N328 Exam 2 Practice Questions

A nurse is caring for a 6-week-old infant client who was admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following nurse assessments is consistent with this diagnosis? A. Distended abdomen B. Effortless regurgitation C. Projectile vomiting D. Metabolic acidosis

C. Projectile vomiting Rationale: Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine, which does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.

A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis

C. Recent episode of gastroenteritis

A nurse is caring for a child in the postoperative period following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to blow her nose gently B. Administer analgesics on a schedule C. Offer orange juice D. Position the child supine

B. Administer analgesics on a schedule

A nurse is providing discharge teaching for 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

B. Administer pancreatic enzymes with meals and snacks

A nurse is teaching a group of parents about Salmonella. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Incubation period is nonspecific B. It is a bacterial infection C. Bloody diarrhea is common D. Transmission can be from house pets E. Antibiotics are used for treatment

B. It is a bacterial infection C. Bloody diarrhea is common D. Transmission can be from house pets

A nurse is caring for a child who has increased ICP. Which of the following actions should the nurse take? (Select all that apply.) A. Suction the endotracheal tube every 2 hr B. Maintain a quiet environment C. Use two pillows to elevate the head D. Administer a stool softener E. Maintain body alignment

B. Maintain a quiet environment D. Administer a stool softener E. Maintain body alignment

A complication seen shortly after birth which is indicative of cystic fibrosis in a newborn is... A. Insulin dependent diabetes B. Meconium ileus C. Neonatal sepsis D. Meconium aspiration pneumonia

B. Meconium ileus

Nursing care of a 9-month-old who has recently undergone cleft palate repair can be expected to include feeding with a(n): A. Plastic spoon B. Open cup C. Pigeon bottle D. Special Needs feeder

B. Open cup

A nurse is caring for a child that is having a tonic-clonic seizure and vomiting. Which of the following is the priority nursing action? A. Place a pillow under the child's head. B. Position the child side-lying. C. Loosen restrictive clothing. D. Clear the area of hazards.

B. Position the child side-lying. Rationale: To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse is assessing an infant who has possible cerebral palsy. Which of the following manifestations of cerebral palsy should the nurse expect to find? A. Tracks an object in surroundings with eyes. B. Sits with pillow props at eight months. C. Smiles when mother appears at three months. D. Uses pincher grasp to pick up a toy.

B. Sits with pillow props at eight months.

The mother of a 20 month old boy tells the nurse that he has a barking cough at night. His temperature is 37C, and the nurse suspects croup. What should she recommend? A. Control fever with acetaminophen and call if cough gets worse at night B. Try a cool-mist vaporizer at night and watch for signs of breathing difficulties C. Try OTC cough medicine and come to the clinic tomorrow if there is no improvement D. Admit to the hospital and observe for impending epiglottitis

B. Try a cool-mist vaporizer at night and watch for signs of breathing difficulties

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse? A. A child who has frequent visitors B. A child who has a BMI indicating obesity C. A child who uses the call light frequently D. A child whose parents answer questions for the child

D. A child whose parents answer questions for the child Rationale: Often the perpetrator of abuse is controlling and will talk for the child to avoid the risk of the child saying something that could expose the abuse. A school-age child should be able to answer most questions. The nurse should gather information when the parents are absent and to determine if the child interacts differently.

A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first? A. Fluticasone (Flovent) B. Budesonide (Pulmicort) C. Montelukast (Singulair) D. Albuterol (Proventil)

D. Albuterol (Proventil)

A child with asthma is having pulmonary function tests. Which explains the purpose of the peak expiratory flow rate (PEFR)? A. Confirm diagnosis of asthma B. Determine cause of asthma C. Identify "triggers" of asthma D. Assess severity of asthma

D. Assess severity of asthma

The child is diagnosed with meningitis. The PNP is performing a spinal tap. What results from CSF fluid would be indicative of meningitis? A. Clear CSF and high protein B. Low protein and low glucose C. No WBC in the gram stain and cloudy CSF D. Cloudy CSF and many WBC in the gram stain

D. Cloudy CSF and many WBC in the gram stain

A nurse is assessing a child after a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage? A. Increased pain B. Poor fluid intake C. Drooling D. Continuous swallowing

D. Continuous swallowing

You are caring for a child with hydrocephalus who is postoperative from a shunt revision. Which assessment finding is your priority for increased intercranial pressure? A. Nausea and refusal to eat postoperatively B. Complaint of a headache C. Irritability and wanting to sleep D. Decrease in heart rate over the last hour

D. Decrease in heart rate over the last hour

A nurse is assessing a 4 month old infant who has meningitis. Which of the following manifestations should the nurse expect? A. Depressed anterior fontanel B. Constipation C. Presence of the rooting reflex D. High-pitched cry

D. High-pitched cry

A nurse is caring or an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. Which of the following disorders does the infant have? A. Encopresis B. Enterocolitis C. Pyloric stenosis D. Hirschsprung disease

D. Hirschsprung disease

The parents of a 7 year old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2C (102.2F), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority? A. Insert an IV catheter. B. Obtain culture specimens. C. Administer an antipyretic. D. Prepare for intubation.

D. Prepare for intubation. Rationale: The client's signs and symptoms suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the nurse must prepare for intubation to maintain airway patency.

Which of the following is an example of a neural tube defect? A. Cerebral palsy B. Hydrocephalus C. Muscular dystrophy D. Spina bifida

D. Spina bifida

A 6 month old infant is experiencing acute respiratory distress secondary to RSV bronchiolitis. The infant is NPO. What is the rationale for the infant's NPO status? A. Hypoxia reduces gastrointestinal peristalsis B. Milk and formula increase mucous production C. Bronchial irritation will cause vomiting D. Tachypnea predisposes an infant to aspiration

D. Tachypnea predisposes an infant to aspiration

A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity? A. Increased BP B. Hyperventilation C. Decreased PaCO2 D. Unconsciousness

D. Unconsciousness

A parent is concerned that her 5 year old child may be exhibiting regression behaviors. The nurse should know the behavior that indicates regression is... A. cuddling a threadbare blanket at bedtime. B. crying when mother leaves. C. eating only food from home. D. bedwetting several times a day.

D. bedwetting several times a day.

A nurse is teaching the mother of a 5 year old child with CF about pancreatic enzymes. The nurse understands that further teaching is needed when the mother states which of the following? A. "I will give my son the enzymes between meals." B. "The enzymes probably won't cause a lot of side effects." C. "The enzymes help him digest fat." D. "I will put the enzyme crystals in his applesauce."

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

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula rather than breastmilk." D. "I should position my baby side-lying during sleep."

A. "I will keep my baby in an upright position after feedings."

A 4 year old child who has croup is admitted to the hospital and wets the bed overnight. When the parent comes to visit the next day, the nurse explains the situation and the parent says, "My child never wets the bed at home. I am so embarrassed." Which of the following is an appropriate response by the nurse? A. "It is normal for hospitalized children to regress. The toileting skills will return when your child is feeling better." B. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." C. "Your child did not seem upset, so I wouldn't worry about it if I were you." D. "I will discuss your child's loss of bladder control with the physician, as this may require further investigation."

A. "It is normal for hospitalized children to regress. The toileting skills will return when your child is feeling better."

