Exam 3 module 4-5

Parents have understood teaching about prevention of childhood otitis media if they make which statement? a. "We wil only prop the bottle during the daytime feedings." b. "We will be sure to keep immunizations up to date." c. "We will place the child flat right after feedings." d. "Breastfeeding will be discontinued after 4 months of age."

b. "We will be sure to keep immunizations up to date." Rationale: Parents have understood the teaching about preventing childhood otitis media if they respond they will keep childhood immunizations up to date. The child should be maintained upright during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position.

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the healthcare provider immediately? a. Appearance of bright red stoma b. A 3-cm increase in abdominal circumference c. Periods of occasional fussiness d. Absence of bowel sounds since surgery

b. A 3-cm increase in abdominal circumference Rationale: Abdominal circumference is measured to monitor for abdominal distention. An increase of 3-cm in 8 hours would require notification of the healthcare provider; it would indicate a substantial degree of accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness, However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the HCP does not need contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 38 hours for gastric motility to resume. New stomas are typically bright red or pink.

Which child can be discharged by physician order with the nurse beginning discharge documentation without further investigation? a. A 6-year old who has been having vomiting and diarrhea for 2 days and has decreased urine output. b. A 3-year old who had a relapse of one diarrhea episode after restarting a normal diet. c. A 10-year old who has just returned from a Scout camping trip and has had several episodes of diarrhea. d. A 2-year old who has had 24 hours of water diarrhea that has changed to bloody diarrhea in the past 12 hours.

b. A 3-year old who had a relapse of one diarrhea episode after restarting a normal diet. Rationale: It is common for children to have a relapse of diarrhea after resuming a regular diet. Diarrhea containing blood needs further investigation, V/D for 2 days requires IVF rehydration, and diarrhea following a camping trip needs investigation for either parasites or bacterial infections.

The nurse is caring for an infant whose cleft lip was repaired. What important aspects of this infant's postoperative care should be included? a. Arm restraints, postural drainage, mouth irrigations b. Cleansing the suture line, supine and side-lying positions, arm restraints c. Supine and side-lying positions, postural drainage, arm restraints d. Mouth irrigations, prone position, cleansing the suture line

b. Cleansing the suture line, supine and side-lying positions, arm restraints Rationale: The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigation, and the child should not be placed in the prone position where injury to the suture site can occur.

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? a. Distention of lower abdomen and constipation b. Visible peristalsis and weight loss c. Rounded abdomen and hypoactive bowel sounds d. Abdominal rigidity and pain on palpation

b. Visible peristalsis and weight loss Rationale: Visible gastric peristaltic waves that move from left to right across the epigastrium and weight loss are observed in pyloric stenosis. Abdominal rigidity and pain on palpation or a rounded abdomen and hypoactive bowel sounds are usually not present. The upper abdomen, not lower abdomen, is distended.

A parent asks the nurse how it will be determined whether their child has respiratory syncytial virus (RSV). Which is the nurse's best response? a. "There is no specific test for RSV. The diagnosis is made based on the child's symptoms." b. "We will have to send a viral culture to an outside lab for testing." c. "We will swab your child's nose and send that specimen for testing." d. "We will do a simple blood tst to determine whether your child has RSV."

c. "We will swab your child's nose and send that specimen for testing." Rationale: The child is swabbed for nasal secretions. The secretions are tested to determine whether a child has RSV.

The nurse is caring for a body with probable intussusception. He had diarrhea before admission but, while waiting for administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate? a. Take vital signs, including blood pressure b. Measure abdominal girth c. Notify practitioner d. Auscultate for bowel sounds

c. Notify practitioner Rationale: Passage of a normal brown stool indicates that the intussusception has reduced itself. This is immediately reported to the practitioner, who may choose to alter the diagnostic-therapeutic care plan. The first action would be to report the normal stool to the practitioner.

