Peds HESI

The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which acid-base disorder would the nurse expect to note in the infant? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2 Rationale:Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis as a result of the vomiting (depletes acid) that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate, and decreased chloride level.

The nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which intervention is the priority for the child? 1. Promoting bed rest 2. Restricting oral fluids 3. Encouraging visits from friends 4. Allowing the child to play with the other children in the playroom

1 Rationale:Bed rest is required during the acute phase, and activity is gradually increased as the condition improves. Providing for quiet play according to the developmental stage of the child is important. Fluids should not be forced or restricted. Visitors should be limited to allow for adequate rest.

A child has epistaxis. The nurse understands that which treatment is appropriate for epistaxis? 1. Have the child sit up and lean forward. 2. Have the child assume a supine position. 3. Have the child sit up and tilt the head backward. 4. Apply continuous pressure to the nose for at least 3 minutes.

1 Rationale:Correct treatment for epistaxis (a nosebleed) involves having a client sit up and lean forward. Therefore, having the child assume a supine position or sit up and tilt the head backward are incorrect. Continuous pressure would be applied to the nose for at least 10 minutes.

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching? 1. "I will give my child cough syrup if a cough develops." 2"During an attack, I will take my child to a . cool location." 3. "I can give acetaminophen if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

1 Rationale:Cough syrups and cold medicines are not to be given because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 mL to 1000 mL of fluids daily is important for thinning secretions.

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position? 1. In a supine, side-lying position 2. Prone, with the head of the bed elevated 15 degrees 3. With the head at a 60-degree angle with the neck slightly flexed 4. With the head and chest at a 30-degree angle, with the neck slightly extended

4 Rationale:The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Options 1, 2, and 3 do not achieve these goals.

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply. 1. Respiratory impairment 2. Anorexia and weight loss 3. Pallor, weakness, irritability 4. Supraorbital ecchymosis and periorbital edema 5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression on the bladder

5, 6 Rationale:The signs and symptoms of a neuroblastoma depend on the location of the tumor. When the tumor is found on the adrenal gland, the findings will be consistent with a firm, nontender, irregular mass in the abdomen. This will likely cause some degree of urinary frequency or retention from compression on the ureter, or kidney.

The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which? 1. Decorticate posturing 2. Decerebrate posturing 3. Flexion of the arms and legs 4. An expected position post-head injury

1 Rationale:Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists, and an extension of the lower extremities with some internal rotation.

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item would the nurse advise the parents to include in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

1 Rationale:Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be lifelong, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

The nurse is caring for a 1-year-old child following a cleft palate repair. Which solution would the nurse use after feedings to cleanse the child's mouth? 1. Sterile water 2. Diluted hydrogen peroxide 3. A soft lemon glycerin swab 4. Half-strength povidone-iodine solution

1 Rationale:Following a cleft palate repair, the mouth is rinsed with water after feedings to clean the palate repair site. Rinsing food and residual sugars from the suture line reduces the risk of infection. Diluted hydrogen peroxide, a soft lemon glycerin swab, and half-strength povidone-iodine solution should not be used.

A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder? 1. Gastric contents regurgitate back into the esophagus. 2. The esophagus terminates before it reaches the stomach. 3. Abdominal contents herniate through an opening of the diaphragm. 4. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm.

1 Rationale:Gastroesophageal reflux is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia.

The nurse is caring for a child who is scheduled for an appendectomy. When the nurse reviews the primary health care provider's preoperative prescriptions, which would be questioned? 1. Administer a Fleet enema. 2. Maintain nothing per mouth (NPO) status. 3. Maintain intravenous (IV) fluids as prescribed. 4. Administer preoperative medication on call to the operating room.

1 Rationale:In the preoperative period, enemas or laxatives should not be administered. No heat should be applied to the abdomen because this may increase the chance of perforation secondary to vasodilation. IV fluids would be started and the child would be NPO. Prescribed preoperative medications most likely would be administered on call to the operating room.

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents? 1. Pain 2. Diarrhea 3. Constipation 4. Increased flatus

1 Rationale:The parents of a child with a hernia need to be instructed about the signs of an incarcerated hernia. These signs include irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene. Diarrhea, increased flatus and constipation are not associated with an incarcerated hernia.

A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research? 1. Males inherit hemophilia from their fathers. 2. Females inherit the carrier status from their fathers. 3. Hemophilia A results from deficiency of factor VIII. 4. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome.

1 Rationale:Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Some females who are carriers have an increased tendency to bleed, and although it is rare, females can have hemophilia if their fathers have the disorder and their mothers are carriers of the genetic disorder. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX.

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching? 1. The mother administered the iron with milk. 2. The mother administered the iron with water. 3. The mother administered the iron with apple juice. 4. The mother administered the iron with orange juice.

1 Rationale:Milk may affect absorption of the iron. Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Water will not assist in absorption.

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further teaching? 1. "The cast will feel warm when it is dried." 2. "I can apply ice to the casted area to prevent swelling." 3. "If the cast becomes wet, a fan may be used to dry the cast." 4. "I need to call the primary health care provider if any blood or drainage appears on the cast."

1 Rationale:Once the cast dries, the cast will sound hollow and will be cool (not warm) to touch. A fan can be directed toward the cast to facilitate drying. The mother must be instructed to call the primary health care provider if any blood or drainage appears on the cast. Ice can be applied to the casted area to prevent swelling.

