epiglottitis. Indications that the child may be experiencing airway obstruction include which of the following?

*2. The child thrusts the chin forward and opens the mouth*

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother of the test results and provides instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding of the care measures?

*3. "I need to call the health care provider if my child complains of abdominal pain or left shoulder pain."*

A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?

*3. "It involves only the anterior portions of the client's brain."*

Several children have contracted rubeola (measles) in a local school and the school nurse conducts a teaching session for the parents of the school-children. Which statement, if made by a mother, indicates a need for further teaching regarding this communicable disease?

*3. "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."*

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

*3. Apply an ice pack to the injection site.*

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting to care for the newborn, the priority concern would be:

*3. Aspiration*

Which of the following assessment findings may indicate that a child had a tonic-clonic seizure during the night?

*3. Blood on the pillow*

A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of:

*3. Confirmation of the diagnosis*

A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which clinical manifestation is likely to be reported?

*3. Conjunctival hyperemia*

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse would expect the blood pressure in the child's legs and arms to be:

*3. Decreased in the legs and increased in the arms*

A child with croup is being discharged from the hospital. The nurse provides home care instructions to the mother and advises the mother to bring the child to the emergency department if the child:

*3. Develops stridor*

A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which of the following nursing interventions would be of highest priority?

*3. Dipstick the urine for protein every 4 hours.*

A nurse who is caring for a child with aplastic anemia reviews the laboratory results and notes a white blood cell (WBC) count of 6000 cells/ mm3 and a platelet count of 27,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

*3. Encourage quiet play activities.*

A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which of the following in the discussion?

*3. Enteric precautions are necessary for HBV but not for HAV.*

A nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flowmeters. The nurse identifies which of the following as an appropriate goal for this child?

*3. Expresses feelings of mastery and competence with breathing devices*

A nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is accurate?

*3. Forty-eight hours after using the antibiotic ointment*

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn and the results indicate a glucose level of 60 mg/dL. The appropriate intervention is to:

*3. Give the child a glass of fruit juice.*

Choose the interventions for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL. *SELECT ALL THAT APPLY.*

*3. Give the child a teaspoon of honey.* *6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.*

The nurse assists in planning care for a child who sustained a burn injury based on which of the following accurate statements?

*3. Lower burn temperatures and shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner.*

A nurse is assigned to care for a child after a spinal fusion for the treatment of scoliosis. The child complains of abdominal discomfort and begins to have episodes of vomiting. On data collection, the nurse notes abdominal distention. Which action should the nurse take?

*3. Notify the registered nurse (RN).*

A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. The nurse tells the mother to immediately:

*3. Place the child's hand under cool running water.*

A nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which of the following would be the appropriate nursing action?

*3. Plan to move the infant to a room with another child with RSV.*

A nurse reviews the record of a 1-year-old child seen in the clinic and notes that the health care provider has documented a diagnosis of celiac crisis. Which of the following symptoms would the nurse expect to note in this condition?

*3. Profuse, watery diarrhea*

A nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which of the following would be included in the plan?

*3. Pull the earlobe down and back before instilling the ear drops.*

A nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. The initial nursing action is which of the following?

*3. Reassure the child that this is a temporary condition.*

The nurse provides instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. Which response by the nurse is accurate?

*3. Respiratory precautions are indicated during the period of communicability.*

A nurse is assisting a health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the health care provider palpates the child at McBurney's point. The nurse understands that McBurney's point is located midway between the:

*3. Right anterior superior iliac crest and the umbilicus*

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse provides instructions to the mother regarding cast care at home. Which of the following instructions would the nurse provide to the mother?

*4. "The cast needs to be kept dry because, when wet, it will begin to disintegrate."*

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). The nursing student responds correctly, knowing that the BCG vaccine is used for:

*4. Asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB*

A nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which of the following is the priority when performing this procedure?

*4. Checking the peripheral pulse in the affected arm*

A nurse caring for a child with nephrotic syndrome reviews the medication record. The nurse notes that prazosin hydrochloride (Minipress) is prescribed for the child. The nurse determines that this medication has been prescribed to:

*4. Control hypertension.*

An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. The appropriate initial nursing intervention is to:

*4. Give the child 6 oz of a regular cola drink.*

A nursing student is asked to discuss human immunodeficiency virus (HIV) during clinical conference. The nursing student includes which correct item in the discussion?

