Transitions Passpoint Exam 1
The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which findings should the nurse anticipate?
Ortolani's sign
The health care provider prescribes an intravenous infusion of 5% dextrose in 0.45% saline to be infused at 2 mL/kg per hour in an infant who weighs 9 lb (4.1 kg). How many milliliters per hour of the solution should the nurse infuse? Round to one decimal place.
8.2
The breastfeeding parent of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what they should do about feeding their infant. Which recommendation would be most appropriate?
"Continue to breastfeed, but eliminate all milk products from your own diet."
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching?
"Immunizations will have to be delayed until the casts come off."
A toddler is in the hospital. The parents tell the nurse they are concerned about the seriousness of the child's illness. Which response to the parents is most appropriate?
"It must be difficult for you when your child is ill and hospitalized. Tell me your concerns."
A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be most appropriate?
"It's okay to cry when something hurts."
At a 6-month well-child check an infant has a high fever and cold symptoms and is diagnosed with otitis media. The child is scheduled to receive their 6-month immunizations. The parent asks the nurse if the child will receive them. What is the nurse's best response?
"Make an appointment to come back to get your child's immunizations when they've finished the antibiotics."
The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way they want, they throw their legs and arms around, scream, and cry. The parent says, "I don't know what to do!" After the nurse teaches the parent about ways to manage this behavior, which statement by the parent indicates that the nurse's teaching was successful?
"Next time my child screams and throws their legs, I'll ignore the behavior."
A parent voices concern to the nurse that a 2-year-old toddler never seems to want to play with other children at the park. What would be the nurse's best response?
"That is considered normal at this age."
The nurse is caring for an adolescent client after an overdose on barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure below 30 mm Hg and a urine output of 5 mL/hr. Serum creatinine and potassium are elevated. The parents of the client ask why there is so little urine in the indwelling catheter drainage bag. What is the best response by the nurse?
"There is not enough blood circulating to the kidneys."
The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which response from the nurse is best?
"This disease is not contagious."
The parent of a child hospitalized with tetralogy of Fallot tells the nurse that the child's 3-year-old sibling has become quiet and shy and demonstrates more than a usual amount of genital curiosity since this child's hospitalization. What should the nurse tell the parent?
"This may be how your child expresses feeling a need for attention."
When teaching caregiver of a client with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?
"Try to maintain your child's usual lifestyle to promote normal development."
Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy?
"We need to make sure that her ear infection has completely cleared."
The nurse obtains the nursing history from the parent of an infant with suspected intussusception. Which question would be most helpful for the nurse to ask?
"What do the stools look like?"
A nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?
"You seem upset. Tell me about it."
The nurse is attempting to reduce the risk for impaired skin integrity related to immobility in a toddler. Which actions does the nurse include in the plan of care? Select all that apply.
-change position frequently -clean skin only when soiled -promote good nutrition
A 3-month-old infant is being discharged on digoxin. The nurse should instruct the parents to report which signs and symptoms? Select all that apply.
-decrease in the amount of infant formula taken or a refusal to take it -pulse rate greater than 140 bpm or less than 100 bpm -signs that the infant is not following moving objects -sudden vomiting or sudden drowsiness
An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place.
187.5
The birth parent of an infant with iron deficiency anemia asks the nurse what they could have done to prevent the anemia. The nurse should teach the birth parent that it is helpful to introduce solid foods into the infant's diet at which age?
6 months
A physician orders an intravenous infusion of dextrose 5% in quarter-normal saline solution (D5.25 NSS) to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb (10 kg). How many milliliters of the ordered solution would the nurse infuse each hour? Record your answer using a whole number.
70
An intravenous (IV) infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?
It may be necessary to remove a small amount of hair from the infant's scalp.
Before a routine checkup, an 8-month-old infant sits contentedly on the parent's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first?
Auscultate the heart and lungs.
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever. What would be the best option?
Allow the parent to hold the child and give the medication.
When teaching a caregiver of a 17-month-old about toilet training, which instruction would initially be most appropriate?
Be sure the toddler is ready before starting to toilet train.
The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?
Keep feedings small, but frequent.
The mother of a toddler asks the nurse what she should do with her toddler when he has a temper tantrum. Which suggestion would be most appropriate?
Leave the toddler alone during the tantrum as long as he is safe.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first?
Clamp the catheter.
The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend?
Continue with breast milk or lactose-free formula.
Which action should the nurse include when developing the plan of care for a neonate before surgical repair of a myelomeningocele?
Covering the defect with moist, sterile saline dressings
As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response?
Do nothing as this is normal behavior for a toddler.
