congenital disorders of children

1) 3) 6) the child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. the signs of perforation and shock are evidenced by fever, and increased heart rate, a change in the level of consciousness or blood pressure, and respiratory distress and need to be reported immediately. the options for hypoactive bowel sounds, profuse projectile vomiting, and ribbon-like stools are a part of the presentation picture of a child with intussusception but are not signs of shock.

a mother with a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. the nurse quickly assesses the child. which manifestations of perforation and shock would the nurse report immediately? select all that apply. 1) fever 2) ribbon-like stools 3) increased heart rate 4) hypoactive bowel sounds 5) profuse projectile vomiting 6) change in the level of consciousness

a) children who have cystic fibrosis have frequent pulmonary infections. administering antibiotics is an expected part of the plan of care. c) children who have cystic fibrosis have difficulty absorbing fat. supplementation of the fat-soluble vitamins is and expected part of the plan of care. d) children who have cystic fibrosis have mucus plugs. administering a bronchodilator is an expected part of the plan of care. e) children who have cystic fibrosis have mucus plugs. administering dornase alfa, which decreases the viscosity of the mucus, is an expected part of the plan of care.

a nurse is assisting with the admission of a child who has cystic fibrosis. for which of the following medications should the nurse anticipate receiving a prescription? (select all that apply.) a) tobramycin b) loperamide c) fat-soluble vitamins d) albuterol e) dornase alfa

b) iodine-based dyes can be used in this procedure, so the child is monitored for allergies to iodine or shellfish which could lead to anaphylaxis.

a nurse is caring for a 2-year-old child who has a heart defect and is scheduled for cardiac catheterization. which of the following actions should the nurse take? a) place on NPO status for 12 hr prior to the procedure. b) check for iodine or shellfish allergies prior to the procedure. c) elevate the affected extremity following the procedure. d) limit fluid intake following the procedure.

b) a client who has hirschsprung's disease requires surgery to remove the affected segment of the intestine. preparing the family for surgery is an appropriate action for the nurse to take.

a nurse is caring for a child who has hirschsprung's disease. which of the following actions should the nurse take? a) encourage a high-fiber, low-protein, low-calorie diet. b) prepare the family for surgery. c) place an NG tube for decompression. d) initiate bed rest.

a) rheumatic fever is caused by group A beta-hemolytic streptococcus. a nonpruritic, macular rash on the trunk and inner aspects of the extremities, called erythema marginatum is a manifestation. c) fever is a common manifestation of rheumatic fever. e) rheumatic fever is cause by group A beta-hemolytic streptococcus. and increase in C-reactive protein is a manifestation.

a nurse is caring for a child who is suspected of having rheumatic fever. which of the following findings should the nurse expect? (select all that apply.) a) nonpruritic macular rash b) continuous joint pain of the digits c) fever d) decreased erythrocyte sedimentation rate e) elevated C-reactive protein

b) the nurse should place elbow restraints on the infant to prevent damage to the incision site.

a nurse is caring for an infant who is postoperative following cleft lip and palate repair. which of the following actions should the nurse take? a) keep the infant NPO for the first 24 hr following surgery. b) place elbow restraints on the infant. c) offer the infant a pacifier containing sucrose. d) inspect the incision site inside the mouth with a tongue blade.

b) the hemoglobin electrophoresis test should be performed to distinguish if the infant has the trait or the disease.

a nurse is caring for an infant whose screening test reveals that he might have sickle cell disease. which of the following tests should be performed to distinguish if the infant has the trait or the disease? a) sickle solubility test b) hemoglobin electrophoresis c) complete blood count d) transcranial doppler

a) wheezing is an expected finding of cystic fibrosis. b) clubbing is an expected finding of cystic fibrosis. c) a barrel-shaped chest is an expected finding of cystic fibrosis.

a nurse is collecting data from a child who has cystic fibrosis. which of the following findings should the nurse expect? (select all that apply.) a) wheezing b) clubbing of fingers and toes c) barrel-shaped chest d) thin, watery mucus e) rapid growth spurts

a) narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in weak or absent femoral pulse and bounding pulses in the arms. b) narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in cool skin of the lower extremities. e) narrowing of the aorta causes increased blood pressure in the upper extremities and lower blood pressure in the lower extremities.

a nurse is collecting data from and infant who has a coarctation of the aorta. which of the following manifestations should the nurse expect? (select all that apply.) a) weak femoral pulses b) cool skin of lower extremities c) severe cyanosis d) clubbing of the fingers e) elevated blood pressure in the arms

a) pressing the nares together for at least 10 min is an appropriate action to take when managing an episode of epistaxis. c) packing cotton or tissue into the naris that is bleeding is an appropriate action when managing an episode of epistaxis. d) applying an ice pack across the bridge of the nose is an appropriate action when managing an episode of epistaxis.

