Care Of Children mina
The nurse should recognize that complications of otitis media include
meningitis, labyrinthitis, and various types of abscesses and thromboses.
The nurse should identify that a firm and bulging fontanel, bradycardia, and increased sleep time an indication of
increased ICP.
A toddler experiencing severe dehydration would exhibit a capillary refill of
4 seconds or greater and skin tenting.
A 4-year-old child should be speaking in
4- to 5-word sentences
imitating animal sounds as a play activity to provide auditory stimulation for a
9- to 12- month-old infant. An activity that provides auditory stimulation for a 4-month-old infant is placing a rattle in the infant's hand.
A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority?
A child who has sickle cell anemia and a urine specific gravity of 1.030 The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is therefore the nurse's priority concern. 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 because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration might cause a sickle cell crisis that can occlude circulation. Incorrect Answers: A. A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. B. A child who has nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding. D. A blood glucose level of 110 mg/dL is within the expected reference range; therefore, this is not the nurse's priority
A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?
A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL The initial goal of therapy for diabetic ketoacidosis (DKA) is reaching a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the client's blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage. Incorrect Answers: A. An elevated WBC count is an expected finding with bacterial pneumonia. B. A low calcium level is an expected finding with chronic kidney disease. D. A decreased hematocrit is an expected finding with leukemia.
A nurse in an urgent care clinic is collecting data from a preschooler who has indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse?
Bruises at various stages of healing Bruises at various stages of healing are a manifestation of physical abuse. Incorrect Answers: A. Depriving a child of medical and dental care is a manifestation of physical neglect. B. Malnutrition is a manifestation of physical neglect. C. Frequent urinary tract infections are a manifestation of sexual abuse.
A nurse is caring for a 5-year-old child who has pneumonia and is experiencing a poor appetite. Which of the following interventions should the nurse take?
Allow the child to choose foods with a lower nutritional content Allowing the child to consume non-nutritional, empty-calorie foods and liquids will still provide needed calories and fluid during periods of illness. Once the child has recovered from the illness, the child's appetite will typically improve.
A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching?
A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching?
A nurse is caring for a preschooler who has a vesicular, honey-colored, crusty region around the nose and mouth and has been diagnosed with impetigo contagiosa. Which of the following instructions should the nurse plan to reinforce with the parents? (Select all that apply.)
A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water E. Wash hands before and after contact with the affected area Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on reinforcing teaching about applying an antibacterial ointment, washing the child's bed linens daily in hot water, and washing hands before and after contact with the affected area to decrease the risk of reinfection or transmission to others. Incorrect Answers: C. The nurse should reinforce teaching with the child's parents about the administration of antibacterial medications. Acyclovir is an antiviral medication used for the treatment of viral skin infections. D. The nurse should reinforce teaching with the child's parents about washing the crusts each day with water and soap to promote healing.
A nurse is reinforcing teaching with the guardians of a 4-month-old infant about how to play with the infant. Which of the following play activities should the nurse suggest for a 4-month-old infant?
Allow the infant to splash in the bathtub placing a toy that has bright colors in the infant's hand. placing a rattle in the infant's hand. The nurse should suggest that the guardians allow this 4-month-old infant to splash in the bathtub as a play activity. Splashing is appropriate for the developmental age of the infant and provides tactile stimulation. The nurse should emphasize and teach bath safety to prevent injury. Incorrect Answers: board book with large pictures 9- to 12-month-old infant. An example of an activity that provides visual stimulation for a 4-month-old infant would be placing a toy that has bright colors in the infant's hand. B. The nurse should suggest imitating animal sounds as a play activity to provide auditory stimulation for a 9- to 12- month-old infant. An activity that provides auditory stimulation for a 4-month-old infant is placing a rattle in the infant's hand. C.The nurse should suggest imitating animal sounds as a play activity to provide auditory stimulation for a 9- to 12- month-old infant. An activity that provides auditory stimulation for a 4-month-old infant is placing a rattle in the infant's hand.
A nurse is reinforcing teaching with a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test?
Immediately after the child wakes up in the morning The nurse should instruct the parent to perform the tape test as soon as the child wakes up in the morning and before the child bathes or uses the restroom. The test should be repeated for 3 mornings in a before the child has a bowel movement and before the child bathes provide the child with a usual diet.
A toddler experiencing severe dehydration would exhibit
absence of tears and sunken eyeballs
Oxybutynin is an
antispasmodic used for clients ages 6 and older who have neurogenic bladders.
A 3-year-old child does not have the
physical coordination to jump rope. This choice is appropriate for a 5-year-old child
The nurse should expect a positive corneal reflex (i.e. blink reflex) from a
15-month-old toddler because this is expected to be present at the time of birth.
A nurse is reinforcing teaching with the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include?
