PED Final Exam Course point ?'s Unit 4

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?

It will determine if the heart is enlarged."

An infant with bladder exstrophy is awaiting surgical repair. What is the priority nursing intervention for the nurse to complete in the care for this infant?

Keep the bladder moist and covered with a sterile bag

A nurse is caring for a 12-year-old girl with a severe peanut allergy. The girl's parents are upset because the school does not permit her to carry her EpiPen with her. It must remain in the school's office per school regulations. Which response by the nurse would be most appropriate?

"She is allowed by law to carry her EpiPen with her; I will talk to school authorities."

The mother of a 4-week-old infant is tearful. She reports the physician has told her that her son has a small atrial septal defect. She reports she is worried and asks the nurse more about the condition. Which statement by the parents best indicates an understanding of the nurse's teaching?

Most of the time this condition spontaneously resolves

An infant with congenital heart disease is to undergo surgery to correct the defect. The mother states, "I guess I'm going to have to stop breastfeeding her." Which response by the nurse would be most appropriate?

"Breast milk may help to boost her immune system, so you can continue to use it."

The nurse is caring for a pediatric client diagnosed with tetralogy of Fallot. After speaking with the physician, the parents state to the nurse, "The doctor said something about our child having too many red blood cells. We don't understand how that could happen?" What is the best response by the nurse?

"Your child's body is trying to compensate for the low blood oxygen levels from the heart defect by making more red blood cells, but this makes the heart actually work harder."

The nurse is caring for children at a local hospital. Which child warrants immediate attention from the nurse?

1-week-old newborn whose oxygenation is not improving with oxygen

A 7-year-old client presents to the emergency room (ER) after experiencing an allergic reaction to a bee sting. The client is breathing and able to verbally communicate. The nurse notes the client's pulse 90 beats/minute, respirations are 23 breaths/minute, blood pressure is 100/60 mm Hg, lungs are clear. Which nursing action is priority?

Ask if any medications were given before arriving to the ER.

What will the nurse include in the feeding plan for a breastfed infant with congenital heart disease?

Breastfeed with small, frequent feeds.

The nurse is performing double diapering for a male infant with hypospadias who has undergone a surgical repair. The nurse performs the following steps. Place the steps in the order in which the nurse performs them.

Cuts a hole in the front of the smaller diaper Unfolds both diapers, placing smaller diaper inside larger diaper Places both diapers under the infant Brings the penis and catheter/stent through the hole in the smaller diaper Closes the smaller diaper Closes the larger diaper

The nurse is assisting with skin testing on a pediatric client with allergies. What will the nurse do first?

Ensure the child has not taken diphenhydramine in the past week.

A child, diagnosed with a urinary tract infection, is afraid to void because it hurts. What action should the nurse recommend to the parent to help relieve this fear?

Have the child sit in a sitz bath of warm water to void.

The nurse is applying a urine bag to a 15-month-old boy to collect a urine specimen. Which action would the nurse take first?

Pat the perineal area dry after cleaning.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in a knee-to-chest position.

An infant with tetralogy of Fallot becomes cyanotic. Which nursing intervention would be the first priority?

Place the infant in the knee-chest position.

When developing the preoperative plan of care for an infant with bladder exstrophy, which intervention would the nurse least likely include?

Placing the infant in a side-lying position

When conducting a physical examination of a child with suspected Kawasaki disease, which finding would the nurse expect to assess?

Strawberry tongue

At 3 years of age, a child has a cardiac catheterization. After the procedure, which interventions would be most important?

Take pedal pulses the first 4 hours

The nurse is caring for a 3-year-old child with the surgical repair of hypospadias. The preschooler returned from the postanesthesia care unit with an indwelling urinary catheter. What parental teaching is most helpful?

The catheter insertion site will leave only a minimal scar. (Think alphabetically Epispadias top, Hypospadias bottom)

After teaching the parents of a child with a hydrocele about this condition, which statement indicates that the teaching was successful?

This condition should gradually go away on its own

The nurse is caring for an infant with grade II vesicoureteral reflux (VUR). The parent is very fearful that the infant will have progressive renal damage. Which response by the nurse would be appropriate?

This condition usually resolves spontaneously with no symptoms."

Parents are told their infant has a hypoplastic left heart. How would the nurse explain this condition to the family?

This is a problem where the left side of the heart did not develop properly.

A mother is asking for more information about her infant's patent ductus arteriosus (PDA). What would be included in the education?

This is caused by an opening that usually closes by 1 week of age

Which is a priority for the nurse caring for a client with bladder exstrophy?

preventing skin breakdown

The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which finding would the nurse most likely expect to assess if the child had transposition of the great vessels?

significant cyanosis without the presence of a murmur