ATI Pediatrics
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° C (99.7° F
A 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 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. Egg
A 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 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 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 teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching? a. "scold your child when they have toileting accident." b. "award your child with a sticker when they sit on the potty chair." c. "play your child's favorite song while teaching them to use the potty chair." d. "teach multiple steps of the skill at the same time."
B
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 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 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. Brightly colored mobile b. Plastic stethoscope c. Small piece jigsaw puzzle d. A book of short stories
B 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 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 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 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 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 planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. Use sterile scissors to remove the dressing from the site. b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. c. Access the site using a non-coring angled needle. d. Use a semipermeable transparent dressing to cover the site.
D
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a. administer pancreatic enzymes 2 hours after meals b. discontinue the use of pancreatic enzymes if steatorrhea develops c. limit fluid intake to 750 mL per day d. increase fat content in the child's diet to 40% of total calories.
D
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. Controls impulsive feelings b. Understands right from wrong c. Easily separates from parents for long periods of time d. Expresses likes and dislikes
D
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 chlorhexidine 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
A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent replacement. 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 infant's penis daily." C."You should clamp your infant's stent twice daily." D. "Allow the stent to drain directly into your infant's diaper"
D
A nurse is reinforcing teaching with an adolescent who has an inflamed nonperforated appendix and is scheduled for a laparoscope assisted appendectomy. Which of the following instructions should the nurse include in the teaching? A. You can begin drinking fluids again 2 days after your surgery B. You will need to ask for pain medication for the first 24 hours after surgery C. You will have your vital signs monitored every 8 hours after surgery D. You will sit in your chair at least twice a day after surgery
D
A nurse is teaching a parent of a 12-month old child about development during the toddles years. Which of the following statements should the nurse include? a. "Your child should be referring to himself using the appropriate pronoun by 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
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 Rationale: The client is placed in the supine position, with the client's legs in a frog position.
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 18 mm/hr b. WBC count 6,200/mm3 c. C-reactive protein 1.4 mg/L d. RBC count 4.7 million/mm
A
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching? a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." b. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c. "A Monospot is a throat culture used to diagnosis mononucleosis." d. "Children who get mononucleosis will need to refrain from sports for 6 months."
A
A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make? a. "Your baby might pull at their ears when they are teething." b. "Rub your baby's gums with an aspirin to decrease discomfort." c. "Place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first.
A
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.
A
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. Pleural friction rub d. Rhonchi
A
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurses priority? a. Episodes of vomiting b. Formula consumption c. Weight d. Temperature
A
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider? a. nasal flaring b. WBC count 11,300/mm^3 c. diarrhea d. abdominal distension
A
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
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
A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. Deep respirations of 32/min b. Shallow respirations of 10/min c. Paradoxic respirations of 26/min d. Periods of apnea lasting for 20 seconds
A
A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. Palpate the dorsum of the child's feet. b. Weigh the child daily using the same scale. c. Assess the child's skin turgor. d. Observe the child for periorbital swelling.
A
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take? a. Place the infant in a knee-chest position. b. Administer a dose of meperidine IV. c. Discontinue administration of IV fluids. d. Apply oxygen at 2 L/min via nasal cannula.
A
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a. Avoid palpating the abdomen when bathing the child before surgery. b. Refrain from auscultating the child's bowel sounds during the postoperative assessment. c. Encourage the child to play with other children on the unit prior to surgery. d. Explain to the child that their pain will be managed after the surgery.
A
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
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
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 1,200 per day." d. "You should give your child a multivitamin once weekly.
A
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 infective 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 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 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 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 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 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 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.
21. 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 foods using a table knife c. Begins writing in cursive d. Prints first and last name clearly
A Rationale: The nurse should explain that copying a circle is a skill achieved by the age of 4 years.
16. 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 infant's perineal area. c. Avoid placing the scrotum inside the collection bag. d. Wait several hours after positioning the device before checking it.
A 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 is caring for a child who has a 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 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 rationale: PICC lines are the preferred venous access device for short to moderate term IV therapy. The can remain in place for long periods with proper care.
. 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? (Select all that apply.) a. Observe the parents' 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,B 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 in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.) i) Increased temperature ii) Gingival hyperplasia iii) Xerophthalmia iv)Bradycardia v) Cervical lymphadenopathy
A,C,E
A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching? A. I will let my baby sleep with me in bed at night B. I will allow my baby to have a pacifier while sleeping C. I will place my baby on a soft mattress to sleep D. I will cover my baby with a quilt while he is sleeping.
B
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) a. The child views death as similar to sleep. b. The child is 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 a punishment
ABE Rationale: The child views death as similar to sleep is correct. Preschool-age children might make this comparison. The 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 due to an improved ability to comprehend what is happening. The child recognizes that death is permanent is not correct. Preschool-age children have difficulty understanding the concept of time and are therefore not likely to believe that death is permanent. They perceive death as reversible. The child believes his thoughts can cause death is correct. Preschool-age children believe that their thoughts and wishes can make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age. The child thinks death is a punishment is correct. Preschool-age children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought.