"Explain what you are doing to the infant while providing care." Exposing the infant to expressive speech is the foundation for the development of expressive skills (the ability to make others understand needs and thoughts) and receptive skills (the ability to understand spoken words). Incorrect Answers: B. Pacifier use is associated with an increased incidence of otitis media and does not encourage language development. The nurse should instruct the parents to discourage pacifier use after 6 months of age. C. Chewing and jaw muscle development do not promote language development. The nurse should instruct the family that hot dogs and carrots are choking hazards and should not be given to infants. D. Leaving a television playing in the child's room can be disruptive to sleep patterns and should be avoided
A nurse is reinforcing teaching with the family of a child about hospice care. Which of the following statements should the nurse include in the teaching?
"Hospice staff members consider the family's needs to be just as important as those of the child." The nurse should inform the family that part of the philosophy of hospice care is to provide care for the family's needs as well as those of the child. Assisting with respite care, counseling, spiritual needs, and care of the family following the child's death are all part of hospice care. Incorrect Answers: A. The nurse should inform the family that the hospice staff works closely with the family to coordinate the care of the child. Family members are active participants in the child's care and attend to the child's personal and hygiene needs as well as administration of medication. C. The nurse should inform the family that hospice care continues after the death of the child. Bereavement care is provided for a year or longer, if needed, to assist the family with adjusting to life following the loss of the child. D. The nurse should inform the family that hospice care focuses on palliative care and supporting the natural process of the child's death.
A nurse is reinforcing teaching with a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching?
"I need to apply paste to the back of the wafer on my child's appliance." The parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma. This will act as a sealant to prevent skin breakdown. Incorrect Answer: A. The parent should dress the infant in 1-piece outfits to restrict the infant's hands from reaching the pouch. B. The parent should use diapers that are larger than those the child usually wears to go over the stoma and help with drainage. D.
A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include?
"Monitor the color of your child's toes every 4 hours for 24 hours." The nurse should instruct the parent to monitor the color of the child's toes every 4 hours to check for alterations in perfusion. The nurse should instruct the parent to notify the provider if the child's toes are discolored or cool to the touch. Incorrect Answers: B. The nurse should instruct the parent not to insert anything into the cast to avoid injury to the skin, which can cause infection. The parent should blow cool air into the cast with a hair dryer or fan if the child experiences itching. C. The nurse should instruct the parent that the fiberglass cast will dry within 30 minutes. Casts made from plaster take up to 72 hours to dry. D. The nurse should instruct the parent that the cast must stay dry at all times. The parent should cover the cast with a plastic bag before the child showers or bathes and assist the child as necessary to ensure the cast stays dry when bathing
A nurse on a pediatric mental health unit is caring for a school-aged child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?
"Tell me about your favorite video game." The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication. Incorrect Answers: A. D. The nurse should avoid using closed-ended questions when attempting to foster rapport. This type of question typically results in a yes or no answer and does not encourage further communication. C. The nurse should avoid nontherapeutic statements that shift the focus away from the client and does not reflect interest in him as an individual
A nurse is reinforcing teaching with an adolescent client who has scoliosis. When discussing how to wear the back brace, the client appears to be holding back tears. Which of the following responses should the nurse make?
"This is a lot of new information to absorb about back braces; can you tell me your thoughts on what we have discussed?" Having scoliosis and wearing a back brace can negatively impact an adolescent's body image. When communicating with an adolescent client, the nurse should show empathy and encourage expression of feelings and thoughts. This allows the nurse to identify and address the client's specific concerns and needs. Incorrect Answers: B. Using stereotypical comments or clichés block therapeutic communication and might prevent the client from sharing fears and concerns. C. While it is therapeutic for the nurse to provide guidance regarding the selection of clothing, in this scenario the nurse is offering unsolicited advice without knowing why the client is crying. D. Close-ended questions elicit yes or no answers rather than allowing the client to express emotions.
A nurse is reinforcing teaching about oxycodone with an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include?
"This medication might cause nausea." The nurse should instruct the adolescent that nausea is an adverse effect of oxycodone. Other adverse effects include dizziness, sedation, and confusion. Incorrect Answers: A. The nurse should instruct the adolescent that constipation is a common adverse effect of oxycodone. B. The nurse should instruct the adolescent that this medication can cause orthostatic hypotension. Therefore, the adolescent should change positions slowly. D. The nurse should instruct the adolescent that this medication can cause dry mouth.
A nurse is talking with a parent of a preschooler. The parent reports that her child becomes upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent?
"Use a stable, relaxing routine such as a bath and story time before bed." Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime and allow parental-child interaction prior to bed. Incorrect Answers: B. Completely darkened rooms can elicit fear in preschoolers, including fear of the dark. C. Allowing the child to fall asleep routinely in a parent's lap might make the child unable to fall asleep alone. Instead, the child should learn to settle to sleep in bed with a transitional object such as a blanket or toy. D. The parent should not respond to attention-seeking behavior in order to avoid reinforcing behavior that will delay and disrupt bedtime.