A nurse is assessing a child who has epiglottitis. Which of the following findings should the nurse expect? (Select all that apply.) A. Hoarseness and difficulty speaking B. Difficulty swallowing C. Low-grade fever D. Drooling E. Dry, barking cough F. Stridor

A. Hoarseness and difficulty speaking B. Difficulty swallowing D. Drooling F. Stridor

A nurse is teaching a group of caregivers about E. Coli. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Severe abdominal cramping occurs B. Watery diarrhea is present for more than 5 days C. It can lead to hemolytic uremic syndrome D. It is a food borne pathogen E. Antibiotics are given for treatment

A. Severe abdominal cramping occurs C. It can lead to hemolytic uremic syndrome D. It is a food borne pathogen

A nurse is teaching an adolescent to self-administer a corticosteroid medication using a metered-dose inhaler (MDI). Which of the following instructions should the nurse include? (Select all that apply.) A. Shake the device prior to use B. Rinse and expectorate after administration C. Inhale slowly with medication administration D. Exhale quickly after medication administration E. Wait 30 seconds between puffs

A. Shake the device prior to use B. Rinse and expectorate after administration C. Inhale slowly with medication administration

A nurse is caring for a 6 year old child who is admitted with possible acute appendicitis. Which of the following manifestations should indicate to the nurse that the client's condition is becoming worse? A. Sudden decrease in abdominal pain B. Diarrhea and vomiting C. Loss of appetite D. Increase in fever

A. Sudden decrease in abdominal pain Rationale: A sudden decrease in abdominal pain may indicate that the appendix has ruptured. If the appendix ruptures, the pain may disappear for a short period and the client may feel suddenly better. However, once peritonitis sets in, the pain returns and may spread to involve the whole abdomen.

A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will the nurse prepare the child for to confirm the diagnosis? A. Sweat chloride test B. A sputum culture C. A stool fat content analysis D. Pulmonary function test

A. Sweat chloride test Rationale: Clients with cystic fibrosis have an increase of sodium and chloride in both saliva and sweat. Therefore, a sweat chloride test is a definitive diagnostic test to determine the diagnosis of cystic fibrosis.

An 8 year old child with an asthma exacerbation is receiving theophylline to relieve bronchospasm. The nurse observes the child for which of the following side effects? A. Tachycardia, agitation, vomiting B. Bradycardia, fatigue, increased BP C. Tachypnea, drowsiness, tachycardia D. Fluid retention, ataxia, decreased BP

A. Tachycardia, agitation, vomiting

You are working with a family that brought their child into the pediatric clinic. The mother describes what may be a type of seizure. What subjective data will help you determine the type? (Select all that apply.) A. The presence or absence of an aura B. If the child appeared disoriented after the seizure C. Presence of vomiting after the seizure D. The duration of the seizure E. If the seizure was related to certain foods or occurred after a certain activity

A. The presence or absence of an aura B. If the child appeared disoriented after the seizure D. The duration of the seizure

A nurse is admitting a child who has cystic fibrosis. Which of the following medications should the nurse to expect to include int he plan of care? (Select all that apply.) A. Tobramycin B. Loperamide C. Fat-soluble vitamins D. Albuterol E. Dornase alfa

A. Tobramycin C. Fat-soluble vitamins D. Albuterol E. Dornase alfa

Define the following: Inflammation of the small sac near the end of the cecum

appendicitis

Define the following: Constipation with fecal soiling

encopresis

Define the following: Telescoping of intestine into itself

intussusception

Define the following: Immunologic, chronic malabsorption disease characterized by intolerance to gluten, a protein found in wheat, barley, and oats

celiac

Define the following: Most common pediatric craniofacial malformation

cleft lip

A nurse is assessing 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 mucus membranes C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger

A. Projectile vomiting B. Dry mucus membranes E. Constant hunger

A 2 month old infant has just undergone repair of a cleft lip and palate. The surgeon prescribes restraints. The nurse should apply which of the following types of restraints for this infant? A. Elbow B. Mummy C. Wrist D. Jacket

A. Elbow Rationale: It is essential to apply elbow restraints immediately after surgery to keep the infant from rubbing the operative site. The nurse should remove them periodically to inspect the skin and allow the infant arm exercise.

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Position the child in a side-lying position B. Try to determine the seizure trigger C. Reorient the child to the environment D. Note the time of the postictal period

A. Position the child in a side-lying position

Define the following: Abdominal contents herniate through umbilical ring; usually with an intact peritoneal sac

omphalocele

A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate B. Encourage the child to take deep breaths C. Ensure proper placement of the sensor probe D. Place the child in the Fowler's position

C. Ensure proper placement of the sensor probe

Cystic fibrosis may affect singular or multiple systems of the body. The primary factor responsible for multiple clinical manifestations is: A. atrophic changes in mucosal wall of intestines B. hypoactivity of autonomic nervous system C. hyperactivity of sweat glands D. mechanical obstruction caused by increased viscosity of mucous gland secretions

D. mechanical obstruction caused by increased viscosity of mucous gland secretions

A 4 month old infant has a tonic clonic seizure. It is important during this time for the nurse to do the following interventions: A. Time and observe the infant's reactions B. Place an oral airway during the infant's seizure C. Administer anticonvulsants as ordered D. Restrain the infant E. Both A and C

E. Both A and C

Define the following: The abbreviated name of the condition caused by the dysfunction of the lower esophageal sphincter and delay in gastric emptying

GER (gastroesophageal reflux)

Define the following: An appliance to prevent cleft lip suture line tension

Logan bow

Define the following: Most common pediatric liver disease necessitating liver transplantation

biliary atresia

Define the following: Hirschsprung's Disease is also known as Congenital Aganglionic _______

megacolon

A 6 year old child is admitted with complaints of fever, headache, lethargy, nuchal rigidity, (+) Brudzinski sign, and (+) Kernig sign. These symptoms are associated with what condition? A. Myelomeningocele B. Meningitis C. Intracranial hemorrhage D. Increase intracranial pressure

B. Meningitis

A 3-month-old infant is seen in the clinic with the following symptoms: irritability, crying, refusal to nurse for more than 2 to 3 minutes, rhinitis, and a rectal temperature of 101.8°F (38.8°C). The labor, delivery, and postpartum history for this term infant is unremarkable. The nurse anticipates a diagnosis of: A. Acute otitis media (AOM) B. Otitis media with effusion (OME) C. Otitis externa D. Respiratory syncitial virus (RSV)

A. Acute otitis media (AOM)

A parent tells a nurse that his 2 month old infant was well until 2 weeks ago, when the infant began spitting up after eating. "Now the vomit practically shoots across the room. After my baby vomits, she cries and acts very hungry." The appropriate response by the nurse is which of the following? A. "You should bring your infant in to the clinic today to be seen." B. "You need to burp your baby more frequently during feedings." C. "You should give your infant an oral rehydrating solution." D. "You might want to try switching to a different formula."

A. "You should bring your infant in to the clinic today to be seen." Rationale: The symptoms of worsening projectile vomiting, which began at about 6 weeks of age, and the child acting hungry afterward, are characteristic of pyloric stenosis. The baby needs to be examined in the clinic by the provider as soon as possible.

A nurse is providing teaching to the guardians of a child who is to have an electroencephalogram (EEG). Which of the following statements, by a guardian, indicates teaching was effective? A. "My child should remain quiet and still during this procedure." B. "I cannot wash my child's hair prior to the procedure." C. "I should not give my child anything to eat prior to the procedure." D. "This procedure will be very painful for my child."

