Evolve: Toddlers week 3 - no rationales
A nurse is teaching a class to parents about keeping medications and household cleaning supplies out of the reach of toddlers. The nurse explains that this is necessary because toddlers:
Have a high level of oral activity
A nurse is caring for a toddler who has undergone bone marrow transplantation. What clinical findings should the nurse anticipate if an infection develops?
Fever and lethargy
To evaluate kidney function, the nurse must accurately measure the hourly urine output of a 1½-year-old toddler weighing 22 lb who has been admitted with extensive burns. What is the minimum safe output per hour for a child this age?
10 to 20 mL
A nurse notes that a child is exhibiting signs of cerebral palsy. At what age are these signs usually first noticeable?
12 months
While reviewing the admission assessment the nurse finds that a 2-year-old child has not received immunization for measles, mumps, and rubella (MMR). At what age should the child have received this vaccine?
12 months
A nurse is performing health screenings of toddlers in a culturally diverse neighborhood. Which child should the nurse consider at risk for β-thalassemia (Cooley anemia)?
2-year-old child of Greek descent with a large abdomen
A nurse is teaching a group of assistants in a daycare center about toddlers' developmental milestones. What behavior should indicate to the assistants that one of the milestones has been achieved?
Accepting external limits
A nurse is teaching a group of parents about the developmental needs of young toddlers. What is the priority topic that the nurse should include?
Accident prevention
A nurse encourages parents to have their toddler's eyes tested especially for monocular strabismus. What should the nurse explain may occur if the condition is not corrected early?
Amblyopia will progress in the weak eye.
A 30-month-old boy with cystic fibrosis is admitted to the pediatric unit with a severe upper respiratory infection. The toddler is small for his age. What pathological process does the nurse know is the cause of his small stature?
An absence of pancreatic enzymes
A nurse determines that a 22-month-old child uses two- or three-word phrases (telegraphic speech), has a vocabulary of about 20 words, and often uses the word "me." The nurse concludes that the child's language development is:
Appropriate
Several 3-year-old girls in the daycare center are having a tea party with their dolls. The center's nurse concludes that this behavior is:
Appropriate make-believe play
A parent tearfully tells a nurse, "They think our toddler is developmentally delayed. We're investigating a preschool program for cognitively impaired children." What is the most appropriate response by the nurse?
Asking for more specific information related to the developmental delays
A nurse who is teaching a growth and development class to a group of parents at the daycare center explains that the toddler strives for a sense of:
Autonomy
A nurse is providing preoperative teaching to the parents of a toddler who is to undergo myringotomy. The nurse explains that the type of infection most common in children that are prone to otitis media is:
Bacterial
The mother of a 2-year-old child calls her neighbor, who is a nurse, exclaiming that her child just ate some automatic dishwasher powder. What should the nurse tell the mother to do first?
Call the poison control center
During a nap, a 3-year-old hospitalized child wets the bed. What is the best response by the nurse?
Change the child's clothes without discussing the incident
A nurse is caring for a 2½-year-old child who is expressing pain. What is the most reliable indicator of this child's pain?
Changes in behavior
What behavior does a nurse expect from a toddler subjected to prolonged hospitalization with limited parental visits?
Cheerful interactions with staff members
A nurse in the pediatric clinic is teaching the parents of a toddler how to prevent accidental poisoning. What should the nurse emphasize?
Child's need for exploration
A toddler with a puncture wound to the sole is brought to the emergency department. Because of a language barrier the caregiver cannot provide a clear history of previous tetanus immunizations. Tetanus immunoglobulin (TIG) is prescribed by the practitioner. The nurse explains to the caregiver that this medication is given because it:
Confers short-term passive defense against tetanus
A nurse is observing hospitalized toddlers in the playroom. What does the nurse identify as their most important need?
Contact with their parents
A parent of a 20-month-old toddler who has experienced an episode of diarrhea calls the pediatric clinic for advice. What instructions should the nurse give the parent, according to evidence-based practice for this situation?