A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make
"You can use a vial of insulin for up to 30 days." The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator. Incorrect Answers: A. Sugar-free cola will not increase the client's blood sugar because it does not contain sugar. The nurse should encourage the child to drink juice or milk with a complex carbohydrate. B. Insulin requirements increase during puberty due to a decreased sensitivity to insulin resulting in an increase in the child's insulin dosage. D. Blood glucose levels rise during illness and stress; therefore, the child might need to contact the provider for an increased insulin dosage.
A nurse is reinforcing teaching on strategies to decrease allergen exposure with a parent whose child has asthma. Which of the following statements should the nurse include?
"You should watch closely for any signs of roaches in your home." Exposure to roaches is a known allergen that can exacerbate an asthma attack. Parents should exterminate if roaches are present and keep the kitchen counters, cabinets, and floors clean and free of food to help prevent infestation. Incorrect Answers: A. While the child's room should be cleaned and vacuumed weekly to decrease exposure to allergens, the child should not perform this task due to the increased risk of causing an asthma exacerbation. B. Exposure to particulate matter from wood burning can increase the risk of an asthma exacerbation. C. Stuffed toys that can be washed in hot water and thoroughly dried weekly are acceptable for children who have asthma.
A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend?
1/2 cup baked beans The nurse should recommend foods high in fiber for a child who has chronic constipation. A half cup of baked beans contains approximately 5 g of fiber. Therefore, the nurse should instruct the guardian to include this food in the child's diet. Incorrect Answers: A. A half cup of whole milk contains no fiber. C. One cup of green leaf lettuce contains no fiber. D. One cup of apple juice contains no fiber
sessions for a preschooler to
10 to 15 minutes each.
An infant begins to localize sounds by the age of
3 months. By 9 months of age, the infant should be able to turn the head toward the location of the sound. This is an indication that the infant's sensory skills are
A nurse is caring for a 10-year-old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest?
3 oz of baked chicken on a whole wheat roll A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g. Incorrect Answers: A. A hot dog on a bun contains over 18.1 g of fat. C. Diced potatoes with scrambled eggs contain 16.5 g of fat. D. A medium blueberry muffin contains 18.2 g of fat.
tying shoelaces and Walking backward are a skill expected of atying shoelaces and Walking backward are a skill expected of a
5-year-old child. B. This is an expected finding in a 4-year-old child.
An infant begins to vocalize chained syllables such as "dada" by the age of
7 months of age. By 10 months of age, the infant associates meaning with words such as "mama." This is an indication that the infant's vocalization skills are ahead of expected findings.
The use of a pincer grasp usually begins to appear at the age of
8 months and becomes more refined by the age of 9 months. This is an indication that the infant's fine motor skills are on track with expected findings.
A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect?
Metabolic acidosis Metabolic acidosis is an expected finding for clients who have acute renal failure. Incorrect Answers: A. Hyperkalemia is an expected finding for clients who have acute renal failure. B. Hypocalcemia is an expected finding for clients who have acute renal failure. C. An elevated plasma creatinine level is an expected finding for clients who have acute renal failure
A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first?
Administer an antipyretic to the child When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of lowering the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.
A nurse is coordinating care for an adolescent who requires peritoneal dialysis (PD) to treat an acute kidney injury. Which of the following actions should the nurse take?
Ask if the adolescent would like to record the amount of solution infused and drained Allowing the adolescent to be involved in helping with the procedure gives the adolescent a sense of control over what is happening. Recording the amounts is an appropriate action for an adolescent. Incorrect Answers: A. check the adolescent's vital signs before and after PD to maintain a precise record of all aspects of the treatment regimen and to help identify any complications that should be reported to the provider. B. The infusion should not be stopped because this is an expected finding during the infusion process. D. This would be appropriate for a school-aged child, but the adolescent needs to be taught how the procedure will be immediately beneficial. When the information being taught only explains how it will affect symptoms at some future date, the adolescent will not remember information as easily
A nurse is reinforcing teaching with a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in a school-aged child?
Assign the child several small chores The nurse should recommend assigning the child several small chores. The completion of each chore in a short amount of time offers the child a sense of accomplishment and promotes achievement of the developmental task of industry. Incorrect Answers: A. Providing consistent care that meets a physical need promotes trust; however, it doesn't promote industry. Trust is a developmental task that should be achieved during infancy. C. The nurse should recommend discussing career choices and plans for adulthood with an adolescent as a means of promoting achievement of the developmental task of identity. D. The nurse should recommend talking about the family's and child's value system with an adolescent as a means of promoting achievement of the developmental task of identity
A nurse is caring for an 8-year-old child in the acute care setting. Which of the following actions should the nurse take?