A. "My child should remain quiet and still during this procedure."

A nurse is caring for a 7 year old client who has a diagnosis of upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction? A. "I will encourage drinking a half a cup of water or sugar-free fluids every 30 minutes." B. "I will report a change in breathing or any signs of confusion." C. "I will notify the doctor if the temperature is not controlled with acetaminophen." D. "I will continue to check his blood sugar two times a day."

D. "I will continue to check his blood sugar two times a day."

Define the following: Developmental failure of the esophagus as a continuous passage to the stomach

esophageal atresia

A nurse is caring for a 6 month old who is postoperative following a myringotomy. Which of the following is an appropriate method to determine the infant's pain level? A. FLACC pain scale B. OUCHER pain scale C. Faces pain scale D. Visual analog pain scale

A. FLACC pain scale

A nurse is teaching a child who has asthma how to use a peak flow meter. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Zero the meter before each use B. Record the average of the attempts C. Perform three attempts D. Deliver a long, slow breath into the meter E. Sit in a chair with feet on the floor

A. Zero the meter before each use C. Perform three attempts

The parent of a child with cystic fibrosis calls the clinic to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic, because these symptoms are suggestive of: A. pneumothorax B. bronchodilation C. carbon dioxide retention D. increased viscosity of sputum

A. pneumothorax

A nurse is developing an educational program about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all that apply.) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)

B. Pneumococcal conjugate vaccine (PCV) D. Haemophilus influenzae type B (Hib) vaccine

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

B. Prepare the family for surgery

Because the absorption of fat-soluble vitamins is decreased in cystic fibrosis, supplementation of which vitamins is necessary? A. C and D B. A, E, and K C. A, D, E, and K D. C and folic acid

C. A, D, E, and K

A 7 month old infant is brought into the ER for injuries stemming from a bookcase falling on her immediately prior to arrival to the hospital. The parents reported the child was pulling herself up using the bookcase when it toppled over. Which clinical findings would lead the nurse to suspect child maltreatment? (Select all that apply.) A. Crying B. Hugging the mother tightly. C. Spiral Fracture of the leg D. A yellow color bruise on the buttock

C. Spiral Fracture of the leg D. A yellow color bruise on the buttock

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child? A. "I promise I won't tell anyone about this." B. "Let's discuss what happened with your family." C. "Your family is bad for doing this to you." D. "It is not your fault that this happened."

D. "It is not your fault that this happened."

One of the goals for children with asthma is to prevent respiratory infection. This is because respiratory infection: A. lessens effectiveness of medications B. encourages exercise-induced asthma C. increases sensitivity to allergens D. can trigger an episode or aggravate asthmatic state

D. can trigger an episode or aggravate asthmatic state

A nurse is expecting delivery of a myelomeningocele. The nurse is aware that this defect, in comparison to a meningocele, will have the following... A.An open sac over the lumbar area B. Lower extremity paralysis C. Infections of the spinal fluid

B. Lower extremity paralysis

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (Select all that apply.) A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects D. Falling to the floor E. Having a piercing cry

A. Loss of consciousness B. Appearance of daydreaming C. Dropping held objects

A 6 month old infant has had surgery to correct intussusception. The surgeon has prescribed clear liquids by mouth. The nurse correctly administers which of the following? A. Oral electrolyte solution B. Half-strength infant formula C. Full-strength orange juice D. Sterile water

A. Oral electrolyte solution

Because children with celiac disease must limit their intake of products containing gluten in wheat, rye, oats, and barley, they are at risk for which of the following nutritional deficiencies? (Select all that apply.) A. Iron deficiency anemia B. Folic acid deficiency C. Zinc deficiency D. Vitamin A, D, E, and K deficiency E. Vitamin B12 deficiency

A. Iron deficiency anemia B. Folic acid deficiency D. Vitamin A, D, E, and K deficiency

A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after initial diagnosis and treatment. The nurse should recognize that the parent understands the child's nutritional needs when she states which of the following? A. "I will make certain that pancreatic enzymes are taken with all of my child's snacks and meals." B. "I will restrict the amount of salt in my child's food." C. "I will limit my child's fluid intake." D. "I will prepare low-fat meals for my child."

A. "I will make certain that pancreatic enzymes are taken with all of my child's snacks and meals." Rationale: CF interferes with the availability of pancreatic enzymes necessary for normal digestion and absorption of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks.

A nurse is performing an assessment on a 4 month old admitted with r/o hydrocephalus and possible placement of a v/p shunt. The nurse would be correct in performing the following assessments of the infant. (Select all that apply.) A. monitor for a bulging or full anterior fontanel B. monitor for high pitch cry C. monitor for pedal edema D. monitor for a headache

A. monitor for a bulging or full anterior fontanel B. monitor for high pitch cry Rationale: The nurse should assess for signs and symptoms of increased ICP.

A newborn is being delivered with a known myelomeningocele. The nurse attending the delivery will perform the following activities. (Select all that apply) A. sterile saline and gauze dressings B. latex free environment C. nasogastric tube to straight drainage D. lay the child supine or side lying position E. establish IV access and administer antibiotics F. rectal temperature

A. sterile saline and gauze dressings B. latex free environment E. establish IV access and administer antibiotics

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take? A. Report the suspected abuse to the authorities. B. Obtain a detailed history. C. Ask a psychiatrist to talk with the parents. D. Separate the child from the parents.

B. Obtain a detailed history. Rationale: The nurse should obtain a detailed history in order to assess for other indicators of abuse.

A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? (Select all that apply.) A. Administer oral prednisone B. Initiate chest percussion and postural drainage C. Administer humidified oxygen D. Suction the nasopharynx as needed E. Administer oral penicillin

C. Administer humidified oxygen D. Suction the nasopharynx as needed

Define the following: Manifested by visible L > R peristalsis, FTT, possible olive-shaped mass

pyloric stenosis

A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These findings are associated with which of the following diagnoses? A. Influenza B. Bronchiolitis C. Croup D. Epiglottitis

B. Bronchiolitis

Diagnosis of cystic fibrosis includes which of the following? A. A positive quantitative sweat chloride test B. Positive blood culture C. Urinalysis demonstrating urinary casts D. Stool guiac demonstrating occult blood

A. A positive quantitative sweat chloride test

A nurse is caring for a child diagnosed with pertussis. The nurse should respond with which of the following when asked by the parent what the common name for this disorder is? A. Chickenpox B. Whooping cough C. Mumps D. Fifth disease

B. Whooping cough

Which of the following assessment findings in a 9 month old diagnosed with spasmodic croup is an indication of a potential complication? A. RR 69, HR 167 B. Respiratory distress is worse at night than during the day C. Occasional crowing-type inspirations can be heard D. Barking cough alternates with a brassy, nonproductive cough

A. RR 69, HR 167 Rationale: These vitals indicated increased respiratory distress. Normal RR and HR for a 9 month old are ~30 and 80-150, respectively.

A 3 year child admitted to the peds floor for seizure control has a generalized tonic - clonic seizure. The first initial action the nurse should perform is the following.. A. Place child on his side and assess the child B. Take off the child's clothes and administer oxygen C. Hold the child down and try to communicate with the patient

A. Place child on his side and assess the child

A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A. Place the client on NPO status B. Prepare the client for a liver biopsy C. Position the client dorsal recumbent D. Put the client in a protective environment

A. Place the client on NPO status Rationale: Place the client on NPO status due to the client's decreased level of consciousness to prevent aspiration.

