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1. A 3-month-old infant is admitted. Upon admission, the nurse assesses her developmental status as appropriate for age. Which of the following is the child least likely to be able to do? 1. Smile in response to mother's face 2. Reach for shiny objects but miss them 3. Hold head erect and steady 4. Sit with slight support Table 16-9 Nursing Diagnoses Related to Lead Poisoning Acute: • Risk for trauma • Risk for deficient fluid volume • Deficientknowledge Chronic: • Imbalanced nutrition, less than body requirements • Chronicconfusion • Chronicpain Source: Delmar/Cengage Learning 2. A 3-month-old infant is doing well after the repair of a cleft lip. The nurse wants to provide the client with appropriate stimulation. What is the best toy for the nurse to provide? 1. Colorful rattle 2. String of large beads 3. Mobile with a music box 4. Teddy bear with button eyes 3. Which toys would be best for a 5-month-old infant who has infantile eczema? 1. Soft, washable toys 2. Stuffed toys 3. Puzzles and games 4. Toy cars 4. Which diversion would be appropriate for the nurse to plan to use with an 8-month-old infant? 1. A colorful mobile 2. Large blocks to stack 3. A colorful rattle 4. A game of peek-a-boo 5. Which activity would best occupy a 12-month- old child while the nurse is interviewing the parents? 1. String of large snap beads and a large plastic bowl 2. Riding toy 3. Several small puzzles 4. Paste, paper, and scissors 6. An 18-month-old child is admitted for a repeat cardiac catheterization. The parents are continuously present and do everything for the child—dress him, feed him, and even play for him. The nurse wants to prepare the child and the parents for the procedure. Which of the following should be included in the care plan? 1. Give the child simple explanations. 2. Talk with the parents to assess their knowledge and how they can help with the child's care. 3. No specific action will be necessary because the child and family have been through a cardiac catheterization previously. 4. Ask the parents to stay away as much as possible because they upset the child. 7. In planning care for an 18-month-old child, the nurse would expect him to be able to do which of the following? 1. Button his shirt and tie his shoes 2. Feed himself and drink from a cup 3. Cut with scissors 4. Walk up and down stairs 16 320 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 8. The mother of a 2-year-old child asks the nurse how to cope with the child's frequent temper tantrums when he does not get what he wants immediately. What information should the nurse include when responding? 1. As long as the child is safe, ignore him during the tantrum. 2. If the child's demands are reasonable, give him part of what he wants. 3. Spank the child if the tantrum continues for more than five minutes. 4. Explain to the child why he cannot have what he wants and promise him a reward when he stops crying. 9. A 3-year-old child is admitted to the pediatric unit for diagnostic tests. His mother is discussing the child's hospitalization with the nurse. She is concerned about staying with this child and caring for her other two children at home. Which suggestion to the mother will most help the child adjust to being in the hospital? 1. Do not visit the child until discharge so that your child won't cry when you leave. 2. Spend the night in the hospital with your child. 3. Bring your child's favorite teddy bear and security blanket to the hospital. 4. Buy your child a gift to let the child know you care deeply. 10. The parents of a 3-year-old child are leaving for the evening. Which behavior would the nurse expect the child to exhibit? 1. Wave goodbye to the parents 2. Cry when the parents leave 3. Hide his/her head under the covers 4. Ask to go to the playroom 11. When planning outdoor play activities for a normal 4-year-old child, which activity is most appropriate? 1. Two-wheeled bike 2. Sandbox 3. Climbing trees 4. Push toy lawn mower 12. A 5-year-old child had major surgery several days ago and is allowed to be up. When planning diversional activity, which action by the nurse is most appropriate? 1. Give the child a book to read. 2. Play a board game with the child. 3. Encourage the child to play house with other children. 4. Turn on the television so the child can watch cartoons. 13. A 6-year-old child is admitted for a tonsillectomy. Considering the child's age, which of the following would be the most important to include in a preoperative physical assessment? 1. Characteristics of tongue, gum, or lip sores 2. Any sign of tonsillar inflammation 3. The number and location of any loose teeth 4. The location and presence of tenderness in any swollen lymph nodes 14. A 6-year-old child is in the terminal stage of leukemia. The child appears helpless and afraid. How can the nurse best help the child? 1. Allow the child to make the major decisions for her care 2. Make all decisions for the child 3. Discuss with the child the fears that dying children usually have 4. Discuss with the child the reasons for her fears 15. The nurse is preparing a 6-year-old child for cardiac surgery. Which preoperative teaching technique is most appropriate? 1. Have the child practice procedures that will be performed postoperatively, such as coughing and deep breathing. 2. Arrange for the child to tour the operating room and surgical intensive care unit. 3. Encourage the child to draw pictures illustrating the operation. 4. Arrange for the child to discuss heart surgery and postoperative events with a group of children who have undergone heart surgery. 16. A 10-year-old girl is being treated for rheumatic fever. Which would be an appropriate activity while she is on bed rest? 1. Stringing large wooden beads 2. Engaging in a pillow fight 3. Making craft items from felt 4. Watching television 17. A 10-year-old boy who is immobilized in a cast following an accident has been squirting other children and the staff with a syringe filled with water. The nurse wants to provide other activities to help him express his aggression. Which activity would be most appropriate? 1. Cranking a wind-up toy 2. Pounding clay 3. Putting charts together 4. Writing a story 18. An 11-year-old boy is admitted to the pediatric unit in traction with a fractured femur sustained in a motorcycle accident. His uncle, who was Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 16 PEDIATRICS 321 driving the cycle when the accident occurred, received only minor injuries. The child tells the nurse that his uncle was not to blame for the accident. He is "the best motorcycle rider in the world." The nurse interprets this to mean that the child is exhibiting which defense mechanism? 1. Denial 2. Repression 3. Hero worship 4. Fantasy 19. The nurse is planning care for an 11-year-old child who has a fractured femur and is in traction. Which activity would be most appropriate? 1. Dramatizing with puppets 2. Building with popsicle sticks 3. Watching television 4. Coloring with crayons or colored pencils 20. A 2-year-old child is hospitalized for a fractured femur. During his first two days in the hospital, he lies quietly, sucks his thumb, and does not cry. Which is the best interpretation of his behavior? 1. He has made a good adjustment to being in the hospital. 2. He is comfortable with the nurses caring for him. 3. He is experiencing anxiety. 4. He does not have a good relationship with his parents. 21. A hospitalized 2.5-year-old child has a temper tantrum while her mother is bathing her. Her mother asks the nurse how she should handle this behavior. Which information should be included in the nurse's reply? 1. Temper tantrums in a hospitalized child indicate regression. 2. Tantrums suggest a poorly developed sense of trust. 3. Discipline is necessary when a child has a temper tantrum. 4. This behavior is a normal response to limit setting in a child of this age. 22. A 3-year-old child resists going to bed at night. Her mother asks the nurse what she should say to her. Which response should the nurse suggest to the mother as most appropriate? 23. 24. 25. 26. 27. 28. 29. An 8-year-old child is terminally ill. Considering the child's age, which statement would you most expect the child to make? 1. "After I'm dead, will you come visit me?" 2. "Who will take care of me when I am dead?" 3. "Will it hurt me when I die?" 4. "Can you help me do a videotape about dying from leukemia?" A father has brought his 4-month-old daughter to the well-baby clinic. Which statement that he makes is the greatest cause for concern to the nurse? 1. "She cannot sit up by herself." 2. "She does not hold the rattle as well as she did at first." 3. "She does not follow objects with her eyes." 4. "She spits up after a feeding." A 3-year-old child has all of the following abilities. Which did he acquire most recently? 1. Walking 2. Throwing a large ball 3. Riding a tricycle 4. Stating his name The mother of a 2-year-old child calls the doctor's office because her child swallowed "the rest of the bottle of adult aspirin" about a half hour ago. The nurse determines that there were about 15 tablets left in the bottle. What initial assessment findings are consistent with aspirin ingestion? 1. Bradypnea and pallor 2. Hyperventilation and hyperpyrexia 3. Subnormal temperature and bleeding 4. Melena and bradycardia A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care? 1. Administration of syrup of ipecac 2. Cardiopulmonary resuscitation 3. Ventilatory support 4. Gastric lavage A 6-month-old child is being seen for a well-baby visit. The child has received all immunizations as recommended so far. What immunizations does the nurse expect to give at this visit? 1. DTP, MMR, IPV 2. DTP, hepatitis B, HIB 3. HIB, IPV, varicella 4. MMR, hepatitis B, HIB The mother of a 6-year-old child who has chickenpox asks the nurse when the child can 322 NCLEX-PN® Review 1. 2. 3. 4. "I don't love you anymore because you don't know how to listen." "All good children go to bed on time." "If you go to sleep now, I'll take you to the zoo tomorrow." "Here is your blanket. It's time to go to sleep." 16 Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. go back to school. What information should be included in the nurse's response? The child is contagious: 1. until all signs of the disease are gone. 2. as long as the child has scabs. 3. as long as there are fluid-filled vesicles. 4. until the rash and fever are gone. 30. A 2-year-old child is in for an annual examination. Which comment by the mother alerts the nurse to a risk for lead poisoning? 1. "Why does he eat paint off the window sills?" 2. "Will his temper tantrums ever stop?" 3. "I haven't been able to toilet train him yet." 4. "He is such a messy eater." Answers and Rationales 1. 4. Sitting with slight support would be expected in a child of 5 months. All of the other tasks are appropriate for this age. 2. 3. Anything that can be put in the mouth is inappropriate for a child with cleft lip repair. A rattle and beads can go in the mouth. Button eyes are a hazard for any infant because the infant may swallow them. A mobile with a music box is appropriate for a 3-month-old who lays in a crib, and this item cannot be put in the mouth. Note that a colorful rattle is also age appropriate but not condition appropriate. 