Continue the child's feedings as usual, observe the frequency of stools, and bring the child to the clinic tomorrow if the diarrhea continues.
An 18-month-old toddler who stepped on a rusty nail 4 days ago shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. The toddler is receiving intravenous diazepam (Valium) as a muscle relaxant every 4 hours. What response to the medication does the nurse anticipate?
Control of hypertonicity and prevention of seizures
A 2-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia major (Cooley anemia). The parents are told that there is no cure but the anemia can be treated with frequent blood transfusions. The father tells the nurse he is glad that there is a treatment that "fixes" his child's problem. Before responding, the nurse should recall that blood transfusions:
Correct the anemia but may cause other problems
A 2-year-old toddler is to have intravenous antibiotic therapy. What should the nurse plan to do to prevent the child from pulling out the IV line?
Covering the IV site with a protective device
A pregnant mother asks about the best time to begin weaning her 2-year-old son from the bottle. What is the best reply by the nurse?
"Anytime, as long as there aren't other changes going on in his life."
The parent of a 2-year-old calls a nurse who is a neighbor and reports that the child just ate several multivitamins with iron. What should the nurse say to the parent?
"Call the poison control center."
The parents of a 2-year-old boy are watching the nurse administer the Denver II Developmental Screening Test to their son. They ask, "Why did you make him draw on paper? We don't let him to draw at home." What is the best response by the nurse?
"It lets us test his ability to perform tasks requiring his hands."
A mother brings her 16-month-old daughter to the well-child clinic for a checkup. She is upset and reports, "My child refuses to eat at mealtimes. It's a battle between us." What is the best response by the nurse?
"It may be helpful to keep a daily diary of the food she eats."
A 15-month-old child is hospitalized after ingesting toilet bowl cleaner. The mother confides that she feels guilty about leaving the cleaner where her child could get it. What is the best response by the nurse?
"It was an accident, but you should consider special locks on your closets."
A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse?
"The palate usually is repaired before a child starts to speak. Some surgeons prefer to wait up to 2 years."
How should a nurse respond to parents who are concerned about separation anxiety in their 15-month-old toddler?
"This is an expected developmental reaction."
Which statement or question is best when asking a toddler about breakfast?
"You can have an egg and toast or cereal with milk."
The mother of an 18-month-old boy with a cleft palate asks the nurse why the pediatrician has recommended that closure of the palate be performed before the child is 2 years old. How should the nurse respond?
"You need to have the surgery performed before he starts to use faulty speech patterns."
A 30-month-old boy who was transferred to a regional hospital has not seen his parents for 2 weeks. He now responds to the staff with friendliness and affection. When his mother visits he turns away from her and ignores her. What should the nurse explain to the mother?
"Your little boy misses you very much; give him time and he'll reach for you."
A 2-year-old boy born with cryptorchidism is to undergo orchiopexy. What should the nurse tell the parents about the anticipated outcome of this surgery?
Damage to the undescended testicle will be prevented.
A dehydrated 15-month-old toddler is admitted to the pediatric unit with a diagnosis of intractable diarrhea. After several days of treatment the child is reevaluated. Which finding indicates to the nurse that the child's hydration status has improved??
Decreased urine specific gravity
On the third day of a 2-year-old toddler's hospitalization the nurse notes that the child, who had been screaming and crying inconsolably, has begun to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?
Despair
The nurse is teaching a parent of a 2-year-old toddler how to administer eardrops. In what direction should the nurse teach the parent to gently pull the pinna?
Down and back
A nurse in the child life center is evaluating a 15-month-old toddler's ability to perform physical tasks. What behavior indicates to the nurse that the child's development is age appropriate? (Select all that apply.)
Drinking from a cup Walking with a wide-based gait Throwing toys around the room
A 19-month-old boy who has been in the hospital for 2 weeks becomes increasingly withdrawn and mute. What is the most appropriate nursing action?
Encouraging the parents to stay with him as much as possible
A toddler who was physically abused is admitted to the pediatric unit. What behavior does the nurse expect when approaching the child?