a nurse is reinforcing teaching about epistaxis with the parent of a school-age child. which of the following should the nurse include as actions to take when managing an episode of epistaxis? (select all that apply.) a) press the nares together for at least 10 min. b) breathe through the nose until bleeding stops. c) pack cotton or tissue into the naris that is bleeding. d) apply a small ice pack across the bridge of the nose. e) insert petroleum into the naris after the bleeding stops.

a) the nurse should instruct the child to sit up and lean to prevent aspiration when experiencing a nosebleed.

a nurse is reinforcing teaching about the management of epistaxis with a school-age child. which of the following positions should the nurse instruct the child to take when experiencing a nosebleed? a) sit up and lean forward. b) sit up and tilt the head up. c) lie in a supine position. d) lie in a prone position.

c) the correct amount of digoxin should be administered at regularly scheduled times to maintain therapeutic blood levels.

a nurse is reinforcing teaching to the parent of a 9-month-old who has a prescription for digoxin. which of the following instructions should the nurse include? a) "do not offer your baby fluids after giving the medication." b) "stop the medication and call your provider if your baby is sleeping poorly." c) "give the correct dose of medication at regularly scheduled times." d) "if your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."

d) the child should take the supplement through a straw to prevent or minimize staining of the teeth.

a nurse is reinforcing teaching with the parent of a child who has a new prescription for liquid oral iron supplements. which of the following statements by the parent indicates an understanding of the teaching? a) "i should take my child to the emergency department if his stools become dark." b) "my child should avoid eating citrus fruits while taking the supplements." c) "i should give the iron with milk to help prevent an upset stomach." d) "my child should take the supplement through a straw."

a) frequent feeding helps decrease the amount of vomiting. b) thickened formula helps decrease the amount of vomiting and promotes weight gain. d) positioning the infant in an upright position following feedings will help decrease the number of vomiting episodes. it is still recommended that these infants be positioned supine for sleep.

a nurse is reinforcing teaching with the parents of an infant about gastrointestinal reflux disease. which of the following interventions should the nurse include in the instructions? (select all that apply.) a) offer frequent feedings. b) thicken formula with rice cereal. c) use a bottle with a one-way valve. d) position the infant upright after feedings. e) use a wide-based nipple for feedings.

4) oxygen administration may be prescribed for the infant with HF for stressful periods, especially during bouts of crying or invasive procedures. drawing blood is an invasive procedure that would likely cause the child to cry.

a primary health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure. in which situation would the nurse administer the oxygen to the child? 1) when the child is sleeping 2) when changing the child's diapers 3) when the mother is holding the child 4) when drawing blood for electrolyte levels

1) a patent ductus arteriosus is caused by a failure of the ductus to close within the first few weeks of life. the infant may by asymptomatic or show signs of heart failure. the defect may be closed during cardiac catheterization or may require surgery. a characteristic machine-like murmur is present with PDA.

the nurse is providing instructions to a parent of a child with patent ductus arteriosus. which statement by the parent would indicate a need for further teaching? 1) "i know that my child will outgrow this problem, just give him time." 2) "i know that i need to be alert for signs of heart failure with this defect until it is repaired." 3) "the doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." 4) "as i understand it, my child may have to have this defect closed, either during a catheterization or by surgery."

3) all vigorous activities need to be restricted for 2 weeks after surgery to promote healing and prevent injury. this will prevent dislodging of the suture, which is internal. normally, 2-year-old children will want to be very active. therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. the parents would be taught to monitor the child's temperature; provide analgesics, as needed; and monitor the urine output.

the nurse is reinforcing discharge instructions to the parents of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. which statement by the parent indicates a need for further teaching? 1) "i'll check is temperature." 2) "i'll give him medication so he'll be comfortable." 3) "i'll let him decide when to return to his play activities." 4) "i'll check his voiding to be sure there are no problems."

2) postoperative management for positioning of infants with hydrocephalus who have undergone ventriculoperitonel shunt is flat in bed to avoid the rapid reduction of intracranial fluid. the nurse observes for increased ICP; if it occurs the nurse would elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt and notify the registered nurse. the nurse would position the infant on the non-operative side to prevent pressure on the shunt valve. the nurse would monitor for signs of infection and check dressings for drainage. a high shrill cry in an infant can be a sign of increased ICP.

the nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. which of the surgeon's prescriptions does the nurse question? 1) position the infant on the nonoperative side. 2) keep the head of the bed elevated at 45 degrees. 3) monitor for signs of infection and check dressings for drainage. 4) observe for irritability, a high shrill cry, lethargy, and poor feeding.