A nurse is assessing a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply.) A. Fever B. Vomiting C. Watery stools D. Bloody stools E. Confusion

A. Fever B. Vomiting C. Watery stools

A nurse is in the emergency department is assessing a child following a motor-vehicle crash. The child is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following actions should the nurse take first? A. Stabilize the child's neck B. Clean the child's laceration with soap and water C. Implement seizure precautions for the child D. Initiate IV access for the child

A. Stabilize the child's neck

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 blood levels of fat-soluble vitamins C. 72 hr stool analysis sample indicating hard, packed stools D. Chest x-ray negative for atelectasis

A. Sweat chloride content 85 mEq/L

A nurse is caring for a child who is diagnosed with otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear

A. Tugging on the affected ear lobe Rationale: Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (only if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear. Pain when manipulating the ear lobe is the classic sign of otitis externa, swimmer's ear. Swimmer's ear is also associated with erythema and edema of the affected ear. Clear drainage from the ear is more commonly associated with CSF drainage.

A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (Select all that apply.) A. Instruct the child that the treatment will last 30 min B. Obtain vital signs prior to the procedure C. Tell the child to take slow deep breaths D. Determine if the child should use a mask E. Attach the device to an air source

B. Obtain vital signs prior to the procedure C. Tell the child to take slow deep breaths D. Determine if the child should use a mask E. Attach the device to an air source

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 swallowing, 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. Group A β-hemolytic streptococcus (GABHS) pharyngitis B. Acute tracheitis C. Acute epiglottitis D. Acute laryngotracheobronchitis

C. Acute epiglottitis

A nurse is caring for an infant who is 24 hr postoperative following a cleft palate repair. Which of the following is an appropriate action by the nurse? A. Providing feedings with a rubber-tipped syringe. B. Suctioning the nasopharynx frequently. C. Administering opioids for pain. D. Changing the oral packing every 6 hr.

C. Administering opioids for pain.

A nurse is caring for a preschool age child who has epiglottitis with a barking cough. Which of the following is an appropriate nursing action? A. Encourage coughing. B. Attempt to obtain a throat culture. C. Visualize the back of the throat. D. Apply oxygen.

D. Apply oxygen. Rationale: Applying high-flow oxygen on the client and keeping the client calm is an appropriate action by the nurse to improve oxygenation. The other three actions may precipitate a complete obstruction.

You are the nurse assigned to care for a child with a basilar skull fracture. Your most important nursing observation is change in level of consciousness. You will be highly alert for: A. Alterations in vital signs that often appear before alterations in consciousness or focal neurologic signs B. Bleeding from the ear, which is indicative of an anterior basal skull fracture C. Seizures that are relatively uncommon in children at the time of head injury D. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement

D. Changes in posturing, such as any signs of extension or flexion posturing, unusual response to stimuli, and random versus purposeful movement

When assessing a child's injury in the emergency department, a nurse suspects physical abuse. Based on this suspicion, the nurse's primary legal responsibility is to: A. Assist the family in identifying resources for support B. Report the case in which the abuse is suspected to the local authorities C. Document the child's physical assessment findings accurately and thoroughly D. Refer the family to the hospital support group

B. Report the case in which the abuse is suspected to the local authorities

Which nursing intervention is most helpful to parents of a neonate with bilateral cleft lip? A. Assure the parents that the correction will be immediate and uncomplicated. B. Show the parents "before-and-after" pictures of an infant whose cleft lip has been successfully repaired. C. Teach the parents about long-term enteral feedings. D. Refer parents to a community agency.

B. Show the parents "before-and-after" pictures of an infant whose cleft lip has been successfully repaired.

A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.) A. Oxygen saturation 95% B. Wheezing C. Retraction of sternal muscles D. Warm extremities E. Nasal flaring

B. Wheezing C. Retraction of sternal muscles E. Nasal flaring

A nurse is preparing a 4 year old client for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions? A. Gently reinsert the tubes. B. Take the child to the emergency department. C. Call the health care clinic to report that the tubes have fallen out. D. Reassure the mother that the tubes will not fall out.

C. Call the health care clinic to report that the tubes have fallen out.

A nurse in a community center is providing an in-service to a group of parents on management of airway obstructions in toddlers. Which of the following responses by one of the caregivers indicates understanding? (Select all that apply.) A. "I will push on my child's abdomen." B. "I will hyperextend my child's head to open the airway." C. "I will listen over my child's mouth for sounds of breathing." D. "I will use my finger to check my child's mouth for objects." E. "I will place my child in my care and take them to the closest emergency facility."

A. "I will push on my child's abdomen." C. "I will listen over my child's mouth for sounds of breathing."

A nurse is caring for 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 and blood in stools D. Vomiting E. Rapid, shallow breathing

A. Abdominal pain C. Mucus and blood in stools

Apnea of infancy has been diagnosed in an infant who will soon be discharged with home monitoring. Which information should the nurse include when teaching the parents about the infant's care? A. Cardiopulmonary resuscitation B. Administration of intravenous fluids C. Reassurance that the infant cannot be electrocuted during monitoring D. Advice that the infant not be left with other caretakers, such as babysitters

A. Cardiopulmonary resuscitation

When child abuse is suspected, the nurse's initial assessment should include: A. Gathering information from many sources to determine how the injury occurred B. Talking with the parents only about the injury C. Looking for risk factors of abuse to confirm suspicions D. Making sure the parents are aware that abuse is suspected

A. Gathering information from many sources to determine how the injury occurred

A 5-year-old is recovering from a tonsillectomy and adenoidectomy and is being discharged home with his mother. Home care instructions should include which of the following? (Select all that apply.) A. Observe the child for continuous swallowing. B. Encourage the child to take sips of cool, clear liquids. C. Administer codeine elixir as necessary for throat pain. D. Observe the child for restlessness or difficulty breathing. E. Encourage the child to cough every 4 to 5 hours to prevent pneumonia. F. Administer an analgesic such as acetaminophen for pain.

A. Observe the child for continuous swallowing. B. Encourage the child to take sips of cool, clear liquids. D. Observe the child for restlessness or difficulty breathing. F. Administer an analgesic such as acetaminophen for pain.

A nurse is teaching a parent of an infant about gastrointestinal reflux disease. Which of the following should the nurse include in the teaching? (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 baby upright after feedings E. Use a wide-based nipple for feedings

A. Offer frequent feedings B. Thicken formula with rice cereal D. Position baby upright after feedings

A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? A. Perform a tape test B. Collect stool specimen for culture C. Test the stool for occult blood D. Initiate IV fluids

A. Perform a tape test

An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to: A. Prevent RSV infection B. Make isolation of infant with RSV unnecessary C. Prevent secondary bacterial infection D. Decrease toxicity of antiviral agents

A. Prevent RSV infection

A nurse is caring for an infant who has manifestations of acute otitis media. Which of the following factors places the infant at risk for otitis media? (Select all that apply.) A. Breastfeeds without formula supplementation B. Attends day care 4 days per week C. Immunizations are up to date D. History of a cleft palate repair E. Parents smoke cigarettes outside

B. Attends day care 4 days per week D. History of a cleft palate repair E. Parents smoke cigarettes outside

A 12-year-old child is in the urgent care clinic with a complaint of fever, headache, and sore throat. A diagnosis of group A β-hemolytic streptococcus (GABHS) pharyngitis is established with a rapid-strep test, and oral penicillin is prescribed. The nurse knows that which of the following statements about GABHS is correct? A. Children with a GABHS infection are less likely to contract the illness again after the antibiotic regimen is completed. B. A follow-up throat culture is recommended after the completion of antibiotic therapy. C. Children with a GABHS infection are at increased risk for the development of rheumatic fever and glomerulonephritis. D. Children with a GABHS infection are at increased risk for the development of rheumatoid arthritis in adulthood.

