Families Exam 3

The nurse is assessing a four-month-old infant. The nurse would anticipate finding that the infant would be able to A. Hold a rattle B. Bang two blocks C. Drink from a cup D. Wave "bye-bye"

A. Hold a rattle

By the end of which of the following would the nurse most commonly expect a child's birth weight to triple? A. 4 months B. 7 months C. 9 months D. 12 months

D. 12 months Rationale: A child's birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.

When the child with rheumatic fever begins involuntary, purposeless movements of her limbs, the nurse recognizes that this is an indication of: a. seizure activity. b. hypoxia. c. chorea. d. decreasing level of consciousness.

c. chorea. As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham's chorea manifested by involuntary, purposeless movements of the limbs.

Activated charcoal is contraindicated in a patient who has ingested a toxic substance if: A. the substance was corrosive. B. there is a history of abdominal surgery. C. there is a history of diarrhea or vomiting. D. the substance was ingested approximately one hour ago.

A. the substance was corrosive.

What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? Select all that apply. a. Spontaneous cyanosis b. Dyspnea c. Weakness d. Dry cough e. Syncope

A, B, C, E Indicators of a paroxysmal hypercyanotic episode or a "tet" episode are spontaneous cyanosis, dyspnea, weakness, and syncope.

How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue? Select all that apply. a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula

A, B, C, E Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held.

The nurse explains that which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? Select all that apply. a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Coarctation of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs)

A, D, E The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus.

The parent of a 3-month-old infant asks the nurse, "At what age do infants usually begin drinking from a cup?" The nurse would reply: A. 6 months. B. 9 months. C. 1 year. D. 2 years.

A. 6 months.

A nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to: A. Allow the newborn infant to signal a need B. Anticipate all of the needs of the newborn infant C. Avoid the newborn infant during the first 10 minutes of crying D. Attend to the newborn infant immediately when crying

A. Allow the newborn infant to signal a need Rationale: According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn's signal would inhibit the development of trust and lead to mistrust of others.

When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to: A. Form a sense of identity. B. Create intimate relationships. C. Separate from parents and live independently. D. Achieve positive self-esteem through experimentation.

A. Form a sense of identity.

An important physical development issue among adolescent boys is what? A. The development of facial hair B. The growth of breasts C. The development of peer relationships D. The ability to state one's needs

A. The development of facial hair Rationale: The development of facial hair is an important physical development issue among adolescent boys. The growth of breasts is a female issue and the development of peer relationships and the ability to state one's needs are psychosocial issues.

Based on knowledge of the developmental tasks of Erikson's Industry versus Inferiority, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy so he will: A. Increase his self-esteem with mastery of a new skill. B. Accept changes in his appearance and physical endurance. C. Experience success in role transitions and increased responsibilities. D. Appreciate his body appearance and function.

A. Increase his self-esteem with mastery of a new skill.

In terms of cognitive development the 5-year-old child would be expected to: A. Use magical thinking. B. Think abstractly. C. Understand conservation of matter. D. Be able to comprehend another person's perspective.

A. Use magical thinking. Rationale: Magical thinking is believing that thoughts can cause events. Abstract thought does not develop until school-age years. The concept of conservation is the cognitive task of school-age children ages 5 to 7 years. Five-year-olds cannot understand another's perspective.

Otoscopy examination on a 2-year old? The nurse should pull the pinna.... A. down and back B. down and forward C. up and back D. up and forward

A. down and back

According to Erikson, the psychosocial task of adolescence is developing: A. Intimacy. B. Identity. C. Initiative. D. Independence.

B. Identity.

A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least _____ pounds. A. 12 B. 16 C. 20 D. 24

B. 16 Rationale: Birth weight is usually doubled by 6 months of age.

Which statement accurately describes physical development during the school-age years? A. The child's weight almost triples. B. A child grows an average of 2 inches per year. C. Few physical differences are apparent among children at the end of middle childhood. D. Fat gradually increases, which contributes to the child's heavier appearance.