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement would be avoided? 1. Rectal 2. Axillary 3. Electronic 4. Tympanic

1 Rationale:Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse would include which in the plan of care? 1. Initiating seizure precautions 2. Using a wheelchair for out-of-bed activities 3. Assisting the child with ambulation at all times 4. Avoiding contact with other children on the nursing unit

1 Rationale:Safety of the child is the nursing priority. Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. A thorough neurological assessment should be performed on the child, and the child's safety should be assessed before allowing the child to get out of bed without help. Assessment of the child's gait should be done daily. However, options 2 and 3 are not required unless functional deficits exist. Isolating the child, option 4, is not necessary.

A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action? 1. Weighing the diapers 2. Monitoring the intake closely 3. Comparing the intake with the output 4. Asking the primary health care provider for permission to insert a Foley catheter

1 Rationale:The best method to assess urine output in an infant is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the intake is not directly related to the subject of the question. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant. In addition, insertion of a Foley catheter places the infant at risk for infection.

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness? 1. "I can remove the harness to bathe my infant." 2. "I need to remove the harness to feed my infant." 3. "I need to remove the harness to change the diaper." 4. "My infant needs to remain in the harness at all times."

1 Rationale:The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings. Option 4 is incorrect.

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction would the nurse reinforce to the mother to prevent the transmission of the disease? 1. "Disease transmission is unknown." 2. "The disease is transmitted through the urine and feces, so the other children should use a separate bathroom." 3. "The disease is transmitted through the respiratory tract, so the child should be isolated from the other children as much as possible." 4. "The disease is transmitted by contact with body fluids, so any items contaminated with body fluids need to discarded in a separate receptacle."

1 Rationale:The method of transmission of roseola is unknown. Options 2, 3, and 4 are not correct transmission routes of roseola.

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron in which way? 1. Between meals 2. Just after a meal 3. Just before a meal 4. With a fruit low in vitamin C

1 Rationale:The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body.

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching? 1. "I understand that I need to leave the scabicide on for 4 hours before washing it off." 2. "I will need to seal up all my child's nonwashable toys in a plastic bag for at least 4 days." 3. "I realize that everyone who has come in contact with my child will need to be treated for scabies." 4. "I know I need to wash all the clothing and bedding in hot water with detergent and dry in a hot dryer."

1 Rationale:The treatment for scabies involves applying a scabicide to cool, dry skin at least 30 minutes after bathing, which needs to be left on the skin for 8 to 14 hours, then washed off. The other statements are correct.

The nurse working in a pediatric clinic is preparing to administer childhood vaccinations to a 15-month-old child. Which vaccine would be added to the child's routine immunizations at this time because the child is older than 12 months of age? 1. Varicella 2. Hepatitis B 3. Hepatitis A 4. Pneumococcal vaccine (PVC)

1 Rationale:Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i.e., children who lack a reliable history of chickenpox and have not been vaccinated). The other vaccines are administered on or before the age of 1 year.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan? 1. Palpate the abdomen for a mass. 2. Check the urine for the presence of hematuria. 3. Monitor the blood pressure for the presence of hypertension. 4. Monitor the temperature for the presence of a kidney infection.

1 Rationale:Wilms' tumor is an intraabdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.

The nurse assists in creating a nursing care plan for the child with an arm cast and would include which interventions in the plan? Select all that apply. 1. Instruct parents to keep the cast clean and dry. 2. Monitor the extremity for circulatory impairment. 3. Instruct the child not to stick objects down the cast. 4. Ensure that rough cast materials are cut off to keep smooth. 5. Notify the registered nurse (RN) immediately if circulatory impairment occurs.

1, 2, 3, 5 Rationale:The cast should have not rough edges, but cutting the cast is not appropriate; the edges can be covered with waterproof adhesive tape to ensure a smooth cast edge. Instruct the parents and the child to keep the cast clean and dry and not to stick objects down the cast. Monitoring for circulatory impairment is important.

The mother of a child with Marfan syndrome asks the nurse what can be done at home to help her child. Which are the best responses by the nurse? Select all that apply. 1. "You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." 3. "You will need to keep your child indoors and avoid sports." 4. "You will need to make regular eye examination appointments for your child." 5. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 6. "You will need to let the dentist know that antibiotics should be given before any procedure."

1, 2, 4, 5, 6 Rationale:Parents of the child with Marfan syndrome should be instructed to monitor for vision problems and get regular eye examinations, avoid participation in contact sports, but it is not necessary to stay indoors. Monitor the curvature of the spine as the child grows, anticipate that antibiotics should be taken before any dental procedure to prevent endocarditis, cardiac medications to decrease stress on the aorta, and surgical replacement of the aortic root and valve may be necessary. Making regular pediatric appointments is important for monitoring the child.

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply. 1. Our child will eventually grow out of this condition. 2. It is likely our child will suffer from a failure to thrive. 3. It is not necessary to avoid individuals with the common cold. 4. It is vital that we keep track of how much our baby eats and any episodes of diarrhea. 5. When our baby has difficulty breathing and turns blue, we should hold the baby in the knee-chest position.