Exhibiting fear of physical contact initiated by anyone
A nurse is caring for a 3-year-old child with acute laryngotracheobronchitis. The child has severe dyspnea and a temperature of 104.0º F (40.0° C) and is receiving cool mist by way of a facemask. The mother asks why her child is not receiving warm mist. The nurse explains that cool mist:
Facilitates reduction of mucosal edema
An 18-month-old toddler who has received the appropriate immunizations on time is visiting the pediatric clinic for the next scheduled immunization. What vaccine should the nurse administer?
Fourth diphtheria toxoid, tetanus toxoid and acellular pertussis (DTaP) vaccine
A 13-month-old toddler has a respiratory tract infection with a low-grade fever. When teaching the parents, which intervention should the nurse emphasize?
Giving small amounts of clear liquids frequently to prevent dehydration
A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate that her toddler:
Has bulky, foul, frothy stools
Discharge planning for a toddler with newly diagnosed celiac disease includes instructions regarding dietary restrictions. What foods should the nurse recommend? (Select all that apply.)
Ice cream Rice cakes Corn crisps
A toddler has frequent temper tantrums. The parents ask a nurse how to limit this acting-out behavior. What should the nurse recommend?
Ignore the tantrum whenever possible.
A 2½-year-old child is admitted to the hospital with deep partial-thickness burns involving the face and chest. The nurse bases a plan of care on concerns related to the child's injury. Place the following concerns in their order of importance.
Impaired gas exchange Presence of pain Disturbed fluid balance Potential for infection Compromised body image
A 16-month-old toddler has had large, frothy, foul-smelling stools since the introduction of table foods and is irritable and apathetic. The child is diagnosed with celiac disease and a gluten-free diet is prescribed. What response does the nurse anticipate in the child after 2 days on the diet?
Improved behavior
What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea?
Improvement of fluid balance
A toddler may not be able to confirm that two glasses of water contain the same amount of liquid if one glass of water is poured into a taller, thinner vessel. What is this behavior characteristic called?
Inability to conserve
An 18-month-old child has received all required immunizations. What immunization should the nurse explain to a parent will be one of the vaccines required between 4 and 6 years of age?
Inactivated poliovirus
A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect?
Increased hematocrit
A nurse is caring for a toddler with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the child's acid-base imbalance?
Increased respiratory rate
A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. What does this finding indicate?
Increased white blood cell (WBC) count
The nurse explains to the parent of a 2-year-old child that the toddler's negativism is expected at this age. What need is this behavior meeting?
Independence
The parents of a 14-month-old boy with bilateral cryptorchidism ask the nurse in the pediatric clinic why it is important for him to have surgery before he is 2 years old. Before responding, the nurse takes into consideration the fact that uncorrected cryptorchidism can result in:
Infertility
After many episodes of otitis media a 3-year-old child is to undergo myringotomy and have tubes implanted surgically. What should the nurse include in the discharge preparation for this family?
Insert earplugs during the child's bath.
During the course of treatment a toddler is to receive an intramuscular injection. What is the priority nursing intervention that should be included in the plan of care to comfort the child?
Involving the parents in comforting the toddler after the injection
While in the playroom of a pediatric unit the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. What does the nurse conclude about this behavioral interaction?
It is a typical expression of toddlers' social development.
A nurse is teaching the parents of a toddler with a recent diagnosis of hemophilia about the disease. What area of the body should the nurse include as the most common site for bleeding?
Joints
A nurse is teaching the mother of a toddler with celiac disease the specific foods allowed on the gluten-free diet. What is the most important information for the nurse to help the mother understand?
Labels of prepared foods must be read carefully.
The parents of a 3-year-old tell the nurse that their child is afraid to sleep alone because of monsters under the bed. They ask for suggestions. What should the nurse recommend?
Leave a small light on at night and state, "Monsters aren't allowed in the house."