C. Children with a GABHS infection are at increased risk for the development of rheumatic fever and glomerulonephritis.

A formerly preterm infant who had surgery for necrotizing enterocolitis is now 6 months old and has short-bowel syndrome. He is unable to absorb most nutrients taken by mouth and is totally dependent on parenteral nutrition, which he receives via a central venous catheter. The clinic nurse following this infant is aware that this infant should be closely observed for the development of: A. Gastroesophageal reflux B. Chronic diarrhea C. Cholestasis D. Failure to thrive

C. Cholestasis

The most common complication that should be anticipated and observed for in an infant with myelomeningocele after surgical repair of the defect is: A. Urinary stress B. Chiari malformation C. Hydrocephalus D. Latex allergy

C. Hydrocephalus

A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. Instructions for diet for this child should include: A. BRAT diet (bananas, rice, applesauce, and toast) for 24 hours, then a soft diet as tolerated B. Chicken or beef broth for 24 hours, then resume a soft diet C. Offer a regular diet as child's appetite warrants D. Keep on clear liquids and toast for 24 hours

C. Offer a regular diet as child's appetite warrants

Pancreatic enzymes are administered to a child with cystic fibrosis. Nursing considerations should include which of the following? A. Hold all pancreatic enzymes if child is concurrently receiving antibiotic therapy B. Decrease the dose of pancreatic enzymes if child is experiencing frequent, large stools C. Pancreatic enzyme capsules can be swallowed whole or sprinkled on food with meals D. Administer pancreatic enzyme capsules between meals if possible

C. Pancreatic enzyme capsules can be swallowed whole or sprinkled on food with meals

A nurse is caring for a toddler who has had three ear infections in the past 5 months. Which of the following long-term complications is the child at risk for developing? A. Balance difficulties B. Rash C. Speech delays D. Mastoiditis

C. Speech delays

Nursing care of a child in the hospital with suspected abuse should include which of the following actions? A. Assign a variety of nurses to the child so that he can get to know and trust the whole staff. B. Praise the child's ability to minimize feelings of shame and guilt. C. Treat the child as someone with a specific problem, not as an "abuse" victim, to promote self-esteem and minimize feelings of guilt. D. Talk with and ask questions as often as possible to show interest and get to know the child better.

C. Treat the child as someone with a specific problem, not as an "abuse" victim, to promote self-esteem and minimize feelings of guilt.

The nurse is caring for a 6 year old after surgery to remove tonsils and adenoids. Which of the following assessment findings would alert the nurse to a possible postoperative complication? A. Child refuses to wear an ice collar B. Child's pharyngeal secretions are brown-tinged C. Child requires analgesia every 4 hours for pain D. Child is swallowing while sleeping

D. Child is swallowing while sleeping

A 4 year old girl is brought to the emergency department. She has a "frog-like" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. What should the nurse do? A. Examine her oral pharynx and report to the physician B. Make her lie down and rest quietly C. Auscultate her lungs and make preparations for placement in a mist tent D. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation

D. Notify the physician immediately and be prepared to assist with a tracheostomy or intubation

A nurse is caring for a 12 month old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse suggest in order to meet the developmental needs of the client? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book

A. Large building blocks

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (Select all that apply.) A. Negative Gram stain B. Normal glucose content C. Cloudy color D. Decreased WBC count E. Normal protein content

A. Negative Gram stain B. Normal glucose content E. Normal protein content

A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis? A. Oral mucosa B. Finger tips C. Ear lobes D. Eye lids

A. Oral mucosa Rationale: The nurse should assess the oral mucosa as an indicator of cyanosis because changes can be seen easily in areas with less pigmentation.

A nurse on a pediatric unit is caring for a client who has a brain tumor. To ensure the client's safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. B. Limit contact with other pediatric clients. C. Initiate seizure precautions for the child. D. Have the child use a wheelchair for all out-of-bed activities.

C. Initiate seizure precautions for the child.

A nurse is assessing an 11 month old infant. Which of the following clinical manifestations is suggestive of a central nervous system infection? A. Oliguria B. Bulging fontanel C. Negative Brudzinski sign D. Jaundice

B. Bulging fontanel Rationale: A central nervous system infection causes increased intracranial pressure. Therefore, bulging fontanel is a clinical manifestation of a central nervous system infection. A positive Brudzinski sign is a clinical manifestation of a central nervous system infection.

A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the following findings should the nurse monitor for as an adverse effect of mannitol? A. Bradycardia B. Weight loss C. Confusion D. Constipation

C. Confusion

A nurse is preparing to begin chest compressions for an infant. The nurse should perform compressions using which of the following techniques? A. Deliver compressions at 1/3 to 1/2 the depth of the chest. B. Deliver compressions with the heel of one hand only. C. Deliver compressions just above the nipple line. D. Deliver compressions at a depth of 1 1/2 to 2 inches.

A. Deliver compressions at 1/3 to 1/2 the depth of the chest.

A nurse is discussing risk factors for asthma with a group of newly licensed nurses. Which of the following conditions should the nurse include in the teaching? (Select all that apply.) A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight E. Being underweight

A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight

A nurse is teaching a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low blood lead levels E. Presence of diphtheria

A. Febrile episodes B. Hypoglycemia C. Sodium imbalances

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A. "As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."

A. "As a nurse, I am required by law to report suspected child abuse."

A nurse in the emergency department is caring for a client who has epiglottitis. The child is crying, and the parents are concerned that their child has not had anything to eat or drink for several hours. They also have expressed a fear that their other children may contract the illness. Which of the following responses should the nurse give? A. "The influenza vaccine can protect your other children from epiglottitis." B. "Did you bring an item that will help comfort your child?" C. "The nurse practitioner will be in shortly to obtain a throat culture." D. "Your child can drink, but cannot have anything solid."

B. "Did you bring an item that will help comfort your child?"

A 2 month old infant has just undergone repair of a cleft lip and palate. The nurse should include which of the following interventions in the client's plan of care? A. Feed the infant half-strength formula for the first 48 hr. B. Apply and release elbow restraints every 2 hr. C. Keep the infant supine. D. Suction the nasopharynx periodically.

B. Apply and release elbow restraints every 2 hr. Rationale: It is essential to apply elbow restraints immediately after surgery to keep the infant from rubbing the operative site. The nurse should remove them periodically to inspect the skin and allow the infant arm exercise.