1, 3 Rationale:Tetralogy of Fallot (TOF) is a congenital condition that consists of four cardiovascular defects: pulmonary artery stenosis, right ventricle hypertrophy, dextroposition of the aorta, and ventricular septal defect, which allow unoxygenated blood to enter the general circulation and lead to cyanosis and hypoxia. Statements that require further teaching are incorrect statements and include that the child will outgrow the condition and that it is not necessary to avoid individuals with the common cold. Infants with TOF often have frequent respiratory infections and should avoid people with the common cold and other respiratory infections. The child will not spontaneously outgrow this condition; when the child is older and more stable, an open heart surgery with cardiopulmonary bypass can totally correct all defects with excellent results. Children with TOF have eating difficulties and dyspnea on exertion, so they are at risk for failure to thrive. Polycythemia develops to compensate for the lack of oxygenated blood. If the child becomes dehydrated due to diarrhea and/or decreased eating, the client is at increased risk for cerebral thrombosis. If the baby has a "tet spell," in which the child turns blue and has difficulty breathing, the parents should hold the baby's knees to his or her chest until the cyanosis and respiratory distress subsides.

The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications would the nurse plan to administer? Select all that apply. 1. Atenolol 2. Tramadol 3. Propranolol 4. Methimazole 5. Levothyroxine

1, 3, 4 Rationale:Treatment for a thyroid storm includes antithyroid drugs and administration of beta-adrenergic blocking agents, which provide relief from the adrenergic hyperresponsiveness that produces the disturbing side effects of the reaction. Propranolol and atenolol are beta-adrenergic blocking agents. Methimazole is an antithyroid medication and should be expected to be given during a thyroid storm. Tramadol is an analgesic and should not be given to anyone with a metabolic disease. Levothyroxine is a synthetic thyroid replacement medication, which would not be given when the thyroid level is too high.

The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign? 1. Tap the facial nerve and check for spasm. 2. Extend the leg and knee and check for pain. 3. Compress the upper arm and check for tetany. 4. Bend the head toward the knees and hips and check for pain.

2 Rationale:Kernig's sign is pain that occurs with extension of the leg and knee. Brudzinski's sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally.

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

2 Rationale:After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent the contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration.

A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen? 1. Catheterizes the infant, using a No. 5 French Foley 2. Attaches a urinary collection device to the infant's perineum 3. Obtains the specimen from the diaper, using a syringe, after the infant voids 4. Monitors the urinary patterns and prepares to collect the specimen into a cup when the infant voids

2 Rationale:Although many methods have been used to collect urine from an infant, the most reliable method is the urine collection device. This device is a plastic bag that has an opening lined with adhesive so that it may be attached to the perineum. Urine for certain tests, such as specific gravity, may be obtained from a diaper. Urinary catheterization is not to be done unless specifically prescribed because of the risk of infection. It is not reasonable to monitor urinary patterns and attempt to collect the specimen in a cup when the infant voids.

The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine? 1. A recent cold 2. Allergy to eggs 3. The presence of diarrhea 4. Any recent ear infections

2 Rationale:Before the administration of a measles, mumps, and rubella vaccine, a thorough health history needs to be obtained. The MMR vaccine is used with caution in a child with a history of allergy to gelatin or eggs because the live measles vaccine is produced by chick embryo cell culture. The MMR vaccine also contains a small amount of the antibiotic neomycin. Options 1, 3, and 4 are not contraindications to administering this immunization.

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing. 2. Notify the registered nurse (RN). 3. Document the findings and continue to monitor. 4. Circle the area of drainage and continue to monitor.

2 Rationale:Colorless drainage on the dressing would indicate the presence of cerebrospinal fluid and should be reported to the RN immediately; the RN would then contact the primary health care provider. The colorless drainage should also be checked for evidence of cerebrospinal fluid; one method is to check for the presence of glucose using a dipstick. Options 1, 3, and 4 are incorrect and delay required immediate interventions.

The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse would would instruct the mother to do which? 1. Use aspirin for pain relief. 2. Pad crib rails and table corners. 3. Use a soft toothbrush for dental hygiene. 4. Use a generous amount of lubricant when taking a temperature rectally.

2 Rationale:Establishment of an age-appropriate safe environment is of paramount importance for hemophiliac clients. Providing a safe environment for an infant includes padding table corners and crib rails, providing extra "joint" padding on clothes, observing a mobile infant at all times, and keeping items that can be pulled down onto the infant out of reach. Use of a soft toothbrush is an appropriate measure for a child with hemophilia, but is not typically necessary for an infant. Rectal temperature measurements and the use of aspirin are contraindicated in hemophiliac individuals because of the risk of bleeding.

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 1. 4 months 2. 9 months 3. 12 months 4. 18 months

2 Rationale:Isoniazid is given to prevent TB infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In infants and children, the recommended duration of isoniazid therapy is 9 months. For children with human immunodeficiency virus infection, a minimum of 12 months is recommended.

The nurse is reinforcing instructions to the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse provide the mother? 1. Administer the iron at mealtimes. 2. Administer the iron through a straw. 3. Mix the iron with cereal to administer. 4. Add the iron to food for easy administration.

2 Rationale:Oral iron supplements should be administered through a straw or medicine dropper placed at the back of the mouth; otherwise, they will stain the teeth. The parents should be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acidic environment to facilitate its absorption in the duodenum.