Assign the child the task of checking her blood sugar before meals School-aged children are in Erikson's stage of Industry versus Inferiority. They are willing to accept and thrive when assigned the responsibility to perform simple tasks. Incorrect Answers: A. This action would be appropriate for an adolescent. School-aged children should receive teaching up to 1 day before the scheduled procedure to allow adequate time to process the information but not cause undue anxiety. C. This action would be appropriate for a toddler or a preschool-aged child. Children in these age groups typically exhibit animism, which is the belief that inanimate objects can assume life-like characteristics. D. This action would be appropriate when caring for a preschooler. Preschool-aged children are fearful of being injured or losing body parts.
A nurse is reinforcing teaching with the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods into the infant's diet?
At 4 to 6 months of age The nurse should identify that infants are developmentally ready for solid foods at 4 to 6 months of age. Incorrect Answers: A. The disappearance of the extrusion reflex, not the rooting reflex, is an indicator of the infant's developmental readiness for solid foods. B. Infants between 2 and 3 months of age still have the extrusion reflex and are not developmentally ready for solid foods. C. The timing of the eruption of the infant's first tooth varies greatly and is not an appropriate indicator of when to introduce solid foods
A nurse is assisting with the care of a school-aged child who had a tonsillectomy. Which of the following interventions should the nurse take?
Avoid providing straws for use when drinking fluids Straws should be avoided because they can accidently damage the surgical site and cause excessive bleeding. Incorrect Answers: A. Suctioning should only be performed as needed and done gently to avoid damaging the surgical site. C. Brown blood is an expected finding following a tonsillectomy. Parents should be instructed to notify the physician if bright red bleeding is occurring or if the child is frequently clearing the throat, as this is a sign of increased bleeding. D. Nose blowing, coughing frequently, and throat clearing can increase bleeding from the surgical site. These actions should be avoided.
A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death?
Believes that her own thoughts can cause death The nurse should expect preschoolers to believe that their own thoughts or actions can cause death, and they might believe that death is a punishment for wrong-doing. Incorrect Answers: B. The nurse should expect a preschooler to view death as a temporary occurrence like sleeping. The preschooler might believe the person can "wake up" again. C. The nurse should expect a school-aged child to be curious about what happens to a body following death. D. The nurse should expect an adolescent to reject traditions surrounding death such as funeral services as unnecessary or unimportant.
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take?
Burp the infant at least 2 to 3 times during the feeding Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed. Incorrect Answers: B. Infants who have a cleft lip and palate are typically "noisy" feeders due to the increased amount of air that is swallowed during a feeding. The nurse should watch the infant carefully for signs of distress during a feeding such as a wrinkled brow, elevated eyebrows, or watering eyes. If these distress signs are noted, the nurse should remove the nipple and allow time for the infant to swallow the formula. C. Formula is expected to appear in the nose of an infant who has a cleft lip and palate due to a lack of separation between the oral and nasal cavities. D. Parents and caregivers should be encouraged to begin feeding the infant as soon as possible. This opportunity enables the caregivers to gain experience and confidence in their ability to feed the infant prior to discharge, which typically occurs before the surgical repair.
A nurse is caring for a toddler in the immediate postoperative period following the placement of a ventriculoperitoneal (VP) shunt. Which of the following interventions should the nurse perform?
Check for abdominal distention Intracranial fluid draining into the abdominal cavity may cause peritonitis or an ileus. The nurse should monitor the abdomen for distention and bowel sounds. Incorrect Answers: B. The child should be positioned flat during the immediate postoperative period to prevent the intracranial fluid from draining too rapidly, which could cause complications. C. While bulging or tenseness are signs of increased intracranial pressure in an infant, a toddler's anterior fontanel is closed. The anterior fontanel typically closes by 12 to 18 months of age. D. The child should be positioned with the operative side up to keep pressure off the shunt valve
A charge nurse is reinforcing teaching about child maltreatment with a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching?
Children who were born prematurely are more likely to be maltreated. Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often has increased care needs, which increases the risk of caregiver fatigue and can lead to a higher potential for maltreatment. Incorrect Answers: A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have additional stressors and restricted access to available support systems.
A nurse is collecting data from a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?
Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify that the child is having a hemolytic reaction. Incorrect Answers: B. Pruritus and flushing are findings that indicate a response to allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction. C. Rales and cyanosis are findings that indicate the blood product might have been administered too quickly. The nurse should identify these findings as an indication the child is experiencing fluid overload. D. Bradycardia and diarrhea are findings that indicate a complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication the child is experiencing an electrolyte imbalance.
A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child?
Coloring book and crayons Preschoolers have increasing fine motor control and imagination abilities. They enjoy toys that allow for creativity and self-expression.
A nurse is reinforcing discharge teaching with the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider?