A nurse in the pediatric clinic is assessing an 11-month old client who is sitting on the mother's lap crying and tugging at the right ear. What likely problem does this behavior indicate? a. Upper respiratory infection b. Child abuse c. Otitis media d. Hearing impairment

c. Otitis media Rationale: Young children who cannot verbalize the presence of pain use nonverbal behaviors to indicate discomfort; crying and tugging at a painful ear are typical behaviors of an infant with otitis media. There are no data to indicate child abuse. Tugging at the ear is not an indication that the child has a hearing problem. Tugging at the ear is specific to otitis media, not an upper respiratory infection.

The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant displays which clinical manifestation? a. Fussiness b. Coughing c. A fever over 99 degrees (F) d. Signs of an earache

d. Signs of an earache Rationale: If an infant with nasppharyngitis shows signs of an earache, it may mean a secondary bacterial infection is present and the infant should be referred to a practitioner for evaluation. Irritability is common in an infant with a viral illness. Cough can be a sign of nasopharyngitis. Fever is common in viral illnesses.

A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests fleeding from which area? a. Lower gastronintestinal tract b. Hemorrhoids or anal fissures c. Perianal or rectal area d. Upper gastrointestinal tract

d. Upper gastrointestinal tract Rationale: Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.

A child who has just had definitive repair of a high rectal malformation is to be discharged. Which should the nurse address in the discharge preparation of this family? (SELECT ALL THAT APPLY). a) Use of diet modification to prevent constipation b) Necessity of firm stools to keep suture line clean c) Perineal and wound care d) Bowel training beginning as soon as child returns home e) Reporting any changes in stooling patterns to practitioner

a) Use of diet modification to prevent constipation c) Perineal and wound care e) Reporting any changes in stooling patterns to practitioner Rationale: Wound care instruction is necessary in a child who is being discharged after surgery. The parents are taught to notify the practitioner if any signs of an anal stricture or other complication develops. Constipation is avoided, since a firm stool will place strain on the suture line. Fiber and stool softeners are often given to keep stools soft and avoid tension on the suture line. The child needs to recover from the surgical procedure. Then bowel training may begin, depending on the child's developmental and physiologic readiness.

The nurse is caring for a 5-year old child who is scheduled for a tonsillectomy in 2 hours. Which actions should the nurse include in the child's postoperative care plan? (SELECT ALL THAT APPLY). a)Allow the child to have diluted juice after the procedure b)Notify the surgeon if the child swallows frequently c)Encourage the child to cough frequently d)Apply a heat color to the child for pain relief e)Place the child on the abdomen until fully wake

a)Allow the child to have diluted juice after the procedure b)Notify the surgeon if the child swallows frequently e)Place the child on the abdomen until fully wake Rationale: Frequent swallowing is a sign of bleeding in children after a tonsillectomy. The child should be placed on the abdomen or the side to facilitate drainage. The child can drink diluted juice, cool water, or popsicles after the procedure. An ice collar should be used after surgery. Frequent coughing and nose blowing should be avoided.

An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (SELECT ALL THAT APPLY.) a)Strict intake and output to avoid congestive heart failure b)Administration of antibiotics c)Cluster care to conserve energy d)Round-the-clock administration of antitussive agents

b)Administration of antibiotics c)Cluster care to conserve energy Rationale: Antibiotics are indicated for bacterial pneumonia. Often the child will have decreased pulmonary reserve, and the clustering of care is essential. Antitussive agents are used sparingly. It is desirable for the child to cough up some of the secretions. Fluids are essential to keep secretions as liquefied as possible.

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the child's care? (SELECT ALL THAT APPLY.) a) Cluster care to encourage adequate rest. b) Place on noninvasive oxygen monitoring. c) Place in a mist tent. d) Administer cough syrup. e) Adminster antibiotics. f) Encourage the child to drink 8 ounces of formula every 4 hours.

a) Cluster care to encourage adequate rest. b) Place on noninvasive oxygen monitoring. f) Encourage the child to drink 8 ounces of formula every 4 hours. Rationale: Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes. Cough syrup suppressed clearing of respiratory secretions and is not indicated for young children.