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need for further teaching? 1. "The femur is the most common site of this sarcoma." 2. "The child does not experience pain at the primary tumor site." 3. "If a weight-bearing limb is affected, then limping is a clinical manifestation." 4. "The symptoms of the disease during the early stage are almost always attributed to normal growing pains."

2 Rationale:Osteogenic sarcoma is the most common bone tumor in children. A clinical manifestation of osteogenic sarcoma is progressive, insidious, intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma.

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question? 1. Position the infant on the inoperative side. 2. Keep the head of the bed elevated 45 degrees. 3. Monitor for signs of infection and check dressings for drainage. 4. Observe for irritability, a high shrill cry, lethargy, and poor feeding.

2 Rationale:Postoperative management for infants with hydrocephalus who have undergone ventriculoperitoneal shunt should be flat in bed to avoid the rapid reduction of intracranial fluid. Observe for increased ICP, if it occurs elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt. Position the infant on the inoperative side to prevent pressure on the shunt valve. Monitor for signs of infection and check dressings for drainage. A high shrill cry in an infant can be a sign of increased ICP.

The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside? 1. Oxygen and a tongue depressor 2. A suction apparatus and oxygen 3. An airway and a tracheotomy set 4. An emergency cart and an oxygen mask

2 Rationale:Seizures cause a tightening of all body muscles that is followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after the seizure. Suctioning and oxygen are helpful to prevent choking and cyanosis. A tongue depressor is not needed because nothing should be placed into the client's mouth during a seizure because of the risk for injury. Inserting a tracheostomy is not done because this is a surgical procedure. An emergency cart should not be left at the bedside; however, it should be available in the treatment room or on the nursing unit.

The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session the nurse notes that one girl is scratching her head. On inspection, the nurse determines that the child has pediculosis capitis. When reinforcing instructions to the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition? 1. "I will put all the stuffed animals in a sealed plastic bag for 14 days." 2. "I will call a carpet cleaning service to clean all my carpets in the house." 3. "My two daughters should not share their hairbrushes or hair ribbons." 4. "I will machine wash all the washable clothing, towels, and bed linens in hot water."

2 Rationale:Teaching about measures to prevent the spread of pediculosis capitis includes washing items in hot water, vacuuming carpets, discouraging sharing of personal items, and sealing items in plastic bags that cannot be vacuumed. Option 2 is too costly for many families and is unnecessary. Option 2 indicates the mother does not understand the measures that will prevent the spread of the parasite.

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic, and the oxygen saturation reading drops to 60%. The nurse would perform which action first? 1. Assist to administer morphine sulfate. 2. Place the child in a knee-chest position. 3. Administer 100% oxygen by face mask. 4. Prepare to administer intravenous fluids.

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

The nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further teaching? 1. "I need to allow my infant time to swallow." 2. "I need to use a nipple with a small hole to prevent choking." 3"I need to stimulate sucking by rubbing the . nipple on the lower lip." 4. "I need to allow my infant to rest frequently to provide time for swallowing what has been placed in the mouth."

2 Rationale:The mother should be taught the ESSR method of feeding the child with a cleft palate: ENLARGE the nipple by cross-cutting a hole so that food is delivered to the back of the throat without sucking; STIMULATE sucking by rubbing the nipple on the lower lip; SWALLOW; then REST to allow the infant to finish swallowing what has been placed in the mouth.

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1. A supine position 2. A side-lying position 3. Prone, with the head elevated 4. Prone, with the face turned to the side

2 Rationale:The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, and 4 will place the child at risk for aspiration if vomiting occurs.

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis? 1, Chest x-ray 2. Blood cultures 3. Echocardiogram 4. Transesophageal echocardiography

2 Rationale:When endocarditis is suspected, a definitive diagnosis is achieved through blood cultures. A negative blood culture does not rule out the existence of endocarditis; it just indicates a lesser likelihood of its existence. A chest x-ray, echocardiogram, and transesophageal echocardiography are performed to aid in the diagnosis of endocarditis.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions would be implemented? Select all that apply. 1. Enteric 2. Contact 3. Airborne 4. Protective 5. Neutropenic

2, 3 Rationale:Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne precautions and contact precautions are required; a mask and gloves are worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 4, and 5 are not indicated for rubeola

The nurse provides information to the mother of a toddler regarding toilet-training. The nurse would tell the mother what information? Select all that apply. 1. "Bladder control is usually achieved before bowel control." 2. "The child should not be forced to sit on the potty for long periods." 3. "The ability of the child to remove clothing is a sign of physical readiness." 4. "Waiting until the child is 24 to 30 months old makes the task considerably easier." 5. "At the age of 24 to 30 months old, the toddler is usually less negative and more willing to control their sphincters to please their parents."

2, 3, 4, 5 Rationale:Waiting until the child is 24 to 30 months old makes the task considerably easier because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents. Bowel control typically occurs before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness.

The nurse is planning education for a parent whose child has recently been prescribed cromolyn sodium as a part of the treatment plan for asthma. Which information would the nurse reinforce in the teaching? Select all that apply. 1. This medication is a bronchodilator. 2. This medication is inhaled using a Spinhaler. 3. This medication is not to be used as a rescue inhaler. 4. This medication should be used after the child exercises. 5. This medication should be inhaled slowly to ensure the medication reaches the lower airways.