3. 1. Soft, washable toys of smooth, nonallergenic material should be used. Stuffed toys are contraindicated. Puzzles and games are not age appropriate. Toy cars could be used for scratching and should be avoided. Toy cars are also not age appropriate. 4. 4. Peek-a-boo is appropriate for an 8-month-old. Peek-a-boo helps the infant with the concept of object permanence; things that are out of sight do exist. An 8-month-old can sit up; once an infant can sit up, the mobiles should be removed because they can strangle an infant who might try to stand up. An 8-month-old infant cannot stack large blocks yet. A colorful rattle is more appropriate for a younger infant. 5. 1. Stringing large beads is appropriate for 12 months. Note that the beads are large and therefore not subject to being swallowed. A riding toy and small puzzles would be more appropriate for a toddler. Paste, paper, and scissors are appropriate for a preschooler when used with supervision. 6. 2. An 18-month-old child cannot understand explanations. The nurse needs to assess the clients' knowledge and base teaching on that assessment. The nurse should not assume that no teaching is needed just because the child has had the procedure before. There are no data to indicate that the parents upset the child. They do appear to be smothering the child, but at this time, the child would probably be more miserable without the parents. The nurse may want to teach parents about growth and development needs of the toddler. 7. 2. An 18-month-old should be able to feed himself and drink from a cup. He may be messy. A 5- or 6-year-old can usually button a shirt and tie shoes. Cutting with scissors is appropriate for a preschool child. A 2-year-old child can go up and down stairs with both feet on the same step, and a 3-year-old child can go up and down stairs by alternating feet. 8. 1. Temper tantrums are common and normal in a 2-year-old because he is developing autonomy. As long as the child is safe, he should be ignored. Giving in to the child's demands is likely to reinforce the negative behavior and create a long- term pattern of behavior. The nurse should not recommend to the parents that they spank a child. Promising a reward to stop crying is bribing the child and should not be recommended. A 2-year- old who is having a temper tantrum is not likely to listen to explanations. 9. 3. The child's teddy bear and security blanket will help to give the child a sense of security. Spending the night would be ideal, but it may not be possible for this mother with two children at home. It is part of the normal separation reaction for a 3-year-old to be upset when the mother leaves. The parents should visit even if the child cries when they leave. Buying a gift will provide less security than bringing the child's favorite comfort items to the hospital. 10. 2. It is normal for a 3-year-old to cry when the parents leave. The child will probably not wave goodbye even though he/she is able to. The child is not likely to hide under the covers. The child will likely be too upset to ask to go to the playroom. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 16 PEDIATRICS 323 11. 2. A sandbox is appropriate for outdoor play. A 4-year-old is too young for a two-wheeled bike or for climbing a tree without strict supervision. He is probably past the age of pushing a toy lawn mower, which is more appropriate for a toddler. 12. 3. Five-year-old children like cooperative play, such as playing house. The other activities are solitary activities. Note that the child is several days postsurgery. Most 5-year-olds are not able to read a book by themselves. Playing a board game with a child is not wrong, but it is a solitary activity. Most 5-year-olds would prefer to play with other children. There is almost always a better alternative than turning on the television. This child is several days postsurgery and is able to be up and play with others. 13. 3. A 6-year-old is apt to be loosing baby teeth. This is an important consideration when anesthesia is to be administered and the child will be intubated. The nurse should assess for loose teeth in any school-age child who is admitted for surgery or other procedures requiring intubation of any kind. 14. 4.Bydiscussingwiththechildthereasonsfor the child's fears, the child will feel less afraid and less abnormal. Discussion of fears should be individualized. The child is not old enough to make care decisions. The child should, however, be given some input into the care plan. The child might decide which site the nurse will use for an injection but not whether or not the medication will be given. The parents will make those decisions. 15. 1. A 6-year-old learns best by doing. A 6-year-old cannot conceptualize what he or she cannot see. Touring the operating room and surgical intensive care unit can be very frightening for a 6-year- old. Drawing pictures of the procedure would be more appropriate postoperatively, when the nurse may want to help him in understanding what happened to him. Drawing pictures is a good way to express feelings that a 6-year-old cannot put into words. Group discussion is more appropriate for an adolescent. A 6-year-old does not have the verbal skills to participate in and learn from a discussion group. 17. 2. Pounding movements allow for the expression of aggression. The other activities would not allow for an expression of aggression. The scenario describes a child who is expressing aggression in a very physical manner. This child is not likely to respond well to writing a story. Writing a story could be used to help a child express aggression, but pounding clay is more appropriate given the child's aggressive behavior. 18. 3. Hero worship is very common among school- age children. Denial would be manifested by saying that his leg really is not broken. Repression is putting an upsetting or guilt-laden experience deep in the unconscious mind. This behavior does not suggest repression. Fantasy is living in a make- believe world. This boy shows no evidence of living in a make-believe world. 19. 2. Building with popsicle sticks will foster his sense of industry and can be done while he is in bed in traction. Puppets and coloring would be more appropriate for younger children. Watching television will not promote his development, although it can be used as diversion occasionally. 20. 3. The child's behavior is typical of the despair phase of toddler responses to anxiety. The child should cry. Lying quietly, sucking his thumb, and saying nothing are suggestive of severe anxiety, a bad adjustment to the hospital, and no comfort with the nurses. This anxiety response does not suggest a poor relationship with his parents. In fact, his severe separation anxiety may be because he is so close to his parents. 21. 4. Temper tantrums are a normal response to limit setting in a 2-year-old child. Answer 1 might be correct if the child were older. However, temper tantrums in a 2-year-old child do not indicate regression; rather, they are normal for this age. Tantrums are not suggestive of a poorly developed sense of trust; they are normal. Ignoring the tantrum is preferable to discipline when a 2-year- old has a tantrum. 22. 4. The best response is to simply state that it is time for sleep and to give the child her security blanket or toy. Answer 1, telling the child that she isn't loved because she won't listen, is not therapeutic. Answer 2 implies that if you don't go to bed on time, you are not a good child. This is not a good suggestion to implant in a child. Answer 3 is bribery and is not appropriate. 23. 3.An8-year-oldisconcernedaboutpainand mutilation. An 8-year-old has an understanding that death is the end of life as we know it and would be unlikely to respond with answers 1 or 2. Answers 1 and 2 are typical of a preschooler. Answer 4 is typical of an adolescent who wants to leave a legacy. 16. 3. Craft work allows her to accomplish something while meeting her needs for rest. Industry is the developmental task for school-age children. The joint pains with rheumatic fever tend to be in the large joints, not the small ones, so craft work using finger activity would probably not be painful. Stringing large wooden beads is appropriate for younger children. Pillow fighting requires too much energy for a child on bed rest and is not appropriate for a hospital environment. Watching television is a solitary activity with no sense of accomplishment. 16 324 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 24. 3. A 4-month-old should follow objects with her eyes. A 4-month-old is not likely to be able to sit up by herself. This behavior is seen at 6 months of age. Not being able to hold the rattle as well as she did at first is typical of the time after the loss of the grasp reflex and before pincer movement is established. Most newborn reflexes are gone by about 4 months of age. Spitting up after a feeding is normal 4-month-old behavior. 25. 3. Riding a tricycle is 3-year-old behavior. Remember, "three years, three wheels." Children start to walk at about 1 year of age. Throwing a large ball and stating his name are 2-year-old behaviors. Remember to use developmental trends when determining the most recently acquired behavior—head to tail and simple to complex. Look for a complex lower body behavior. 26. 2. The child will have an elevated body temperature. Contrary to what you might expect, metabolism is increased following aspirin overdose. The child will be hot and flushed. Hyperpyrexia means high temperature. The child will be in metabolic acidosis from the acid load of the aspirin. Compensation for metabolic acidosis is rapid, deep breathing. The first choice is incorrect; the child will be hyperventilating and will be flushed, not pale. The third choice is not correct; the temperature will be high, not low. Bleeding may occur following aspirin ingestion, but not initially. The fourth choice is not correct. Melena is hidden blood in the stool. It will take some time for a gastrointestinal bleed to develop and pass through the stool. Bradycardia will not be present. The child will have tachycardia. 27. 4. Since the child is breathing, there is no need for cardiopulmonary resuscitation (CPR) or ventilatory support. Gastric lavage is usually used rather than inducing emesis. In any event, the child is difficult to arouse, so it would not be safe to induce vomiting. 28. 2. At 6 months of age, the nurse would expect to administer the third DTP, the third hepatitis B, and the third Haemophilus influenzae type B (HIB) immunizations. MMR (measles, mumps, and rubella) is not given until 15 months of age. IPV is given at 2 months and 4 months and then again at 18 months and preschool. Varicella vaccine is given between the ages of 1 year and 12 years. 29. 3. Chickenpox is contagious as long as there are fluid-filled vesicles. Scabs are not contagious. The child will have scabs for a while. The fever may be down, but if there are fluid-filled vesicles, the child is contagious. 30. 1. Eating paint is one of the major risk factors for lead poisoning. Temper tantrums are normal in a 2-year-old. Most 2-year-olds are not toilet trained. Most 2-year-olds are messy eaters.

