Peds/Maternity

An airway obstruction

The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?

Turn the client to the side during a seizure. Keep side rails and other hard objects padded.

A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.

Providing a quiet atmosphere with dimmed lighting

A child is diagnosed with Reye's syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan?

Before the child is 3 years old

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother?

Urine output

A health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child should check which highest priority item before administration of the potassium?

Check for a patent airway.

The emergency department nurse is gathering initial data on a child suspected of epiglottitis. Which is the nurse's highest priority?

Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list?

Initiating seizure precautions

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

Lack of social interaction and awareness

Which represents a primary characteristic of an autism spectrum disorder?

Pull the earlobe down and back before instilling the eardrops.

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which should be included in the plan?

Bacteriuria

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?

Remove the stinger by carefully scraping it out horizontally.

The nurse in a health care provider's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which instruction should the nurse reinforce to the mother?

"I will give my child cough syrup if a cough develops."

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?

"I will place a steam vaporizer in my child's room."

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

"I need to take my child's rectal temperature daily."

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

Fears of separation and mutilation are present.

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account?

Confirmation of the diagnosis

A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of which finding?

Invagination of a section of the intestine into the distal bowel

A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which is a characteristic of this disorder?

Encourage quiet play activities.

The nurse, caring for a child with aplastic anemia, is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 cells/mm3 and a platelet count of 20,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?

"I need to shampoo my child's hair, apply the medication, leave it on for 10 minutes, and then rinse it out."

The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin (Nix) has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching?

"Bad mouth odor is normal and may be relieved by drinking more liquids."

A child is scheduled for a tonsillectomy in the day-stay surgical unit. On the day following surgery, the mother calls the surgical unit and expresses concern because the child has a very bad mouth odor. The nurse should make which response to the mother?

Primary nocturnal enuresis is common, and most children will outgrow bed-wetting without therapeutic intervention.

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 should the nurse relay to the mother about primary nocturnal enuresis?

Increased reticulocyte count

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?

Apply a thin layer of cream, and rub it into the area thoroughly.

A corticosteroid cream is prescribed by a health care provider for a child with atopic dermatitis (eczema). The nurse reinforces instructions to the mother regarding how to apply the cream. Which instruction is appropriate?

Elevated vanillylmandelic acid (VMA) levels in the urine

A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record?

Attaching a urinary collection device to the infant's perineum for collection

A nursing student caring for a 6-month-old infant is asked to collect a urine specimen from the infant. The student collects the specimen by performing which action?

Weighing the diapers

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?

The child's cervical spine

A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?

Initiate an intravenous line. Maintain nothing-by-mouth status. Administer intravenous antibiotics. Administer preoperative medications.

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply.

Elevated temperature

A child with a brain tumor returns from the recovery room following "debulking" of the tumor. The nurse assigned to care for the child monitors the child for brainstem involvement. Which sign would indicate that brainstem involvement occurred during the surgical procedure?

Vomiting

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 hernial strangulation. The nurse tells the parents that which manifestation requires health care provider (HCP) notification by the parents?

"Our child sleeps in our bedroom at night."

The nurse is assisting in collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching?

Fever, Irritability, & Nuchal rigidity

The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms should the nurse expect to find during the initial data collection? Select all that apply.

Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

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?

175 mL per feeding

The nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year-old consumes approximately which amount?

Projectile vomiting

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record?

Allergy to eggs

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?

"I will avoid immunizations and dental hygiene treatments for my child."

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?

Foul-smelling, ribbon-like stools

The nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which manifestation led the mother to seek health care for the infant?

Side-lying position

The nurse should place the child who had a tonsillectomy in which position?

Fine, grayish-red lines

A mother of a 3-year-old child tells the nurse that the child has been continuously scratching the skin and has developed a rash. On data collection, which finding indicates that the child may have scabies?

Obtain a blood glucose reading.

The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?

The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).

The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome?

Checking the child's ability to perform range of motion to the shoulder area of the affected extremity

The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?

Notify the registered nurse (RN).

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?

Our child will eventually grow out of this condition. It is not necessary to avoid individuals with the common cold

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.

"I can use a warm mist humidifier to keep the secretions loose."

The nurse is reinforcing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further teaching?

The child thrusts the chin forward and opens the mouth

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

Hemophilia A results from deficiency of factor VIII.

The nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor which fact about hemophilia?

Place the child on a wheeled scooter board.

A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. To meet these goals, which action should the nurse take when working with the child?