2, 3, 5 Rationale:Cromolyn sodium is a nonsteroidal anti-inflammatory drug (NSAID) used for prevention of asthma. The medication is inhaled slowly using a Spinhaler to ensure the medication reaches the lower airway. Cromolyn sodium should be used before exercise, not after exercise, to prevent exercise-induced asthma because this medication is not a rescue inhaler. Bronchodilators include albuterol and terbutaline.

The nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which immediate problem as the priority for the infant? 1. Infection 2. Elimination 3. Skin disruption 4. Lack of parental understanding

3 Rationale: In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is skin disruption related to the exposed bladder mucosa. Although the infant needs to be monitored for elimination patterns and kidney function, this is not the priority concern for this condition. Lack of parental understanding related to the diagnosis and treatment of the condition will need to be addressed, but again, is not the priority. Although infection related to the anatomically located defect can be a problem, it is not the immediate one.

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF? 1. Immunoglobulin 2. Red blood cell count 3. Antistreptolysin O titer 4. White blood cell count

3 Rationale:A diagnosis of RF is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, streptozyme, or an anti-DNase B assay. Options 1, 2, and 4 will not assist in confirming the diagnosis of RF.

A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which characteristic of this disease? 1. Increased platelet count 2. Increased hematocrit count 3. Increased reticulocyte count 4. Increased hemoglobin count

3 Rationale:A laboratory diagnosis is established on the basis of a complete blood cell count, examination for sickled red blood cells (RBCs) on the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin, hematocrit, and platelet counts; increased reticulocyte count; and the presence of nucleated red blood cells. Elevated reticulocyte counts occur in children with sickle cell disease because the life span of their sickled RBCs is shortened.

A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the primary health care provider did not prescribe antibiotics. The nurse makes which response to the mother? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3 Rationale:Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present. Options 1, 2, and 4 are incorrect. In addition, the question does not include any supporting data to indicate that the child may be allergic to antibiotics.

The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction would the nurse give the mother? 1. The child may attend school if antibiotics have been started. 2. Save any unused eye medication in case a sibling gets the eye infection. 3. The child's towels and washcloths should not be used by other members of the household. 4. Wipe any crusted material from the eye with a cotton ball soaked in warm water, starting at the outer aspect of the eye and moving toward the inner aspect.

3 Rationale:Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include good hand washing and not sharing towels or washcloths with others. The child should be kept home from school until 24 hours after antibiotics are started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.

The nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which question would the nurse ask the mother of the child? 1. "Has the child had any sore throats?" 2. "Has the child been eating properly?" 3. "Is the child allergic to any antibiotics?" 4. "Has the child been exposed to any infections?"

3 Rationale:Before administration of the MMR vaccine, a thorough health history must be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture, and MMR also contains a small amount of the antibiotic neomycin. Sore throat, improper eating, and exposure to infections are not contraindications to administering immunizations.

The nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review? 1. Creatinine 2. 2Urinalysis 3. Platelet count 4. Blood urea nitrogen (BUN)

3 Rationale:Before the surgical procedure, the child is assessed for signs of active infection and for redness and exudate of the throat. Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin (PT), partial thromboplastin time (PTT), platelet count, hemoglobin and hematocrit (H&H), white blood cell (WBC) count, and urinalysis are performed preoperatively. The platelet count result would identify a potential for bleeding. The BUN and creatinine would not determine the potential for bleeding but rather evaluate renal function.

The nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation would the nurse expect to note documented in the health record? 1. Frothy diarrhea 2. Foul-smelling ribbon stools 3. Profuse watery diarrhea and vomiting 4. Diffuse abdominal pain unrelated to meals or activity

3 Rationale:Celiac disease causes profuse watery diarrhea and vomiting. Option 1 is a symptom of lactose intolerance. Option 2 is a symptom of Hirschsprung's disease. Option 4 is a symptom of irritable bowel syndrome.

The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis? 1. Blindness 2. Strabismus 3. Cat's-eye reflex 4. Red, painful eye

3 Rationale:Clinical symptoms of retinoblastoma include cat's-eye reflex, which is sometimes called "white eye," (most common sign); strabismus (second most common sign); red, painful eye; and blindness (late signs). Cat's-eye reflex is commonly observed by the parent and is described as a whitish "glow" in the pupil. This represents visualization of the tumor as the light momentarily falls on the mass and is the most common sign.

A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder? 1. Anorexia in the evening 2. Incomplete development of the anus 3. The infrequent and difficult passage of dry stools 4. Invagination of a section of the intestine into the distal bowel

3 Rationale:Constipation can affect any child at any time, although its incidence peaks at ages 2 to 3 years. Option 3 describes encopresis, which can develop as a result of constipation and is one of the major concerns regarding constipation. Encopresis generally affects preschool and school-age children. Option 1 is not associated with encopresis. Option 2 describes imperforate anus, which is diagnosed in the neonatal period. Option 4 describes intussusception, which is the most common cause of bowel obstruction in children ages 3 months to 6 years.

A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which nursing intervention would be of highest priority? 1. Weigh morning and afternoon. 2. Maintain a strict intake and output. 3. Dipstick the urine for protein every 4 hours. 4. Take vital signs with blood pressure every 2 hours.