*4. HIV virus attacks the immune system by destroying T lymphocytes.*

A child with a fractured femur is placed in Buck's skin traction and the nurse is planning care for the client. Which information about this type of traction is correct?

*4. Is a type of skin traction that pulls the hip and leg into extension*

Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following would indicate this type of anemia?

*4. RBCs that are microcytic and hypo chromic*

An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. How would the nurse determine whether the treatment is effective?

*1. The child has a productive cough of thick sputum.*

A nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?

*2. Using pillows to elevate the head and shoulders*

A nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?

*4. The synthetic cast allows for greater mobility than a plaster cast.*

A child is diagnosed with scarlet fever. A nurse collects data regarding the child. Which of the following is a clinical manifestation of scarlet fever?

*1. Pastia's sign*

A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant:

*3. With the head and chest at a 30-degree angle, with the neck slightly extended*

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of:

*1. Peripheral hypoxia*

A nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which of the following symptoms would be noted in determining this finding?

*1. Oliguria*

A nurse is providing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further instruction?

*1. "The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."*

A nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. The appropriate nursing response is which of the following?

*1. "This type of breathing is used to mobilize secretions so that they can be easily coughed out."*

Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement, if made by a parent, would indicate that the instructions were understood?

*1. "We will administer the antibiotics until they are gone."*

A nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which of the following is essential information to obtain before the administration of this vaccine?

*1. Allergy to eggs*

An emergency department nurse is gathering initial data on a child suspected of epiglottitis. The nurse's priority would be to:

*1. Assess for a patent airway.*

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is

*4. Palpating the anterior fontanel*

A nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The HCP performs the Ortolani maneuver. Which of the following best describes the action/purpose of the Ortolani maneuver?

*4. Reducing the dislocated femoral head back into the acetabulum*

A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which of the following is associated with this type of cancer?

*4. Reed-Sternberg cells are found on biopsy.*

A nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that the primary signs of meningitis include:

*4. Severe headache and neck stiffness*

A nurse is performing a neurovascular check on a child with a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should be taken by the nurse?

*3. Notify the health care provider (HCP).*

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse informs the parents about which priority care measure?

*3. Preventing infection at the surgical site*

A nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing:

*1. Decorticate posturing*

A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?

*1. Gastric contents regurgitate back into the esophagus.*

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse provides instructions to the adolescent regarding home care for treatment of the sprain and tells the adolescent which of the following?

*1. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.*

A nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which of the following diagnostic tests that will confirm the diagnosis?

*1. Blood cultures*

When checking a child's trochlear nerve function, the nurse would perform which data collection technique?

*1. Have the child look down and in.*

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as what level of dehydration?

*4. Moderate dehydration*

A nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?

*4. Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.*

An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which of the following indicates to the nurse that the parents need further information about the care of their HIV-positive infant?

*4. The parents plan to use rice cereal to help with watery stools when they occur.*

A health care provider has prescribed oxygen as needed for a 10-year-old child with congestive heart failure (CHF). In which situation would the nurse administer the oxygen to the child?

*4. When drawing blood for the measurement of electrolyte levels*

A nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?

*3. Platelet count*

A nurse is assigned to care for a child who is in skeletal traction. The nurse avoids which of the following when caring for the child?

*3. Placing the bed linens on the traction ropes*

A nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which of the following will be a component of the instructions that the nurse provides to the mother?

*2. No live virus vaccines should be administered to the child.*

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?

*4. Reticulocyte count*

A nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse tells the parents that the infant should be maintained in:

*3. An upright angle 24 hours a day*

A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF?

*3. Antistreptolysin O titer*

A nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instructions are needed if the mother states that she will include which of the following in the child's nutritional plan?

*3. Oatmeal*

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position in which to place this infant at this time is:

*3. On his or her left side*

A nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:

*4. An airway obstruction*

A nurse is collecting data on a child with a diagnosis of rheumatic fever. Which of the following questions would the nurse initially ask the mother of the child?

*4. "Has the child complained of a sore throat within the past few months?"*

A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness?

*4. "I can remove the harness to bathe my infant."*

A nursing student is assigned to help administer immunizations to children in a clinic. The nursing instructor asks the student about the contraindications to receiving an immunization. Immunization is contraindicated in the presence of which condition?

*4. A severe febrile illness*

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse would question this prescription if the child had documented evidence of which condition?