B. A child grows an average of 2 inches per yea

A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant: A) Uses simple words such as "mama" B) Uses monosyllabic babbling C) Links syllables together D) Coos when comforted

B) Uses monosyllabic babbling Rationale: Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama" occurs between 9 and 12 months. Linking syllables together when communicating occurs between 6 and 9 months. Cooing begins at birth and continues until 2 months.

A nurse is teaching a preschool-aged child. Which teaching method is most appropriate for the nurse to use when teaching a child in this age group? A. Demonstrations B. Coloring books C. Small groups D. Videos

B. Coloring books

A 4-year-old boy is hospitalized with a serious bacterial infection. He tells the nurse that he is sick because he was "bad." The nurse's best interpretation of this comment is that it is: A. A sign of stress. B. Common at this age. C. Suggestive of maladaptation. D. Suggestive of excessive discipline at home.

B. Common at this age. Rationale: From ages 3-6, children are in Erikson's stage of "initiative vs. guilt." In this stage, children believe that events are a direct result from their actions. ("Bad things happen because I was bad" and vice-versa)

A 6-month-old infant who was seen in the Emergency Department with wheezing and coughing is admitted to the pediatric unit with a diagnosis of bronchiolitis. During the admission assessment, which of these will alert the healthcare provider the infant's condition is worsening? A. Respiratory rate of 38 breaths/min B. Decreased inspiratory breath sounds C. Irritability and crying D. Dysphasia and loss of appetite

B. Decreased inspiratory breath sounds

What type of play is typical of toddlers? A. Solitary B. Parallel C. Associative D. Competitive/Cooperative

B. Parallel Rationale: Toddlers observe other children and then engage in activities nearby

The mother of an infant who has had a series of hospitalizations related to bronchiolitis asks the healthcare provider why her infant seems to be prone to respiratory infections. Which of these provide the most accurate information about the respiratory systems of infants and young children? A. Infants and young children have more rigid chest walls which increases the work of breathing. B. Respiratory airways of infants and young children are more narrow so they are easily obstructed. C. The metabolic rate and oxygen consumption of infants and young children are slower than older children. D. Decreased surfactant in infants and young children makes it harder for them to keep their airways open.

B. Respiratory airways of infants and young children are more narrow so they are easily obstructed.

The nurse is assessing a six-month-old child. Which developmental skills are normal and should be expected? A. Speaks in short sentences. B. Sits alone. C. Can feed self with a spoon. D. Pulling up to a standing position.

B. Sits alone.

The parent of a 4-year-old son tells the nurse that the child believes "monsters and boogeyman" are in his bedroom at night. The nurse's best suggestion for coping with this problem is to: A. Insist that the child sleep with his parents until the fearful phase passes. B. Suggest involving the child to find a practical solution such as a night light. C. Help the child understand that these fears are illogical. D. Tell the child frequently that monsters and boogeyman do not exist.

B. Suggest involving the child to find a practical solution such as a night light Rationale: A night light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents will not get rid of the fears. A 4-year-old is in the preconceptual age and cannot understand logical thought.

A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. Abdominal breathing in this patient should be viewed as a: A. sign of impending respiratory failure. B. normal finding for a toddler. C. sign of decreased perfusion to the respiratory center. D. compensatory mechanism to increase the volume of air inhaled and respiratory rate.

B. normal finding for a toddler.

The infant is sitting alone using its arms for support. At what age is this child at this stage of motor development? A. 3 months B. 4 months C. 7 months D. 12 months

C. 7 months

A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? A. Encourage independent learning. B. Use discussion throughout the teaching session. C. Apply a bandage to a doll's ear. D. Develop a problem-solving scenario.

C. Apply a bandage to a doll's ear. Rationale: Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll) to toddlers. Encouraging independent learning is for the middle-aged adult. Use of discussion is for older children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices. Problem solving is too advanced for a toddler.

