Unit 4 Exam
A 6-month old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse's best response is: 1. "At 6 months his weight should be approximately three times his birth weight" 2. "Each child gains weight at his or her own pace" 3. "At 6 months his weight should be approximately twice his birth weight" 4. "At 6 months a child should weigh about 10 lb more than his or her birth weight"
"At 6 months his weight should be approximately twice his birth weight"
Which instruction would be of highest priority for the mother of an infant receiving his first oral rotavirus vaccine? 1. "Call the physician if he develops fever or cough" 2. "Call the physician if he develops fever redness, or swelling at the injection site" 3. "Call the physician if he develops a bloody stool or diarrhea" 4. "Call the physician if he develops constipation and irritability"
"Call the physician if he develops a bloody stool or diarrhea"
A male infant is visiting the pediatrician for his 6-month well-child checkup. His mother tells the nurse she wants to advance the infant's diet. Which statement by the infant's mother leads the nurse to believe that she needs further education about the nutritional needs for a 6-month old? 1. "I will continue to breastfeed my son and will give him rice cereal three times a day" 2. "I will start my son on fruits and gradually introduce vegetables" 3. "I will start my son on carrots and will introduce one new vegetable every few days" 4. "I will not give my son any more than 8 ounces of baby juice per day"
"I will start on fruits and gradually introduce vegetables"
The mother of 11-year old fraternal twins tells the nurse at their well-child checkup that she is concerned because her daughter has gained more weight and height than her twin brother. The mother is concerned that there is something wrong with her son. The nurse's best response is: 1."I understand your concern. I will talk with the physician, and we can draw some lab work" 2. "I understand your concern. Has your son been ill lately?" 3. "It is normal for girls to grow a little taller and gain more weight than boys at this age" 4. "It is normal for you to be concerned, but I am sure your son will catch up with your daughter eventually"
"It is normal for girls to grow a little taller and gain more weight than boys at this age"
Which statement by the mother of an 18-month old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay? 1. "My child is able to stand but is not yet taking steps independently" 2. "My child has a vocabulary of approximately 15 words" 3. "My child is still thumb sucking" 4. "My child seems to be quite wary of strangers"
"My child is able to stand but is not yet taking steps independently"
The nurse is caring for a 12-month old girl. The child's mother asks if the unit has any toys that her daughter can play with. The nurse goes to the toy area in search of a toy for the child. Which toy is the best choice for this child? 1. A doll 2. A musical rattle 3. A board book 4. Colorful beads
A musical rattle
What would be the priority nursing action on finding the varicella vaccine at room temperature on the shelf in the medication room? 1. Ensure the varicella vaccine's integrity is intact; if intact, follow the five rights for medication administration 2. Do not administer this batch of vaccine 3. Ensure the varicella vaccine is intact; if intact, give the vaccine after verifying proper physician orders 4. Ask the mother if the child has had any prior reactions to varicella
Do not administer this batch of vaccine
The nurse caring for an 8-year old boy is trying to encourage developmental growth. What can the nurse do to reinforce the child's intellectual initiative when he asks the nurse about his upcoming surgery? 1. Allow the child to choose what time to take his medication 2. Provide the child with the homework his teacher has sent in 3. Allow the child to assist with his bath 4. Allow the child to help with his dressing change
Provide the child with the homework his teacher has sent in
Which nursing intervention should take place prior to all vaccination administration? 1. Document the vaccination to be administered on the immunization record and medical record 2. Provide the vaccine information statement handout, and answer all questions 3. Administer the most painful vaccination first, and the alternate injection sites 4. Refer to the vaccination as "baby shots" so the parent understands the baby will be receiving an injection
Provide the vaccine information statement handout and answer all questions
A 2-day-old girl is being discharged from the hospital. Her mother asks the nurse when she will receive her first hepatitis B immunization. Which is the nurse's best response? 1. "Babies receive the hep B vaccine only if their mother is hep B positive" 2. "She will receive her first dose of the hep B vaccine prior to discharge today" 3. "She will receive her first hep B vaccine when she is 1 year of age" 4. "She will receive her first hep B vaccine at 6 months of age"
