Custom: Pediatrics practice questions # 2 (Ana)

A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

"Avoid triggers that cause an attack."

A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the following information should the nurse include in the teaching?

"Encourage your child to avoid sharing hats with other children."

A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?

"I will be sure my child aspirates before injecting the insulin."

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?

"I will give my son the enzymes between meals."

A nurse is teaching the parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching?

"Temper tantrums are the toddler's attempt to gain control of a situation."

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse?

"The teacher says my child has to squint to see the board."

A nurse is providing teaching to the parents of a 1 week old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

"We will rotate the probe of the pulse oximeter every 24 hours."

A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include?

"Your baby will receive a hepatitis B vaccine prior to discharge."

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

A child who has nephrotic syndrome

A nurse is caring for an adolescent who has abdominal pain. Nurses' Notes Diagnostic Results Nurses' Notes Adolescent client presents to the emergency department reporting abdominal pain that began 10 hr prior to admission. Vital signs: Temperature: 38° C (100.4° F), Heart rate: 124, Respiratory rate: 24/min, Blood pressure: 114/65 mm Hg. Client is accompanied by guardians (mother and father) and is awake, alert and orientated to person, place and time. Client reports pain as 9 on a scale of 0 to 10, and describes pain as cramping, located in the right lower quadrant. Client has intermittent nausea with emesis x1 earlier today. Decreased appetite. Denies changes in urine output. Last bowel movement yesterday. Client is guarding abdomen during examination. Bowel sounds hypoactive in all quadrants, positive obturator sign. Moves all extremities upon request. Lungs clear, no work of breathing, heart rate increased, no murmur noted. Client states, "I am really worried that something is wrong with me." The client is rocking gently in bed and ringing their hands. Guardians are attentive at bedside. Diagnostic Results Hemoglobin: 13 g/dL (11.5 to 15.5 g/dL) Hematocrit: 39% (35% to 45%) WBC cou

Abdominal pain is correct. WBC count is correct

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Administer antibiotics when available.

A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

BUN 50 mg/dL

A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider?

The infant does not sit steadily without support.

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.)

bananas

A nurse is caring for an adolescent who was admitted with anorexia nervosa. Which of the following finding should the nurse expect?

bloating

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.)

have a parent stay with the child during proceduresperform procedures as quickly as possibleallow the child to keep a toy from home with her

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?

orthopnea

A nurse is caring for a toddler. Nurses' Notes Physical Examination Vital Signs Diagnostic Results Nurses' Notes Guardians report child has had a decrease in activity for two weeks. The child has been complaining of pain in the legs. Guardians state that their child has been napping longer than usual and appears tired throughout the day. The child has had persistent cold symptoms, with a fever and congestion for the past ten days. Guardians have been administering acetaminophen for fever with moderate relief. Vital Signs Temperature: 38.9 C (102 F) Heart rate: 150/min Respiratory rate: 28/min Oxygen saturation: 96% on room air Blood Pressure: 90/43 mm Hg

ropdown 1: By using the urgent and non-urgent approach to care the nurse should address the child's temperature first. The child has a temperature that is above the expected reference range and should be addressed to prevent further complications. Although the child's heart rate is above the expected reference range, there is no clinical indication that the child has an underlying cardiac condition. Bruising should be addressed; however, this could be result of thrombocytopenia. The child's pain should be monitored and addressed. Currently the child is experiencing mild pain, which may require intervention; however, there is another action the nurse should address first. Dropdown 2: By using the urgent and non-urgent approach to care the nurse should next address the child's laboratory values. This child has laboratory values suggestive of Acute Lymphoblastic Leukemia (ALL). Anemia and thrombocytopenia need to be addressed to avoid bleeding and adverse cardiac and systemic effects of anemia. The high white count may be indicative of an infection on top of the leukemia and needs to be addressed. The nurse should address petechiae and nasal stuffiness which could indicate other conditions; however, it is not priority. The respiratory rate is above the expected reference range; however, this is not a priority for the nurse to address.

A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?

takes an axillary temperature

A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take?

Assess the rest of the child's body for a rash.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Encourage the client to complete school work.

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions

Encourage the parents to rock the infant.

A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

Frequent swallowing

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

Give the child acetaminophen for discomfort.

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

Give with orange juice.

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

Administer sodium biphosphate/sodium phosphate.