3 Rationale:Continuous monitoring of fluid retention and excretion is an important nursing intervention in the care of the child with nephrotic syndrome. Although it is important to maintain a strict intake and output in monitoring fluid retention and excretion, the goal of treatment with this child is to decrease the amount of protein lost in the urine. Because this is the goal, option 3 has the highest priority. Although weight is monitored, it is not necessary to check the weight morning and evening. Taking vital signs with blood pressure is important but is not the priority in this situation and does not have to be monitored every 2 hours.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2, Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3 Rationale:Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which would the nurse instruct the mother to do? 1. Give the child children's aspirin for the discomfort. 2. Be sure that the child is resuming normal activities. 3. Give the child acetaminophen for the discomfort as per discharge instructions. 4. Speak to the primary health care provider because the child should not be having any discomfort.

3 Rationale:Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen or ibuprofen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present.

The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction? 1. "Expect an increased urine output from the shunt." 2. "Call the primary health care provider if the infant is fussy." 3. "Call the primary health care provider if the infant has a high-pitched cry." 4. "Position the infant on the side of the shunt when the infant is put to bed."

3 Rationale:If the shunt is broken or malfunctioning, the fluid from the ventricular part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is increased intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected. Option 1 is a concern only if other signs indicative of a complication are occurring.

he nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease? 1. It is an acquired cell-mediated immunodeficiency disorder. 2. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. 3. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. 4. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.

3 Rationale:Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse would tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1. Fats and vitamin A 2. Zinc and vitamin C 3. Calcium and vitamin D 4. Thiamine and vitamin B

3 Rationale:Lactose intolerance is the inability to tolerate lactose, the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and vitamin D.

The nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which information in the conference? 1. PKU is an autosomal dominant disorder. 2. Treatment includes dietary restriction of sodium. 3. PKU results in central nervous system (CNS) damage. 4. Some state laws require routine screening of all newborn infants for PKU.

3 Rationale:PKU is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake (not sodium). PKU is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood. All 50 states require routine screening of all newborn infants for PKU.

The nurse has reinforced discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further teaching? 1. "I should encourage fluid intake." 2. "I should avoid toilet training right now." 3. "I should carry my child by straddling the child on my hip." 4. "I should use double diapers to hold the surgery site in place."

3 Rationale:Parent teaching following hypospadias repair includes restricting the child from activities that put pressure on the surgical site. Straddling the child on the hip will cause pressure on the surgical site. The parents should be instructed to use double diapers to hold the stent in place and should be instructed how to hold the child during the postoperative period. Fluids should be encouraged to maintain hydration. Toilet training should not be an issue during this stressful period.

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention would be incorporated into the plan of care? 1. Encourage naps. 2. Encourage a diet high in iron. 3. Encourage quiet play activities. 4. Maintain strict isolation precautions.

3 Rationale:Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, quiet activities, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

The nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse would tell the parents that the infant would be maintained in which position? 1. A 30-degree angle when supine 2. A 60-degree angle when prone 3. A 60-degree angle when supine 4. A 20-degree angle when side-lying

3 Rationale:Proper positioning is an important component of reflux management. Ideally the goal is to maintain the infant in an upright angle 24 hours a day, at a 60-degree angle when supine, and at a 30-degree angle when prone. This position is maintained until the infant remains asymptomatic for 6 weeks.

A client has been prescribed valproic acid for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching? 1. "I need to take the pills whole and not crush them." 2. "I need to take the medication with food so that I won't get an upset stomach." 3. "I am so glad that I won't lose any of my hair. I was worried what my friends would think." 4. "I know that I might gain weight with the medication, so I need to be careful to not eat a lot of sweets and to eat more fruits and vegetables."

3 Rationale:Side effects of valproic acid include nausea and vomiting, tremors, weight gain, and hair loss. It is important to take the medication whole and not crush or cut the medication.

A mother of a child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen is not very effective. Which is the best suggestion by the nurse? 1. Increase the dose of the acetaminophen. 2. Encourage the child to lie on the left side. 3. Encourage the child to lie on the right side. 4. Increase the frequency of the acetaminophen.

3 Rationale:Splinting of the affected side by lying on that side may decrease discomfort. It is inappropriate to advise the mother to increase the dose or frequency of the acetaminophen. Lying on the left side will not be helpful in alleviating discomfort.

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse would prepare for which diagnostic study that can confirm this diagnosis? 1. A platelet count 2. A lumbar puncture 3. A bone marrow biopsy 4. A white blood cell (WBC) count

3 Rationale:The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. The WBC count may be high or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that are indicative of central nervous system disease. An altered platelet count occurs as a result of chemotherapy.

The nurse is providing instructions to a mother regarding the administration of eardrops for her infant. The nurse observes the mother administer the drops and determines that the mother is performing the procedure correctly if the mother performs what action? 1. Pulls up and back on the earlobe and directs the solution onto the eardrum 2. Pulls down and back on the auricle and directs the solution onto the eardrum 3. Pulls down and back on the earlobe and directs the solution toward the wall of the canal 4. Pulls up and back on the auricle and directs the solution toward the wall of the ear canal

3 Rationale:The infant should be turned onto the side, with the affected ear uppermost. With the nondominant hand, the mother pulls down and back on the earlobe while resting the wrist of the dominant hand on the infant's head. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum. The infant should be held or positioned with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult, the auricle is pulled up and back to straighten the auditory canal.