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.) A. Symptoms are continuous throughout the day. B. Daytime symptoms occur more than twice a week. C. Nighttime symptoms occur approximately twice a month. D. Minor limitations occur with normal activity. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

B. Daytime symptoms occur more than twice a week. D. Minor limitations occur with normal activity. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

A nurse is monitoring a child who has just had a tonsillectomy for signs of hemorrhage. Which of the following findings is a sign of this postoperative complication? A. Mouth breathing B. Frequent swallowing C. Reports of thirst D. Reports of pain

B. Frequent swallowing

A nurse is providing teaching to the parent of a child diagnosed with acute group A beta-hemolytic streptococci. Which of the following should the nurse include in the teaching? A. Avoid the use of warm compresses around the head or neck. B. Intramuscular injections will be required monthly. C. Replace the child's toothbrush after 24 hr on antibiotics. D. Keep the child home from school for at least 1 week.

C. Replace the child's toothbrush after 24 hr on antibiotics. Rationale: This is done to prevent the spread of infection or re-infection.

A nurse is providing teaching to the parent of a child diagnosed with celiac disease. The nurse should include which of the following as an acceptable food choice for this child? A. Barley B. Rye C. Rice D. Wheat

C. Rice

A nurse is orienting a newly licensed nurse in the care of an infant diagnosed with spina bifida (myelomeningocele). Which of the following actions by the new nurse indicates teaching has been effective? A. Performing range of motion on the hips B. Maintaining of a dry dressing over the myelomeningocele sac C. Taking an axillary temperature on the newborn D. Placing infant in a side-lying position

C. Taking an axillary temperature on the newborn Rationale: Infants should be place prone with myelomeningocele to avoid accidental rupture of the sac. Drying of the myelomeningocele should be prevented with the application of sterile, moist, nonadhesive dressings until surgical repair can be performed.

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse take to prevent aspiration? A. Place a bedside humidifier at the head of the client's bed. B. Suction the nasopharynx as needed. C. Withhold fluids until the client demonstrates a gag reflex. D. Perform chest physiotherapy (CPT).

C. Withhold fluids until the client demonstrates a gag reflex.

A nurse is caring for a toddler admitted with laryngotracheobronchitis who is placed in a cool mist tent. As a result of this treatment, the nurse expects to observe... A. barking cough. B. improved hydration. C. decreased stridor. D. decrease in fever.

C. decreased stridor. Rationale: Laryngotracheobronchitis, or croup, is a condition of breathing difficulty common in infants caused by infection of the upper airway (larynx, trachea, and bronchus) and characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The child's breathing becomes more difficult and requires increasing physical effort. The direct purpose of a cool mist tent is to humidify the inspired air, which will decrease the respiratory effort.

A nurse is teaching the parents of a child who has a streptococcal infection about preventing disease transmission. Which of the following instructions should the nurse include? A. "I'll continue to encourage him to drink lots of fluids." B. "I'll take his temperature every 4 hr." C. "I'll give him Tylenol for the pain." D. "I'll discard his toothbrush and buy another."

D. "I'll discard his toothbrush and buy another."

A nurse is teaching an assistive personnel to count respiration rate on a newborn. Which of the following statements indicates understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." B. "Newborns do not expand their lungs fully with each respiration." C. "Activity will increase the respiration rate." D. "The rate and rhythm are irregular in newborns."

D. "The rate and rhythm are irregular in newborns." Rationale: Abdominal breathing, varied labor of breathing, and activity increasing the respiratory rate have no impact on obtaining a respiratory rate.

A nurse is providing care or an infant following a surgical repair of a cleft lip. Which of the following actions should the nurse take to minimize the infant's crying? A. Rock the infant with a favorite blanket. B. Offer the infant a pacifier. C. Place the infant in a playpen at the nurses' station. D. Position the infant on the abdomen.

A. Rock the infant with a favorite blanket.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings are associated with this diagnosis? (Select all that apply.) A. Coughing B. Apnea C. Sunken abdomen D. Cyanosis E. Frothy saliva

A. Coughing B. Apnea D. Cyanosis E. Frothy saliva

To relieve thirst following a tonsillectomy, a nurse should offer a child which of the following? A. Orange ice pop B. Orange juice C. Ice cream D. Cranberry juice

A. Orange ice pop Rationale: Cold, clear liquids are well-tolerated following a tonsillectomy. Liquids that are brown or red should be avoided in order to tell the difference between the liquid and fresh or old blood. Acidic fluids should be avoided as they can be irritating to the throat. Dairy products should be avoided as they increase the viscosity of the mucus, causing the child to frequently clear her throat. This can lead to bleeding.

A nurse is caring for a hospitalized 4 year old child who is on airborne precautions. Which of the following activities is appropriate for the nurse to implement for this child? A. Putting a puzzle together B. Watching a video game in the playroom C. Pulling a wagon with toys in the hallway D. Constructing a model airplane

A. Putting a puzzle together

A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are indications of increased intracranial pressure (ICP)? (Select all that apply.) A. Report of headache B. Alteration in pupillary response C. Increased motor response D. Increased sleeping E. Increased sensory response

A. Report of headache B. Alteration in pupillary response D. Increased sleeping

A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer antibiotics when available. B. Reduce environmental stimuli. C. Document intake and output. D. Maintain seizure precautions.

A. Administer antibiotics when available. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness.

A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is 40C (104F). The father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate response by the nurse? A. "This is within the expected range for your baby." B. "The fever is causing an increase in your baby's heart rate." C. "As your baby begins to fall asleep, the heart rate will decrease." D. "Your baby's heart is beating fast in an attempt to cool down the body."

B. "The fever is causing an increase in your baby's heart rate." Rationale: The expected range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to 37.2° C (98.9° F). This infant has a fever. The infant's heart rate will increase as a result of the fever. The expected range for heart rate in an infant 3 months to 2 years old is 80-150/min while awake and 70-120/min while asleep. If the infant is active or has a fever, the heart rate may be as high as 220/min.

A nurse is planning care for a child with suspected epiglottitis. Which of the following is an appropriate action for the nurse to take? A. Obtain a throat culture. B. Place client in an upright position. C. Transfer for a throat x-ray. D. Visualize the epiglottis with a tongue depressor.

B. Place client in an upright position. Rationale: Placing the child in an upright position will assist in maintaining a patent airway and is an appropriate action for the nurse to take. Obtaining a throat culture on a child and attempting to visualize the throat with a tongue depressor with suspected epiglottitis could precipitate obstruction of the airway and should be avoided.

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse question? A. Maintain NPO status. B. Monitor oral temperature every 4 hr. C. Medicate the client for pain every 4 hr as needed. D. Administer sodium biphosphate/sodium phosphate (Fleet Enema) today.

D. Administer sodium biphosphate/sodium phosphate (Fleet Enema) today.

A nurse is teaching an adolescent about the appropriate use of his asthma medications. Which of the following medications should the nurse instruct the client to use as needed before exercise? A. Fluticasone/salmeterol B. Montelukast C. Prednisone D. Albuterol

D. Albuterol

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? A. Cromolyn (Intal) via metered-dose inhaler B. Oral montelukast (Singular) C. Budesonide (Pulmicort) via dry-powder inhaler D. Albuterol (Proventil) via jet nebulizer

D. Albuterol (Proventil) via jet nebulizer

A nurse is caring for a male infant admitted with a palpable mass in the upper right quadrant, and passage of stools mixed with blood and mucus. Which of the following diagnoses are these findings associated with? A. Tracheoesophageal fistula B. Inguinal hernia C. Hypertrophic pyloric stenosis D. Intussusception

D. Intussusception

A nurse is caring for a child who has just received a ventriculoperitoneal (VP) shunt. Which of the following should the nurse know is the appropriate position for this client? A. Dorsal recumbent B. On the operative side C. Prone D. Low Fowler's

D. Low Fowler's Rationale: A VP shunt is surgery performed to relieve intracranial pressure caused by hydrocephalus (enlargement of the ventricles of the brain with cerebrospinal fluid). Shunting is necessary to drain the excess fluid and relieve the pressure in the brain. Elevating the head of the bed 30 degrees in the immediate postoperative period helps to decrease swelling and pressure in the brain.