A nurse is administering vaccines at a county health immunization clinic. Which of the following clients should the nurse plan to administer the meningococcal conjugate (MCV4) vaccine?

An 11-year-old school-age child

A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?

An anxiety reaction

A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?

Apply a topical corticosteroid ointment to the affected area.

A nurse is caring for an infant in a provider's office. Medical History Nurse's Notes Vital Signs Diagnosis: • Upper respiratory infection Provider prescriptions: • Amoxicillin and clavulanate suspension 225 mg PO twice daily for 10 days • Ibuprofen liquid 50 mg PO every 6 to 8 hr, maximum 4 times daily, to treat fever Provider Visit #1 Infant presents with increased congestion, fever, and general fussiness. Crackles auscultated bilaterally in lungs. Thick yellow nasal drainage noted. Instructed caregivers on medication administration, fever reduction, and hydration measures. Provider Visit #2 (4 days later) Return visit for infant. Crackles auscultated bilaterally in lungs. Thick, white nasal drainage noted. Decreased appetite; loose-to-watery stool for 2 days. Contact dermatitis to perineal area; skin red and inflamed, no drainage, tender. Caregiver reports it started 2 days ago and has worsened. Mucous membranes moist. Capillary refill greater than 3 seconds to finger. Provider Visit #1 Axillary temperature 39.7° C (103.5° F) Heart rate 144/min Respiratory rate 32/min Oxygen saturation 95% on room air Provider Visit #2 (4 days later) Axillary temperature 37.4° C (99.3° F) Heart ra

Cleanse diaper area with soap and water is correct. Perfumed soaps and harsh cleansers should be avoided because they could cause further damage to the skin. Teach caregivers to change diaper when wet is correct. Changing the infant's diaper whenever it is wet will keep the infant's skin as dry as possible, giving the skin time to heal. Instruct caregivers to apply zinc oxide with each diaper change is correct. Zinc oxide is a moisture barrier. It will protect the infant's skin.

A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). Vital Signs Nurses' Notes Medication Administration Record Physical Examination Vital Signs Oral temperature 38⁰ C (100.2⁰ F) Respiratory rate 34/min Heart rate 115/min Blood pressure 86/54 mm Hg SaO2 94% Nurses' Notes Awake, alert, oriented x 3 for age. Lung sounds clear to auscultation. Tachypnea, rate 34/min. Oxygen infusing at 2 L/min bi-nasal cannula. Telemetry intact. Sinus tachycardia, rate 118/min. Lactated Ringer's infusing to left forearm at 88 mL/hr. Bowel sounds hypoactive in all four quadrants. Abdomen soft, non-tender. Nasogastric tube intact to right nare with low intermittent suction, small amount of bile noted. Bilateral lower extremities with full-thickness burns noted anteriorly and posteriorly. Skin dry with white coloring anteriorly to thighs with erythema noted on shins anteriorly and posterior legs. No blanching. 4+ edema noted to bilateral lower extremities. Pedal pulses nonpalpable. FACES scale rating of 8 for lower extremity pain. Urinary catheter intact draining 35 mL/hr. Weight 27.2 kg (60 lb). A nurse is initiating the client's plan of care. Co

Compartment syndrome is correct. Edema is correct.

A nurse on the pediatric unit is assessing an infant who is 2 months of age. Medical History Graphic Record Physical Examination Medical History Infant was born by spontaneous vaginal delivery at 39 2/7 weeks. Birthing parent was Gravida 1 Para 1, received regular routine prenatal care and was positive for group B streptococcus. Infant weighed 2,948 grams (6 lbs 8 oz) and was 18 inches (45.7 cm) in length at birth. Guardians report that infant is irritable and hard to console within the last 3 days. Infant will consume 59.1 to 88.7 mL (2 to 3 ounces) of bottle formula and vomit 30 min after feedings. Graphic Record Axillary Temperature: 37.1°C (98.8°F) Heart rate: 130/min Respiratory rate: 28/min Current weight: 3,266 grams (7 lbs 1 oz) Physical Examination Alert and responsive to stimuli. Skin warm and dry and tone is appropriate for ethnicity. Lungs clear. Respirations regular, non-labored, no retractions. Apical heart rate regular. Abdomen distended with visible peristaltic waves. Bowel sounds hypoactive. Small, olive-sized mass noted in right upper quadrant near the umbilicus. Full range of motion to all extremities, no clicks noted.Complete the diagram by dragging from the choices b

