ATI Pediatric

A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps, rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? a. I am not going to let my child play with other children for 2 days. b. I will need to return in 2 weeks for my child to receive the varicella immunization. c. I can give my child acetaminophen for discomfort associated with the immunization. d. My child might have discharge from the injection site.

c. I can give my child acetaminophen for discomfort associated with the immunization. Rationale: Parents can give acetaminophen for minor discomforts such as low-grade fever and local tenderness resulting from the administration of the immunization.

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. Reports an absence of nausea and vomiting b. Reports experiencing an onset of loose stools within 15 mins of administration c. Serum potassium level 4.1 mEq/L d. Blood pressure 86/52 mm Hg

c. Serum potassium level 4.1 mEq/L

A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d. Visual analog

a. FACES

A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? a. Perform the assessment in a head to toe sequence. b. Minimize physical contact with the child initially. c. Explain procedures using medical terminology d. Stop the assessment if the child becomes uncooperative.

b. Minimize physical contact with the child initially. Rationale: The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.

A nurse in an emergency department is caring for a school-age child who has epiglottis. Which of the following actions should the nurse take? a. Obtain a throat culture from the child. b. Monitor the child's oxygen saturation. c. Put a warm mist humidifier in the child's room. d. Place the child in the supine position

b. Monitor the child's oxygen saturation.

A nurse is performing a physical assessment on a 6-month old infant. Which of the following reflexes should the nurse expect to find? a. Stepping b. Babinski c. Extrusion d. Moro

b. Babinski Rationale: The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.

A nurse in the emergency department is caring for a 2-yr old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the following priority action by the nurse? a. Remove the child's contaminated clothing. b. Check the child's respiratory status. c. Administer an antidote to the child. d. Establish IV access for the child.

b. Check the child's respiratory status. Rationale: When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen change to occur.

A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? a. Give the toddler milk. b. Go to an emergency department. c. Call the poison control center. d. Induce vomiting

c. Call the poison control center. Rationale: According to evidence-based practice, the nurse should instruct the parents to first call the poison control center, which will then identify what further actions the parents should take.

A nurse is assessing an 8-year-old who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? a. Insert an indwelling urinary catheter b. Measure weight and height c. Initiate IV access d. Maintain ECG monitoring

c. Initiate IV access

A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? a. Age 10 b. First hospitalization c. Male gender d. calm. quiet demeanor

c. Male gender Rationale: Male clients are at increased risk fr hospitalization-related stress compared to female clients.

A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include? a. Clean your baby's sutures daily with a mixture of chlorohexidine and water. b. Expect your baby to swallow more than usual over the next few days. c. Inspect your baby's tongue for white patches using a tongue depressor every 8 hours. d. Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days.

d. Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days.

A nurse is planning care for a newly admitted school- age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? a. Ensure that a padded blade is at the child's bedside. b. Allow the child to play video games on a tablet computer. c. Allow the child to take a tub bath independently. d. Ensure the oxygen source is functioning in the child's room.

d. Ensure the oxygen source is functioning in the child's room.

A nurse is caring for a school age-child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. Decreased edema b. Increased abdominal girth c. Decreased appetite d. Increased protein in the urine

a. Decreased edema

A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. Erythrocyte sedimentation rate 18mm/hr b. WBC count 6,200/mm3 c. C-reactive protein 1.4mg/L d. RBD count 4.7 million/mm3

a. Erythrocyte sedimentation rate 18mm/hr

A nurse is providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? a. Follow a nightly routine and established bedtime. b. Encourage active play prior to bedtime. c. Let the child remain awake until tired enough to go to sleep. d. Reward the child with a food treat just prior to sleep if the child goes to bed on time.

a. Follow a nightly routine and established bedtime. Rationale: Preschool-age children test limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.

A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. Head lags when pulled from a lying to a sitting position b. Absence of startle and crawl reflexes c. Inability to pick up a rattle after dropping it d. Rolls from back to side

a. Head lags when pulled from a lying to a sitting position Rationale: At the age of 5 months, the infant should have no head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.