The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate? a. "I understand, but feel free to visit or call anytime to see how your child is doing." b. "Can you find someone to stay with your children? Your child needs you here." c. "It really is not necessary to stay with your child. We will take very good care of him." d. "You really should not leave right now. Your child is very sick."

a. "I understand, but feel free to visit or call anytime to see how your child is doing." Rationale: The nurse's best course of action would be to support the mother. This is best done by conbeying understanding and encouraging the mother to visit or call. Telling the mother that she should not leave and that the child is very sick is critical and insensitive. It implies guilt should the mother leave. Toddlers in particular need family members present because of the stresses associated with hospitalization so saying the child does not need anyone is untrue. Toddlers experience anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children at home is inappropriate. The children at home also need the mother's support and/or minimal disruptions in family life resulting from the toddler's hospitalization and to maintain consistency.

Which child is at highest risk for requiring hospitalization to treat respiratory syncytial virus (RSV)? a. A 2-month old who was born at 32 weeks b. A 3-year old with a congenital heart defect c. A 4-year old who was born at 30 weeks d. A 16-month old with a tracheostomy

a. A 2-month old who was born at 32 weeks Rationale: The younger the child, the greater the risk for developing complications related to RSV. This infant is at highest risk because of age and premature status.

Which manifestation would the nurse expect to see in a 4-week old infant with biliary atresia? a. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine. b. No manifestations until the disease has progressed to the advanced stage. c. Abdominal distention, multiple bruises, bloody stools, and hematuria. d. Yellow sclera and skin tones, excessively oily skin, and prolonged bleeding times

a. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine. Rationale: The infant with biliary atresia usually has an enlarged liver and spleen. The stools appear clay-colored because of the absence of bile pigments. The urine is tea-colored because of the excretion of bile salts. Typically, no blood in stools, skin usually dry and itchy, not oily, and manifestations of biliary atresia usually appear by 3 weeks of life.

A 5-year old is seen in the urgent care clinic with the following history and symptoms; sudden onset of severe sore throat after going to bed, drooling and difficulty swalloing, axillary temperature of 102.2 F (39.0 C), clear breath sounds, and absence of cough. The child appears anxious and is flushed. Based on these symptoms and history, the nurse anticipates a diagnosis of: a. Acute epiglottitis b. Acute laryngotracheobronchitis c. Acute tracheitis d. Group A beta-hemolytic streptococcus pharyngitis

a. Acute epiglottitis Rationale: Rapidly progressive onset, difficulty swallowing, high fever, in addition to the three clinical observations for absence of spontaneous cough, presence of drooling, and agitation all relate to the diagnosis of epiglottis.

A nurse is discussion the need for genetic counseling with a male teenager who has a sibling with cystic fibrosis (CF). The identification of which test by the teenager indicates that he understands the genetic counseling? a. Carrier DNA testing b. Chromosomal assay c. Sweat chloride d. Chest x-ray

a. Carrier DNA testing Rationale: More than one gene can cause cystic fibrosis (CF); carrier testing is done to detect known alleles. The results of a chest x-ray will not determine whether the individual is a carrier of CF; this may be one of the tests that are conducted when CF is suspected. A sweat chloride test is performed to diagnose CF, not to determine whether the adolescent is a carrier. CF does not result from a chromosomal anomaly.

The nurse is caring for a 14-year old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? a. Cheese, banana slices, rice cakes, and whole milk b. Oat cereal, breakfast pastry, and nonfat skim milk c. Pancakes, orange juice, and sausage links d. Eggs, bacon, rye toast, and lactose-free milk

a. Cheese, banana slices, rice cakes, and whole milk Rationale: Cheese, bananas, rice cakes, and whole milk do not contain gluten. Rye toast, pancakes, oat cereal and a breakfast pastry could contain gluten and should be avoided by the adolescent.