Question1

31. A 6-year-old boy has tetralogy of Fallot. He is being admitted for surgery. The nurse knows that which problem is not associated with tetralogy of Fallot? 1. Severe atrial septal defect 2. Pulmonary stenosis 3. Right ventricular hypertrophy 4. Overriding aorta 32. A 6-year-old child with tetralogy of Fallot is being admitted for surgery. While the nurse is orienting the child to the unit, the child suddenly squats with the arms thrown over the knees and knees drawn up to the chest. What is the best immediate nursing action? 1. Observe and assist if needed 2. Place the child in a lying position 3. Call for help and return the child to the room 4. Assist the child to a standing position 33. A 6-year-old child with tetralogy of Fallot is being admitted for surgery. What is most important to teach the child during the preoperative period? 34. 3. The importance of drinking plenty of fluids 4. Positions of comfort A 6-year-old with tetralogy of Fallot has open heart surgery. The septal defect was closed, and the pulmonic valve was replaced. When the child returns to the unit, he has oxygen, IVs, and closed chest drainage. How should the nurse position the chest drainage system? 1. Above the level of the bed 2. At the level of the heart 3. Below the level of the bed 4. Alternating above and below the bed every two hours A parent brings a 3-week-old infant to the clinic. The parent states that the baby does not eat very well. She takes 45 cc of formula in 45 minutes and gets "tired and sweaty" when eating. The nurse observes the baby sleeping in the parent's arms. Her color is pink, and the child is breathing without difficulty. What is the best response for the nurse to make? 1. "It's normal for an infant to get tired while feeding. That will go away as the child gets older." 2. "It's normal for an infant to get tired while feeding. You could try feeding the baby smaller amounts of formula more frequently." 3. "This could be a sign of a health problem. Does your baby's skin color change while eating?" 4. "This could be a sign of a health problem. How does your baby's behavior compare with your other children when they were that age?" The nurse is explaining cardiac catheterization to the parents of a child. The nurse explains to the parents that information about which of the following can be obtained during cardiac catheterization? 1. Oxygen levels in the chambers of the heart 2. Pulmonary vascularization 3. Presence of abdominal aortic aneurysm 4. Activity tolerance The nurse is caring for a toddler who is six hours post cardiac catheterization. The nurse is administering antibiotics. The child's mother asks why the child needs to have antibiotics. The nurse's response should indicate that antibiotics are given to the client to prevent which type of infection? 1. Urinary tract infection 2. Pneumonia 3. Otitis media 4. Endocarditis 35. 1. Strict hand washing technique 2. How to cough and deep breathe 16 332 NCLEX-PN® Review 36. 37. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 38. The nurse is caring for a toddler with a cardiac defect who has had several episodes of congestive heart failure in the past few months. Which data would be the most useful to the nurse in assessing the child's current congestive heart failure? 1. The degree of clubbing of the child's fingers and toes 2. Amount of fluid and food intake 3. Recent fluctuations in weight 4. The degree of sacral edema 39. A child with a cyanotic heart defect has an elevated hematocrit. What is the most likely cause of the elevated hematocrit? 1. Chronic infection 2. Recent dehydration 3. Increased cardiac output 4. Chronic oxygen deficiency 40. The nurse is administering the daily digoxin dose of 0.035 mg to a 10-month-old child. Before administering the dose, the nurse takes the child's apical pulse, and it is 85. Which of the following interpretations of these data is most accurate? 1. The child has just awakened, and the heart action is slowest in the morning. 2. This is a normal rate for a 10-month-old child. 3. The child may be going into heart block due to digoxin toxicity. 4. The child's potassium level needs to be evaluated. 41. The nurse is discussing dietary needs of a child with a serious heart defect. The child is being treated with digoxin and hydrochlorothiazide (Hydrodiuril). The nurse should stress the importance of giving the child which of the following foods? 1. Cheese and ice cream 2. Finger foods such as hot dogs 3. Apricots and bananas 4. Four glasses of whole milk per day 42. A child with a cyanotic heart defect has a hypoxic episode. What should the nurse do for the child at this time? 1. Administer PRN oxygen and position the child in the squat position 2. Position the child side-lying and give the ordered morphine 3. Ask the parents to leave and start oxygen 4. Give oxygen and notify the physician 43. The nurse notes that a child who has had a serious heart condition since birth does not do the expected activities for that age. The child's mother says, "I worry constantly about my child. I don't let the older children or the neighborhood kids play with my child very much. I try to make things as easy for my child as I can." What is the best interpretation of these data? 1. The child is physically incapable due to his cardiac defect. 2. The child's mother is overprotective and allows the child few challenges to develop skills. 3. The child is probably mentally retarded from the effects of continual hypoxia. 4. The child has regressed due to the effects of hospitalization. 44. Ten days after cardiac surgery, an 18-month-old child is recovering well. The child is alert and fairly active and is playing well with the parents. Discharge is planned soon. The nurse notes that the parents are still very reluctant to allow the child to do anything without help. What is the best initial action for the nurse to take? 1. Reemphasize the need for autonomy in toddlers 2. Provide opportunities for autonomy when the parents are not present 3. Reassess the parent's needs and concerns 4. Discuss the success of the surgery and how well the child is doing 45. Sodium salicylate is prescribed for a child with rheumatic fever. What should the nurse assess the child for because the child is on this medication? 1. Tinnitus and nausea 2. Dermatitis and blurred vision 3. Unconsciousness and acetone odor of breath 4. Chills and elevation of temperature Answers and Rationales 31. 1. Atrial septal defect is not associated with tetralogy of Fallot. The four defects are pulmonary stenosis, which causes right ventricular hypertrophy, ventricular septal defect, and overriding aorta. 32. 1. The squatting position will help the child with tetralogy of Fallot to have better hemodynamics. It increases intra-abdominal pressure and increases pulmonary blood flow. Placing the child in a lying or standing position will increase his symptoms and be counterproductive. It is not necessary to call for help because this is not an emergency situation. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 16 PEDIATRICS 333 33. 2. The child will have to learn to cough and deep breathe postoperatively. Studies demonstrate that preoperative teaching makes it easier for the client to perform coughing and deep breathing exercises in the postoperative period. The nurses will do strict hand washing, not the client. Fluids will likely be restricted postoperatively. It is important to teach the client about positions of comfort, but it is more important to teach the child how to deep breathe and cough. 34. 3. Chest bottles are always positioned below bed level to prevent the reflux of material into the chest cavity. 35. 3. Activity intolerance related to feeding is often a key sign of a serious cardiac problem in an infant. Taking only 45 cc of formula in 45 minutes at 3 weeks of age probably indicates difficulty sucking. This is definitely not normal. The fact that the infant's color is pink at rest does not tell you what happens during exertion, such as with eating. Asking about skin color during feeding is a good first question to ask. Answers 1 and 2 are incorrect because they interpret the infant's behavior as normal, which it is not. Answer 4 is not correct. It does identify the behavior as abnormal but suggests comparing it to the child's siblings. This is not the appropriate question to ask to get the most information. 36. 1. The catheter is passed into the chambers of the heart, and oxygen levels can be measured. The cardiac catheter does not assess pulmonary vascularization. Coronary arteries can be visualized, however. An abdominal aortic aneurysm is diagnosed with an arteriogram, not a cardiac catheterization. A cardiac catheterization gives information about the heart structures but does not give information about activity tolerance. 37. 4. During a cardiac catheterization, a catheter is inserted into the heart; therefore, the infection that the client is most at risk for is endocarditis. Urinary tract infection, pneumonia, and otitis media are not related to a client undergoing a cardiac catheterization. 