Constant clearing of the throat A manifestation of hemorrhage following a tonsillectomy is the constant clearing of blood that is draining in the back of the throat. Therefore, the provider should be notified if the adolescent begins constantly clearing her throat following a tonsillectomy. Incorrect Answers: A. Following a tonsillectomy, some secretions can contain old blood. Old blood is a dark brown color, and fresh blood is bright red. Nasal secretions containing dark brown blood should not be reported to the provider because this is an expected finding. C. Following a tonsillectomy, an unpleasant odor from the oral cavity for several days is an expected manifestation. D. Following a tonsillectomy, a low-grade fever for several days is an expected manifestation.
A nurse is collecting data from an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing?
High-pitched cry The nurse should identify that an infant's high-pitched cry is an indication of increased ICP. Other indications include a bulging fontanel, a high-pitched cry, and increased sleeping. Incorrect Answers: B. The nurse should identify that a firm and bulging fontanel is an indication of increased ICP. C. The nurse should identify bradycardia as an indication of increased ICP. D. The nurse should identify increased sleep time as an indication of increased ICP
A nurse is collecting data from a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration?
Deep, rapid respirations This finding is a manifestation of severe dehydration. Other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia.
A nurse is checking the motor development of a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay?
Dropping a cube when passing it between the hands The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider. Incorrect Answers: A. The pincer grasp is an expected fine motor skill for a 9-month-old infant. C. Falling to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant. D. A 9-month-old infant should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways.
A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety?
Encourage rooming-in Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope in an unfamiliar environment. Incorrect Answers: A.Toddlers are not as concerned about privacy as school-aged children and adolescents. Instead, they prefer to be with someone during procedures. B. The nurse should provide the toddler with short, simple explanations. A long explanation might cause heightened anxiety for the child. D. When speaking to a toddler, the nurse should refrain from using the word "fix" because this will cause toddlers to assume they are broken. Instead, the nurse should say, "I will help make you feel better."
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use?
FACES pain rating scale The FACES pain rating scale presents the client with various images of faces that represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels. Incorrect Answers: A. A word-graphic rating scale uses a line with words identifying a scale of no pain to worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. However, children who are 3 years old will have difficulty understanding the words. B. The color tool uses 4 markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. D. Using a numeric scale (0 to 10) to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older.
A nurse working on a maternal-newborn unit is assisting with planning an in-service training session for staff about assisting new mothers with breastfeeding. Which of the following infant conditions should the nurse recommend including in the teaching as a contraindication for breastfeeding?
Galactosemia An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes. Incorrect Answers: B. An infant who has hyperbilirubinemia can develop jaundice due to the accumulation of bilirubin in the system. Breastfeeding is encouraged in the early postpartum period for infants who develop hyperbilirubinemia because the colostrum in breast milk is a natural laxative that promotes the excretion of excess bilirubin. C. Glycogen storage disease is a congenital disorder in which glycogen, which is usually stored in the liver and metabolized into glucose when needed, cannot be metabolized into glucose due to a missing or deficient enzyme. As a result, the infant develops hypoglycemia and can experience neurological damage. Treatment involves continuous nasogastric or gastrostomy feedings during the night. However, breastfeeding is not contraindicated for infants who have glycogen storage disease. D. Infants who are born with congenital hypothyroidism will require lifelong treatment with a thyroid-replacement medication. However, breastfeeding is not contraindicated for infants who have hypothyroidism.
A nurse is reinforcing teaching with an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?
Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site. Incorrect Answers: B. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the upper arms during basketball competitions. C. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the thighs during basketball competitions. D. The lower leg is not a recommended injection site for insulin. Insulin is administered subcutaneously into adipose or fat tissue over a muscle. Recommended injection sites for insulin are the abdomen, hips, buttocks, upper arms and thighs. When participating in vigorous exercise, the nurse should instruct the client to select an injection site that is not on an extremity involved in the activity
A nurse is reinforcing teaching with the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include?
Instruct the child to walk the bike through intersections The child should walk the bike through intersections and crosswalks to decrease the risk of injury. Incorrect Answers: A. The child should ride a bike with the flow of traffic to decrease the risk of injury. C. The child should ride a bike that is the appropriate size to prevent injuries. The balls of the child's feet should be on the ground when the child sits on the bicycle seat. D. The bike helmet should not obstruct the child's eyes or ears to decrease the risk of injury
A nurse is performing a neurological examination on a 15-month-old toddler. Which of the following findings should the nurse expect?
Negative Babinski reflex The nurse should expect a negative Babinski reflex from a 15-month-old toddler because this reflex usually disappears around 12 months of age. Incorrect Answers: B. The nurse should expect a negative Moro reflex from a 15-month-old toddler because this reflex usually disappears around 4 months of age. C. The nurse should expect a positive corneal reflex (i.e. blink reflex) from a 15-month-old toddler because this is expected to be present at the time of birth. D. The nurse should expect the palmar grasp to be absent from a 15-month-old toddler because this reflex is usually replaced by the pincer grasp around 8 to 9 months of age.