1) the treatment plan for children with attention deficit hyperactivity disorder includes stimulant medications that may have the adverse effect of appetite suppression and weight loss, not overeating. treatment for these children includes behavioral therapy, maintaining a consistent environment, and appropriate classroom placement. regular medication administration and regular follow-up visits are also important instructions for the parents.

the nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. which statement by the parent indicates a need for further teaching? 1) "i hear that the side effects of the medication that my child will be on can cause overeating." 2) "i know that consistent medication and regular follow-up visits are a part of the plan for my child." 3) "i know i need to maintain a consistent home environment because my child is easily distracted." 4) "i understand that i will need to learn some behavioral modification techniques to help my child's impulsivity."

4) the nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. options 1, 2, and 3 are appropriate statements. the parents are also provided instructions regarding measures to take in the event of blunt trauma, and they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

the 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 teaching? 1) "i will supervise my child closely." 2) "i will pad the corners of the furniture." 3) "i will remove household items that can easily fall over." 4) "i will avoid immunizations and dental hygiene treatments for my child."

3) any child who exhibits the "3 Cs"- coughing and choking during feedings and unexplained cyanosis- would be suspected of having a tracheoesophageal fistula. options 1, 2, and 4 are not specifically associated with TEF.

the 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 is suspected. the nurse expects to note which most likely manifestation of this condition in the medical record? 1) incessant crying 2) coughing at nighttime 3) choking with feedings 4) severe projectile vomiting

2) after hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. rather, sponge baths are given. diapers are placed on the child to prevent contamination of the surgical site. toilet training would not be an issue during this stressful period. fluids need to be encouraged to maintain hydration.

an 18-month-old child is being discharged after surgical repair of hypospadias. which postoperative nursing care measure would the nurse stress to the parents as they prepare to take the child home? 1) leave diapers off to allow the site to heal. 2) avoid tub baths until the stent has been removed. 3) encourage toilet training to ensure that the flow of urine is normal. 4) restrict the fluid intake to reduce urinary output for the first few days.

3) during the acute stage of kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. during the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. during the convalescent stage, the child appears normal, but signs of inflammation may be present.

the nurse assists with admitting a child with a diagnosis of acute stage kawasaki disease. when obtaining the child's medical history, which manifestation is likely to be noted? 1) cracked lips 2) a normal appearance 3) conjunctival hyperemia 4) desquamation of the skin

4) pain crisis may be precipitated by infection, hydration, hypoxia, trauma, or general stress. the mother of a child with sickle cell disease would encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

the nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. which, if identified by a parent as a precipitating factor, indicates the need for further teaching? 1) stress 2) trauma 3) infection 4) fluid overload

3) after the repair of a cleft lip, the infant would be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. in this case it is best to place the infant on the left side. additionally, the flat or prone position can result in aspiration if the infant vomits.

an infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. which is the best position to place this infant at this time? 1) a flat position 2) a prone position 3) on his or her left side 4) on his or her right side

3) the most common complications associated with orchiopexy are bleeding and infection. the parents are instructed in postoperative homecare measures, including the prevention of infection, pain control, and activity restrictions. the measurement of intake and output is not required. anticholinergics are prescribed for the relief of bladder spasms; they are not necessary after orchiopexy. cold, wet compresses are not prescribed. the moisture from a wet compress presents a potential for infection.

the child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. the nurse would reinforce instructions to the parents about which priority care measure? 1) measuring intake and output 2) administering anticholinergics 3) preventing infection at the surgical site 4) applying cold, wet compresses to the surgical site

2) 3) 4) 5) 6) parents of the child with marfan syndrome need to be instructed to monitor for vision problems and get regular eye examinations, and avoid participation in contact sports; however, it is not necessary for the child to stay indoors. the nurse needs to monitor the curvature of the spine as the child grows. antibiotics need to be taken before any dental procedure to prevent endocarditis. cardiac medications need to be taken to decrease stress on the aorta, and surgical replacement of the aortic root and valve may be necessary. making regular pediatric appointments is important for monitoring the child.

the mother of a child with marfan syndrome asks the nurse what can be done to help her child. which are the best responses by the nurse? select all that apply. 1) "you will need to keep your child indoors and avoid sports." 2) "you will need to consider surgery in the future if recommended." 3) "you will need to make regular pediatric appointments for your child." 4) "you will need to make regular eye examination appointments for your child." 5) "you will need to be sure your child takes prescribed cardiac medication to decrease stress on the aorta." 6) "you will need to let the dentist know so antibiotics can be prescribed before any procedure."

4) cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. meningitis is an infectious process of the central nervous system. encephalitis is an inflammation of the brain that occurs as a result of a viral illness or central nervous system infection. down syndrome is an example of a congenital condition that results in moderate to severe retardation.

the parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. the nurse bases the response on the understanding that cerebral palsy is which type of condition? 1) in infectious disease of the central nervous system 2) an inflammation of the brain as a result of a viral illness 3) a congenital condition that results in moderate to severe retardation 4) a chronic disability characterized by impaired muscle movement and posture

4) bladder exstrophy is a congenital anomaly that is characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. the cause is unknown and there is a higher incidence among males. options 1, 2, and 3 are not characteristics of this disorder.

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. which response would the nurse give to the parents about bladder exstrophy? 1) "it is a hereditary disorder that occurs in every other generation." 2) "it is caused by the use of medications taken by the mother during pregnancy." 3) "it is a condition in which the urinary bladder is abnormally located in the pelvic cavity." 4) "it is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."

2) 3) 4) the early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. a cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. slow and shallow breathing is not associated with heart failure.

the nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure. the nurse would observe for which early signs of HF? select all that apply. 1) cough 2) irritability 3) scalp diaphoresis 4) tachypnea, tachycardia 5) slow and shallow breathing

2) epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. in clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. this anatomical characteristic leads to the easy access of bacterial entry into the urine. options 1, 3, and 4 are not characteristically noted with this condition.

the 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 finding? 1) hematuria 2) bacteriuria 3) glucosuria 4) proteinuria

3) the child with aortic stenosis shows signs of activity intolerance, chest pain, and dizziness when standing for long periods. pallor may be noted, but it is not specific to this type of disorder alone. options 2 and 4 are not related to this disorder.

the nurse reviews the record of a child who was just seen by the primary health care provider. the PHCP has documented a diagnosis of suspected aortic stenosis. which specific sign/symptom of aortic stenosis would the nurse anticipate? 1) pallor 2) hyperactivity 3) activity intolerance 4) gastrointestinal disturbances

1) phenylketonuria is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood. it is characterized by blood phenylalanine levels greater than 20 mg/dL. the normal level is 0 mg/dL to 2 mg/dL. a result of 0 mg/dL is a negative test result.

a mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. the test indicates a serum phenylalanine level of 0 mg/dL. the nurse reviews this result and makes which interpretation? 1) it is negative. 2) it is a concern. 3) it is inconclusive. 4) it requires rescreening at age 6 weeks.

a) children who have cystic fibrosis excrete an excessive amount of sodium and chloride in their sweat. a sweat chloride content of 85 mEq/L is above the expected reference range and is an indication of cystic fibrosis.

a nurse is reviewing the diagnostic findings for a preschool-age child who is suspected of having cystic fibrosis. which of the following findings should the nurse identify as an indication of cystic fibrosis? a) sweat chloride content 85 mEq/L b) increased serum levels of fat-soluble vitamins c) 72-hr stool analysis sample indicating hard, packed stools d) chest x-ray negative for atelectasis

4) the parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. options 1, 2, and 3 are accurate instructions regarding the administration of this medication. additionally, the parents need to be instructed that if a dose is missed and it is not noticed until 4 hours or more later, the dose should not be administered.

the nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. which statement by a parent indicates the need for further teaching? 1) "i will not mix the medication with food." 2) "if more than one dose is missed, i will call the doctor." 3) "i will take my child's pulse before administering the medication." 4) "if my child vomits after medication administration, i will repeat the dose."

b) an infant who has infective endocarditis has an increased WBC due to the presence of a bacterial infection. c) and infant who has infective endocarditis has an elevated ESR due to the presence of inflammation caused by bacterial infection. e) an infant who has infective endocarditis often exhibits a new heart murmur or a change in a previously existing heart murmur caused by damage to heart valves by bacterial infection.

a nurse is collecting data from and infant who has infective endocarditis. which of the following manifestations should the nurse expect? (select all that apply.) a) bradycardia b) increased WBC c) elevated erythrocyte sedimentation rate d) increased appetite e) heart murmur

2) PKU is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood, not the gastrointestinal system. PKU is an autosomal-recessive disorder and treatment includes the dietary restriction of phenylalanine intake. all 50 states require screening newborns for PKU.

the nursing instructor asks a nursing student about phenylketonuria. which statement made by the student indicates a need for further teaching? 1) "PKU is an autosomal-recessive disorder." 2) "PKU primarily affects the gastrointestinal system." 3) "treatment of PKU includes the dietary restriction of phenylalanine." 4) "all 50 states require routine screening of all newborns for PKU."

b) children who have cystic fibrosis have pancreatic insufficiency. the nurse should provide instruction about administering pancreatic enzymes with meals or within 30 min of a meal or snack.

a nurse is reinforcing discharge teaching with the parents of a child who has cystic fibrosis. which of the following instructions should the nurse include? a) provide a low-calorie, low-protein diet. b) administer pancreatic enzymes with meals and snacks. c) implement a fluid restriction during times of infection. d) restrict physical activity.