38. 3. Weight is the best indicator of fluid balance. Congestive heart failure causes fluid retention. Sacral edema is positionally dependent. Weight will give a better indication of the child's status. Clubbing of the fingers and toes is an indication of chronic hypoxemia, not the status of his current congestive heart failure. Fluid and food intake is a general indicator of his status and is not particularly related to his current congestive heart failure. 39. 4. The body tries to compensate for chronic oxygen deficiency by making additional red cells to transport oxygen. The additional red cells increase the hematocrit, which is the percentage of blood that is red blood cells. Chronic infection is more likely to cause anemia. Recent dehydration will cause an elevated hematocrit because there is less fluid in the blood. However, there is no indication that the child is dehydrated, and we are told that he has a cyanotic heart defect, which makes him chronically hypoxic. Therefore, answer 4 is better than answer 2. Answer 3, increased cardiac output, is also incorrect. Increased cardiac output does not cause an elevated hematocrit. 40. 3. A pulse below 100 in a 10-month-old child who is taking digoxin most likely indicates digoxin toxicity. The nurse should withhold the medication and notify the physician. The normal pulse for this age is about 120 or a little more at rest. The pulse rate does not tell us that the child needs to have his/her potassium level checked. If the child is also taking Lasix or another potassium-depleting diuretic, then the potassium should be checked. 41. 3. The child should be on a sodium-restricted diet with high-potassium foods because he is taking Hydrodiuril, a potassium-depleting diuretic. Apricots and bananas are low in sodium and high in potassium. Cheese and ice cream are high in sodium. Hot dogs are high in sodium. Whole milk is high in sodium. Not only is potassium needed, but excessive sodium should also be avoided because those with severe heart defects are prone to fluid retention. 42. 1. The knee-chest or squat position increases intra-abdominal pressure and increases blood flow to the lungs. Oxygen is also indicated because the child is hypoxic. Positioning on the side is not appropriate because it will not improve the blood flow to the lungs. There is no need to ask the parents to leave. In fact, they need to know how to handle these episodes if they are not yet comfortable doing so. Children with cyanotic heart defects have hypoxic episodes fairly regularly. Positioning in the squat position is more important at this time than notifying the physician. 43 2. The child's mother does not let the child play with others and appears to do everything for the child. She seems to be overprotective. Most children with heart defects are capable of doing most age-appropriate activities. There is no evidence to support that the child is mentally retarded. There are no data to support that the child has regressed. 16 334 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 44. 3. Before the nurse can teach the parents, it will be necessary to reassess their needs and concerns. The question asks for the best initial action. Initially, the nurse should assess. Later, the nurse may emphasize the toddler's need for autonomy. The nurse may provide the child with opportunities to develop autonomy, although it would be better to teach the parents. The nurse may also discuss the success of the surgery and how well the child is doing, but this is not the initial action. 45. 1. Tinnitus and nausea are signs of toxicity to

Question 4

71. A 10m old is seen in a well baby clinic. Which assessment finding by the nurse indicates a need for further neurological evaluation? 1. Inability to crawl 2. Speaking only two to four words 3. Inability to sit up without support 4. Presence of crude pincer grasp What should the nurse do to protect a child from injury during a seizure? 1. Restrain the child's arms and legs 2. Place a tongue blade in the child's mouth 3. Place a pillow under the child's head 4. Provide a waterproof pad for the bed The nurse is teaching the parents of a child who has cerebral palsy to feed the child. What position is best to recommend? 1. A normal eating position and provide stabilization of the jaw 2. A semi-reclining position 3. Upright while using a nasogastric or gastrostomy tube 4. Hyperextension of the neck A 1-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which room should the nurse assign to this child? 1. A room with a 2-year-old who had surgery for a hernia repair 2. A room with a 1-year-old child who has pneumonia 3. A room with a 2-year-old child who has cerebral palsy 4. A private room with no roommates The nurse is caring for an infant who is admitted with bacterial meningitis. What is the first priority when providing nursing care for this child? 1. Administerorderedantibioticsassoonaspossible. 2. Keep the room quiet and dim. 3. Explain all procedures to the parents. 4. Begin low-flow oxygen via mask. 76. A newborn has a myelomeningocele. What is the most important nursing action prior to surgery? 1. Turn the infant every two hours 2. Encourage holding and cuddling by the parents 3. Apply sterile, moist, nonadherent dressings over the lesion 4. Administer pain medication every three to four hours 77. A 3-year-old child is being seen in the neurology clinic for a routine visit. The child had a repair of a myelomeningocele shortly after birth. The child's mother asks the nurse when she can accomplish bladder training. What is the best reply? 1. "You need to take your child to the bathroom every two hours." 2. "We will teach you how to do intermittent, clean catheterization." 3. "Continue to diaper the child until school age." 4. "Your child needs to learn how to do self- catheterization." 78. Which assessment regularly performed on newborns and infants will do most to help with early identification of infants who might have hydrocephalus? 1. Head circumference 2. Weight measurement 3. Length measurement 4. Presence of reflexes 79. How should the nurse position a 4-month-old infant who has hydrocephalus? 1. Side-lying 2. Sitting up in an infant seat 3. Alternating prone and supine 4. Left Sims' position 80. The parents of a child who has otitis media ask the nurse why the doctor told them to give the child acetaminophen instead of aspirin. What should the nurse include when answering? 1. Acetaminophen is more effective against ear pain than aspirin. 2. Acetaminophen is better at reducing temperature than aspirin. 3. Aspirin may cause gastritis in children. 4. Aspirin is thought to cause Reye's syndrome, a very serious disease. 81. The parents of a child who is newly diagnosed with Tay-Sachs disease ask the nurse, "If we have more children, could they be affected?" Which information should be included when responding to the parents? 1. Boys are more likely to inherit the disease than girls. 2. Tay-Sachs is not inherited, so there is little chance other children will have it. 3. Thereisaone-in-fourchancethateachpregnancy will result in a child who has the disease. 4. Fifty percent of the girls will have the disease. 82. When planning care for an infant who has Tay-Sachs disease, the nurse knows that the care is aimed at which of the following? 1. Providing supportive care until the child dies 2. Preventing spread of the disease to others 3. Curing the underlying problem so the child will grow normally 4. Providing for maximum development of the child 83. An infant is born with a meningomyelocele. How should the nurse position the infant before surgery? 1. Prone with a pillow under the legs 2. Supine with head elevated 3. Side-lying with a pillow at the back 4. Semi-Fowler's with a small pillow 84. Theparentsofa2-year-oldchildwhohasmeningitis ask the nurse why the lights are dim in the child's room even in the daytime. What information should the nurse include in the answer? 1. Rest is essential, and a dimly lit room promotes rest. 2. The child is sensitive to light and may develop seizures. 3. The IV medications are very sensitive to light. 4. Light could cause severe damage to the eyes and possible blindness. 85. A 6-year-old child is brought to the doctor's office with crusts on the eyelid and a very red conjunctiva. The doctor prescribes antibiotic eye drops. The child's mother asks the nurse if the child can go back to school this afternoon. How should the nurse respond? 1. Teach the child not to touch his eyes, and take him back to school. 2. He should stay out of school today but can go back tomorrow. 3. He should stay out of school for a week because it usually takes a week for the condition to clear. 4. This condition is very contagious. The child should stay out of school for the next two days. 86. The nurse is administering eye drops to a child who has conjunctivitis. Where should the eye drops be placed? 