A nurse is contributing to the plan of care for a child who has aplastic anemia. Which of the following interventions is the priority for the nurse to include?
Place the child in a protective environment with positive air pressure The greatest risk to a child who has aplastic anemia is infection. The child has decreased RBCs, platelets, and WBCs, causing severe suppression of the immune system. Therefore, the priority intervention for the nurse to include is to initiate protective environment isolation. Incorrect Answers: A. The nurse should pad the side rails of the child's bed with thick towels or blankets to minimize or prevent bruising. However, another intervention is the priority. C. The nurse should inspect and remove toys that have sharp corners or edges to minimize bruising and prevent bleeding. However, another intervention is the priority. D. The nurse should hold pressure on the child's puncture site for 5 minutes when obtaining blood samples to prevent bleeding. However, another intervention is the priority.
A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take?
Prepare concentrated sucrose for oral administration The nurse should provide the newborn with oral sucrose 2 minutes prior to performing the heel puncture. This practice, along with non-nutritive sucking, has been shown to decrease the pain the newborn experiences during the heel puncture. Incorrect Answers: A. Tolmetin is an oral analgesic medication for clients 2 years of age and older. Therefore, the nurse should not administer this medication to the newborn. B. The nurse should apply EMLA cream to the puncture site about 1 hour prior to the procedure. This allows time for the EMLA cream to decrease the pain the newborn experiences during the heel puncture. D. If skin-to-skin contact with a parent is not possible, the nurse should swaddle and rock or hold the infant to decrease the pain that the newborn experiences during the heel puncture. Swaddling the newborn can reduce pain associated with procedures because it mimics the feeling of being in the womb, whereas being placed in an extended position would be uncomfortable for the newborn and would likely increase pain because it is not a natural position at this age.
A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse, "My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take?
Prepare to administer intravenous fluids The nurse should prepare to assist with the administration of intravenous fluids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to finish a bottle of formula. Also, fluids will help loosen congestion, which typically occurs with RSV. Incorrect Answers: A. The infant's inability to finish a bottle of formula does not indicate the need to assess the infant's sucking reflex. The sucking reflex begins to diminish at about 6 months of age. A weak or nonexistent sucking reflex would have been identified much earlier than 6 months of age because it would have impeded feeding. B. The infant might require suctioning to clear secretions; however, suctioning should only be performed when necessary and not as a prophylactic treatment because it can cause tissue damage. D. There is no indication that the nurse should place the infant in a negative-pressure isolation room. This type of isolation is used for clients who have tuberculosis.
A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse take to help decrease the child's risk of experiencing a vaso-occlusive crisis?
Provide adequate fluid intake throughout the day Adequate hydration is an effective strategy for preventing sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation. Incorrect Answers: B. Oxygen might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis. C. A blood transfusion might be necessary to manage a sickle cell crisis, but it is not routinely used to prevent a crisis. D. The nurse can administer ibuprofen to manage the pain of a sickle cell crisis, but it will not prevent a crisis from occurring
A nurse is reinforcing teaching about home safety with the parent of a 2-month-old infant. Which of the following information should the nurse include?
Remove bibs before the infant goes to sleep The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation. Incorrect Answers: B. The nurse should instruct the parent to dress the infant in a 1-piece sleep sack and avoid using blankets to decrease the risk of suffocation. C. The nurse should instruct the parent to avoid placing the infant in direct sunlight for more than 2 to 3 minutes at a time. If the infant will be exposed to sunlight for a longer period, the parent should cover any exposed areas of skin. D. The nurse should instruct the parent to set the hot water heater to no more than 49°C (120°F) to prevent burn injuries
A nurse is planning to perform chest physiotherapy (CPT) for an infant who has cystic fibrosis. Which of the following techniques should the nurse plan to include?
Repeatedly strike the infant's chest using a cupped hand Percussion involves striking a cupped or curved palm against the infant's chest to produce an audible thumping noise. This technique loosens the mucus in the airway for expectoration and should not produce discomfort. Incorrect Answers: B. CPT is best scheduled before meals or at least 1 hour after a meal so the subsequent coughing does not cause vomiting. C. When draining the apical segment of the left upper lobe, the nurse should position the infant on the nurse's lap. D. Hyperoxygenation is not necessary prior to CPT. It should be used prior to suctioning an infant. "
A nurse is collecting data from a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development?