A 10-year-old fifth-grader enjoys having his artwork displayed on the family refrigerator. This behavior is indicative of which developmental stage as described by Erikson? A. Initiative versus guilt B. Intimacy versus isolation C. Industry versus inferiority D. Identity versus role confusion

C. Industry versus inferiority

A nurse is testing a child for strabismus. Which of the following is the correct technique for performing this examination? A. Check for presence of the red reflex B. Check for visual acuity C. Perform the cover-uncover test D. Test for pupillary reaction to light

C. Perform the cover-uncover test

Which of the following is the most appropriate activity for a 5-year-old child? A. Squeeze toy. B. Board games. C. Play-Doh. D. Computer games.

C. Play-Doh. Rationale: In the preschooler, play is simple and imaginative and includes activities such as puppets, play-doh, and coloring book. Squeeze toys are appropriate for infants Board games are appropriate for the school-age child. Computer games are appropriate for an adolescent.

Magical Thinking is an attribute of which age group? A. Infants (birth - 1 year) B. Toddlers (1 -3 years) C. Preschoolers (3 - 6 years) D. School-Age Children (6 - 12 years)

C. Preschoolers (3 - 6 years)

A mother of a three (3)-year-old tells a clinic nurse that the child is constantly rebelling and having temper tantrums. The nurse most appropriately tells the mother to: A. Punish the child every time the child says "no", to change the behavior B. Allow the behavior because this is normal at this age period C. Set limits on the child's behavior D. Ignore the child when this behavior occurs

C. Set limits on the child's behavior Rationale: Being consistent and setting limits on the child's behavior are the necessary elements. A and D: Saying things like "no" or "mine" and having temper tantrums are common during this period of development. B: According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes.

Which of the following terms accurately describes toddlers? A. Creative B. Invincible C. Dependent D. Egocentric

D. Egocentric Rationale: -Creativity is a trait of middle adults -Invincibility is a trait of adolescents (their feeling of invincibility leads to risky behaviors) -Dependence is a trait of infants (toddlers want to be independent) -Toddlers are unable to see things from another's perspective. They can only see things from their point of view (egocentric)

The healthcare provider is teaching the parents of an 18-month-old child with bronchiolitis how to take their child's temperature. Which of these statements provides the most accurate information? A. "Rectal temperatures tend to be lower than oral or axillary temperatures." B. "Axillary temperatures are more accurate than oral temperature or rectal temperatures." C. "When taking a rectal temperature, advance the thermometer slightly past where resistance is felt." D. "For a tympanic temperature, pull the pinna down and back before inserting the probe into the ear."

D. "For a tympanic temperature, pull the pinna down and back before inserting the probe into the ear."

The nurse is observing children playing in the hospital playroom. She would expect to see 4-year-old children playing: A. Competitive board games with older children B. With their own toys along side with other children C. Alone with hand held computer games D. Cooperatively with other preschoolers

D. Cooperatively with other preschoolers

Which of the following should not be fed to a toddler? A. Bananas B. Green beans C. Cake D. Grapes

D. Grapes Rationale: While cake is high in sugar and fat, grapes pose a choking hazard for toddlers and should be avoided for safety reasons. Bananas and green beans are appropriate for children of this age.

The healthcare provider is planning care for a child with a diagnosis of bronchiolitis. Which of the following interventions should be included in the child's plan of care? A.Performing chest physiotherapy B. Drawing blood for blood cultures C. Administering a cough suppressant D. Promoting hydration and nutrition

D. Promoting hydration and nutrition

What congenital heart defect causes cyanosis in children? A. Atrial septal defect B. Coarctation of the aorta C. Ventricular septal defect D. Transposition of the great arteries

D. Transposition of the great arteries Rationale: With transposition of the great arteries, the pulmonary artery is attached to the left ventricle and the aorta is attached to the right ventricle. The child is cyanotic because blood reaches the tissues from the right ventricle before being oxygenated by the lungs. In atrial septal defect and ventricular septal defect, blood is shunted from the left side of the heart to the right side through patent openings. Because the blood travels from left to right, it's oxygenated and doesn't produce cyanosis. Coarctation of the aorta is a narrowing of the aorta that decreases the circulation of oxygenated blood to the body. With this condition, the child won't be cyanotic unless cardiac output drops.