The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1. Heart rate 2. Lung sounds 3. Level of consciousness 4. Amount of edema at the site of the burn injury

3 Rationale:The sensorium, or level of consciousness, is an important guide to the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of consciousness in the child. Options 1, 2, and 4, although important in the assessment of the child with a burn injury, would not provide an accurate assessment of the adequacy of fluid resuscitation.

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

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

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record would the nurse question? Select all that apply. 1. Measure abdominal girth daily. 2. Monitor strict intake and output. 3. Take temperature measurements rectally. 4. Start clear liquid diet after 8 hours postoperative. 5. Maintain IV fluids until the child tolerates oral intake. 6. Monitor the surgical site for redness, swelling, and drainage.

3, 4 Rationale:Postoperative management of Hirschsprung's disease includes taking vital signs but avoiding taking the temperature rectally. The client needs to remain NPO (nothing by mouth) status until bowel sounds return or flatus is passed, usually within 48 to 72 hours. The other options are correct postoperative management.

A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct? 1. Requires frequent pin care 2. Places the child at risk for infection 3. Uses skeletal traction and weights to provide a counterforce 4. Is a type of skin traction that pulls the hip and leg into extension

4 Rationale: Buck's skin traction is a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension. Countertraction is applied by the child's body. Options 1, 2, and 3 describe skeletal traction.

A topical corticosteroid is prescribed by the primary health care provider for a child with atopic dermatitis (eczema). Which instruction would the nurse give the parent about applying the cream? 1. Apply the cream over the entire body. 2. Apply a thick layer of cream to affected areas only. 3. Avoid cleansing the area before application of the cream. 4. Apply a thin layer of cream and rub it into the area thoroughly.

4 Rationale:Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by performing which action? 1. Covering the bladder with a dry sterile dressing 2. Covering the bladder with a wet-to-dry dressing 3. Applying sterile water soaks to the bladder mucosa 4. Covering the bladder with a nonadhering plastic wrap

4 Rationale:Care should be taken to protect the exposed bladder tissue from drying while allowing drainage of urine. This is best accomplished by covering the bladder with a nonadhering plastic wrap. The use of wet-to-dry dressings should be avoided because this type of dressing adheres to the mucosa and may damage the delicate tissue when removed. Sterile dressings and dressings soaked in solutions can also dry out and damage the mucosa when removed.

The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement? 1. Cerebral palsy is an infectious disease of the central nervous system. 2. Cerebral palsy is an inflammation of the brain as a result of a viral illness. 3. Cerebral palsy is a congenital condition that results in moderate to severe retardation. 4. Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

4 Rationale:Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

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

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

The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse would provide which information when discussing Down syndrome? 1. The condition is characterized by above-average intellectual functioning with deficits in adaptive behavior. 2. The condition is characterized by average intellectual functioning and the absence of deficits in adaptive behavior. 3. The condition is characterized by subaverage intellectual functioning with the absence of deficits in adaptive behavior. 4. The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).

4 Rationale:Down syndrome is a form of mental retardation. It is a congenital condition that results in moderate to severe mental retardation. The syndrome has been linked to an extra group G chromosome, chromosome 21 (trisomy 21). Options 1, 2, and 3 are incorrect descriptions.

A child is scheduled for a tonsillectomy. Which would present the highest risk of aspiration during surgery? 1. Difficulty swallowing 2. Bleeding during surgery 3. Exudate in the throat area 4. The presence of loose teeth

4 Rationale:In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Options 1 and 3 are incorrect. Bleeding during surgery will be controlled via packing and suction as needed.

The nurse is reinforcing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the mother? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4 Rationale:It is essential that children with cystic fibrosis be adequately protected from communicable diseases by immunization. It is recommended that in addition to the basic series of immunizations, children with cystic fibrosis also should receive yearly influenza vaccines.

A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. Which would the nurse relay to the mother about primary nocturnal enuresis? 1. Primary nocturnal enuresis does not respond to treatment. 2. Primary nocturnal enuresis is caused by a psychiatric problem. 3. Primary nocturnal enuresis requires surgical intervention to improve the problem. 4. Primary nocturnal enuresis is common, and most children will outgrow bed-wetting without therapeutic intervention.

4 Rationale:Primary nocturnal enuresis is bed-wetting and is described as occurring in a child that has never been dry at night for extended periods. It is common in children, most of whom will outgrow bed-wetting without therapeutic intervention. The child is not able to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system (CNS). It is not caused by a psychiatric problem. Behavioral conditioning with use of alarms has been used for treatment in the older child with nocturnal enuresis. A device that contains a moisture-sensitive alarm is worn on the child's pajamas. As the child starts to void, the alarm goes off, awakening the child. The alarm system may need to be used consistently over 15 weeks for resolution.

A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting with care for the child checks the intravenous (IV) and medication supply area for which item? 1. Potassium 2. NPH insulin 3. 5% dextrose IV infusion 4. 0.9% normal saline IV infusion

4 Rationale:Rehydration is the initial step in resolving DKA. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose levels reach an acceptable level. IV potassium may be required depending on the potassium level, but it would not be part of the initial treatment.