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 The nurse should prepare the infant for an abdominal ultrasound and insert a nasogastric tube. The infant is most likely experiencing pyloric stenosis indicated by vomiting after feeding and the olive-sized mass in the right upper quadrant near the umbilicus. An abdominal ultrasound is used to confirm this condition and the nasogastric tube will be used to decompress the stomach prior to surgery. Prior to surgery, the nurse should monitor the infant's electrolyte values and intake and output because the infant is at risk for developing metabolic alkalosis related to the vomiting. After surgery the nurse should monitor the infant's intake and output to evaluate hydration status. the nurse should monitor to assess the client's progress.

A nurse is caring for a 15-year-old adolescent. Nurses' Notes Physical Examination Vital Signs Diagnostic Results Nurses' Notes 0900: Admitted with reports of shortness of breath and productive cough. States has been feeling tired and weak for 2 days. Parents state adolescent has not eaten in 2 days and has had low-grade fever since yesterday. Reports headache and chest discomfort as a 4 on a scale of 0 to 10. Adolescent reports not having an appetite. Drag words from the choices below to fill in each blank in the following sentence. The nurse reviews the EMR and determines that the adolescent is at risk for developing which of the following complications?The adolescent is at risk for developing

Dehydration is correct. Pleural effusion is correct.

A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect?

Lethargy

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following?

Negative behaviors characterized by the need for autonomy

A nurse is caring for a school-age child. Medical History Nurses' Notes Vital Signs Medical History Diagnosis: Bilateral pneumonia Past medical history: Cystic fibrosis Plan: Aggressive airway clearance therapy Intravenous antibiotic therapy Nurses' Notes Day 1: Caregiver reports child has had increased coughing, fatigue, and a poor appetite for the past several days. Wheezing and rhonchi auscultated bilaterally. Respirations labored with accessory muscle use. Frequent cough productive with thick, yellow blood-streaked sputum. Dyspnea noted with activity. Child reports "a bit of a stomachache" and rates the discomfort as 3 on a scale of 0 to 10. Abdomen soft and non-tender to palpation. Active bowel sounds auscultated. Day 3: Respirations rapid with accessory muscle use. Dyspnea noted while at rest. Frequent cough. Thick yellow sputum expectorated following airway clearance therapy. Child reports chest discomfort as 4 on a scale of 0 to 10. Child consumes approximately 50% of meals. Denies abdominal pain. Passed three large, frothy, foul-smelling stools. Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should repor

Oxygenation is correct. The child's oxygen saturation is below the expected reference range. A decrease in oxygen saturation, along with increased shortness of breath, labored respirations, tachycardia, and hypotension, can indicate the occurrence of a pneumothorax. Therefore, this finding should be reported to the provider. Pain is correct. New onset of chest pain in a child who has cystic fibrosis and pneumonia can indicate the occurrence of a pneumothorax. Additional indicators of a possible pneumothorax include increased shortness of breath, decreased oxygen saturation, labored respirations, tachycardia, and hypotension. Therefore, this finding should be reported to the provider. Blood pressure is correct. The child's blood pressure is below the expected reference range. Hypotension, along with respiratory distress, decreased oxygenation, and chest pain in a child who has pneumonia and cystic fibrosis, is indicative of a possible pneumothorax. Therefore, this finding should be reported to the provider. Respiratory effort is correct. The child's respiratory rate is above the expected reference range, along with the presence of accessory muscle use. The child also reports worsening of the dyspnea. This finding should be reported to the provider.

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?

Patent ductus arteriosus

A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. Which of the following actions should the nurse

Perform gastric lavage with activated charcoal.

A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.)

Place a disposable covering on the scale is correct. The nurse should use a thin disposable cover to promote safety and minimize transmission of pathogens. Measure the infant from crown of the head to the heels of feet is correct. The nurse should place the infant in a recumbent position, keeping the head against the top of the board and the heels against the footboard. The nurse can also help extend the infant's body by gently holding the infant's legs down against the board .Balance the scale to 0 prior to use is correct. The nurse should balance the scale to 0 prior to weighing the infant to ensure an accurate measurement.

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Position the child laterally.