1. On the pupil 2. In the conjunctival sac 3. By the inner canthus 4. On the sclera 87. The nurse is caring for a 5-month-old infant who had a craniotomy following a head injury. Which observation the LPN/LVN makes should be reported to the charge nurse? 1. Respirations of 38 2. Difficulty arousing the baby from a nap 3. Pulse rate of 120 4. The baby cannot sit up by herself. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 88. Thenurseiscaringforachildwhohascerebralpalsy. The nurse notes that the child does not writhe when 16 PEDIATRICS 349 sleeping but is in constant motion when awake. How should the nurse interpret this observation? 1. The child should be encouraged to do something productive so she will not think about writhing. 2. This indicates that the child could control the movements if she wanted to. A behavior modification program may be effective. 3. This is typical of cerebral palsy. The nurse should assist the child with activities of daily living (ADLs) as needed. 4. The child should be sedated much of the time to prevent the dangerous writhing that occurs during waking. 89. A 10-year-old boy tells his neighbor, a nurse, that his eyes were "stuck together" this morning when he woke up. The nurse notes that his eyes are red, and the conjunctiva is inflamed. What should the nurse neighbor recommend to the boy's mother? 1. Tell his mother that he may have a contagious disease and should be seen by his doctor today. 2. Encourage the mother to make an appointment to see the eye doctor. 3. Suggest to the mother that the boy go to school today but make an appointment with the doctor if the condition does not clear up soon. 4. Explaintotheboythatheshouldwashhisface and eyes with a wash cloth as soon as he wakes up. 90. Thenurseiscaringforaninfantwhohashadsurgery for a meningomyelocele. When thinking of long-term care needs, which understanding is most accurate? 1. The surgery corrects the defect, and the infant should develop normally. 2. The infant is likely to have lower body paralysis and bowel and bladder dysfunction. 3. Theinfantshoulddevelopnormallyphysicallybut is likely to have some degree of mental retardation. 4. The surgery may need to be repeated if the condition recurs. Answers and Rationales 71. 3. A child who is 10 months of age should have been sitting without support for several months. This sign indicates a developmental lag and the need for further assessment. The ability to crawl is usually acquired between 9 and 12 months. Saying two to four words is normal for a child of 10 months. The development of the pincer grasp is refined by 11 months of age. It is normal for a 10-month-old child to use a crude pincer grasp. of a child who is having a seizure. No restraints or force should be used during a seizure. Nothing should be put in the mouth of a person who is having a seizure. Although having a waterproof mattress or pad would prevent the bed from being soiled, it has nothing to do with the child's safety. 73. 1. Upright with stabilization of the jaw is important because jaw control is often lacking in a child with cerebral palsy. Feeding in a semi- reclining position does not promote swallowing. A child with cerebral palsy does not usually need tube feeding or a gastrostomy. Hyperextending the neck may interfere with swallowing. 74. 4. Bacterial meningitis is infectious. The child should be placed in a private room with respiratory precautions. 75. 1. The first priority is to begin antibiotics as soon as possible. The more quickly antibiotics are started, the better the child's prognosis. The nurse will keep the room quiet and dim and will explain actions to the parents. However, these actions are not as high of a priority as administering the antibiotics. Oxygen is administered only if the child's respiratory status is impaired. 76. 3. It is important to prevent the defect from becoming dry and cracked and allowing microorganisms to enter. Infants with myelomeningocele remain in a prone position to prevent excessive pressure or tension on the defect. In most cases, infants with myelomeningocele cannot be held and cuddled as other babies are. The parents should stroke and touch the infant even if they cannot hold him or her. The infant is not usually in pain. 77. 2. Parents should be taught intermittent, clean catheterization. Parents can begin using this procedure at the age when unaffected children are toilet trained (about 3 years). Children who have myelomeningocele do not usually have bowel and bladder control, so taking him to the bathroom would serve no purpose. The child does not need to wear diapers until he goes to school. He should be as normal as possible. A 3-year-old child is not old enough to learn self-catheterization techniques. He will learn when he is older and has better motor coordination and understanding of the procedure. 78. 1. Head circumference is the most important tool in early identification of hydrocephalus. Head circumference is measured at birth and at all well-baby visits. Measurements above the norm will be seen in infants with hydrocephalus. Weight and length do not have any connection with hydrocephalus. An infant with severe hydrocephalus may have abnormal reflexes, but head circumference will do the most to help with 72. 3. Placing a pillow under the head, using padded side rails, and removing sharp or hard objects from the immediate area all provide for the safety 16 350 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. the early identification of infants who might have hydrocephalus. 79. 2. The infant with hydrocephalus should be positioned sitting up in an infant seat to promote drainage as much as possible and reduce intracranial pressure. Side-lying, Sims', prone, and supine are not indicated. These positions would increase intracranial pressure. 80. 4.Aspiringiventochildren,especiallythosewho may have a viral infection, is associated with the development of Reye's syndrome, a very serious problem affecting the brain and the liver that is often fatal. Therefore, we do not give aspirin to children. Acetaminophen is nearly as effective as aspirin in relieving pain and fever; it is not more effective. Aspirin can cause gastritis in anyone, but that is not the reason why we do not give it to children. 81. 3.Tay-Sachsdiseaseisanautosomal,recessive condition. That means that both parents must have the gene and that there is a one-in-four chance with every pregnancy that the child will have the condition. The disease is not X-linked, so it is not seen more frequently in boys. Hemophilia is X-linked. 82. 1. There is no cure for Tay-Sachs disease. The child is missing the enzyme hexosaminidase A, which is necessary for all tissues. The child will become blind and lose any skills that he may have developed and will eventually die. There is no cure and no way to stop the progress of the disease. The disease is not communicable; it is genetic. The parents will need genetic counseling, but that is not the goal of care for the child. 83. 1. Infants with meningomyelocele should be positioned prone with a pillow under the lower legs. Every effort is made to avoid putting pressure on the sac. Breaking the sac would likely cause the infant to develop meningitis. All of the other position choices would put pressure on the sac. 84. 2. The child is sensitive to light and may develop seizures. A dimly lit room reduces the chance that seizures will occur. The child does need rest, but that is not the reason for a dimly lit room. The other answer choices are not correct. 85. 4. The condition described is probably pink eye, and it is very contagious. Once antibiotic treatment is started, the child should stay out of school for 24 to 48 hours. 86. 2. Eye drops should be placed in the conjunctival sac. Gentle pressure should be applied to the inner canthus to prevent the eye drops from entering the tear ducts and causing a runny nose. 87. 2.Difficultyarousingthechildfromanapsuggests a change in level of consciousness, a cardinal sign of increased intracranial pressure, and should be reported immediately to the charge nurse. The other findings are all normal for a 5-month-old infant. 88. 3. Children with cerebral palsy who have athetoid movements are in constant motion during waking hours but move much less during sleep. The nurse should assist the child with ADLs as needed. The child cannot control these movements. The child should not be sedated constantly. 89. 1. The symptoms suggest conjunctivitis or "pink eye," which is very contagious. The child should not go to school and should be seen by his physician today. Conjunctivitis is treated by the pediatrician or primary care physician and does not require an eye doctor. 90. 2. Infants who have meningomyelocele usually have lower body paralysis and bowel and bladder dysfunction. The surgery closes the defect, but when the spinal nerves are in the sac, there is usually permanent damage. Unless there is associated hydrocephalus, the infant may well have normal mental development.