A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider? a. Heart rate 175/min b. Respiratory rate 26/min c. Blood pressure 88/40 mm hg d. Temperature 37.6 Celcius (99.7 F)

a. Heart rate 175/min Rationale: A heart rate of 175/min is above the expected reference range for a 12-month-old infant; therefore, the nurse should report this finding to the provider

A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? a. I lock my medications in the medicine cabinet b. I keep my child's crib mattress at the highest level c. I turn pot handles to the side of my stove while cooking. d. I will give my child syrup of ipecac if she swallows something poisonous.

a. I lock my medications in the medicine cabinet Rationale: Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow for further exploration of the environment and possible access to hazardous substances.

A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (SATA) a. Observe the parent's actions when feeding the child. b. Maintain a detailed record of food and fluid intake. c. Follow the child's cues as to when food and fluids are provided. d. Sit beside the child's high chair when feeding the child. e. Play music videos during scheduled meal times.

a. Observe the parent's actions when feeding the child. b. Maintain a detailed record of food and fluid intake. Rationale: Observing the parents' actions when feeding the child is correct. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. Maintaining a detailed record of food and fluid intake is correct. A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake. Following the child's cues as to when food and fluids are provided is not correct. A consistent structured routine of feeding the child at the same time and place is used to promote weight gain. A child who has failure to thrive might not offer feeding cues. Sitting beside the child's high chair when feeding the child is not correct. Caregivers should sit directly in front of the child to maintain a face-to-face position during feeding and promote eye contact. The emphasis is on encouraging feeding. Playing music videos during scheduled meal times is not correct. A quiet, stimulation-free environment should be provided at meal times to avoid distractions and focus attention on food intake.

A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse? a. Presence of sparse, fine pubic hair b. Decreased head circumference compared to full height c. Increased leg length related to height d. Presence of a loose, central incisor

a. Presence of sparse, fine pubic hair Rationale: The development of sexual characteristics prior to the age of 9 years in boys, and 8 years in girls, is an indication of precocious puberty and requires further evaluation.

A nurse is planning developmental activities for a newly admitted 10-year old child who has neutropenia. Which of the following actions should the nurse plan to take? a. Provide the child with a book about adventure. b. Arrange frequent visits from family members and peers. c. Give the child a large-piece puzzle. d. Use puppets to entertain the child.

a. Provide the child with a book about adventure.

A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? a. The PICC line will last several weeks with proper care. b. The The public health nurse will rotate the insertion site every 3 days. c. You will need to make certain the arm board is in place at all times. d. Your child will go to the operating room to have the line placed.

a. The PICC line will last several weeks with proper care. Rationale: PICC lines are the preferred venous access device for short to moderate term IV therapy. They can remain in place for long periods with proper care.

A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. The child should be able to stand on the balls of their feet when sitting on the bike. b. The child should ride their bike 2 feet to the side of other bike riders. c. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. d. The child should ride the bike facing traffic when it is necessary to ride in the street

a. The child should be able to stand on the balls of their feet when sitting on the bike.

A nurse is caring for a preschool-age children who is dying. Which of the following findings is an age appropriate reaction to death by the child? (SATA) a. The child views death as smilier to sleep. b. The child interested in what happens to his body after death. c. The child recognizes that death is permanent. d. The child believes his thoughts can cause death e. The child thinks death is punishment

a. The child views death as smilier to sleep. b. The child interested in what happens to his body after death. e. The child thinks death is punishment Rationale: A child is interested in what happens to his body after death is not correct. A school-age child is interested in post-death services and what happens to the body after death d/t an improved ability to comprehend what is happening. The child does not recognize death is permanent because they have difficulty understanding the concept of time. Preschool- age children sometimes believe that death is the result of guilt or punishment d/t something they have done, said, or thought.

A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? a. Wash and dry the infant's genitalia and perineum thoroughly. b. Apply a small coating of water-soluble lubricant to the skin of the infants perineal area. c. Avoid placing the scrotum inside the collection bag. d. Wait several hours after positioning the device before checking it.

a. Wash and dry the infant's genitalia and perineum thoroughly. Rationale: This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device.