A toddler is placed in a bilateral hip spica cast for the treatment of developmental dysplasia of the hip. The nurse should teach the parents to monitor their child and report to the practitioner the occurrence of:
Leg numbness
A father asks the nurse about the immunization schedule for his 15-month-old toddler, who is being treated for acute lymphoid leukemia. What vaccine is contraindicated for a child undergoing chemotherapy?
MMR (measles, mumps, rubella)
A nurse teaches the mother of a 2-year-old child who has celiac disease which foods to avoid. Which foods identified by the mother indicate that she understands the teaching?
Macaroni and cheese
A 3-year-old child has a tentative diagnosis of pinworm infestation. What should the nurse teach the parents about obtaining a specimen to confirm the diagnosis?
Make an anal impression on cellophane tape when the child awakens.
When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by the:
Medulla
What is included in a toddler's diet if the family follows a lactovegetarian diet? Select all that apply.
Milk Fruit Vegetables
A nurse is caring for a toddler in acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103° F (39.4° C). What is the priority nursing intervention?
Monitoring respiratory status continuously
A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure?
Monitoring the site for bleeding
A 2-year-old toddler has hearing loss caused by recurrent otitis media. What treatment does the nurse anticipate that the practitioner will recommend?
Myringotomy
A parent tells a nurse at the clinic, "Each morning I offer my 24-month-old juice, and all I hear is 'No.' What should I do? I know she needs fluid!" What is the best response by the nurse?
Offer the child a choice of two juices.
The mother of a 2-year-old child tells the nurse that she is concerned about her child's vision. What behavior when the child is tired leads the nurse to suspect strabismus?
One eye moves inward.
The nurse manager of the infection control service is teaching a class for nurses on the care of young children with viral infection-related diarrhea. What therapy should the nurse manager recommend?
Oral rehydration therapy until fluid balance is restored
An 18-month-old toddler who stepped on a rusty nail is brought to the emergency department a week later. The nurse determines that the family lives in a rural area and that the toddler has never received health care. The child shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. What does the nurse conclude is the cause of these clinical findings?
Painful muscle rigidity caused by exposure of the nervous system to the exotoxin of the causative organism
A nurse is obtaining a health history from the parents of a toddler who has recently been diagnosed with acute lymphocytic leukemia. Which early physiological changes does the nurse expect the parents to report? (Select all that apply.)
Pale skin Eating less food Purplish spots on the skin
A nurse is observing two 18-month-old children playing side by side in a sandbox. Although they watch each other, neither interacts with the other. What type of play does the nurse identify?
Parallel
A nurse is teaching several aides about the play behavior of 2-year-old toddlers. What is this type of play called?
Parallel
A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse tell the parents is the most important factor in the process of toilet training?
Parents' attitude about it
A mother tells her neighbor, a nurse, that her toddler has been found to have parasites (worms) and that the whole family will need to be treated. She asks the nurse what kind of worm it is. What is the most likely type of worm infestation?
Pinworm (Enterobius)
A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend?
Placing him near a cool-mist humidifier
A 2-year-old toddler is admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the most important safety measure for the nurse to institute immediately after the child has a seizure?
Placing the child in the side-lying position
A toddler who was admitted in acute respiratory distress is now resting quietly. The parents tell the nurse that they must leave. What should the nurse suggest that the parents do?
Plan to visit the child as frequently as possible
What action should the nurse suggest to help parents promote the effectiveness of their toddler's myringotomy procedure?
Positioning the child with the affected ear down
A 2-year-old boy who has fallen from a tree tells his parents and the nurse, "Bad, bad tree." The nurse concludes that the child is within the cognitive developmental norm of Piaget's:
Preconceptual operations
A parent tells the nurse in the emergency department, "My 3-year-old has had a fever for several days and has been vomiting." After prescribed measures to reduce the fever have been instituted, what nursing action is most important?
Preventing shivering
The nurse notes that a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure. What is the priority nursing responsibility at this time?
Protecting the child from self-injury
While in the hospital's playroom a male toddler suddenly has a nosebleed that leaves blood on the play table. What is the nurse's first response in this situation?