Question5

91. The nurse is teaching the mother of a newborn who has a cleft lip and palate to feed the infant. Which would be least appropriate to include? 1. Place the tip of the Asepto syringe at the front of the baby's mouth so that the baby can suck. 2. Rinse the mouth with saline after each feeding to minimize infections. 3. Feed the baby in an upright position and bubble frequently to reduce air in the stomach. 4. Apply lanolin to lips to reduce dryness associated with mouth breathing. 92. The mother of a 2-month-old infant with a cleft lip and palate calls the clinic. She tells the nurse that the baby has a temperature of 102°F, has been turning her head from side to side, and has been eating poorly. What should the nurse advise? 1. Clean the baby's ears with warm water. 2. Give the baby infant Tylenol 0.3 cc and call back in four hours after taking her temperature. 3. Bring the baby into the clinic for evaluation. 4. Give the baby 4 oz of water and retake her temperature in one hour. 16 356 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 93. A 3-month-old infant is hospitalized for repair of a cleft lip. Following surgery, the baby returns to the unit with a Logan bow in place. The baby is awake and beginning to whimper. The baby's color is pink, and pulse is 120 with respirations of 38. An IV is ordered in the baby's right hand at 15 cc per hour. The fluid is not infusing well. Her right hand is edematous. The jacket restraint has loosened, and one arm has partially come out. What is the priority nursing action? 1. Recheck the baby's vital signs 2. Check the baby's IV site for infiltration 3. Check to see if the baby has voided 4. Replace the restraints securely 94. Following surgery for repair of a cleft lip, it is important to prevent excessive crying by the infant. What should the nurse do to accomplish this? 1. Give the baby a pacifier to meet his/her sucking needs. 2. Place the baby in the usual sleeping position, which is on the abdomen. 3. Ask the baby's mother to stay and hold the child. 4. Request a special nurse to hold the infant. 95. The nurse is doing discharge planning and establishing long-term goals for an infant who had a cleft lip repair. The baby also has a cleft palate. Which long-term goal is most appropriate and necessary for this child? 1. Prevent joint contractures. 2. Promote adequate speech. 3. Promote bowel regularity. 4. Prevent infection of surgical incision. 96. The nurse is caring for an 8-month-old infant who has had diarrhea for two days. Which is the most useful in assessing the degree of dehydration? 1. Number of stools 2. Skin turgor 3. Mucus membranes 4. Daily weight 97. An infant who has severe diarrhea and dehydration is hospitalized and is NPO. Intravenous fluids are ordered. What is the immediate goal of care? 1. Restoration of intravascular volume 2. Prevention of further diarrhea 3. Promotion of skin integrity 4. Maintenance of normal growth and development 98. The nurse is caring for a 9-month-old infant who is allowed only clear fluids. What are the most appropriate liquids for the nurse to offer? 1. 7-Up and ginger ale 2. Pedialyte and glucose water 3. Half-strength formula 4. Tea and clear broth 99. The nurse is caring for an infant who is being treated for severe diarrhea. Twenty-four hours after admission, the diet is advanced from NPO to clear liquids. After clear liquids are started, the baby has four stools in two hours. What should the nurse do? 1. Continue oral feedings 2. Take the pulse, temperature, and respirations 3. Stop feeding the child orally 4. Weigh the child 100. A 12-month-old child who was diagnosed at birth as having Hirschsprung's disease has been maintained at home under conservative treatment. The parents have brought the child to the clinic for a well-baby examination. After interviewing the child's parents, the nurse concludes that an appropriate treatment regimen is being followed. Which of the following would indicate this? 1. Use of tap water enemas and a low-residue diet 2. Use of soap suds enemas and a high-fiber diet 3. Use of isotonic saline enemas and a high-fiber diet 4. Use of isotonic saline enemas and a low- residue diet 101. A 3-month-old infant is admitted to the pediatric unit with a diagnosis of Hirschsprung's disease. What is most important when monitoring the infant's status? 1. Weigh the infant every morning. 2. Maintain intake and output records. 3. Measure abdominal girth every four hours. 4. Check serum electrolyte levels. 102. An infant who has Hirschsprung's disease is scheduled for surgery. Which explanation should the nurse include when discussing the upcoming surgery with the parents? 1. They will need to learn colostomy care because the child will have a permanent colostomy. 2. The baby will have tap water enemas until Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. clear before the surgery. 16 PEDIATRICS 357 3. The baby will have a temporary colostomy to allow the bowel time to heal. 4. They will need to learn how to administer gastrostomy feedings while the colostomy is present. 103. A 5-week-old infant is seen in the physician's office for gastroesophageal reflux. What should the nurse suggest to the parents regarding feeding practices? 1. Dilute the formula to facilitate better absorption. 2. Position the child at a 30- to 45-degree angle after feedings. 3. Change from milk-based formula to soy-based formula. 4. Delay burping to prevent vomiting. 104. Which assessment finding would the nurse expect in an infant diagnosed with pyloric stenosis? 1. Abdominal rigidity 2. Ribbon-like stools 3. Visible waves of peristalsis 4. Rectal prolapse 105. An infant has had frequent episodes of green, mucus-containing stools. The nursing assessment reveals that the infant has dry mucus membranes, poor skin turgor, and an absence of tearing. Based on these data, what is the most appropriate nursing diagnosis? 1. Impaired skin integrity related to irritation caused by frequent, loose stools 2. Deficient fluid volume related to frequent, loose stools 3. Pain related to abdominal cramping and diarrhea 4. Imbalanced nutrition: less than body requirements related to diarrhea 106. The nurse is caring for an infant admitted with diarrhea, poor skin turgor, and dry mucus membranes. Which laboratory data would cause the nurse the most concern? 1. Sodium 140 mmol/L 2. Urine specific gravity 1.035 3. Hematocrit 38% 4. Potassium 4 mmol/L 107. Following surgery for pyloric stenosis, a 5-week- old infant is started on glucose water. When will infant formula be started? 108. The nurse is feeding a newborn infant glucose water. Which finding would make the nurse suspect that the infant has esophageal atresia? 1. The infant has projectile vomiting. 2. The infant sucks very slowly. 3. The infant seems fatigued after only a few sucks. 4. The infant chokes after taking a few sucks of water. 109. The parents of an infant who has esophageal atresia ask the nurse how the baby will eat. Which response by the nurse is most accurate? 1. "A tube will be passed from the nose to the stomach." 2. "The doctor will place a tube through the abdomen into the baby's stomach." 3. "Your baby will be given nutrients through a vein." 4. "Your baby can tolerate small feedings given frequently." 110. The nurse is teaching the parents of a child who has celiac disease about the dietary modifications that need to be made. Which foods, if selected by the parents, indicate an understanding of the child's dietary needs? 1. Toast, orange juice, and an egg 2. Rice cake, milk, and a banana 3. Crackers, apple juice, and a hot dog 4. Hamburger, grape juice, and fries Answers and Rationales 91. 1. The Asepto syringe should be placed in the unaffected side of the baby's mouth and back far enough to encourage swallowing. All of the other answers are correct. The baby's mouth should be rinsed with saline after each feeding to minimize the chance of infection. The baby should be held in an upright position and bubbled or burped frequently because the baby tends to swallow air. The baby with a cleft palate is a mouth breather and will have dry lips. Applying lanolin is appropriate. 92. 3. The symptoms suggest ear infection. A child with an ear infection needs to be seen by a physician and probably treated with an antibiotic. Children with cleft palate are very susceptible to infections and need to be treated promptly to reduce the chance of hearing loss from recurrent ear infections. 1. 2. 3. 4. Following the return of bowel sounds After vital signs are stable When the infant is able to retain clear liquids When there is no evidence of diarrhea 16 358 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 93. 4. Priority care following cleft lip repair is to keep the child from pulling at the lip repair site. The IV is probably infiltrated. Further assessment of the IV should be done after the restraint has been replaced. The vital signs are normal. Checking to see if the baby has voided is not a priority measure. 94. 3. Having the mother hold the infant would be most comforting to the infant. A child with cleft lip repair cannot have a pacifier and cannot be on the abdomen. A special nurse is not necessary; the mother will do very well. 95. 2. Promoting speech is a very important long-term goal for a child who has a cleft palate because speech problems are common. Immobilization following a cleft lip repair is brief. Preventing joint contractures is not a long- term goal. Preventing infection at the surgical site is also a short-term goal. 96. 4. Daily weights are the best indicator of fluid balance. The number of stools gives an indication of fluid loss but is not the best indicator of fluid balance. Skin turgor and assessing mucus membranes are helpful, but daily weights are the best indicator of fluid balance. 97. 1. Restoration of intravascular volume is the immediate goal. This will prevent life- threatening fluid and electrolyte imbalances. The others are goals but are not immediate. 98. 2. Pedialyte and glucose water are appropriate. The infant needs clear liquids, and these are age appropriate. Pedialyte gives electrolytes, and glucose water gives sugar. A 9-month-old infant does not drink carbonated beverages such as 7-Up and ginger ale. Half-strength formula is not a clear liquid. Tea is not appropriate for an infant, and broth is too salty for an infant. 99. 