2) the child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. hypercyanotic episodes often occur among infants with tetralogy of fallot. if a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. the knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

the nurse was caring for an infant who had come to the nursing unit for observation and treatment of tatralogy of fallot. the child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. the nurse would perform which action first? 1) assist to administer morphine sulfate. 2) place the child in a knee-chest position. 3) administer 100% oxygen by face mask. 4) prepare to administer intravenous fluids.

4) children with CF are managed with a high-calorie, high-protein diet. pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamins supplements are administered. fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. chicken tenders and a baked potato with butter provide a high-calorie and high-protein meal that includes fat.

the nurse is instructing the mother of a child with cystic fibrosis about the appropriate dietary measures. which meal best illustrates the most appropriate diet for a client with CF? 1) veggie salad and a caramel apple 2) strawberry jelly sandwich and pretzels 3) plate of nachos and cheese and a cupcake 4) chicken tenders and a baked potato with butter

4) a weight gain of 0.5 kg in 1 day is a result of the accumulation of fluid. the nurse would monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. tachypnea and increased BP would occur with fluid accumulation. diaphoresis is a sign of HF, but it is not specific to fluid accumulation and it usually occurs with exertional activities.

the nurse is monitoring the daily weight of an infant with heart failure. which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? 1) bradypnea 2) diaphoresis 3) decreased blood pressure 4) a weight gain of 1 lb in 1 day

a) abdominal pain is a manifestation of meckel's diverticulum. c) mucus and bloody stools is a manifestation of meckel's diverticulum.

a nurse is collecting data from a child who has meckel's diverticulum. which of the following manifestations should the nurse expect? (select all that apply.) a) abdominal pain b) fever c) mucus, bloody stools d) vomiting e) rapid, shallow breathing

a) a client who has a pyloric stricture has thickening of the pyloric sphincter, resulting in projectile vomiting. b) a client who has pyloric stricture is unable to consume adequate food and fluid, resulting in dehydration. dry mucous membranes is a manifestation of hypertrophic pyloric stenosis. e) a client who has pyloric stricture is unable to consume adequate food and fluid, resulting in constant hunger.

a nurse is collecting data from an infant who has hypertrophic pyloric stenosis. which of the following manifestations should the nurse expect? (select all that apply.) a) projectile vomiting b) dry mucous membranes c) currant jelly stools d) constant hunger

b) the nurse should use the Z-track method when administering an IM dose to prevent staining of the skin at the injection site.

a nurse is preparing to administer iron dextran IM to a school-age child who has iron deficiency anemia. which of the following actions by the nurse is appropriate? a) administer the dose in the deltoid muscle. b) use the Z-track method when administering the dose. c) monitor the child for flu-like manifestations after the injection. d) massage the injection site for 2 min after administering the dose.

3) 4) postoperative management of hirschsprung's disease includes taking vital signs but avoiding taking the temperature rectally. the client needs to remain NPO status until bowel sounds return or flatus is passed, usually within 48 to 72 hours. the other options are correct postoperative management.

the nurse is reviewing the postoperative surgeon's prescription for a 3-week-old infant with hirschsprung's disease admitted to the hospital for surgery. which prescriptions documented in the child's record would the nurse question? select all that apply. 1) measure abdominal girth daily. 2) monitor strict intake and output. 3) take temperature measurements rectally. 4) start clear liquid diet after 8 hours postoperative. 5) maintain intravenous fluids until the child tolerates oral intake. 6) monitor the surgical site for redness, swelling, and drainage.

2) signs/symptoms of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

the 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? 1) watery diarrhea 2) projectile vomiting 3) increased urine output 4) vomiting large amounts of bile

3) treatment for clubfoot is started as soon as possible after birth. serial manipulation and casting are performed at least weekly. if sufficient correction is not achieved within 3 to 6 months, surgery is usually indicated. because clubfoot can recur, all children with the condition require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

the nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. which statement by the parent indicated the need for further teaching regarding this disorder? 1) "i understand treatment needs to be started as soon as possible." 2) "i realize my child will require follow-up care until fully grown." 3) "i need to bring my child back to the clinic in 2 months for a new cast." 4) "i need to come to the clinic every week with my child for the casting."