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? a. Wheezes b. Crackles c. Pleaural friction rub d. Rhonchi

a. Wheezes

A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? a. You should offer your child high-protein meals and snacks throughout the day. b. You should decrease your child's dietary fat intake to less than 10% of their caloric intake c. You should restrict your child's calorie intake to 1200 per day. d. You should give your child a multivitamin once weekly

a. You should offer your child high-protein meals and snacks throughout the day.

A nurse in an emergency department is caring for a school-age child who has sustained minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a. Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. b. Apply an antimicrobial ointment to the affected area. c. Leave the burn area open to air. d. Place an ice pack on the affected area.

b. Apply an antimicrobial ointment to the affected area.

A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? a. Assign an assistive personnel to feed the child. b. Explain sounds the child is hearing c. Have the child use a cane when ambulating d. Rotate nurses caring for the child.

b. Explain sounds the child is hearing Rationale: The noises in a facility can be frightening to a child who is experiencing a sensory loss. It is important to explain these noises to allay the child's fears.

A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? a. Administer the medication while the infant is supine b. Give the medication at the side of the patient's mouth c. Add the medication to a full bottle of the infant's formula d. Administer the medication slowly while holding the nares closed.

b. Give the medication at the side of the patient's mouth Rationale: When administering medications to an infant, a needless oral syringe or medicine dropper is placed in the side of the mouth (buccal cavity alongside the tongue) to prevent gagging and aspiration.

A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? a. Creeps on hands and knees b. Inability to vocalize vowel sounds c. Uses crude pincer grasp d. Stands by holding onto support

b. Inability to vocalize vowel sounds Rationale: The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word.

A nurse is caring for an 18-yr old adolescent who is up to date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory. a. Pneumococcal polysaccharide b. Meningococcal polysaccharide c. rotavirus d. Herpes zoster

b. Meningococcal polysaccharide Rationale: The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.

A nurse is providing teaching to the parent of a 4-year old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? a. Brightly colored mobile b. Plastic stethoscope c. Small piece jigsaw puzzle d. A book of short stories

b. Plastic stethoscope Rationale: Preschool play centers on imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.

A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. Presence of a central incisor tooth b. Presence of strabismus c. Presence of an open anterior fontanel d. Presence of external cerumen

b. Presence of strabismus

A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hrs ago. The nurse should instruct the guardians to report which of the following findings to the provider? a. Capillary refill time less than 2 seconds. b. Restricted ability to move the toes. c. Swelling of the casted foot when the leg is dependent. d. Pedal pulses +3 bilateral

b. Restricted ability to move the toes.

A nurse is assessing a 3-year old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? a. Ask the parents. b. Use the FACES scale c. Use the numeric rating scale d. Check the child's temperature

b. Use the FACES scale Rationale: Pain is a subjective experience even for a 3-year-old child. The FACES scale can be used to accurately determine the presence of pain in children as young as 3 years of age.

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (SATA) a. Steatorrhea b. Vomiting c. Lethargy d. Constipation e. Weight gain

b. Vomiting c. Lethargy

A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infants pain? a. Use a manual lancet to obtain the heel blood sample. b. Apply an ice pack to the infant's heel prior to obtaining the sample. c. Allow the mother to breastfeed while the sample is being obtained. d. Apply a topical lidocaine cream prior to obtaining the sample.

c. Allow the mother to breastfeed while the sample is being obtained.

A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? a. Primary dentition is complete b. Unable to hop on one foot c. Birth weight is tripled d. Able to state first and last name

c. Birth weight is tripled Rationale: The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.

A nurse is preparing to administer recommended immunizations to a 2-month old infant. Which of the following immunizations should the nurse plan to administer. a. Human papilloma virus (HPV) and hepatitis A b. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) c. Haemophilus influenza type B (Hib) and inactivated polio virus (IPV) d. Varicella (VAR) and live attenuated influenza vaccine (LAIV)

c. Haemophilus influenza type B (Hib) and inactivated polio virus (IPV) Rationale: The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The IPV immunization series consists of 4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.

A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicated an understanding of this ingestion? a. The absence of oral burns excludes the possibility of esophageal burns. b. Treatment focuses on neutralization of the chemical. c. Injury by a corrosive liquid is more extensive than by a corrosive solid. d. Immediate administration of activated charcoal is warranted.

c. Injury by a corrosive liquid is more extensive than by a corrosive solid. Rationale: The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury.