Providing nursing care to stop his nosebleed
A nurse anticipates that surgery will be needed for an 18-month-old child with undescended testes because:
Psychological damage is limited
Elbow restraints are prescribed for an 18-month-old toddler who just had surgery for a cleft palate. The nurse explains to the parents that the restraints are used to keep the child from:
Putting fingers into the mouth
A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? (Select all that apply.)
Report swelling of fingers. Elevate casted arm when the child is standing.
A toddler undergoes cardiac catheterization as part of a diagnostic workup for pulmonic stenosis. In which part of the cardiovascular system should the nurse expect an increase in pressure?
Right ventricle
A nurse is teaching a mother how to care for her toddler who is in a spica cast. In what position should the nurse suggest that the mother place the toddler during a feeding?
Semi-Fowler on a padded, adjustable tilt board
A toddler with cystic fibrosis has been hospitalized with bacterial pneumonia. The nurse determines that the child has no known allergies. What does the nurse conclude is the reason that the health care provider selected a specific antibiotic?
Sensitivity of the bacteria
What should the nurse teach a mother that will best help her 2½ -year-old son learn to control his behavior?
Set limits and be consistent.
A 3-year-old child is admitted with partial- and full-thickness burns over 30% of the body. What significant adverse outcome during the first 48 hours should the nurse attempt to prevent?
Shock
When is the best time to prepare a toddler for impending surgery?
Shortly before the procedure
A 2-year-old child who was admitted to the hospital for further surgical repair of a clubfoot is standing in the crib, crying. The child refuses to be comforted and calls for the mother. As the nurse approaches the crib to provide morning care, the child screams louder. In light of the fact that this behavior is typical of the stage of protest, what is the most appropriate nursing intervention?
Sitting by the crib and bathing the child later when the anxiety decreases
A toddler who has undergone cleft palate repair is now able to tolerate fluids. What should the nurse use to offer the toddler fluids?
Small cup
A nurse knows that play is an integral part of a child's social development. Place in order the types of play children engage in as they get older.
Solitary play Parallel play Dramatic play Peer group team play Competitive team play
During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak—he ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss?
Speech therapy in addition to hearing aids may be required.
A nurse takes a 1-year-old child to the hospital playroom. What toy should the nurse select for this child?
Squeaky plastic duck
The parent of a 14-month-old toddler asks the nurse how to proceed with bowel training. What is the best response by the nurse?
Start by having the child sit on a potty chair
At 1 am a 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. At 3 am, after the child is settled in, the mother tells the nurse, "I have to leave now, but whenever I try to go my child gets upset and then I start to cry." What is the best action by the nurse?
Staying with the child while the mother leaves
A nurse in the pediatric clinic is advising the mother of a toddler who has a pinworm infestation. What should the nurse teach the mother about caring for her child during and after treatment? (Select all that apply.)
Strategies to prevent reinfestation The need for medication for the entire family The importance of handwashing before eating
A nursing student is selecting liquids for an 18-month-old toddler after oral surgery. Which choice by the student should cause the nurse to intervene?
Strawberry gelatin
The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections?
Structural differences between eustachian tubes of younger and older children
The mother of a 2-year-old child expresses concern to the nurse in the pediatric clinic that her child still takes a bottle of milk to bed at night. How should the nurse explain to the mother that this practice should be stopped?
The child is at increased risk for dental caries.
A 2-year-old child who has been restricted to bedrest because of a diagnosis of meningitis is now allowed out of bed. The nurse suggests going to the playroom. The child responds by shaking the head vigorously from side to side, screaming, "No! Won't!" However, the child is trying to climb out of the crib at the same time. In light of these behaviors, what is the most likely conclusion by the nurse?
The child is trying to assert independence.
A toddler with lead poisoning is started on chelation therapy. Succimer (Chemet) is ordered. What information should the nurse give the parents concerning the administration of this medication?
The contents of the capsules may be sprinkled on food.