"She will receive her first dose of the hep B vaccine prior to discharge today"
Which would be the nurse's best response if a mother asks if her baby still needs the Hib vaccine because he already had Hib? 1. "Yes, it is recommended that the baby still get the Hib vaccine" 2. "No, if he has had Hib, he will not need to receive the vaccine" 3. "Let me take a nasal swab first; if it is negative, he will receive the Hib vaccine" 4. "The physician will order a blood test, and depending on results, your child may need the vaccine"
"Yes, it is recommended that they baby still get the HIB vaccine"
Which is the nurse's best response when the mother of a 2-month-old who is going to get the IPV tells the nurse the older brother is immunocompromised? 1. "Your baby should not be immunized because your immunocompromised son could develop polio" 2. "Your baby should receive the oral poliovirus vaccine instead so your immunocompromised son does not get sick" 3. "You should separate your 2-month-old child from the immunocompromised son for 7 to 14 days after the IPV" 4. "Your baby can be immunized with the IPV; he will not be contagious"
"Your baby can be immunizd with the IPV; he will not be contagious"
The parents of a 12-month-old male with HIV are concerned about his receiving routine immunizations. What will the nurse tell them about immunizations? 1. "Your child will not receive routine immunizations today" 2. Your child will receive the recommended vaccines today; regular immunizations help prevent childhood illnesses" 3. "Your child is not severely immunocompromised, but I would still be concerned about his receiving them. Let's not give them today" 4. "Your child may develop infections if he gets his routine immunizations. Your child will not be immunized today."
"Your child will not receive routine immunizations today"
A 3-year-old female is hospitalized for an ASD repair. Her parents have decided to go home for a few hours to spend time with her siblings. The child asks when her mommy and daddy will be back. The nurse's best response is: 1. "Your mommy and daddy will be back after your nap" 2. "Your mommy and daddy will be back at 6 pm" 3. "Your mommy and daddy will be back later this evening" 4. "Your mommy and daddy will be back in 3 hours"
"Your mommy and daddy will be back after your nap"
A 3-year old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child's sense of autonomy? 1. Allow the child what time to receive her oral antibiotics 2. Allow the child to have a doll for medical play 3. Allow the child to administer her own dose of Keflex via oral syringe 4. Allow the child to watch age-appropriate videos
Allow the child to administer her own dose of Keflex via oral syringe
Which of the following would be the priority teaching to the parent of a child diagnosed with chickenpox (varicella) who was prescribed diphenhydramine (Benadryl) for itching? 1. Give a warm bath with mild soap before lotion application 2. Avoid Caladryl lotion while taking diphenhydramine 3. Apply Caladryl lotion generously to decrease itching 4. Give a cool shower with mild soap to decrease itching
Avoid Caladryl lotion while taking diphenhydramine
Which of the following would be the priority intervention the nurse should initiate for a child suspected of having varicella (chickenpox)? 1. Contact precautions 2. Contact and droplet respiratory precautions 3. Droplet respiratory precautions 4. Universal precautions and standard precautions
Contact and droplet respiratory precautions
A 16-year old male is hospitalized for cystic fibrosis. He will be an inpatient for 2 weeks while he receives IV antibiotics. As the nurse caring for this patient, what action can you take that will most enhance his psychosocial development? 1. Fax the teen's teacher, and have her send in his homework 2. Encourage the teen's friends to visit him in the hospital 3. Encourage the teen's grandparents to visit frequently 4. Tell the teen he is free to use his phone to call friends
Encourage the teen's friends to visit him in the hospital
Which medication is most important to have available in all clinics and offices if immunizations are administered? 1. Benadryl (diphenhydramine) injection 2. Epinephrine 1:10,000 injection 3.Epinephrine 1:1000 injection 4. Benadryl (diphenhydramine) liquid
Epinephrine 1:1000 injection
A 17 yr old male is being seen in the ER. In order to obtain the adolescent's health information, his nurse should: 1. Interview the adolescent using direct questions 2. Gather information during a casual conversation 3. Interview the adolescent only in the presence of his parents 4. Gather information only from the parents
Gather information during a casual conversation