A nurse is assessing a 6-month old infant at a well-child visit. Which of the following findings indicates the need for further assessment? a. Grabs feet and pulls them to her mouth b. Posterior fontanel is closed c. Legs remain crossed and extended when supine d. Birth weight has doubled

c. Legs remain crossed and extended when supine Rationale: Legs crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the legs flex at the knees when the infant is supine. Crossed and extended legs when supine is a finding associated with cerebral palsy.

A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? a. Hand-eye coordination b. Sense of trust c. Object permanence d. Egocentrism

c. Object permanence Rationale: Object permanence refers to the cognitive skill of knowing an object still exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.

A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? a. Use a wheeled infant walker b. Place soft pillows around the edge of the infant's crib. c. Position the car seat so it is rear-facing d. Secure a safety gate at the top and bottom of the stairs. e. Maintain the water heater temperature at 49 degrees celsius (120 degrees Fahrenheit)

c. Position the car seat so it is rear-facing d. Secure a safety gate at the top and bottom of the stairs. e. Maintain the water heater temperature at 49 degrees celsius (120 degrees Fahrenheit) Rationale: Using a wheeled infant walker is incorrect. A stationary infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury. Placing soft pillows and cushions around the edge of the infant's crib is incorrect. Soft pillows and cushions should not be used in cribs d/t increased risk of suffocation. Positioning the care seat so it is rear facing is correct until age 2 yrs or til they reach the recommended H&W per manufacturer's guidelines. To prevent a burn injury, the temperature of the water should not exceed 49C (120F)

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistant asthma. Which of the following instructions should the nurse include? a. You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing. b. You should monitor your child's weigh weekly while they are receiving inhaled corticosteroid therapy. c. Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy. d. When using the peak expiratory flow meter, record your child's average of three readings.

c. Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy.

A nurse is assessing a 7-year old child's psychological development. Which of the following findings should the nurse recognize as requiring further evaluation? a. The child prefers playmates of the same sex. b. The child is competitive when playing board games. c. The child complains daily about going to school. d. The child enjoys spending time alone.

c. The child complains daily about going to school. Rationale: Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychological developmental stage of industry vs. inferiority. Children in this stage want to learn and master new concepts. If the child complains daily about going to school, it warrants further evaluation.

A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take? a. Have the toddler wear a disposable gown when in the unit's playroom. b. Wear sterile gloves when changing the toddler's diapers. c. Wear a mask when assisting the toddler with meals. d. Ask visitors to wear an N-95 mask when entering the room.

c. Wear a mask when assisting the toddler with meals. Rationale: The nurse should wear a mask when within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large droplet particles expelled in the air.

A nurse in a providers office is caring for a school-age child who has varicella. The parents ask the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. When your child no longer has an increased temperature. b. Three days after you first noticed the rash appear on your child. c. When your child's lesions are crusted, usually 6 days after they appear. d. Two to three weeks, when your child's lesions completely disappear.

c. When your child's lesions are crusted, usually 6 days after they appear.

A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? a. Have the adolescent sign a consent form for treatment b. Instruct the adolescent to return with a guardian c. Obtain consent from the adolescent's guardian over the phone. d. Treat the adolescent without a consent form.

consent form for treatment

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? a. An 18-month-old toddler who has unintelligible speech. b. a 3-month-old infant who has an exaggerated startle response c. A 4-year-old preschooler who prefers playing with others rather than alone d. An 8-month old infant who is not yet making babbling sounds

d. An 8-month old infant who is not yet making babbling sounds

A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parents about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching? a. Decrease the child's vitamin C intake until the blood lead level decreases to zero. b. Administer a folic acid supplement to the child each day. c. Give pancreatic enzymes to the child with meals and snacks. d. Ensure the child's dietary intake of calcium and iron is adequate.

d. Ensure the child's dietary intake of calcium and iron is adequate. Rationale: A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.