A nurse is caring for an infant who has gastroesophageal reflux. Which of the following findings are associated with this condition? (Select all that apply.) A. Vomiting B. Weight loss C. Rigid abdomen D. Wheezing E. Pallor

A. Vomiting B. Weight loss D. Wheezing

When caring for a child following a tonsillectomy, what should the nurse do? A. Watch for continuous swallowing B. Encourage gargling to reduce discomfort C. Position the child on the back for sleeping D. Apply warm compresses to the throat

A. Watch for continuous swallowing

A nurse is performing an admission assessment for 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. Wheezing B. Clubbing of fingers and toes C. Barrel-shaped chest

While performing an exam on a 7 month old infant, the nurse would suspect cerebral palsy in the following finding(s)? (Select all that apply.) A. tongue extrusion B. positive tonic neck reflex C. absence moro reflex D. no head lag- pull to sitting E. scissoring of legs in ventral suspension

A. tongue extrusion B. positive tonic neck reflex E. scissoring of legs in ventral suspension

Hepatitis A virus is transmitted by which of the following? (Select all that apply.) A. Breast milk from mother with HAV B. Ingestion of contaminated food C. Fecal-oral route D. Casual contact with infected person E. Blood transfusion

B. Ingestion of contaminated food C. Fecal-oral route

A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? A. Offer chicken broth B. Initiate oral rehydration therapy C. Start hypertonic IV solution D. Keep NPO until the diarrhea subsides

B. Initiate oral rehydration therapy

Define the following: Protrusion of an organ through an abnormal opening

hernia

A nurse is reviewing treatment options with the guardian of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (Select all that apply.) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection E. Radiation therapy

A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection

A 2-month-old formerly healthy infant born at term is seen in the urgent care clinic with intercostal retractions, respiratory rate of 62, heart rate of 128, refusal to breastfeed, abundant nasal secretions, and a pulse oximeter reading of 88% in room air. The diagnosis of respiratory syncytial virus is made. The infant's oxygen saturation remains 95% in room air, and the respiratory rate is 54, with intercostal retractions; heart rate is 120 beats per minute. After 2 hours of observation and an intravenous bolus of fluids, the infant is being discharged home. The nurse provides which of the following home care instructions for this infant? (Select all that apply.) A. Continue breastfeeding infant. B. Discontinue breastfeeding and administer Pedialyte for 24 hours. C. Observe infant for labored breathing or apnea (cessation of breathing). D. Instill normal saline drops in both nares and suction thoroughly before feeding and before placing to sleep. E. Place infant to sleep on his side with the head of bed slightly elevated to facilitate breathing. F. Keep the infant out of day care or nursery.

A. Continue breastfeeding infant. C. Observe infant for labored breathing or apnea (cessation of breathing). D. Instill normal saline drops in both nares and suction thoroughly before feeding and before placing to sleep. F. Keep the infant out of day care or nursery.

Which order should the nurse question when caring for a 5-year-old child after surgery for Hirschsprung's disease? A. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C. B. Assess stools after surgery. C. Keep the child NPO until bowel sounds return. D. Maintain IV fluids at ordered rate.

A. Monitor rectal temperature every 4 hours and report an elevation greater than 38.5° C.

A 4 year old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate breathing to use it effectively. The nurse should suggest that he use a: A. Spacer B. Nebulizer C. Peak expiratory flow meter D. Trial of chest physiotherapy

A. Spacer

You are working with a pediatric nurse who has just transferred to the pediatric clinic. You are role-playing phone triage related to a child with a head injury. You ascertain that the nurse needs more teaching based on what response? A. "After initial physical examination, if there was no loss of consciousness with the head injury, the child can be observed at home." B. "If there is a language barrier, written instructions can be given, followed by discharge." C. "Another physical examination should take place in 1 or 2 days." D. "Parents should call the doctor if their child has any of these signs: blurred vision, walking unsteadily, or is hard to awaken."

B. "If there is a language barrier, written instructions can be given, followed by discharge."

A premature infant with apnea of prematurity is being discharged from the hospital on an apnea monitor. Which statement by the parents demonstrates that they understand the discharge instructions? A. "If the baby stops breathing, I will call 911 and wait for them to arrive." B. "Rubbing the baby's back or feet may stimulate him to breathe." C. "If the baby stops breathing for 10 seconds, I'll start CPR." D. "The apnea monitor will stimulate the baby to breathe."

B. "Rubbing the baby's back or feet may stimulate him to breathe."

A nurse is caring for a toddler who has had rhinitis,, cough, and diarrhea for 2 days. Upon assessment, it is noted that the tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse to make? A. "Your child has an ear infection that requires antibiotics." B. "Your child could experience transient hearing loss." C. "Your child will need to be on a decongestant until this clears." D. "Your child will need to have a myringotomy."

B. "Your child could experience transient hearing loss."

A 5-month-old infant is seen in the well-child clinic for a complaint of vomiting and failure to grow. His birth weight was 7 lb, and he now weighs 8 lb, 10 oz. The infant's mother reports that he is taking 4 to 7 oz of formula every 4 to 5 hours, but he "spits up a lot after eating and then is hungry again." The child is noted to be alert but appears malnourished. The mother reports that his stools are brown in color, and he has 1 to 2 bowel movements every day. Based on these findings, the nurse anticipates the infant has: A. Meckel diverticulum B. Hypertrophic pyloric stenosis C. Intussusception D. Hirschprung disease

B. Hypertrophic pyloric stenosis

A child with the spina bifida is placed on a bowel program at the clinic. The nurse assigned to the patient knows this is a result of... A. Lack of mobility causes constipation B. Lack of innervations in the anal sphincter or colon causes incontinence or constipation C. Lack of mobility causes spasticity in the colon and results in constipation

B. Lack of innervations in the anal sphincter or colon causes incontinence or constipation

The nurse is caring for a 4 year old in the emergency room. The child is sitting quietly in be, leaning forward, and has a frightened look on his face. Epiglottitis is suspected, and the following medical orders are written. Which order should be questioned by the nurse? A. Give misted oxygen 6 LPM by face tent B. Obtain and send throat culture and sensitivity C. Insert IV and begin 35 mL/hr of D5 0.25NS D. Portable x-ray of lateral neck

B. Obtain and send throat culture and sensitivity

A nurse is caring for an infant who has just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take? A. Remove the packing in the mouth B. Place the infant in an upright position C. Offer a pacifier with sucrose D. Assess the mouth with a tongue blade

B. Place the infant in an upright position

A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? (Select all that apply.) A. Decreased pain in the supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying

B. Rolling head side to side C. Loss of appetite E. Crying

The nurse caring for a 4-month-old infant with biliary atresia and significant urticaria can anticipate administering: A. Diphenhydramine B. Ursodiol (ursodeoxycholic acid) C. Loratidine D. Zantac