Which statement indicates the parent needs further teaching on how to prevent his other children from contracting respiratory syncytial virus (RSV)? a. "I should insist that anyone with a respiratory illness avoid contact with my children until well." b. "I should make sure that both my children receive palivizumab (Synagis) injections every year." c. "I should insist that all people who come in contact with my children thoroughly wash their hands before playing with them." d. "I should be sure to keep my infected child away from his brother until he has recovered."

b. "I should make sure that both my children receive palivizumab (Synagis) injections every year." Rationale: Palivizumab (Synagis) will not help the child who already contracted the RSV illness; it is an immunization and a method of primary prevention.

Which therapeutic management should the nurse prepared to initiate first for a child with acute diarrhea and moderate dehydration? a. Oral rehydration solution(ORS) b. Antidiarrheal medications such as paregoric c. Clear liquids d. Absorbents, such as kaolin and pectin

a. Oral rehydration solution(ORS) Rationale: ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended. Antidiarrheals are not recommended because they do not get rid of pathogens.

Which is an important nursing consideration in the care of a child with celiac disease? a. Refer to a nutritionist for detailed dietary instructions and education b. Teach proper hand washing and standard precautions to prevent disease transmission c. Suggest ways to cope more effectively with stress to minimize symptoms d. Help child and family understand that diet restrictions are usually only temporary

a. Refer to a nutritionist for detailed dietary instructions and education Rationale: The main consideration is helping the child adhere to dietary management. Considerable time is spent explaining to the child and parents about the disease process, the specific role of gluten in aggravating the condition, and foods that must be restricted. Referral to a nutritionist would help in this process. The most severe symptoms usually occur in early childhood and adult life. Dietary avoidance of gluten should be lifelong. Celiac disease is not transmissible or stress related.

The parents of a 3-year old child who has recurrent attacks of acute spasmodic laryngitis (spasmodic croup) ask the nurse why this happens to their child. What is the best rationale for the nurse to convey why this is a disorder of young children? a. They have small airways. b. They are mouth breathers. c. They have immature immune systems. d. They are prone to upper respiratory infections

a. They have small airways. Rationale: Swelling and edema in airways with small diameters lead to the signs and symptoms of croup. Mouth breathing is not the cause of group. An immature immune system is too general an explanation; it depends on the specific resistance of the individual child. A tendency to contract upper respiratory infections does not explain why only small children get croup.

A family wants to begin oral feeding of their 4-year-old son, who is ventilator-dependent and currently tube-fed. They ask the home health nurse to feed him the baby food orally. The nurse recognizes a high risk of aspiration and an already compromised respiratory status. What is the most appropriate nursing action? a. Refuse to feed him orally because the risk is too high b. Acknowledge their request, explain the risks, and explore with the family the available options c. Feed him orally because the family has the right to make this decision for their child d. Explain the risks involved, and then let the family decision what should be done

b. Acknowledge their request, explain the risks, and explore with the family the available options Rationale: Parents want to be included in the decision making for their child's care. The nurse should discuss the request with the family to ensure this is the issue of concern, and then they can explore potential options together. Merely refusing to feed the child orally does not determine why the parents wish the oral feedings to begin and does not involve them in the problem solving. The decision to begin or not change feedings should be a collaborative one, made in consultation with the family, nurse, and appropriate member of the health care team.

Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies that are being treated with antihistamines. What should the nurse suspect caused the constipation? a. Allergies b. Antihistamines c. Diet d. Emotional factors

b. Antihistamines Rationale: Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known change in her habits, the addition of antihistamines is most likely the cause of the diarrhea. With a change in bowel habits, the role of any recently prescribed medications should be assessed.