Requiring support to sit for prolonged periods An infant should be able to sit unsupported by the age of 8 months. The nurse should report this finding to the provider because it is an indication of a delay in gross motor development. Incorrect Answers: A. The use of a pincer grasp usually begins to appear at the age of 8 months and becomes more refined by the age of 9 months. This is an indication that the infant's fine motor skills are on track with expected findings. C. An infant begins to localize sounds by the age of 3 months. By 9 months of age, the infant should be able to turn the head toward the location of the sound. This is an indication that the infant's sensory skills are on track with expected findings. D. An infant begins to vocalize chained syllables such as "dada" by the age of 7 months of age. By 10 months of age, the infant associates meaning with words such as "mama." This is an indication that the infant's vocalization skills are ahead of expected findings.
A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect?
Sodium 125 mEq/L The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEq/L is below the expected reference range for an infant. Incorrect Answers: A. The nurse should expect an infant with acute renal failure to have an elevated BUN level. A BUN level of 5 mg/dL is within the expected reference range for an infant. B. The nurse should expect an infant with acute renal failure to have an elevated creatinine level. A creatinine level of 0.2 mg/dL is within the expected reference range for an infant. D. The nurse should expect an infant with acute renal failure to have hyperkalemia. A potassium level of 4.2 mEq/L is within the expected reference range for an infant.
A nurse is collecting data from a 4-year-old child for growth and developmental milestones during a well-child visit. Which of the following findings suggest a possible delay in development?
Speaking using 2- or 3-word sentences A 4-year-old child should be speaking in 4- to 5-word sentences. Speaking in 2- to 3-word sentences is typical for a 2-year-old child.
A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following?
Speech patterns The nurse should recognize that chronic otitis media can result in hearing loss, which can affect speech development.
A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room?
Suction equipment When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonic-clonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or fluids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed. Incorrect Answers: A. The nurse should have a pulse oximeter available in the child's room because the child is at risk for hypoxia from a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room. B. The nurse should have oxygen therapy equipment available in the child's room because the child is at risk for hypoxia from a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room. C. The nurse should have a bag valve mask available in the child's room because the child might need rescue breaths following a tonic-clonic seizure; however, another item is the priority for the nurse to have in the child's room.
A nurse is caring for a 2-year-old child who has a history of frequent urinary tract infections. When reinforcing teaching with the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include?
Teach the child to wipe from front to back The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra. Incorrect Answers: B. The child should avoid bubble baths because they can cause urethral irritation. C. The child should urinate at least every 4 hours to prevent stasis of urine in the bladder, which can cause bacteria growth. D. Oxybutynin is an antispasmodic used for clients ages 6 and older who have neurogenic bladders.
A nurse is reviewing the dynamics of a family in which abuse is suspected. Which of the following findings should the nurse report to the provider?
The child has several unexplained scars and bruises. The nurse should suspect child maltreatment when the child has multiple unexplained scars and bruises. The nurse should report this finding to the provider. Incorrect Answers: A. Parents providing emotional support to the child is an expected finding. An unexpected finding would be the parents showing no emotion at all toward the child. C. A fear of health care staff is an expected finding in a child. An unexpected finding would be the child showing indiscriminate friendliness toward strangers such as the health care provider. D. Parents offering consistent stories about the child's injuries is an expected finding. An unexpected finding would be the parents presenting conflicting stories about the injury.
A nurse in the outpatient setting is planning to administer the varicella vaccine to a toddler. Which of the following findings is a contraindication to the child receiving this vaccination?
The child is receiving chemotherapy Severe immunosuppression is a contraindication to receiving a live virus vaccine such as the varicella vaccine. Potentially, the live virus could reproduce in an immunocompromised host and cause a vaccine-induced illness. Incorrect Answers: A. The presence of a minor illness is not a contraindication to receiving a vaccination. Routine vaccinations should be delayed if the child displays manifestations of a serious febrile illness. B. This is not a contraindication to receiving a routine vaccination. Extensive research shows no link between routine vaccinations and autism. D. An allergy to eggs is not a contraindication to receiving the varicella vaccine.
A nurse is preparing to assist with the physical assessment of a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination?
The child prefers to sit on the parent's lap during the Engaging in play near other children A toddler is expected to play in parallel with other children. As socialization begins, the child plays alongside other children, not with them.
A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful?
The infant has a total bilirubin level of 0.3 mg/dL. A bilirubin level of 0.3 mg/dL is within the expected reference range and indicates the surgery was successful. Incorrect Answers: A. Weight loss is an indication that the surgery was not successful. The infant should gain weight following the surgery due to improved intestinal absorption. C. An AST level of 120 units/L is above the expected reference range and indicates continued biliary obstruction. D. If the surgical correction was successful, the infant's stools should turn yellow and then brown in color. Gray stools indicate continued biliary obstruction
an expected fine motor skill for9-month-old infant should
The pincer grasp Falling to a sitting position from a standing position ability to maintain balance while leaning forward in a sitting position.
A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups?