A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and would include which intervention in the plan? 1. Assess hearing loss. 2. Monitor urine output. 3. Change body position every 2 hours. 4. Provide a quiet atmosphere with dimmed lighting.

4 Rationale:Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question would the nurse ask the family to elicit information specific to the development of RF? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Has the child had a sore throat or a fever within the past 2 months?"

4 Rationale:Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse would take which action? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Place the child in a Sims' position. 4. Notify the registered nurse.

4 Rationale:Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus.

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct? 1. "BCG is administered to children with a positive Mantoux test." 2. "BCG is administered to all children to prevent tuberculosis (TB)." 3. "BCG is administered to children with both a positive Mantoux test and positive chest x-ray." 4. "BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."

4 Rationale:The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results who have had repeated exposures to TB and for asymptomatic HIV-infected children who are at increased risk for developing TB.

The school nurse notes that the child has a rash and suspects that it is caused by erythema infectiosum (fifth disease). The nurse bases this determination on the observation that the rash results in which appearance? 1. Rose-pink maculopapules 2. Pruritic macule-to-papules 3. Pinkish red maculopapules 4. A "slapped-face" appearance

4 Rationale:The classic rash of erythema infectiosum, or fifth disease, is the erythema on the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic profuse macule-to-papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles).

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease? 1. "Small blue-white spots with a red base may appear in the mouth." 2. "The rash usually begins centrally and spreads downward to the limbs." 3. "Respiratory symptoms such as a very runny nose, cough, and fever occur before the development of a rash." 4. "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."

4 Rationale:The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal (catarrhal) stage. Options 1, 2, and 3 are accurate descriptions of rubeola. The small blue-white spots found in this communicable disease are called Koplik spots. Option 3 describes the incubation period for rubella, not rubeola.

The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate? 1. The harness must be worn 8 hours a day. 2. The infant should never be moved when out of the harness. 3. The harness must be removed for diaper changes and for feeding. 4. The harness needs to be removed to check the skin and for bathing.

4 Rationale:The harness should be worn 23 hours a day and should be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings.

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention? 1. Monitoring the output 2. Checking pupillary responses 3. Changing the body position every 2 hours 4. Providing a quiet atmosphere with dimmed lights

4 Rationale:The major elements of care for a child who has Reye's syndrome are to maintain effective cerebral perfusion and to control intracranial pressure. Decreasing stimuli in the environment should decrease the stress on the cerebral tissue and the neuron responses. Cerebral edema is a progressive part of this disease process. Checking pupillary responses and output are part of assessment but not the priority. Changing the body position every 2 hours is important but would not directly affect the cerebral edema and intracranial pressure. The child should be in a head-elevated position to decrease the progression of the cerebral edema and to promote the drainage of cerebrospinal fluid.

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother of the test results and reinforces instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding of the care measures? 1. "I need to keep my child on bed rest for 3 weeks." 2. "I will call the primary health care provider if my child is still feeling tired in 1 week." 3. "I need to isolate my child so that the respiratory infection is not spread to others." 4. "I need to call the primary health care provider if my child complains of abdominal pain or left shoulder pain."

4 Rationale:The mother needs to be instructed to notify the primary health care provider if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.

The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? 1. "I will supervise my child closely." 2. "I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." 4. "I will avoid immunizations and dental hygiene treatments for my child."

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

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching? 1. "I need to watch for diarrhea, so my child does not get dehydrated." 2. "I think that once my child's hair starts to fall out that I can keep a hat on him." 3. "I understand that the radiation will cause nausea and vomiting and I need to keep my child hydrated." 4. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

4 Rationale:The side effects of radiation therapy include dry or moist desquamation (peeling of the skin) and the intervention includes washing the skin daily, using mild soap, applying a lubricant as prescribed. Options 1, 2, and 3 are appropriate statements.

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives in the unit, which action would the nurse do first? 1. Weigh the child. 2. Take the child's temperature. 3. Ask the parents about the child. 4. Place the child on a pulse oximeter.

4 Rationale:To adequately determine whether the child is getting enough oxygen, the child is placed on a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately placed on a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. The nurse would then gather data including taking the child's temperature and weight and asking the parents about the child.

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions? 1. "I need to use a different site for each insulin injection." 2. "I should use only my stomach and my thighs for injections." 3. "I need to use the same site for 1 month before rotating to another site." 4. "I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."

4 Rationale:To help decrease variations in absorption from day to day, the child should use one location within a major site for the morning injection. The child should then rotate to another site for the evening injection, and a third site for the bedtime injection. The child should follow this pattern for a period of 2 to 3 weeks before changing major sites.

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse reinforces instructions to the adolescent regarding home care for treatment of the sprain and provides the adolescent with which information? 1. Elevate the extremity and maintain strict bed rest for a period of 7 days. 2. Immobilize the extremity and maintain the extremity in a dependent position. 3. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. 4. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.

4 Rationale:To treat a sprain, the injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for no longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period? 1. Pain level 2. Ability to turn using the logroll technique 3. Ability to flex and extend the lower extremities 4. Capillary refill, sensation, and motion in all extremities

4 Rationale:When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular assessments including circulation, sensation, and motion should be done every 2 hours. Level of pain and ability to flex and extend the lower extremities are important postoperative assessments but not the priorities of the options provided. Logrolling would be performed by nurses.