) A nurse in an emergency department is caring for a school-age child who has sustained a 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
11) A nurse is an emergency department is caring for a school-age child who has epiglottitis. 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
A nurse in the emergency department is caring for a 2-year-ols 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 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
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
A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? a. Urine specific gravity 1.045 b. Sodium 155 mEq/L c. Blood glucose 45 mg/dL d. Urine output 35 mL/hr
B
A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a. Apply a cooling blanket to the toddler. b. Dress the toddler in minimal clothing. c. Give the toddler a tepid bath. d. Administer diphenhydramine to the toddler
B
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
A nurse is planning n educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." b. "Choose a waterproof sunscreen with a minimum SPF of 15." c. "Dress your child in loose weave polyester fabric prior to sun exposure." d. "Reapply sunscreen every 4 hours."
B
A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following finding 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 pulse +3 bilateral
B
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
B
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching? a. "Limit movement of the child's large joints." b. "Encourage the child to perform independent self-care." c. "Provide the child with a soft mattress for sleeping." d. "Schedule a 2-hour daily nap for the child in the afternoon."
B
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Use a kitchen teaspoon to measure the medication." b. "Brush the child's teeth after giving the medication." c. "Double the next dose if the child misses a dose." d. "Repeat the dose if the child vomits."
B
A nurse is caring for an 18-year-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 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 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 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 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 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 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 infant'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 Rationale: When administering medications to an infant, a needleless 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 admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) a. Steatorrhea b. Vomiting c. Lethargy d. Constipation e. Weight gain
B,C
) A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the childs 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
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
A nurse assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. Hypotension b. Reports insomnia c. Difficulty concentrating d. Tachycardia
C
A nurse in a providers office is caring for a school-age child who has varicella. The parents asks 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
A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. Heart rate 124/min b. Increased tear production c. Sunken anterior fontanel d. Capillary refill 2 seconds
C
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 min of administration c. Serum potassium level 4.1 mEq/L d. Blood pressure 86/52 mm Hg
C
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
A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. Levothyroxine
C
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. Which of the following is an appropriate reaching point for the nurse to give the parents? A. Give the toddler milk B. Get to an emergency center c. Call poison control d. induce vomiting
C
A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "My child can resume usual activities since this was just an outpatient surgery." b. "My child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat."
C
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 weight 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
A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will offer my child small amounts of fruit juice frequently." b. "I will avoid giving my child solid foods until the diarrhea has stopped." c. "I will monitor my child's number of wet diapers." d. "I will give my child polyethylene glycol daily for 7 days."
C
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. ½ cup whole milk b. 1 cup orange juice c. ½ cup raisins d. 1 cup raw carrots
C
A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Stay home from school for 1 week following the procedure." b. "follow a diet that is low in fiber for 1 week." c. "wait 3 days before taking a tub bath." d. "apply a pressure dressing to the site for 3 days."
C
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
19. A nurse is assessing a 7-year-old child's psychosocial 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 Rationale: Complaining every day about going to school is an unexpected finding for a 7-yearold child. The child is in Erikson's psychosocial development 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.
12. 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 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 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 Rationale: Male clients are at increased risk for hospitalization-related stress compared to female clients.
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 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 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 Rationale: The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.
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 Rationale: The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury.
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 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 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 tongue 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
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 papillomavirus (HPV) and hepatitis A b. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) c. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) d. Varicella (VAR) and live attenuated influenza vaccine (LAIV)
C 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 is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and 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 some discharge from the injection site."
C 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 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° C (120° F).
CDE 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 due to the increased risk of suffocation. Positioning the car seat so it is rear-facing is correct. Infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. Securing a safety gate at the top and bottom of the stairs is correct. As the infant begins to crawl and becomes more mobile, the risk of falls increases. Maintaining the water heater temperature at 49° C (120° F) is correct. To prevent a burn injury, the temperature of the water heater should not exceed 49° C (120° F).
) A nurse is discussion 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
) A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have ADHD in the morning."
D
9) 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
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? a. Resists having an axillary temperature taken b. Exhibits withdrawal behaviors when their parent leaves c. Has multiple bruises on their knees d. Poor personal hygiene
D
A nurse is caring for a 2yo child with cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be the most appropriate for the child? a. cutting and gluing b. blowing soap bubbles c. riding a tricycle d. building block towers
D
A nurse is collecting data from a school-age child. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Recurrent urinary tract infections D. Bruises at various stages of healing
D
A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include? a. Maintain the child's room temperature at 80° F. b. Prepare the child for a lumbar puncture. c. Administer aspirin to the child for a temperature greater than 38.3° C (101° F). d. Initiate airborne precautions for the child
D
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? a. Until the adolescent is afebrile b. For 7 days following admission to the facility c. Until the adolescent has a negative blood culture d. For 24 hr following initiation of antimicrobial therapy
D
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
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 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 ounces 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 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 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 Rationale: Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age.
. A nurse is caring for an adolescent who is receiving 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 hr. 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 pain level of 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 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 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 Rationale: The nurse can implement relaxation strategies by sitting with the child in a wellsupported position such as against the chest, and then rocking or swaying back and forth in long, wide movements.