A nurse is caring for an infant who has congenital heart disease. Medical History Nurses' Notes Medical History Infant has been feeding poorly and has had difficulty gaining weight. Admitted for feeding support and management. Infant has Tetralogy of Fallot. Nurses' Notes 1400:Infant resting in guardian's arms. Infant is pale, skin is warm and dry, and respirations are unlabored while at rest. Infant became tachypneic and fatigued quickly during feeding. 1500:Infant became agitated during peripheral blood draw. Generalized profound cyanosis observed. Skin cool to touch. Tachypneic with nasal flaring and intercostal retractions noted. Which of the following actions should the nurse take? For each nursing action, click to specify if the action is indicated or contraindicated for the client.

Provide 100% oxygen by face mask is indicated. During a hypercyanotic spell, there is a decrease in pulmonary blood flow and an increase in right-to-left shunting of the blood in the heart. This results in hypoxia and acidosis. Prompt intervention is needed to correct the hypoxia and prevent brain damage and death. Prepare to assist with the insertion of a chest tube is contraindicated. Hypercyanotic spells are not related to a pneumothorax. They are caused by a spasm of the heart muscle below the pulmonary artery, which then results in obstruction of blood flow to the lungs and an increase in desaturated blood in the systemic circulatory system. Place the infant in a knee-chest position is indicated. Positioning the infant with their knees pulled up toward their chest reduces the return of desaturated venous blood from the legs and increases systemic vascular resistance. This results in an increased amount of blood flowing into the pulmonary arteries, which increases oxygenation. Request a prescription for a diuretic is contraindicated. Infants and children who have cyanotic heart defects are prone to developing polycythemia. The increased number of red blood cells increases the viscosity of the blood. It is essential to maintain adequate hydration to decrease the risk of a cerebral vascular accident occurring. Perform nasopharyngeal suctioning for a maximum of 5 seconds is contraindicated. There is no indication of a need to suction the nasopharynx. This action will likely result in agitating the infant, which will increase the severity of the hypercyanotic spell. The nurse should instead take actions to calm the infant. Administer morphine via IV bolus is indicated. Morphine can relax the spasms of the infundibular region in the heart, which is located below the pulmonary valve. This will relieve the obstruction and increase pulmonary blood flow.

A nurse is caring for a 2-month-old in the emergency department. Nurses Notes Vital Signs Nurses Notes 1000: Infant is irritable and difficult for guardian to console..console. Rhinorrhea present with copious clear secretions..secretions. Crackles and mild expiratory wheeze present in bilateral lower lobes. Moderate substernal and subcostal retractions with nasal flaring noted., Guardian reports poor feeding over the past 24 hours. Contact and droplet precautions initiated 1200: Diminished breath sounds noted in right lower lobe. Cough present. Infant listless in guardian's arms. IV saline lock inserted in left forearm Vital Signs 1015: Temperature: 101.8°F/38.8°C Pulse: 172 beats/min Respirations: 56 breaths/min (min B/P: 85/50 mmHg Oxygen Saturation: 93% 1200: Temperature: 101.6°F/38.2°C Pulse: 168 beats/min Complete the following sentence by using the list of options.

Respiratory syncytial virus is correct Retractions are correct

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?

Scoliosis

A nurse is caring for a 4-year-old child who has an atrial septal defect (ASD). Medical History Vital Signs Nurses' Notes Medical History The child was diagnosed early in infancy with a small ASD near the center of the septum. The ASD has remained open, and the child is beginning to have increased pulmonary blood flow per echocardiogram 1 month ago. Admitted today to cardiac catheterization procedure unit for transcatheter closure of the ASD using a septal occluder. Vital Signs Post-catherization: 1200 Temperature 35.6°C (96°F) Heart Rate 130/min Respiratory Rate 22/min BP 87/40 mm Hg Oxygen saturation 95% on room air Post-catheterization: 1600 Temperature 36.5°C (97.7°F) Heart Rate 130/min Respiratory Rate 20/min BP 85/42 mm Hg Oxygen saturation 96% on room air Nurses' Notes 1200: Child returns from the cardiac catheterization room. Is drowsy but arouses easily and is able to follow simple directions. Right groin pressure dressing is intact and has a small amount of blood on the dressing. Right leg is extended and straight in bed. Right leg is cool to touch, and slightly darker in color than left leg. Capillary refill is delayed when compared to left lower extremity. Right pedal and

Temperature 36.5°C (97.7°F) is correct. Right groin pressure dressing is intact and has a small amount of dried blood on the dressing is correct. Right leg is warm to touch and equal in color to the left leg is correct. Pedal and popliteal pulses strong and equal in bilateral lower extremities is correct. Apical heart rate is strong and regular is correct.