*4. A viral infection*

A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and thus to the need to notify the registered nurse?

*4. A weight gain of 1 lb in 1 day*

A nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for:

*4. An elevated temperature*

A nurse is caring for a child diagnosed with Down syndrome. In describing the disorder to the parents, the nurse bases the explanation on the fact that Down syndrome is a:

*4. Congenital condition that results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G)*

In planning care for a child with contact dermatitis, which concern is the highest priority for the child?

*1. Pain*

A mother of a child with cystic fibrosis asks the clinic nurse about the disease. The nurse tells the mother that it is:

*2. A chronic multisystem disorder affecting the exocrine glands*

A nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which of the following food items will the nurse mix with the medication?

*2. Applesauce*

A nursing student is asked to administer a tepid bath to a child with a fever. The student avoids which of the following when performing this procedure?

*2. Applies alcohol-soaked cloths over the child's body*

A nurse provides information to the mother of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the mother indicates the need for further instruction regarding this disorder?

*3. "I need to bring my child back to the clinic in 1 month for a new cast."*

A nurse is caring for a child who is scheduled for an appendectomy. When the nurse reviews the health care provider's preoperative prescriptions, which of the following would be questioned?

*1. Administer a Fleet enema.*

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which of the following interventions has the highest priority in the care of this child immediately following the procedure?

*1. Assess for any bleeding on the dressing.*

A child with a brain tumor returns from the recovery room following "debulking" of the tumor. The nurse assigned to care for the child monitors the child for brainstem involvement. Which of the following signs would indicate that brainstem involvement occurred during the surgical procedure?

*1. Elevated temperature*

A nurse is assisting in developing a plan of care for a diagnosed with acute glomerulonephritis. The nurse includes which intervention in the plan of care?

*1. Encourage limited activity and provide safety measures.*

A child with croup is placed in a cool-mist tent. The mother asks if the child may have her security blanket inside the tent. The appropriate response is:

*1. "The child may have the security blanket inside the tent."*

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives in the unit, the nurse would first:

*1. Place the child on a pulse oximeter.*

After a tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child?

*1. Yellow Jell-O*

A nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which of the following would the nurse expect to note in this infant?

*2. Metabolic alkalosis*

A 1-year-old child is seen in the health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which of the following would most likely indicate the child has acute otitis media?

*4. The mother states the child had purulent discharge from the ear last night.*

A nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. The nurse understands that which of the following is unassociated with this disorder?

*4. The passage of currant jelly-like stools*

A child is scheduled for a tonsillectomy. Which of the following would present the highest risk of aspiration during surgery?

*4. The presence of loose teeth*

A nursing instructor assigns a student nurse to present a clinical conference to the student group about brain tumors in children. The student prepares for the conference and plans to include which of the following in the presentation?

*4. The significant symptoms are headaches and morning vomiting.*

A child is seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus vaccine). One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which of the following instructions would the nurse provide to the mother?

*4. To apply cold compresses for 24 hours following the injection*

A nurse receives a call from the mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse responds:

*4. Touch the object gently with a cotton swab, and lift it out.*

A nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. The nurse should give the child which of the following to treat the reaction?

*4. ½ cup of fruit juice*

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse understands that which diagnostic study will confirm this diagnosis?

*3. Bone marrow biopsy*

A nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which clinical manifestation of this disorder would the nurse expect to note documented in the record?

*3. Hiccupping and spitting up after a meal*

A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?

*3. The harness needs to be removed to check the skin and for bathing.*

A 2-year-old child is diagnosed with constipation. Which of the following describes a characteristic of this disorder?

*3. The infrequent and difficult passage of dry stools*

A nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis?

*3. Cat's-eye reflex*

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. The nurse tells the mother to:

*3. Give the child acetaminophen (Tylenol) for the discomfort.*

A nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which of the following questions to the mother will most specifically elicit information regarding this disorder?

*1. "Does your infant have foul-smelling, ribbon-like stools?"*

A nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. The initial nursing action is to:

*1. Notify the registered nurse (RN).*

A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?

*1. Notify the registered nurse of the finding.*

A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the health care provider's prescriptions would be important for the nurse to question?

*1. Obtain a throat culture.*

A child has been diagnosed with Reye's syndrome. The nurse understands that a major symptom associated with Reye's syndrome is:

*1. Persistent vomiting*

A nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which of the following should the nurse expect to note in the child?