The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect is: a. a loud, harsh murmur with a systolic tremor. b. cyanosis when crying. c. blood pressure higher in the arms than in the legs. d. a machinery-like murmur.

a. a loud, harsh murmur with a systolic tremor. A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.

The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. The nurse can determine the father understood the instructions when he states "If the baby turns blue, I will: a. hold him against my shoulder with his knees bent up toward his chest." b. lay him down on a firm surface with his head lower than the rest of his body." c. immediately put the baby upright in an infant seat." d. put the baby in supine position with his head elevated."

a. hold him against my shoulder with his knees bent up toward his chest." In the event of a paroxysmal hypercyanotic or "tet" spell, the infant should be placed in a knee-chest position.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, "How does Kawasaki disease affect my child's heart and blood vessels?" The nurse's response is based on the understanding that: a. inflammation weakens blood vessels, leading to aneurysm. b. increased lipid levels lead to the development of atherosclerosis. c. untreated disease causes mitral valve stenosis. d. altered blood flow increases cardiac workload with resulting heart failure.

a. inflammation weakens blood vessels, leading to aneurysm. Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.

The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. "He is always hungry." b. "He tires out during feedings." c. "He is fussy for several hours every day." d. "He sleeps all the time."

b. "He tires out during feedings." Fatigue during feeding or activity is common to most infants with congenital cardiac problems.

A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Non-tender subcutaneous nodules and fever b. Painful, tender joints and carditis c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate

b. Painful, tender joints and carditis The presence of two major Jones' criteria would indicate a high probability of rheumatic fever.

The nurse clarifies to the parents of a 4-year-old child recovering from rheumatic fever that the child will need to receive monthly injections of penicillin G for a minimum of _____ year(s). a. 1 b. 2 c. 5 d. 10

c. 5 Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections (about 200,000 units per dose) for a minimum of 5 years, to an indefinite amount of time.

The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, "Why do my child's fingertips look like that?" The nurse bases a response on the understanding that clubbing occurs as a result of: a. untreated congestive heart failure. b. a left-to-right shunting of blood. c. decreased cardiac output. d. chronic hypoxia.

d. chronic hypoxia. Clubbing of the fingers develops in response to chronic hypoxia.

The finding the nurse would expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta is blood pressure that is: a. higher on the right side. b. higher on the left side. c. lower in the arms than in the legs. d. lower in the legs than in the arms.

d. lower in the legs than in the arms. The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.

An infant with congestive heart failure is receiving digoxin (Lanoxin). The nurse recognizes a sign of digoxin toxicity, which is: a. restlessness. b. decreased respiratory rate. c. increased urinary output. d. vomiting.

d. vomiting. Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

When developing a plan care for a hospitalized child, nurse Mica knows that children in which age group are most likely to view illness as a punishment for misdeeds? A. Infancy B. Preschool age C. School age D. Adolescence

B. Preschool age

The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age: A. Is highly sensitive to criticism B. Loves to tattle C. Still depends on the parents D. Rebels against scheduled activities

A. Is highly sensitive to criticism Rationale: In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a friend

A charge nurse reviews the postoperative plan of care formulated for a child after a tonsillectomy. Which interventions are appropriate for this client? Select all that apply. A. Offer clear, cool liquids when awake. B. Administer pain medication as prescribed C. Monitor for bleeding from the surgical site. D. Suction every 15 minutes and PRN as necessary. E. Initially eliminate milk or milk products from the diet.

A, B, C, E Rationale: After tonsillectomy, clear, cool liquids are encouraged. Options 2 and 3 are important interventions after any type of surgery. Suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Milk and milk products are avoided initially because they coat the throat; this causes the child to clear the throat, thereby increasing the risk of bleeding.