A 3-year-old child sustains multiple fractures in a motor vehicle collision, and casts are applied. The child is admitted for observation to rule out internal injuries. The health care provider asks that vital signs, including blood pressure, be taken every 4 hours. The nurse decides to use the posterior tibial artery to obtain the blood pressure. Mark the extremity where the blood pressure cuff should be positioned to obtain this blood pressure.
The posterior tibial artery is posterior to the medial malleolus on the inner aspect of the ankle. The blood pressure cuff should be positioned 1 inch above the ankle.
At 18 months of age a child born with a cleft lip and palate is readmitted for palate surgery. Why does the nurse teach the parents not to brush their child's teeth immediately after the surgery?
The suture line might be injured.
Why is it essential for the nurse to obtain the height and weight of a severely dehydrated toddler?
The values are used to calculate fluid replacement and medication dosages.
A nurse explains to the parents of a toddler why 2-year-old children are at risk for lead poisoning. What major risk factor does the nurse includes in the discussion?
They explore the environment by touching and tasting.
A nurse in the daycare center is teaching a group of assistants why toddlers are prone to lead poisoning. What factor primarily contributes to their risk for lead poisoning?
They have a high level of oral activity.
A parent tells the nurse, "Our 2½ -year-old child only uses two-word phrases when he's talking, and we can only understood him maybe a quarter of the time. We're really concerned." What should the nurse consider before responding?
This seems to be slow language development for a 2½ -year-old.
A 2-year-old toddler requires close supervision to protect against potential accidents. The nurse teaches a class for parents about the learning style of toddlers. How do toddlers learn self-protection?
Through trial-and-error strategies
Which toddler behavior reflects animism?
Toddlers attribute lifelike qualities to inanimate objects.
What is a characteristic of play among toddlers?
Toddlers play beside each other.
A 30-month-old toddler is brought to the emergency department in acute respiratory distress, and a diagnosis of laryngotracheobronchitis (viral croup) is made. What is the most important equipment for the nurse to have available when the child is admitted to the pediatric unit?
Tracheotomy set
Which of the following signs are indications of hydration status during a sickle cell crisis? (Select all that apply.)
Turgor of tissue
Which of the following signs are indications of hydration status during a sickle cell crisis? (Select all that apply.)
Turgor of tissue Texture of mucous membranes
A 2-year-old child with previously diagnosed hemophilia is admitted to the pediatric unit for observation after a motor vehicle collision. The toddler has several bruises but no other apparent injuries. What is the nurse's specific concern regarding this child?
Undetected injury
A nurse is observing the growth and development skills of several 2-year-olds in the clinic playroom. The nurse determines that the child requiring further evaluation is the one who:
Uses echolalia when speaking
A 3-year-old boy has been observed in the clinic waiting room taking toys from others, tearing pages out of books, and striking his mother. The nurse takes time when interviewing the mother to ask about television habits because:
Viewing violent programs is positively correlated with the development of aggression
A nurse must administer a medication by means of injection to a 2-year-old whose parent is not present. What is the most therapeutic approach for the nurse to use?
Warning the child about the injection just before administering it, saying that it is OK to cry, and then comforting the child
What is the priority nursing responsibility in the care of a young toddler after a circumcision?
Watching for bleeding around the penis
A 2-year-old toddler is admitted to the pediatric unit with tachycardia, tachypnea, and shortness of breath. The nurse auscultates the toddler's lungs. What term should the nurse use in the medical record to document the following sound heard during auscultation of the lungs? Listen to the audio.
Wheezes
When is a toddler considered ready for toilet training? Select all that apply.
When the child is able to sit, walk, and squat When the child is capable of removing his or her own clothing When the child is able to recognize the urge to defecate or urinate
Which is the most appropriate toy for a nurse to offer a 2½-year-old child?
Wooden puzzle with large pieces
A 3-year-old child is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, the respiratory rate is 56 breaths/min, the pulse is 102 beats/min, and there is a nonproductive cough. What does the nurse expect regarding the child's blood gas values?
pH of 7.32
A toddler with a history of enlarged lymph nodes, prolonged fever that is unresponsive to antibiotics, erythema of the extremities, and a rash is admitted to the pediatric unit with a diagnosis of Kawasaki disease. What does the nurse suspect was essential in confirming this diagnosis?