3. The bowel still needs rest. Stop the feedings, and notify the charge nurse or the physician. Taking vital signs and weighing the child do not address the issue, which is that oral feedings stimulate diarrhea, indicating the bowel is still irritable and needs further rest. 100. 4. The child should be receiving isotonic saline enemas. Repeated tap water or soap suds enemas would cause fluid and electrolyte imbalances. A low-residue diet is indicated because the child has no peristalsis. High-fiber diets are contraindicated. 101. 3. In Hirschsprung's disease, a lack of peristalsis in the lower colon causes accumulation of intestinal contents, distention of the bowel, and possible obstruction. Measuring abdominal girth is most important. The other actions are not wrong, but they are not the most important. 102. 3. The baby will have a temporary colostomy to allow the bowel time to heal and return to normal functioning. The usual surgery for Hirschsprung's disease involves a temporary colostomy, not a permanent colostomy. The child will receive enemas prior to surgery, but they will be saline enemas, not tap water enemas. Tap water enemas cause fluid shifts. A gastrostomy tube is unlikely after surgery. Following recovery from anesthesia, the child should return to oral intake and normal feedings. 103. 2. Small, frequent feedings followed by positioning at a 30- to 45-degree angle have been found to prevent gastric distention and vomiting in the infant with gastroesophageal reflux. Diluting the formula is not appropriate. Infants with gastroesophageal reflux do not have a problem with the absorption of nutrients. Gastroesophageal reflux is not related to milk intolerance, so a change in formula is not indicated. Delaying burping can aggravate gastroesophageal reflux. An infant with gastroesophageal reflux needs frequent burping to prevent reflux. 104. 3. Visible waves of peristalsis moving from left to right across the epigastrium are usually seen in infants with pyloric stenosis. Abdominal rigidity is not typical of pyloric stenosis. Ribbon- like stools might be seen in the child with Hirschsprung's disease. The child with pyloric stenosis will have small, rabbit pellet stools. Rectal prolapse is seen in children with cystic fibrosis. 105. 2. The data presented (dry mucus membranes, poor skin turgor, no tearing) suggest a deficient fluid volume related to frequent stools. Impaired skin integrity is a possibility with frequent stooling, but there are no data to confirm this. Pain related to cramping is a possibility, but there are no data to confirm this. Imbalanced nutrition, less than body requirements, is also a possibility, but there are no data to confirm this. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 16 PEDIATRICS 359 106. 2. A urine specific gravity of 1.035 indicates dehydration. Normal range for an infant is 1.002 to 1.030. The normal sodium level is 135 to 146 mmol/L. The normal hematocrit for an infant is 28% to 42%. The normal potassium for an infant is 3.5 to 6.0 mmol/L. 107. 3. Once the infant retains small, frequent feedings of glucose for 24 hours, the nurse may begin small, frequent feedings of formula until the infant returns to a normal feeding schedule. Answer 1 is not correct because bowel sounds need to be present before starting clear liquids. A decrease in bowel sounds is not normally a problem in the child who has undergone surgical correction for pyloric stenosis because the surgery does not enter the stomach itself but rather the pyloric muscle. Answer 2 is not correct because vital signs do not directly affect the initiation of infant formula. Answer 4 is not correct. The absence of diarrhea is not the criterion for beginning formula. 108. 4. With esophageal atresia, the esophagus ends in a blind pouch. The infant will choke after a few sucks of water because it has no place to go. Projectile vomiting, especially at the age of 2 or 3 weeks, is suggestive of pyloric stenosis. Slow sucking and fatigue with sucking would be more suggestive of cardiac problems. 109. 2. Infants with esophageal atresia will need a gastrostomy tube because the esophagus ends in a blind pouch. There is no connection between the esophagus and the stomach, so a nasogastric tube cannot be passed. Intravenous or total parenteral nutrition (TPN) feedings are not indicated. Gastrostomy tube feedings are much safer. Because there is no connection between the esophagus and the stomach, the infant cannot have anything by mouth. 110. 2. There is nothing in this choice that contains barley, rye, oats, or wheat, which all contain gluten. Toast, crackers, and hamburger rolls all contain wheat, which has gluten, and are not allowed in a child who has celiac disease and cannot tolerate glute

Question3

The nurse makes an initial assessment of a 4-year-old child admitted with possible epiglottitis. Which observation is most suggestive of epiglottitis? 1. Low-grade fever 2. Retching 3. Excessive drooling 4. Substernal retractions Which nursing action could be life-threatening for a child with epiglottitis? 1. Examining the child's throat with a tongue blade 2. Placing the child in a semi-sitting position 3. Maintaining high humidity 4. Obtaining a nasopharyngeal culture Which factor would most likely be a cause of epiglottitis? 1. Acquiring the child's first puppy the day before the onset of symptoms 2. Exposure to the parainfluenza virus 3. Exposure to Haemophilus influenzae, type B 4. Frequent upper respiratory infections as an infant The nurse is caring for a child who has epiglottitis. What position would the child be most likely to assume? 1. Squatting 2. Sitting upright and leaning forward, supporting self with hands 3. Crouching on hands and knees and rocking back and forth 4. Knee-chest position The nurse is assessing a child who has epiglottitis and is having respiratory difficulty. Which of the following is the nurse most likely to assess in the child? 1. Flaring of the nares; cyanosis; lethargy 2. Diminished breath sounds bilaterally; easily agitated 3. Scattered rales throughout lung fields; anxious and frightened 4. Mouth open with a protruding tongue; inspiratory stridor 51. Which of the following is the most important goal of nursing care in the management of a child with epiglottitis? 1. Preventing the spread of infection from the epiglottis throughout the respiratory tract 2. Reduction of high fever and prevention of hyperthermia 3. Maintaining a patent airway 4. Maintaining the child in an atmosphere of high humidity with oxygen 52. Which of the following is the most important nursing action when caring for a child with epiglottitis? 1. Cardiac monitoring 2. Blood pressure monitoring 3. Temperature monitoring 4. Monitoring intravenous infusion 53. A 5-year-old child is admitted with his first asthma attack. Which of the following would have been least likely to have precipitated his asthma attack? 1. A new puppy in the house 2. A visit from his uncle who smokes cigars 3. An unusually early snowstorm 4. Eating fresh fruit salad 54. During aminophylline infusion, a child becomes restless and nauseated, and his blood pressure drops. What is the appropriate nursing response to these findings? 1. Because these are common side effects of the drug, which will pass when the infusion is completed, simply chart the response. 2. Stop the infusion immediately and notify the physician or charge nurse because the symptoms are suggestive of an adverse response to aminophylline. 3. Continue to monitor the child because the symptoms are probably related to the child's illness because they are not commonly associated with aminophylline. 4. Continue to monitor the child because these are expected responses to aminophylline. 55. It is important to teach the parents of a child with asthma about the disease and its long-term management. Teaching the child a play technique such as blowing cotton balls or ping pong balls across a table is good for him. Which is the best explanation for this play technique? 1. It decreases expiratory pressure. 2. It provides for an extended expiratory phase of respiration. 3. It promotes a fuller expansion of the thoracic cavity during inspiration. 4. It develops the accessory muscles of respiration. 56. After having chronic sore throats and repeated absences from school over the past year, a 6-year- old has been admitted to the pediatric unit for a tonsillectomy. Which would be the most important information to obtain in a preoperative health history? 1. Evidence of bleeding tendencies 2. Parents' responses to anesthesia, especially adverse reactions 3. Child's perception of the surgical procedure 4. Frequency and type of bacterial tonsillar infections 57. A 6-year-old has just returned from having a tonsillectomy. The child's condition is stable, but the child remains quite drowsy. How should the nurse position this child? 1. On her back with head elevated 30 degrees 2. Upright 3. Semi-prone 4. Trendelenburg 58. The nurse is caring for a child who had a tonsillectomy this morning. The child is observed to be swallowing continuously. What is the most appropriate initial nursing action? 1. Administer acetaminophen for pain 2. Place an ice collar around her throat 3. Call the charge nurse or surgeon immediately 4. Encourage the child to suck on ice chips 59. The nurse is caring for a 6-year-old child who had a tonsillectomy this morning. Once the child is fully awake and alert, which liquid is the best to offer her? 1. A cherry popsicle 2. Apple juice 3. Orange juice 4. Cranberry juice 60. A 10-year-old child has had diagnosed bronchial asthma for three years. The child has been admitted to the pediatric unit in acute respiratory distress. Which of the following would be most characteristic of the child's asthmatic attack upon admission? 1. Expiratory wheezing 2. Inspiratory stridor 3. Cyanotic nail beds 4. Prolonged inspiratory phase 16 340 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 61. A child is admitted with asthma. Which aspects of the health history would be most closely associated with asthma? 1. The child's grandfather died of emphysema at age 76. 2. The child's grandmother died of lung cancer. 3. The child had respiratory distress syndrome following premature birth. 4. The child had eczema as an infant and toddler. 62. A stat dose of epinephrine is ordered for a child with asthma. How should the nurse administer the epinephrine? 