*1. Petechiae spots located on the palate*

A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. *SELECT ALL THAT APPLY.*

*1. Place the infant in a private room.* *2. Place the infant in a room near the nurses' station.*

A nurse reviews the results of a Mantoux test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. The nurse would interpret these results as:

*1. Positive*

A nurse is assigned to care for a child with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. Which of the following positions would the nurse place the child in during the preoperative period?

*1. Prone with the head of the bed elevated*

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?

*1. Prone*

A nurse is reviewing the record of a child admitted to the hospital with nephrotic syndrome. Which finding would the nurse expect to note documented in the record?

*1. Proteinuria*

A nurse has reviewed the health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to:

*1. Collect a 24-hour urine sample.*

A nurse is providing discharge instructions to the mother of a child who had a myringotomy with insertion of tympanostomy tubes. The nurse instructs the mother that if the tubes fall out, she should:

*1. Contact the health care provider.*

A nurse teaches a child with cystic fibrosis how to perform the "huff" maneuver and tells the child to take a:

*1. Deep breath then exhale, rapidly whispering the word "huff"*

A nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger and it returns to its original color in 2 seconds. Which action should be taken by the nurse?

*1. Document the findings.*

A nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, the nurse takes which action?

*1. Documents the findings*

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. The nurse tells the child to:

*1. Drink a half a cup of orange juice before soccer practice.*

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse provide to prevent another crisis from occurring? *SELECT ALL THAT APPLY.*

*1. Drink plenty of fluids.* *5. Wash hands before meals and after playing.* *6. Report a sore throat immediately.*

A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor should the nurse expect to find documented in the child's record?

*1. Elevated vanillylmandelic acid (VMA) levels in the urine*

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. A nurse is asked to assist in preparing a plan of care for this child and makes suggestions, knowing that this surgery is taking place at a time when:

*1. Fears of separation and mutilation are present*

A nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? *SELECT ALL THAT APPLY.*

*1. Fever* *2. Constipation* *3. Failure to thrive* *5. Abdominal distention* *6. Explosive, watery diarrhea*

A nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms would the nurse expect to find during the initial data collection? *SELECT ALL THAT APPLY.*

*1. Fever* *3. Irritability* *5. Nuchal rigidity*

Choose the home care instructions that the nurse would provide to the mother of a child with acquired immunodeficiency syndrome (AIDS). *SELECT ALL THAT APPLY.*

*1. Frequent handwashing is important.* *2. The child should avoid exposure to other illnesses.* *5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).*

A nurse is admitting a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to assess?

*1. Frothy stools*

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which of the following in the plan of care?

*1. Initiating seizure precautions*

A nursing student is asked to discuss the topic of clubfoot at a clinical conference. The student plans to tell the group that clubfoot:

*1. Is a congenital anomaly*

A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which of the following?

*1. It is a congenital aganglionosis or megacolon.*

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse tells the mother that she should

*1. Keep the child in a room with dim lights.*

A 3-year-old child has returned to his room following a tonsillectomy. Which assessment finding needs immediate notification of the registered nurse?

*2. Nasal flaring and rib retractions*

A nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings would the nurse expect to note if JIA were present? *SELECT ALL THAT APPLY.*

*1. Malaise, fatigue, and lethargy* *2. Painful, stiff, and swollen joints* *3. Limited range of motion of the joints* *6. History of late afternoon temperature, with temperature spiking up to 105° F*

A nurse is checking the status of jaundice in a child with hepatitis. The nurse checks which of the following that will provide the best data regarding the presence of jaundice?

*1. Nailbeds*

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle accident for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?

*1. Nausea*

A nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? *SELECT ALL THAT APPLY.*

*1. Restrict fluid intake.* *6. Administer meperidine (Demerol) 25 mg for pain.*

A nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse plans to:

*1. Restrict fluids, as prescribed.*

A nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?

*1. Side-lying*

A nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:

*1. Signs of increased intracranial pressure*

A nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which of the following are characteristic of this illness? *SELECT ALL THAT APPLY.*

*1. The cough is harsh and metallic.* *2. Inspiratory stridor may be present.* *3. Symptoms usually worsen at night and are better during the day.* *5. It is usually preceded by several days of upper respiratory infection symptoms.*

A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? *SELECT ALL THAT APPLY.*

*1. Time the seizure.* *3. Stay with the child.* *5. Move furniture away from the child.*

The school nurse is visiting a kindergarten classroom to teach the students the importance of handwashing. During the teaching session the nurse notes that one girl is scratching her head. On inspection the nurse determines that the child has pediculosis capitis. When teaching the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition?