A combination of signs
A nurse is teaching the parents of an 18-month-old child the procedure for instilling ear drops. How should this procedure be done?
By pulling the pinna down and back to straighten the auditory canal before instillation of the drops
An IV of 800 mL/24 hr is prescribed for a 2½-year-old child. At how many milliliters per hour should the nurse set the volume control device?
33 mL
Oral phenobarbital 30 mg every 6 hours is prescribed for a toddler who has had a seizure. A bottle of phenobarbital liquid labeled "20 mg/4 mL" is available. How much solution should the nurse administer? Record your answer using a whole number. __________
6 mL
An 18-month-old toddler is to receive an intravenous infusion of 1000 mL 5% dextrose and 0.45% sodium chloride over 24 hours. At what rate should the nurse set the volume-control device? Record your answer using a whole number. __________ mL/hr
42 mL/hr
An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube?
Before each feeding
A mother in the postpartum unit expresses concern that her 3-year-old daughter will be jealous of her new brother. What should the nurse suggest?
Bringing home a new baby doll for the daughter when her baby brother is brought home
A 1-year-old infant is receiving zidovudine (AZT) for management of HIV infection. The nurse determines that the infant is exhibiting signs of life-threatening zidovudine toxicity. What clinical finding supports this conclusion?
Bruises over the body
What are the best ways to remove plaque from a toddler's teeth? Select all that apply.
Brushing Flossing
What chelating agent does the nurse anticipate will be prescribed for a toddler with lead poisoning?
Succimer (Chemet)
A major developmental milestone of a toddler is the achievement of autonomy. What should the nurse instruct the parents to do to enhance their toddler's need for autonomy?
Teach the child to accept external limits
A nurse is evaluating a toddler and the family dynamics of the child's family, in which abuse is suspected. What behavior is expected? (Select all that apply.)
The child cringes when approached. The child has unexplained healed injuries. The child lies still while surveying the environment.
The mother of a 2-year-old toddler tells the nurse that her child is frequently constipated. The nurse asks the mother how she handles the child's toileting. Which response indicates to the nurse that the mother requires further education?
"I schedule my child's toileting for before each meal."
A 2-year-old child with developmental dysplasia of the hip has a spica cast applied. The mother asks the nurse how to keep the cast clean. How should the nurse respond?
"Place plastic wrap or duct tape around the perineal edges of the cast."
During a routine visit to the child health clinic the parent of a 3-year-old girl reports, "My daughter is still sucking her thumb." What is the nurse's best response?
"She'll stop when she's ready."
A mother indicates to the nurse in the pediatric clinic that she is concerned that her 20-month-old son's bedtime thumb-sucking will cause his teeth to protrude. How should the nurse respond?
"There is no reason to be concerned about the teeth protruding unless he keeps sucking his thumb after his permanent teeth have come in."
A toddler with hemophilia A is receiving factor VIII. The mother asks the nurse, "If my son hurts himself, I'll give him 2 children's Advil. Is that right?" How should the nurse respond?
'Give him Tylenol—Advil may cause bleeding."
The mother of an 18-month-old toddler tells the nurse in the pediatric clinic that her child is "unmanageable and into everything." What is the most important teaching to include during this clinic visit?
Accidents are the leading cause of death and injury in this age group.
A 3-year-old child with chronic lead poisoning who has not responded to succimer (Chemet) therapy must be given multiple injections of edetate calcium disodium (calcium EDTA). How should the nurse prepare the child psychologically for this treatment?
Allow the child to play with a syringe, using a doll, before treatment is initiated and after each injection is administered
The parents of a 2-year-old child who is being admitted to the hospital tell the nurse that their child is accustomed to sleeping with a favorite blanket. What should the nurse do, knowing that the blanket is worn and dirty?