1. Intramuscular 2. Sublingual 3. Subcutaneous 4. Nebulization 63. A child with an asthma attack has received epinephrine. The child is also to receive isoproterenol (Isuprel) via intermittent positive pressure breathing. When should the isoproterenol be given in relation to the epinephrine? 1. Isoproterenol should be given 30 minutes prior to the administration of epinephrine. 2. Isoproterenol should never be given in conjunction with epinephrine. Check with the physician. 3. Isoproterenol should not be given within one hour after the administration of epinephrine. 4. Isoproterenol should be given at the same time as epinephrine for maximum benefit. 64. A child is having an asthma attack. The nurse places the child in an upright position for which of the following reasons? 1. To prevent the aspiration of mucus 2. To visualize abnormal inspiratory excursion 3. To prevent atelectasis 4. To relieve dyspnea 65. A 13-month-old child is diagnosed with croup and placed in a croup tent. Which toy is most appropriate for the nurse to give the child? 1. A doll made of cotton 2. A music box 3. A soft fuzzy toy made of synthetic materials 4. A wind-up bunny 66. The nurse is caring for a 5-year-old child who has cystic fibrosis. What should the nurse do to help the child manage secretions and avoid respiratory distress? 1. Administer continuous oxygen therapy 2. Perform chest physiotherapy every four hours 3. Administer pancreatic enzymes as ordered 4. Encourage a diet high in calories 67. The nurse is to administer pancreatic enzymes to an 8-month-old child who has cystic fibrosis. When should this medication be administered? 1. A half hour before meals 2. With meals 3. An hour after meals 4. Between meals 68. A 10-month-old child is being treated for otitis media. What is the most important nursing action to prevent recurrence of the infection? 1. Administer acetaminophen as ordered 2. Encourage the parents to maintain a smoke-free home environment 3. Explain to the parents that they must give the child all of the prescribed antibiotic therapy 4. Encourage the parents to bottle-feed the child in an upright position 69. The nurse is caring for a 6-month-old infant who is in a croup tent. The child's mother calls and tells the nurse that the child's clothes are all wet. What is the best action for the nurse to take? 1. Explain to the mother that this is normal because the croup tent has high humidity 2. Change the child's clothing 3. Cover the child with a dry blanket 4. Remove the child from the croup tent until his/her clothes are dry 70. A 5-year-old child has cystic fibrosis. What is best to offer the child on a hot summer day? 1. Kool-Aid 2. Ice cream 3. Lemonade 4. Broth Answers and Rationales 46. 3. Excessive drooling is a sign of epiglottitis. A child with epiglottitis is apt to have a high fever. Retching is not typical. Retractions could occur if respiratory distress was great enough, but drooling is the hallmark of epiglottitis. 47. 1. Examining the child's throat with a tongue blade may cause the epiglottis to become so irritated that it will close off completely and obstruct the airway. The child should be placed in a semi-sitting to upright position. Humidity is not a problem. A nasopharyngeal culture would not cause problems. The nurse should get a throat culture, however. Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 16 PEDIATRICS 341 48. 3. H. influenzae is the usual causative agent of epiglottitis. A puppy would be more apt to cause asthma than epiglottitis. 49. 2. Sitting upright and leaning forward, supporting self with hands, is the position typically assumed by children with epiglottitis. It helps to promote the airway and drainage of secretions. Squatting is more typically seen in children who have cyanotic heart defects. 50. 4. The child with an edematous glottis will keep his mouth open with his tongue protruding to increase free movement in the pharynx. In the presence of potential laryngeal obstruction, laryngeal stridor can be heard, especially during inspiration. Rales and diminished breath sounds are more typical of croup. Cyanosis is typical of late-stage, extremely critical respiratory distress. 51. 3. In a child with epiglottitis, the first signs of difficulty in breathing can progress to severe inspiratory distress or complete airway obstruction in a matter of minutes or hours. The child usually has a high fever, but the airway takes precedence. High humidity may also be appropriate, but the highest priority is maintaining an airway. 52. 1. Regular monitoring of cardiac rate is essential because a rapidly rising heart rate is an initial indication of hypoxia and impending obstruction of the airway. The blood pressure and temperature may well be monitored, but they are not the most important. An IV will be monitored, if present, but is not the highest priority. 53. 4. Pets, smoke, and changes in temperature can all precipitate asthma. A fruit salad is least likely to precipitate an asthma attack. It is possible that someone could be allergic to something in a fruit salad, but these are not common asthma triggers. 54. 2. These are symptoms of an adverse response to aminophylline. The IV should be stopped and the physician notified immediately. The child may be going into shock. 55. 2. Blowing will extend the expiratory phase of respiration and help the child with asthma exhale more completely. Blowing ping pong balls is exhalation, not inhalation. It does not develop accessory muscles of respiration. 56. 1. The most common and serious complication following tonsillectomy is hemorrhage. The nurse should ask about bleeding tendencies. Information about any familial adverse responses may be nice to know but is not as important as information about the child's tendency to bleed. The child's perception of the surgery is also nice to know but is not the most important information. The frequency and type of tonsil infections is nice to know but not essential. 57. 3. Because the child is sleepy, the child should be semi-prone to prevent aspiration in case the child vomits. When the child is alert, he/she can be in a semi-sitting position. Trendelenburg position is contraindicated because it would cause more swelling in the operative area. 58. 3. Continual swallowing indicates bleeding. The charge nurse or surgeon should be notified at once. None of the other responses is appropriate. The child may be hemorrhaging. 59. 2. The child needs clear, cold liquids that are not red and are not citrus. Red would make it difficult to determine if vomitus was blood or juice. 60. 1. Bronchial constriction occurs in asthma. This increases the airway resistance to airflow. The respiratory difficulty is accentuated during expiration, when the bronchi are supposed to contract and shorten, as opposed to inspiration, when the bronchi are dilating and elongating. Inspiratory stridor is characteristic of croup. Note that answers 2 and 4 both deal with the inspiratory phase. Asthma affects the expiratory phase. 61. 4. Asthma is an allergic condition and frequently follows eczema, also an allergic condition. Having relatives with emphysema or lung cancer is not usually related to childhood asthma. Respiratory distress syndrome as an infant does not predispose the child to asthma. 62. 3. Epinephrine is a rapid-acting drug of short duration. The subcutaneous route is the most effective for rapid relief of respiratory distress. The stat dose is not given intramuscularly, sublingually, or by nebulizer. 63. 3. The side effects of epinephrine (tachycardia, increase in blood pressure, tremors, weakness, and nausea) are potentiated by isoproterenol. Therefore, when given concurrently, isoproterenol should not be given within one hour after administration of epinephrine. 16 342 NCLEX-PN® Review Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. 64. 4. By providing for maximum ventilatory efficiency, the upright position increases the oxygen supply to the lungs and helps to relieve dyspnea. This is most important for the asthmatic child who is experiencing a diminished ventilatory capacity. 65. 1. The major concern regarding toys for a child in a croup tent is that there not be any chance of static electricity or a spark because the croup tent contains oxygen. Cotton does not create static electricity. Wool and synthetic materials create static electricity. A wind-up toy could create a spark. 66. 2. Chest physiotherapy aids in loosening secretions throughout the respiratory tract. Oxygen therapy does not loosen secretions and may be contraindicated because many children with cystic fibrosis experience carbon dioxide retention and respiratory depression with too high levels of oxygen. Pancreatic enzymes will be given to this child, but to improve the absorption of nutrients, not to facilitate respiratory effort. A diet high in calories is appropriate for a child with cystic fibrosis. However, it does not facilitate respiratory effort. 67. 2. Pancreatic enzymes should be given with meals. They can be mixed with applesauce. The purpose of the enzymes is to help with the digestion and absorption of nutrients. Therefore, they must be given when the child is having food. 68. 3. The child should receive all of the antibiotic medication. Parents are apt to stop giving it to the child when he/she begins to feel better. This encourages recurrence of the infection that may be resistant to antibiotic therapy. Acetaminophen may be given to the infant, but it is for pain and does not prevent recurrence of the infection. There is some evidence that children who live around smokers have a higher incidence of otitis media. This teaching is relevant but not the most important. Children who go to sleep with milk or juice in their mouths after feeding have a higher incidence of otitis media, but this is not the most important nursing action to prevent recurrence of infection. 69. 2. A croup tent is high humidity, and the child's clothes will get wet. When they do, they should be changed so that the child will not get chilled. It is appropriate to explain this to the mother, but the best response is to change the child. Covering the child will not prevent chilling. The nurse should not remove the child from the croup tent just because his/her clothing is wet. 70. 4. The child with cystic fibrosis has a problem with chloride metabolism and loses excessive amounts of salt in sweat. The child should be given something with high amounts of sodium, such as broth. Ice cream contains some sodium, but not as much as broth. Kool-Aid and lemonade contain no sodium.