*2. "I will call a carpet cleaning service to clean all my carpets in the house."*

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child?

*2. Bradycardia*

A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period?

*2. Capillary refill, sensation, and motion in all extremities*

A nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for the earliest sign of increased ICP by assessing for:

*2. Changes in level of consciousness (LOC)*

A nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse should expect that which medication would be prescribed?

*2. Furosemide (Lasix)*

A nurse is monitoring for bleeding in a child after surgery for the removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?

*2. Notify the registered nurse (RN).*

A nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 AM, the child suddenly complains of weakness, headache, and blurred vision. The nurse should immediately:

*2. Obtain a blood glucose reading.*

A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. The nurse's initial action would be to:

*2. Obtain a complete history of the child's feeding habits.*

A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse tells the mother to:

*2. Pad crib rails and table corners.*

A health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse instructs the mother regarding this procedure and tells the mother to

*2. Place the patch on the left eye.*

The mother of a child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which of the following would require further investigation?

*2. Possible sexual abuse*

A nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. The highest priority in the postoperative plan of care for this child is to:

*2. Prevent tension on the suture.*

A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which of the following would the nurse anticipate to be a component of the treatment plan?

*2. Supportive treatment*

A nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which of the following findings would the nurse expect to note in this child?

*2. Tachycardia*

A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Several diagnostic studies are performed to determine the presence of this disease. When evaluating the diagnostic results, the nurse would expect to note which of the following if this child had Hodgkin's disease?

*2. The presence of Reed-Sternberg cells*

A nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, the nurse tells the mother to:

*2. Thicken the feedings by adding rice cereal to the formula.*

The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these symptoms, the nurse might suspect that the newborn has which of the following conditions?

*2. Tracheoesophageal fistula*

A nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which of the following statements should the nurse make to the mother?

*3. "The fluid retention should be controlled by medication and diet."*

A nurse provides instructions regarding the use of permethrin 1% (Nix) to the parents of a child who has been diagnosed with pediculosis capitis (head lice). Which statement by a parent indicates the need for further instruction?

*3. "The medication is applied to the hair after shampooing and left on for 24 hours."*

A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need to further research this disorder?

*3. "This disease is twice as likely to occur in boys rather than girls."*

A nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which of the following would be the priority in the plan of care for this child on return from the procedure?

*3. Check circulation in the feet.*

A nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely clinical manifestation of this condition in the medical record?

*3. Choking with feedings*

A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which of the following that is a characteristic of this disease?

*3. Increased reticulocyte count*

A nurse is assigned to care for an infant with cryptorchidism. The nurse anticipates that diagnostic studies will be prescribed to evaluate:

*3. Kidney function*

Which of the following represents a primary characteristic of autism

*3. Lack of social interaction and awareness*

A nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position will the nurse place the child during this procedure?

*3. Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest*

A nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which of the following immediate problems as the priority for the infant?

*3. Skin disruption*

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible hernial strangulation. The nurse tells the parents that which of the following signs would require health care provider (HCP) notification by the parents?

*3. Vomiting*

A nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which of the following is the priority in the plan of care?

*3. Wound care*

A nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement, if made by the student, indicates an understanding of this disorder?

*4. "All 50 states require routine screening of all newborns for PKU."*

The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother replies:

*4. "I know I need to monitor my infant's stools and if there are more than four stools a day, I will increase the pancreatic enzyme."*

A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting to care for the child checks the intravenous (IV) and medication supply area for which of the following?

*4. 0.9% normal saline IV infusion*

A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 AM, 12 noon, and at 6:00 PM The nurse tells the mother that the postural drainage should be performed at:

*4. 10:00 AM, 2:00 PM and 8:00 PM*

A nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which of the following priority items at the newborn's bedside?

*4. A bottle of sterile normal saline*

A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis?

*4. A piece of fried chicken and a loaded baked potato*

An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse who is assisting in caring for the infant will ensure that the gastrostomy tube is:

*4. Elevated*

A nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. The appropriate procedure to elicit Kernig's sign is to:

*4. Extend the leg and knee and check for pain.*

A nurse is reviewing a chart of a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which of the following would the nurse expect to note on data collection of the child?