The nurse lifted up a neonate from the bassinet. The neonate became startled, extended the arms with hands open and started crying. What intervention would be most appropriate for the nurse?
Document the finding as a normal response.
Which action should the nurse take when suspecting that a child has been abused by the parent?
Ensure that any and all findings are reported to the proper authorities.
Assessment of a 6-week-old infant reveals a weight and length in the 50th percentile for age and a head circumference at the 95th percentile. What should the nurse do first?
Examine the fontanels and sutures.
The nurse develops the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery. Which method is most appropriate?
Explain to the parents how the defect will be corrected.
A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?
IV administration of lactated Ringer's
The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an elevated serum potassium level. What is the priority assessment action for the nurse based on the laboratory data?
Institute telemetry monitoring.
A 4-month-old infant has been carried into the emergency department after falling off the parents' bed and hitting the head on the floor. What should the nurse do first?
Move the family to an area where an assessment can be completed and call for a physician.
When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next?
No action is needed; this is a normal finding.
A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess?
Number of wet diapers the in the last 24 hours
A nurse is performing a neurologic assessment on an infant. When assessing for function of cranial nerve X (vagus), which technique is most appropriate to use?
Press a tongue blade on the posterior surface of the tongue.
The parents of a 3-month-old infant have been told that their infant has died of sudden unexplained infant death syndrome (SUIDS). Which intervention is most important to include in the plan of care to assist the parents with their grieving process?
Provide an opportunity for the parents to see the infant.
A parent calls the nurse to report that their toddler has just been burned on the arm. What should the nurse advise the parent to do first?
Run cool water over the burned area, and then wrap it in a clean cloth.
Parents ask the nurse for advice about handling their 2-year-old's negativism. What is the best recommendation?
Set realistic limits for the child, and then be sure to stick to them.
A diagnosis of hemophilia A is confirmed in an infant. Which instruction should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
Sew thick padding into the elbows and knees of the child's clothing.
A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant?
Talk quietly to the infant while he is awake.
A charge nurse is making shift assignments when a staff nurse requests to not be assigned to a particular child because of the quantity of time the child requires. The charge nurse knows that the child and family have bonded with the staff nurse. What should the charge nurse do next?
Talk with the staff nurse about the assignment and the concerns voiced.
A nurse is caring for a child with intussusception. Which of the following is an expected client outcome related to the nursing diagnosis Acute pain related to cramping, which might be made for this child?
The child exhibits no manifestations of discomfort.
The nurse is caring for the following infant after surgery. Which short term goal is the priority?
The infant will remain infection free in the postoperative period.
A 10-month-old infant is admitted with a harsh, barking cough and respiratory stridor. What are the most appropriate precautions for the nurse to follow when caring for the child?
Use an isolation gown and gloves in the room.
When administering an oral medication to an infant, the nurse should take which action to decrease the risk of aspiration?
Use an oral syringe to place the medication beside the tongue, and administer the medication slowly.
A 10-month-old child has cold symptoms. The birth parent asks how they can clear the infant's nose. What would be the nurse's best recommendation?
Use saline nose drops and then a bulb syringe.
The nurse admits an infant with pyloric stenosis to the hospital. Which aspect of the plan of care should the nurse implement first?
Weigh the infant.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately?
a 3-cm increase in abdominal circumference
A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first?
a restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening
Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused?
absence of crying during the examination
Twelve hours after cardiac surgery, the nurse assesses a 3-year-old who weighs 33 lb (15 kg). The nurse should notify the surgeon about which clinical finding?
alterations in levels of consciousness
When assessing speech development, the nurse should refer which child for further re-evaluation?
an 18-month-old who only says "no"
The parents of a healthy infant request information about advance directives. The nurse's best response is to
ask open-ended questions to understand the parents' concerns.
An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to:
ask to see a copy of the advance directive.
A client brings her 6-month-old infant in for a well-baby visit. During the exam, the nurse is unable to elicit the Moro reflex. Which is the appropriate action by the nurse?
explaining to the client that this reflex disappears around 3-4 months
For a client with a Wilms' tumor, which preoperative nursing intervention takes highest priority?
avoiding abdominal palpation
A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?
being an infant
The nurse is evaluating an infant for auditory ability. What is the expected response in an infant with normal hearing?
blinking and stopping body movements when sound is introduced
A toddler hospitalized with nephrotic syndrome has marked dependent edema and hypoalbuminemia. The child's urine is frothy. When assessing the child's vital signs, the nurse should report which finding to the health care provider?