Which would be an appropriate nursing care management of a child diagnosed with mononucleosis? a. Clear liquids diet b. Only visitors within the family c. Limited daily fluid intake d. Strict bedrest/No OOB allowed

b. Only visitors within the family Rationale: Children with mononucleosis are more susceptible to secondary infections. Therefore, they should be limited to visitors within the family, especially during the acute, infectious phase of the illness. Children typically self-limit their activities, do not require restricted food diets, usually have decreased appetites, but it is essential that they remain hydrated.

A mother brings her 6-year old child to the pediatric clinic, stating that the hcild has not been feeling well, is weak and lethargic, and has a poor appetite, headaches, and smoky-colored urine. What additional information should the nurse obtain that will aid diagnosis? a. Recent weight loss of 2 lbs (0.9 kg) b. Strep throat in the past two weeks c. Rash on palms and feet d. Shoulder and knee pain

b. Strep throat in the past two weeks Rationale: The smoky urine and the stated symptoms should lead the nurse to suspect glomerulonephritis, which usually occurs after a recent streptococcal infection. A rash on the hands and feet is associated with scarlet fever, shoulder and knee pain are associated with rheumatic fever, and weight loss generally occurs in children who have type I diabetes, not in those with glomerulonephririts.

A 4-month-old infant has gastroesophageal reflux (GERD) but is thriving without other complications. Which should the nurse suggest to minimize reflux? a. Give larger, less frequent feedings b. Thicken formula with rice cereal c. Give continuous nasogastric tube feedings d. Place in Trendelenburg position after eating

b. Thicken formula with rice cereal Rationale: Small, frequent feedings of formula combined with 1 teaspoon to 1 Tablespoon of rice cereal per ounce of formula have been recommended. Milk-thickening agents have been shown to decrease the number of episodes of comiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GERD. Placing the child in Trendelenburg position would increase the reflux. Continuous nasogastic feedings are reserved for infants with severe reflux and failure to thrive.

A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. What is the initial therapeutic approach for the mother? a. Recognizing that negative feelings toward the child continue throughout childhood b. Emphasizing the normalcy of her baby and the baby's need for mothering c. Encouraging her to express her feelings d. Restating what the physician has told her about plastic surgery

c. Encouraging her to express her feelings Rationale: For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must emphasize not only the infant's physical needs, but also the parents' emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurse's actions should convey to the parents that the infant is a previous human being. The nurse emphasizes the child's normalcy and helps the mother recognize the child's uniqueness.

A 10-year old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. An abdominal ultrasound is scheduled, and a blood count has been obtained. The child vomits, finds the pain relieved, and calls the nurse. Which should be the nurse's next action? a. Prepare for the probably discharge of the patient b. Cancel the ultrasound and prepare for administration of an intravenous bolus c. Immediately notify the health-care provider of the child's status d. Cancel the ultrasound and obtain an order for oral ondansetron (Zofran)

c. Immediately notify the health-care provider of the child's status Rationale: The health-care provider should be notified immediately, because a sudden change or loss of pain often indicates a perforated appendix. The nurse would not cancel the ultrasound or any diagnostic tests without an order from the health-care provider, but should get the ultrasound done as medical emergency, place child in NPO status because surgery is imminent. Discharge would not occur due to possible perforated appendix.

Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease. What enema solution should be used? a. Phosphate preparation b. Tap water c. Normal saline d. Oil retention

c. Normal Saline Rationale: Isotonic solutions should be used in chidlren. Saline is the solution of choice. Plain water is not used. This is a hypotonis olution and can cause rapid fluid shift, resulting in fluid overload. Oil retention enemas will not achieve the "until clear" result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis.

A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurse's response should be based on what knowledge about this drug? a. Indicated because it slows intestinal motility b. Indicated because it decreases fluid and electrolyte losses c. Not indicated for this disease process or age group d. Indicated because it decreases diarrhea

c. Not indicated for this disease process or age group Rationale: Antidiarrheal medications are not recommended for the treatment of acute infectinous diarrhea. These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and dehydration. Antidiarrheal medicatinos are not recommended in infants and small children.