Allow the parents to give it to the child
A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is:
An obstructed eustachian tube
An 18-month-old toddler requires an intramuscular injection. As the nurse enters the room with the medication, the child begins to scream and flail about on the bed. The father is sitting at the child's bedside and gets up to leave. What action should the nurse take to best handle this situation?
Ask the father to stay to comfort the child while the injection is being given
A 13-month-old child is admitted with a tentative diagnosis of bacterial meningitis, and the practitioner schedules a lumbar puncture. What is the most important action the nurse should take in preparation for the lumbar puncture?
Asking the parents what they were told about the test
A 2½-year-old toddler arrives at the well-baby clinic for a routine physical examination. The child opens all of the cabinets in the examination room and carefully moves the tongue depressors and other items to different places. What psychosocial developmental stage does the nurse determine that this child is in?
Autonomy
What is the priority nursing care in the immediate postoperative period for a toddler with a newly applied hip spica cast?
Checking the toddler's peripheral circulation
The mother of a toddler complains that the toddler has not been acting quite right lately. She has had a fever for a couple of days and now presents with decreasing oral intake and a rash over her hands and feet. Which condition does the nurse suspect?
Coxsackievirus infection
An 18-month-old toddler is admitted to the pediatric unit. The child has never been separated from the mother before this admission. What behavior does the nurse expect from the toddler?
Crying relentlessly and consoled by no one but a parent
A toddler is admitted to the pediatric unit with diarrhea and severe dehydration. After several days of treatment the child is evaluated. What clinical findings indicate that the child is rehydrated? (Select all that apply.)
Decreased hematocrit Increase in daily weight Decreased blood urea nitrogen level
A nurse in the pediatric clinic receives a call from a mother who states that her 2½-year-old daughter, whom she discovered in a kitchen cabinet, is crying that her mouth hurts. She is drooling, and her tongue and gums are white. The nurse gives the mother the number of the poison control center, telling her to call immediately because the nurse suspects that the child has ingested:
Dishwashing detergent
A 5-year-old child is brought into the clinic with lethargy, abdominal ascites, and peripheral and periorbital edema. The history indicates ongoing diarrhea and decreased urine output. The child is found to have nephrotic syndrome and started on corticosteroid therapy. The nurse informs the parents that after a week or two of medication therapy, they can expect the child to exhibit:
Diuresis
A toddler who swallowed drain cleaner is hospitalized for observation because of the risk for vomiting and aspiration. Over the next 24 hours the child does not exhibit any respiratory distress and does not vomit. At discharge the nurse emphasizes that the parents should monitor their child for the onset of:
Gagging and vomiting
An 18-month-old toddler with celiac disease is to be started on a gluten-free diet. The nurse teaches the parents to identify foods that should be avoided. Which food named by the parents as one to be avoided indicates to the nurse that the teaching has been successful?
Grilled frankfurter
A nurse in the well-baby clinic determines that a 15-month-old toddler's motor development is age appropriate. Which behavior confirms this conclusion?
Holding and scribbling with a crayon
A 2½-year-old child is receiving intravenous fluid. A 500 mL bag of D5 in ½NS is hung at 1 am and is to infuse at 45 mL/hr. At 6 am the nurse notes that there is 125 mL left in the bag. The nurse correctly concludes that the fluid that has infused:
Is more than the child should have received
The health care provider is assessing a 2-year-old child for the presence of celiac disease. For what specific signs and symptoms should the nurse be alert? (Select all that apply.)
Steatorrhea Distended abdomen Iron-deficiency anemia
The nurse is giving unlicensed assistive personnel (UAP) strategies to care for a 2-year-old child admitted to the hospital with severe diarrhea. Which strategies should the nurse provide?
Weighing the child at the same time every day
A nurse teaches the mother of a toddler which foods are the best sources of thiamine, a B-complex vitamin. What food that is high in thiamine should the nurse include in the teaching plan?
Whole grains
As the working mother of a toddler is preparing to take her child home after a prolonged hospitalization during which she was not able to visit often, she asks the nurse what type of behavior she should expect. What is the most appropriate description by the nurse of her child's probable behavior?
Withdrawn, without emotional ties to the mother