*4. Sleeps unless aroused and, once aroused, interacts poorly with the environment*

A child has a basilar skull fracture. Which of the following health care provider's prescriptions should the nurse question?

*4. Suction via the nasotracheal route as needed.*

A nurse is reviewing the health record of a child who has been recently diagnosed with glomerulonephritis. Which finding noted in the child's record is associated with the diagnosis of glomerulonephritis?

*4. The child had a streptococcal throat infection 2 weeks before diagnosis.*

A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?

*4. The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.*

A nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which of the following in the conference?

*2. PKU results in central nervous system (CNS) damage.*

A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. Which response by the nurse is appropriate?

*4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic at some point before the age of 3 years."*

A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. Which is the correct response by the nursing student?

*4. "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."*

An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition?

*4. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table*

A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would the nurse expect to note in this child?

*4. Blood and mucus in the stools*

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which of the following foods would the nurse instruct the mother to avoid?

*1. Hard cheeses*

A nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse makes which response to the mother?

*2. "In 3 weeks".*

A clinic nurse reads the results of a Mantoux test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. The nurse should interpret these results as:

*1. Negative*

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse give to the mother to prevent the transmission of the disease?

*1. "Disease transmission is unknown."*

A nurse provides instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which of the following should the nurse include in the instructions?

*1. "Feed the infant in an upright position."*

A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?

*1. "I will give my child cough syrup if a cough develops."*

A nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further instruction?

*1. "I will place a steam vaporizer in my child's room."*

A nurse is monitoring a child following a tonsillectomy. Which finding may indicate that the child is bleeding?

*1. Restlessness*

The nurse should implement which of the following in the care of a child who is having a seizure? *SELECT ALL THAT APPLY.*

*1. Time the seizure.* *3. Stay with the child.* *6. Loosen clothing around the child's neck.*

After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to

*1. Turn the child to the side.*

A nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?

*1. Urinary output is increased.*

A nurse is caring for a 1-year-old child following a cleft palate repair. Which solution should the nurse use after feedings to cleanse the child's mouth?

*1. Water*

An infant with congestive heart failure (CHF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output (I&O). Which is the best method for the nurse to use to monitor the urine output?

*1. Weighing the diapers*

A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which of the following is the appropriate nursing action?

*1. Withhold the medication.*

A nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit information about the cause of this disease?

*2. "Did your child recently complain of a sore throat?"*

A nurse is providing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further instructions?

*2. "I am so pleased that I won't have to eliminate oatmeal from my child's diet."*

A nurse has reinforced home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement, if made by the mother, indicates the need for further instructions?

*2. "I can apply lotion or powder to the incision if it is itchy."*

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse about radiation therapy because it was not prescribed as a part of treatment. The appropriate response to the mother is:

*2. "The child is too young to have radiation therapy."*

Isoniazid (INH) is prescribed for a 2-year-old child with a positive Mantoux test. The mother of the child asks the nurse how long the child will need to take the medication. The appropriate response is:

*2. 9 months*

A nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder?

*2. A child of Mediterranean descent*

A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse tells the mother that this disorder is:

*2. A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel*

A nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which of the following in the plan of care?

*2. Inspect the urine for the presence of hematuria at each voiding.*

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. The mother inquires about the infectious period associated with varicella, and the nurse tells the mother that the infectious period:

*2. Is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions*

A nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease?

*2. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.*

A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. *SELECT ALL THAT APPLY.*

*2. Keep small toys and sharp objects away from the cast.* *5. Contact the health care provider if the child complains of numbness or tingling in the extremity.* *6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.*

A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research?

*2. Males inherit hemophilia from their fathers.*

A nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). In the preoperative period, the priority nursing action is to monitor:

*2. Moisture of the normal saline dressing on the gibbous area*

A nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis?

*2. Red-brown urine*

A nurse collecting data on a child suspects physical abuse. The nurse understands that which of the following is a primary and legal nursing responsibility?

*2. Report the case in which the abuse is suspected.*

A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the health care provider did not prescribe antibiotics. The nurse makes which response to the mother?

*3. "Antibiotics are not indicated unless a bacterial infection is present."*

A child is scheduled for a tonsillectomy in the day-stay surgical unit. On the day following surgery, the mother calls the surgical unit and expresses concern because the child has a very bad mouth odor. The nurse makes which response to the mother?