A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? a. I can give my baby 4 oz of juice to drink each day. b. I will offer my baby dry cereal and chilled banana slices as snacks. c. I am introducing my baby to the same foods the family eats. d. My infant drinks at least 2 quarts of skim milk each day.

d. My infant drinks at least 2 quarts of skim milk each day. Rationale: As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids which are needed for growth and development.

A nurse is teaching a parent of a 12-month old child about development during the toddler years. Which of the following statements should the nurse include? a. Your child should be referring to himself using the appropriate pronoun by the 18 months of age b. a toddler's interest in looking at pictures occurs at 20 months of age c. a toddler should have daytime control of his bowel and bladder by 24 months of age. d. your child should be able to scribble spontaneously using a crayon at the age of 15 months

d. your child should be able to scribble spontaneously using a crayon at the age of 15 months Rationale: The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively

A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children. a. Cow's milk b. Wheat bread c. Corn syrup d. Eggs

a. Cow's milk Rationale: According to evidence-based practice, the nurse should instruct the parent that cow's milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow's milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow's milk.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? a. A toddler who has a concussion and an episode of forceful vomiting b. An adolescent who has ineffective endocarditis and reports having a headache. c. An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10. d. A school-age child who has acute glomerulonephritis and brown-colored urine.

a. A toddler who has a concussion and an episode of forceful vomiting

A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? a. Copies a circle b. Cuts old using a table knife c. Begins writing in cursive d. Prints first and last name clearly

a. Copies a circle Rationale: The nurse should explain that copying a circle is a skill achieved by the age of 4 years.

A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? a. Ask the child to hold his breath and then blow it out slowly. b. Ask the child to describe a pleasurable event. c. Bounce the child gently while holding him upright. d. Rock the child in long rhythmic movements.

d. Rock the child in long rhythmic movements. Rationale: The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements.

A nurse in an emergency department is caring for an 8-year-old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? a. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine b. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) c. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine d. Adult tetanus booster (Td)

d. Adult tetanus booster (Td) Rationale: Td is recommended for wound prophylaxis in children ages 7 yrs and older. Td is also recommended q 10 yrs after 18 yrs of age.

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a. You may bathe your infant in an infant bathtub when you go home b. Apply hydrocortisone cream to your infants penis daily c. You should clamp your infants stent twice daily. d. Allows the stent to drain directly into your infants diaper.

d. Allows the stent to drain directly into your infants diaper.

A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? a. Cutting figures from colored paper b. Drawing stick figures using crayons c. Riding a tricycle d. Building towers of blocks

d. Building towers of blocks Rationale: Building towers of blocks is appropriate activity for a 2-year-old child. It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization.

A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. Inform the parents that written consent is required prior to organ donation b. Provide written information to the parents about organ donation. c. Ask the provider to explain misconceptions of organ donation to the parents. d. Explore the parents' feelings and wishes regarding organ donation.

d. Explore the parents' feelings and wishes regarding organ donation.

A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperature above 38.0C (100.5 F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100mg/5ml. How many mL should the nurse administer to the infant per dose?

2 mL

A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first? a. Check the child for a head injury b. Observe for oral bleeding c. Check the child's respiratory rate d. Observe for extremity weakness

c. Check the child's respiratory rate

A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurses priority? a. Length of stay b. Treatment schedule c. Disease process d. Self-care ability

c. Disease process

A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100ml IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number)

25 gtt Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. Wrist b. Great toe c. Index finger d. Heel

b. Great toe

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. Furosemide b. Captopril c. Regular insulin d. Potassium Chloride

d. Potassium Chloride

A nurse is caring for an adolescent who is reciting pain medication via a PCA pump. When the nurse assess the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 100, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hrs. Which of the following actions should the nurse take? a. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication. b. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain. c. Reevaluate the client in 1 hr since a 5 is acceptable on a scale of 1 to 10. d. Reinforce teaching with the client about how to push the button to deliver the med.

d. Reinforce teaching with the client about how to push the button to deliver the med. Rationale: The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively.

A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? a. Side-lying b. Semi-recumbent c. Flexed sitting d. Supine

d. Supine Rationale: The client is placed in the supine position, with the client's legs in a frog position.