A 4-month old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child whas bronchiolitis and needs to be hospitalized for observation and treatment. While assessing the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion? a. Fine crackles on deep inspiration b. Wheezing cough c. Sudden absence of breath sounds d. Intercostal retractions

c. Sudden absence of breath sounds Rationale: A sudden absence of breath sounds occurs when bronchioles become obstructed and respiratory failure is imminent. A wheezing cough is a common manifestation of bronchiolitis and is caused by the passage of air through the narrowed airways; it does not hearld respiratory failure. Intercostal retractions occur with mild and moderate respiratory distress in infants. Fine crackles are a routine occurrence with bronchiolitis, not a sign of respiratory failure.

An 18-month old child is seen in the clinic with Acute Otitis Media (AOM). Trimethoprim-sulfamethoxazole (Bactrim) is prescribed. Which statement made by the parent indicates a correct understanding of the instructions? a. "I should continue medication until the symptoms subside." b. "I will immediately stop giving medication if I notice a change in hearing." c. "I will stop giving medication if fever is still present in 24 hours." d. "I should administer all the prescribed medication."

d. "I should administer all the prescribed medication." Rationale: Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics should continue to be given. Medication may take 24 to 48 hours to make symptoms subside. It should be continued.

What assessment finding in a newborn is suggestive of cystic fibrosis (CF)? a. Excessive crying b. Sternal retractions c. Rapid heart rate d. Abdominal distention

d. Abdominal distention Rationale: Meconium ileus is an indication that a newborn may have cystic fibrosis. The small intestine is blocked with thick, tenacious, mucilaginous meconium, usually near the ileocecal valve. This causes intestinal obstruction with abdominal distention, vomiting, and fluid and electrolyte imbalance. Rapid heart rate is not a sign of cystic fibrosis in the newborn. Excessive crying does not have special significance in cystic fibrosis. Sternal retractions are not a sign of cystic fibrosis in the newborn.

The nurse is caring for a child admitted with acute abdominal pain and possible appendicits. Which is appropriate to relieve the abdominal discomfort? a. Administer a saline enema to cleanse bowel b. Place in Trendelenburg position c. Apply moist heat to the abdomen d. Allow to assume position of comfort

d. Allow to assume position of comfort Rationale: The child should be alloed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and crease the risk of perforation.

Which is an approriate nursing intervention when caring for an infant with an upper respiratory tract infection and elevated temperature? a. Give tepid water baths to reduce fever. b. Have child wear heavy clothing to prevent chilling. c. Encourage food intake to maintain caloric needs. d. Give small amounts of favorite fluids frequently to prevent dehydration.

d. Give small amounts of favorite fluids frequently to prevent dehydration. Rationale: Preventing dehydration by small frequent feedings is an important intervention in the febrile child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may result in the child vomiting. The febrile child should be dressed in light, loose clothing.

Which physical findings would be of most concern in an infant with respiratory distress? a. Tachypnea b. Wheezing c. Mild retractions d. Grunting

d. Grunting Rationale: Grunting is a sign of impending respiratory failure and is a very concerning physical finding. Tachypnea, retractions, and wheezing should be monitored closely, as possibly occurring with respiratory distress events.

How does the nurse interpret the laboratory analysis of a stool sample containing excessive amounts of azotorrhea and steatorrhea in a child with cystic fibrosis (CF)? a. Eating too many foods high in fiber b. Eating too many foods high in fat c. Not compliant with taking her vitamins d. Not compliant with taking her enzymes

d. Not compliant with taking her enzymes Rationale: If the child is not taking enzymes, the result would be a large amount of undigested foods, azotorrhea, and steatorrhea in the stool. Pancreatic ducts in clients with CF become glogged with thick mucus that blocks the flow of digestive enzymes from the pancreas to the duodenum. Therefore, clients must take digestive enzymes with all meals and snacks to aid in absorption of nutrients. Often, teens are noncompliant with their medication regimen because they want to be like their peers.