body temperature of 102.8° F (39.3° C)
Which method should the nurse use to feed an infant after surgical repair of a cleft lip?
bottle with a high flow nipple
An 11-month-old infant is admitted to the hospital with severe diarrhea. To determine the severity of the diarrhea, the nurse should assess which stool characteristic?
consistency
Which nursing activity supports the principles of palliative care for a dying infant and the infant's family?
creating a therapeutic, homelike environment for the infant and the infant's family
A nurse observes two 2-year-old children playing. The nurse documents what form of play as normal for this age group?
digging side-by-side in a sandbox
The nurse discusses appropriate iron-rich food selections with the parent of an 11-month-old infant with iron deficiency anemia. The nurse determines that teaching has been successful when the parent verbalizes that they will include which foods in the child's diet?
eggs, fortified cereals, meats, and green vegetables
The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child?
elevating the neonate's head and giving nothing by mouth
A young child who has been sexually abused has difficulty putting feelings into words. Which approach should the nurse employ with the child?
engaging in play therapy
The birth parent of an infant with myelomeningocele asks if the child is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder?
excessive cerebrospinal fluid within the cranial cavity
A 5-month-old infant is brought to the clinic by their parents because the infant "cries too much" and "vomits a lot." The infant's birth weight was 3000 g (6 lb, 10 oz), and their current weight is 3289 g (7 lb, 4 oz), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority?
feeding pattern
The nurse develops the plan of care for a toddler with an acetaminophen overdose. Which intervention should the nurse expect to include as part of the initial treatment?
gastric lavage
The nurses teaches the parents of an infant how to perform back slaps to dislodge a foreign body. What should the nurse tell the parents to use to deliver the blows?
heel of the hand
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can
hold and rock the child and give the child a security object.
The nurse teaches a parent how to care for their child during the first few days after surgery to repair a cleft lip. Which parental activity offers the most support to the child?
holding and cuddling the child
The nurse determines the parents' compliance with treatment for their infant who has otitis media. Which behavior would indicate that the parents are adhering to the treatment plan?
holding the child upright when feeding with a bottle
After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?
holding the infant semi-upright during feedings
A mother and infant are admitted to the emergency department following a motor vehicle collision. The mother has a Glasgow coma scale score of 6. The parents are divorced and have joint custody of the infant. The infant's father was not involved in the collision and arrives in the emergency department. Who should the nurse contact about consent for treatment of the infant?
infant's father
The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to which problem?
iron deficiency
While examining a 2-year-old client, the nurse sees that the anterior fontanel is open. The nurse should
notify the physician.
The parent of an infant with hemophilia tells the nurse that they are planning to do homeschooling when the child reaches school age. The parent does not want their child in school because the teacher will not watch the child as well as the parent would. The parent's comments represent what common parental reaction to a child's chronic illness?
overprotection
The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise?
padded tongue blade at the bedside
A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should:
place the infant's arms in soft elbow restraints.
The nurse prepares to admit an infant diagnosed with diarrhea to the pediatric unit. Which room should the nurse assign the infant to?
private room
A nurse is caring for an infant with dehydration and weight loss. The infant's parent states that the infant doesn't like to eat and the parent hates to make the infant eat. The nurse should
request that a dietitian talk with the parent about infants and nutrition.
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?
rubber dropper
Which family should the nurse determine as most in need of follow-up?
single parent with a toddler who has third-degree burns over 20% of the body
The nurse performs a developmental screening on an 8-month-old child. The nurse should refer the family to the health care provider (HCP) if the child was unable to demonstrate which gross motor ability?
sitting without support for long periods of time
What liquid does the nurse recommend the parents of a 1½-month-old infant with hypothyroidism use to administer levothyroxine with?
small amount of formula or breast milk
The nurse gives anticipatory guidance to the parents of a 5-month-old infant about toy safety. What toys should the nurse recommend?
soft, washable toys
A nurse is caring for a young client with tetralogy of Fallot (TOF). The client is upset and crying. The nurse observes that the client is dyspneic and cyanotic. Which position would help relieve the client's dyspnea and cyanosis?
squatting
Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema?
stools that progress from clay-colored to brown
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit?
sunken fontanel
The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery?
suture line surrounded by erythema
A toddler has a temperature above 101°F (38.3°C). The healthcare provider orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of
thrombocytopenia
A parent calls the pediatric clinic to express concern over the child's eating habits. The parent says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of:
toddlers
A 24-month-old child has been diagnosed with pneumococcal pneumonia. The healthcare provider has prescribed penicillin G, 300,000 units IM daily. What site should the nurse use to administer this injection?
ventrogluteal muscle