*3. "Bad mouth odor is normal and may be relieved by drinking more liquids."*

A nurse determines that an adolescent client with diabetes mellitus needs further information about glycosylated hemoglobin levels and their purpose if the client made which statement when told that a level will be drawn?

*3. "I already had a complete blood cell [CBC] count drawn an hour ago, so this test is not necessary."*

A client has been prescribed valproic acid (Depakene) for the treatment of generalized seizures, and the nurse teaches the child about the potential side effects of the medication. Which statement by the client would indicate that further teaching is required?

*3. "I am so glad that I won't lose any of my hair. I was worried what my friends would think."*

Griseofulvin (Gris-PEG) is prescribed for a child with tinea capitis. The nurse provides instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further instructions?

*3. "I need to administer the medication 2 hours before meals."*

A child is scheduled to receive a measles, mumps, and rubella (MMR) vaccine. The nurse who is preparing to administer the vaccine reviews the child's record. Which finding should make the nurse question the health care provider's prescription?

*3. A history of an anaphylactic reaction to neomycin*

A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which of the following is an unassociated risk factor related to otitis media?

*3. A history of urinary tract infections*

A nurse is preparing for the administration of ribavirin (Virazole) to a child with respiratory syncytial virus. Which of the following supplies will the nurse obtain for the administration of this medication?

*3. A pair of goggles*

Following tonsillectomy, which of the health care provider's prescriptions would the nurse question?

*3. Allow ice cream when awake.*

A mother of a 6-year-old child with type 1 diabetes mellitus calls the clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it showed positive ketones. Which of the following would the nurse instruct the mother to do?

*3. Encourage the child to drink liquids.*

A mother of a child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen (Tylenol) is not very effective. The appropriate suggestion by the nurse would be to:

*3. Encourage the child to lie on the right side.*

A nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor that:

*3. Hemophilia A results from deficiency of factor VIII.*

The nurse is caring for a pediatric client in skin traction. To prevent skin breakdown, the best nursing intervention for this child is to:

*3. Stimulate circulation with gentle massage over pressure areas.*

A nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?

*3. Swimming*

A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse looks for which early sign of CHF?

*3. Tachycardia*

When checking a child's glossopharyngeal nerve function, the nurse would perform which data collection technique?

*3. Test sense of sour or bitter taste on the posterior segment of the tongue.*

A day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which of the following observations may be indicative of this condition?

*3. The child consistently tilts his or her head to see.*

A nurse provides discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further instructions?

*4. "I need to be sure my child uses soft tissues to blow his nose."*

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement, if made by the adolescent, would indicate an understanding of the instructions?

*4. "I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."*

A nurse reinforces home-care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further instructions?

*4. "I will avoid immunizations and dental hygiene treatments for my child."*

A nurse provides home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further instructions?

*4. "I will insert a glycerin suppository before the dilation."*

The parents of a newborn have been told that their child was born with bladder exstrophy, and the parents ask the nurse about this condition. The nurse bases the response on knowledge that this condition is:

*4. An extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall*

A corticosteroid cream is prescribed by a health care provider for a child with atopic dermatitis (eczema). The nurse teaches the mother how to apply the cream. Which instruction is appropriate?

*4. Apply a thin layer of cream, and rub it into the area thoroughly.*

A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. The nurse bases the response on the fact that primary nocturnal enuresis:

*4. Is common and most children will outgrow bed-wetting without therapeutic intervention*

A child is diagnosed with infectious mononucleosis. The nurse provides home-care instructions to the parents about the care of the child. Which information given by the nurse is accurate?

*4. Notify the HCP if the child develops abdominal or left shoulder pain.*

A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by:

*4. Obtaining a history regarding factors that may occur before the seizure activity*

A nurse is reviewing the health record of a 14-year-old child who is suspected of having Hodgkin's disease. Which of the following is the primary characteristic of this disease?

*4. Painless, firm, and movable lymph nodes in the cervical area*

A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The initial nursing action is to:

*4. Place the infant in a knee-chest position.*

A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chickenpox (varicella). The nurse should take which of the following actions to provide safety for all children on the unit?

*4. Place the infected child and any immunocompromised children in isolation.*

A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse would work with the child to meet these goals by:

*4. Placing the child on a wheeled scooter board*

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

*4. Respiratory*