B. Ursodiol (ursodeoxycholic acid)

A 2 year old child is hospitalized with acute laryngotracheobronchitis (viral croup syndrome). What is the most important nursing consideration in caring for this child? A. Administer antibiotics as ordered B. Prevent cross-contamination to other patients C. Prevent respiratory obstruction D. Provide psychological support

C. Prevent respiratory obstruction

A 7 year old girl falls from the jungle gym and lands on her head. The child is examined in the ER and is suspected to have an epidural hematoma. The nurse knows this disorder has the following characteristics: A. Slow onset venous bleed and Sx present a week later B. Slow onset arterial bleed and Sx present 48 hrs after the trauma C. Rapid onset arterial bleed and Sx present within minutes or hours after the trauma

C. Rapid onset arterial bleed and Sx present within minutes or hours after the trauma

As the nurse assigned to a child diagnosed with bacterial meningitis, you know that: A. The child will not need to be placed in isolation because antibiotics have been started B. Enteric precautions will remain in place for up to 48 hours C. Respiratory isolation will remain in place for 24 hours after antibiotics are started D. Due to headache, the child will want the head of the bed elevated with two pillows

C. Respiratory isolation will remain in place for 24 hours after antibiotics are started

A nurse is caring for a child who is experiencing respiratory distress. Which of the following findings are early manifestations of respiratory distress? (Select all that apply.) A. Bradypnea B. Peripheral cyanosis C. Tachycardia D. Diaphoresis E. Restlessness

C. Tachycardia D. Diaphoresis E. Restlessness

What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? A. Teach parents to position the infant on the left side. B. Reinforce the parents' knowledge of the infant's developmental needs. C. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). D. Have the parents keep an accurate record of intake and output.

C. Teach the parents how to do infant cardiopulmonary resuscitation (CPR).

What factor indicates that a child has a recently ruptured appendix? A. Abdominal pain shifts from the left to the right side. B. Vomiting and diarrhea become more intense. C. Elevated temperature decreases to normal. D. Abdominal pain is relieved.

D. Abdominal pain is relieved.

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support to the family B. Educate the family on care of the child C. Provide a diversional activity D. Administer analgesics

D. Administer analgesics

The nurse assesses the neonate immediately after birth. The presence of what symptom would cause a tracheoesophageal fistula to be suspected? A. Jaundice B. Oligohydramnios C. Absence of sucking D. Excessive amount of frothy saliva in the mouth

D. Excessive amount of frothy saliva in the mouth

A nurse is caring for a 6 month old infant. Which of the following findings should indicate to the nurse that the client is experiencing pain following a procedure? A. Decreased heart rate B. Decreased respiratory rate C. Increased formula consumption D. Increased crying episodes

D. Increased crying episodes

Define the following: Abbreviation of the life-threatening inflammatory disease of the intestinal tract that occurs primarily in premature, very low birth weight infants

NEC (necrotizing enterocolitis)

Define the following: Bowel herniates abdominal wall; peritoneal sac is not present

gastroschisis

Define the following: Inflammation of the liver, usually caused by a virus

hepatitis

A nurse is caring for a 4 year old client who just had abdominal surgery. Which of the following techniques should the nurse use to get the client to take deep breaths? A. "Let's play a game of blowing cotton balls across your table." B. "You can't go to the playroom until you finish doing your deep breathing." C. "I'll leave your blow bottle here on your table, so that you can use it yourself like a big boy." D. "I will give you a sticker each time you take a deep breath."

A. "Let's play a game of blowing cotton balls across your table." Rationale: By engaging the child in a form of play, the nurse may effectively distract him from the discomfort associated with deep breathing following abdominal surgery.

A nurse is reinforcing discharge teaching with the parents of a preterm 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? A. "We will rotate the probe of the pulse oximeter every 24 hours." B. "The probe of the pulse oximeter can be applied to a finger or a toe." C. "The pulse oximeter may not be accurate during times of excessive movement." D. "We will notify the doctor if the pulse oximeter consistently reads 100%."

A. "We will rotate the probe of the pulse oximeter every 24 hours." Rationale: Pulse oximeters are a noninvasive method of monitoring oxygen saturation (SaO2) of the blood. It is obtained by the application of a probe around the hand, foot, finger, toes, or earlobe, which is then connected to a machine that provides continuous oxygen saturation levels. The probe should be rotated every 3 to 4 hr to prevent pressure necrosis from occurring. Excessive movement, as well as heat and light, can interfere with the results. Due to the risk of oxygen toxicity, which is a particular concern with preterm infants, the parents should be instructed to notify the provider for consistent SaO2 readings over 95%. This may be an indication the infant is receiving too much oxygen and the amount should be decreased.

A nurse is assessing a child who has a concussion. Which of the following findings should the nurse expect? (Select all that apply.) A. Amnesia B. Systemic hypertension C. Bradycardia D. Respiratory depression E. Confusion

A. Amnesia E. Confusion

A nurse is caring for a child who is having a seizure. Which of the following is an appropriate action by the nurse? (Select all that apply.) A. Assess the client's airway patency. B. Place a tongue depressor in the client's mouth. C. Place the bed in a low position. D. Place the client in prone position. E. Restrain the client.

A. Assess the client's airway patency. C. Place the bed in a low position.

A nurse is caring for a child who has acute appendicitis. Which of the following should the nurse anticipate when reviewing this client's lab values? A. White blood cell (WBC) level of 17,000/mm3 B. A neutrophil level of 3,000/mm3 C. A WBC shift to the right D. An increase in lymphocytes

A. White blood cell (WBC) level of 17,000/mm3

A nurse is caring for an infant with gastroesophageal reflux. Which of the following is an appropriate action for the nurse to take? A. Place in a prone position after feeding. B. Place in an infant seat after feeding. C. Place on left side after feeding. D. Place on right side after feeding.

B. Place in an infant seat after feeding.

A nurse is planning care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Perform chest percussion B. Place the child in an upright position C. Monitor oxygen saturation D. Administer bronchodilators E. Administer dornase alfa daily

B. Place the child in an upright position C. Monitor oxygen saturation D. Administer bronchodilators

A nurse is admitting a 9 year old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions? A. "Has your son had a sore throat recently?" B. "Was your son born with this cardiac defect?" C. "Has your child had any injuries recently?" D. "Are you aware that your son will have to be in isolation?"

A. "Has your son had a sore throat recently?" Rationale: Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether or not the child previously has a sore throat.

A nurse in the emergency department is assessing a newly-admitted infant. Which of the following findings is an early indication of hypoxemia? A. Nonproductive cough B. Hypoventilation C. Tachypnea D. Nasal stuffiness

C. Tachypnea

A nurse is bathing a toddler and notices that she has several bruises. Which of the following should the nurse take first? A. Ask the toddler what caused the bruises. B. Notify the provider. C. Ask the parents what caused the bruises. D. Notify social services.

C. Ask the parents what caused the bruises. Rationale: The toddler might or might not be able to verbalize what caused the bruises, depending on the toddler's age and development. The nurse should gather additional data. Inconsistencies between the history and the injury are the most important criterion on which to base the decision to report suspected abuse.

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse determines that the procedure was effective with which of the following assessment findings? A. Increased respiratory rate B. Stable oxygen saturation C. Clear breath sounds D. Brisk capillary refill

C. Clear breath sounds

A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb 11.6 and Hct 37% B. Inflamed and reddened throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus

C. Frequent swallowing and clearing of the throat