A nurse on a pediatric unit is assessing a 1-month-old infant. Physical Examination Vital Signs Diagnostic Results Physical Examination 0700: Infant asleep in upright position in parent's arms. Cyanosis noted on oral mucus membranes, nailbeds, and around the mouth. A gallop rhythm is present that does not improve with positional changes. Abdomen is soft, bowel sounds present in all quadrants. Pedal pulses difficult to palpate. Skin is cool to palpation on arms and legs. Capillary refill greater than 3 seconds on all extremities. Vital Signs 0700: Temperature 36.9° C (98.4° F) temporal Blood pressure 70/40 mm Hg Heart rate 178/min apical Respiratory rate 66/min SpO2 85% room air

The nurse should administer prostaglandin E1 and prepare the infant for an ASO because this infant is most likely experiencing transposition of the great vessels, which has caused heart failure because the infant has a gallop rhythm, tachycardia, tachypnea at rest, decreased SpO2, cyanosis, prolonged capillary refill time, and cool extremities. The nurse should monitor the infant's urine output and daily weight to assess for manifestations of worsening heart failure.

A nurse is caring for an 18-month-old infant. Nurses' Notes Vital Signs Nurses' Notes 0800: Presents to emergency department (ED) with parents who report child has had two episodes of severe abdominal pain causing child to pull knees to chest and become inconsolable. Parents also report that the child has passed red, jelly-like stools this morning. Child is lying on bed with knees drawn to chest and crying. Abdomen distended and tender with a small palpable mass in right upper quadrant of abdomen. Assessment findings reported to provider. The nurse has completed the child's admission assessment. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Vital Signs 0815: Temperature: 36.8° C (98.2° F) Heart rate: 120/min Respiratory rate: 28/min Blood pressure: 87/46 mm Hg Oxygen saturation: 98% on room air

The nurse should place the child on NPO status and prepare the child for an air enema because the child is exhibiting manifestations of intussusception or telescoping of the proximal bowel into the distal section of the bowel. If the provider cannot reduce the intussusception using an enema, surgery will be needed. The nurse should monitor the stools for return of an expected stool pattern indicating reduction of the intussusception, or continued red, jelly-like stools indicating that the intussusception was not relieved. The nurse should monitor for return of abdominal pain indicating recurrence of the intussusception.

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Trust vs. mistrust Autonomy vs. shame and doubt Initiative vs. guilt Industry vs. inferiority Identity vs. role confusion

The nurse is caring for a 4-month-old infant in the emergency department. Nurses' Notes Flow Sheet Vital Sign History and Physical Nurses' Notes 1100: Infant was very difficult to arouse. Pupils slightly sluggish. Flow Sheet Growth chart from pediatric clinic: Birth Weight 3.18 kg (7 lb; 25-50th percentile) Birth Length 50 cm (19.75 in; 50th percentile) Head circumference 34.2 cm (13.5 in; 50th percentile) 2-month Weight 4.8 kg (10 lb 9 oz; 10-25th percentile) 2-month Length 58 cm (22.75 in; 50th percentile) 2-month Head circumference 40 cm (15.75 in; 75th percentile) 1030: Weight 5.9 kg (13 lb; 10th percentile) Length 64 cm (25.25 in; 50th percentile) Head circumference 43.6 cm (17.2 in; 95th percentile)

Upon recognizing and analyzing the infant cues of signs of increased intracranial pressure and retinal hemorrhage, the nurse's priority hypothesis is that this infant is most likely experiencing abuse head trauma. It is important for the nurse to generate solutions and take actions that will determine if the infant exhibits any other signs of physical abuse and minimize the effects of increased intracranial pressure. Therefore, the nurse should elevate the head of the crib slightly, observe caregiver-infant interactions for cues related to abuse, as well as monitor for decreasing heart rate and respiratory rate as these may indicate worsening of increased intracranial pressure. To evaluate these interventions the nurse would continue to assess for further manifestations of increased intracranial pressure. Other physical signs of abuse may or may not be found, yet caregiver behaviors may be indicative, though not diagnostic, of maltreatment.

A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine on the diaper. Which of the following disorders should the nurse suspect?

Wilms' tumor

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

at the end