What would be the best plan of care for a newborn whose mother's hepatitis B antigen status is unknown? 1. Give the infant the hep B vaccine within 12 hours of birth 2. Give the infant the hep B vaccine and hep B immune globulin within 12 hours of birth 3. Give the infant the hep B vaccine within 24 hours of birth 4. Give the infant the hep B vaccine and hep B immune globulin within 24 hours of birth
Give the infant the hep B vaccine and hep B immune globulin within 12 hours of birth
A 9-year old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that says "No boys allowed." The child's parents are concerned that she is excluding their neighbor's son, and they are upset. What should the school nurse tell the child's parents? 1. Her behavior is cause for concern and should be addressed 2. Her behavior is common among school-age children 3. Her feelings about boys will subside within the next year 4. They should have their daughter speak with the school counselor
Her behavior is common among school-age children
The mother of 21-day old male tells the nurse she is residing in a homeless shelter and is concerned about his mild cough, poor appetite, low-grade fever, weight loss, and irritability over the last 2 weeks. Which nursing intervention would be the highest priority? 1. Weight the baby to have an accurate weight using standard precautions 2. Reassure the mother that the baby may only have a cold, which can last a few weeks 3. Immediately initiate droplet face-mask precautions, and isolate the infant 4. Take a rectal temperature while completing the assessment using standard precautions
Immediately initiate droplet face-mask precautions, and isolate the infant
According to developmental theories, which important event does the nurse understand is essential to the development of the toddler? 1. The child learns to feed self 2. The child develops friendships 3. The child learns to walk 4. The child participates in being potty-trained
The child participates in being potty-trained
The nurse is performing a physical assessment on a 6-month old baby. Which finding should the nurse understand as abnormal for this child? 1. The child's posterior fontanel is open 2. The child's anterior fontanel is open 3. The child has the beginning signs of tooth eruption 4. The child is able to track and follow objects
The child's posterior fontanel is open
The mother of a child 2 years 6 months has arranged a play date with the neighbor and her 3-year-old daughter. During the play date the two mothers should expect that the children will do which of the following? 1. The children will share and trade their toys while playing 2. The children will play with one another with little or no conflict 3. The children will play alongside one another but not actively with one another 4. The children will play with one or two items, ignoring most of the other toys
The children will play alongside one another but not actively with one another
The nurse is assessing a 3-week old with suspected bacterial meningitis. Isolation respiratory precautions have already been initiated. Which clinical assessment by the nurse would warrant immediate intervention? 1. The neonate is irritable 2. The neonate has a rectal temp of 100.6F 3. The neonate is quieter than usual 4. The neonate's respiratory rate is 24 breaths per minute
The neonate's respiratory rate is 24 breaths per minute
Which of the following would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be give the first Hep B vaccine by 2 months of age 2. The newborn should receive the Hep B vaccine and Hep B immune globulin within 12 hours of birth 3. The newborn should receive the Hep B vaccine and Hep B immune globulin within 24 hours of birth 4. The newborn should receive Hep B immune globulin only within 12 hours of birth
The newborn should receive the Hep B vaccine and Hep B immune globulin within 24 hours of birth
A mother requests tat her child receive the varicella vaccine at her 9-month well-child checkup. The nurse tells the mother that: 1. The nurse cannot give the vaccine 2. The nurse will administer vaccine after the physician examines the child 3. Children who are vaccinated will likely develop a mild case of the disease from the vaccine 4. The child will need a booster vaccination at 18 months of age
The nurse cannot give the vaccine
How can the nurse best facilitate the trust relationship between infant and parent while the infant is hospitalized? 1. The nurse should encourage the parents to remain at their child's bedside as much as possible 2. The nurse should keep parents informed about all aspects of their child's condition 3. The nurse should encourage the parents to hold their child as much as possible 4. The nurse should encourage the parents to participate actively in their child's care
The nurse should encourage the parents to hold their child as much as possible