Toddlers Toddlers demonstrate parallel play. Incorrect Answers: A. Infants demonstrate solitary play. C. Preschoolers demonstrate associative play. D. School-aged children demonstrate cooperative play.
A nurse on a pediatric unit is assisting with the care of a preschooler who is prescribed an IV medication. Which of the following techniques should the nurse use to assist with preparing the child for the procedure?
Use role-play activities with the child The nurse should use role-play activities to decrease the child's anxiety about the procedure. This approach will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Incorrect Answers: B. The nurse should avoid giving a detailed explanation , easy words and phrases. C. sessions for a preschooler to 10 to 15 minutes each. D. The nurse should allow the child to see, hold, and ask questions about needleless IV supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Giving the child identical IV supplies to play with is a major safety risk because the child will likely be injured by the needle.
A nurse in a pediatric clinic is preparing to assist with a sweat chloride test for a toddler who is suspected to have cystic fibrosis. Which of the following actions should the nurse plan to take?
Warm the temperature of the toddler's examination room The nurse should ensure that the examination room is warm. A warm environment promotes the toddler's ability to produce sweat for the sweat chloride test. To further promote sweating, the nurse should apply blankets to maintain the toddler's body heat during the test. Incorrect Answers: A. The nurse should ensure that the toddler has adequate fluid intake prior to the sweat chloride test. If the toddler is dehydrated, the test results can be inaccurate due to a decreased ability to produce sweat and an increased concentration of electrolytes. B. The nurse should review and document the toddler's food intake for 72 hours if the toddler is having a stool analysis for the diagnosis of cystic fibrosis. A 72-hour stool test analyzes the amounts of fat and enzymes in the stool samples. D. The nurse should expose the thigh of an infant and the forearm of an older child for application of electrodes during a sweat chloride test. The nurse should keep other areas of the toddler's body covered with blankets to maintain body heat during the test.
Speaking in 2- to 3-word sentences is typical for
a 2-year-old child
The pincer grasp is an expected fine motor skill for should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways.
a 9-month-old infant. C. Falling to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant.
age 6 years and older.
a game of checkers to have the cognitive ability to identify left and right
Pruritus and flushing are findings that indicate a response to
allergens present in the transfused blood product. The nurse should identify that the child is having an allergic reaction.
A child who has a colostomy will need
bladder training when developmentally ready because the urinary system is still intact.
Rales and cyanosis are findings that indicate the
blood product might have been administered too quickly. The nurse should identify these findings as an indication the child is experiencing fluid overload.
9- to 12-month-old infant.
board book with large pictures imitating animal sounds as a play activity to provide auditory stimulation for a
Adolescents are typically concerned about
comparing their development to the development of peers. Toddlers are just beginning to understand their existence as a separate person from their mother and are not concerned with how their development compares to other toddlers
Bradycardia and diarrhea are findings that indicate a
complication due to the transfusion of large amounts of blood or a problem with the kidneys. The nurse should identify these findings as an indication the child is experiencing an electrolyte imbalance
The nurse should expect a 4-year-old preschooler to
cut out a picture using scissors.
4 years child
cut out a picture using scissors. is able to hop on 1 foot gross motor ability to skip and hop on 1 foot until about
The nurse should expect a 3-year-old preschooler to
have the ability to draw a circle but not print letters until age5
Preschool and school-aged children are typically interested in a demonstration of
how the examination equipment works. Toddlers might want to inspect the equipment before use but are not usually interested in how it functions.
The disappearance of the extrusion reflex,
not the rooting reflex, is an indicator of the infant's developmental readiness for solid foods.
5 y child
physical coordination to jump rope. draw a stick figure that has 7 to 9 parts. tying shoelaces and Walking backward are a skill expected of a Play becomes associative At this age, the child attempts to follow rules but might cheat to prevent losing. ability to identify time-related words such as the days of the week. Print letters
A 3-year-old child might be able to
play a game with simple rules. However, build a tower of 9 to 10 blocks. to have the fine motor ability to stack 10 blocks. understand the concept of sharing until around
Pressuring a child to eat might cause the child to
rebel and then use food consumption as a control mechanism. The nurse should praise the child for what is eaten and avoid using any tactics to force the child to eat.
Larger portions might overwhelm the child and prompt a refusal to eat. Instead, the nurse should provide
smaller, more frequent meals and offer second helpings when food is eaten.
School-aged children are typically interested in how
the body works and are open to instructions. Toddlers can understand the names and basic actions that body parts can perform, but they do not usually ask specific questions about body functions.
If both the meal and dessert are offered together, the child will likely fill up on
the dessert first and might choose to not eat the other options. Instead, dessert should be offered at the end of the meal.
The nurse should expect a 3-year-old preschooler to have the language ability to
use 3- to 4-word sentences. Seven-word sentences are not expected until age 5.
