PrepU Ch. 34 Peds
The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
"This is normal; her circulatory system will take a few days to adjust."
The nurse is performing a health history on a 6-year-old who is having trouble adjusting to school. Which question would most likely elicit valuable information?
"What are your new classmates like?"
The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?
Between the sternum and the left nipple
The pediatric nurse is performing a head-to-toe exam on a 2-year-old child during a well child assessment. Which method will the nurse use to accurately determine the child's heart rate?
Counting the apical rate
An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first?
Determine the type of ingestion.
When percussing the chest of an infant the nurse hears hyperresonant sounds. What action should the nurse take?
Document the finding.
A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding?
Fanning of the infant's toes
A 4-year-old child reports having ear pain. To examine the child's ear, how should the nurse proceed?
Grasp the pinna and pull up and back.
A full term gestation infant weighed 8 pounds 1 ounce (3.7 kg) at birth. The baby's weight at the 4-month-old well-child visit is 10 pounds 2 ounces (5 kg). Which intervention should the nurse implement first?
Notify the healthcare provider of the findings.
A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's parent, "What did you do to help your child before coming to health facility?" This is an example of which type of question?
Open-ended
A mother tells the nurse at the clinic she did not bring her child to have his scheduled immunization because the child had a cold. What symptoms are important for the nurse to teach the mother about contraindications for immunizations? Select all that apply.
The child has 102ºF (38.9°C) fever Wheezing 100ºF (37.8°C) fever for 3 days
What is typical of a grade II heart murmur?
The murmur is soft but easily heard.
The nurse is assessing a child's heart sounds for the characteristic S1 and S2. Where would the nurse place the stethoscope to hear S2 "dub" sound the loudest?
The second intercostal space
The nurse suspects sexual maltreatment in a 10-year-old girl. The nurse would assess which primary finding to help make this determination?
Vaginal discharge