A child with Kawasaki disease is admitted to the pediatric ward. Which of the following medications will you expect to be a part of the treatment? Select all that apply A. Gamma Globulin. B. Warfarin. C. Acetaminophen. D. Aspirin. E. Atenolol.

A, B, D Rationale: The principal goal of treatment for Kawasaki disease is to prevent coronary artery disease and to relieve symptoms such as fever and joint pain so an antipyretic, antiplatelet, and gamma globulin is used. Option C is antipyretic but is not responsive to this disease. Option D is a beta blocker.

A child with rheumatic fever is admitted to the hospital. The nurse reviews the child's record and expects to note which clinical manifestations documented in the record? Select all that apply. A. Cardiac murmur B. Cardiac enlargement C. Cool pale skin over the joints D. White painful skin lesions on the trunk E. Small nontender lumps on bony prominences F. Purposeless jerky movements of the extremities and face

A, B, E, F Rationale: Rheumatic fever is a systemic inflammatory disease that may develop as a delayed reaction to an inadequately treated infection of the upper respiratory tract by group A beta-hemolytic streptococci. Clinical manifestations of rheumatic fever are related to the inflammatory response. Major manifestations include carditis manifested as inflammation of the endocardium, including the valves, myocardium, and pericardium; cardiac murmur and cardiac enlargement; subcutaneous nodules, manifested as small nontender lumps on joints and bony prominences; chorea, manifested as involuntary, purposeless jerky movements of the legs, arms, and face with speech impairment; arthritis manifested as tender, warm erythematous skin over the joints; and erythema marginatum, manifested as red, painless skin lesions usually over the trunk.

The nurse is caring for a child with a patent ductus arteriosus (PDA). The nurse reviews the health care record and plans care, knowing that which findings are characteristic of this type of disorder? Select all that apply. A. Pulmonary blood flow is increased. B. Pulmonary blood flow is decreased. C. Oxygenated and unoxygenated blood mix. D. Blood is shunted to the left side of the heart. E. Blood is shunted to the right side of the heart. F. Oxygenated and unoxygenated blood never mix

A, C, E Rationale: A patent ductus arteriosus (PDA) is a left-to-right shunt. Blood is shunted to the right side of the heart, because the left side is normally functioning at a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow, because the abnormal communication or opening sends more blood to the right side of the heart than normal.

A nurse provides medication instructions to a first-time mother. Which statement made by the mother indicates a need for further instructions? A. "I should mix the medication in the baby food and give it when I feed the child". B. "I should administer the oral medication sitting in an upright position and with the head elevated". C. "I will give my child a toy after giving the medication". D. "I will offer my child a juice drink after swallowing the medication".

A. "I should mix the medication in the baby food and give it when I feed the child". Rationale: The nurse would teach the mother to avoid putting medications in foods because it may cause an unpleasant taste to the food, and the child may refuse to accept the same food in the future. Additionally, the child may not consume the entire serving and would not receive require medication dosage. Option B: Administering the medication in an upright position and head elevation will prevent the risk of aspiration. Option C: Offering a toy will provide comfort measures to the child. Option D: The mother should offer drink such as juice or a soft drink to lessen the aftertaste of the medication.

The nurse is monitoring a student who is preparing to suction a child through a tracheostomy. The nurse determines the student needs additional teaching if the student plans to do which intervention? A. Apply suctioning when inserting the catheter. B. Limit insertion and suctioning time to 5 seconds. C. Reoxygenate the child between suction catheter passes. D. Apply intermittent suctioning, with a twisting motion when withdrawing the catheter.

A. Apply suctioning when inserting the catheter. Rationale: Applying suctioning when inserting the catheter can cause trauma to tissues and should not be done. Intermittent suctioning is applied when withdrawing the catheter. Options 2, 3, and 4 represent correct actions regarding this procedure.

Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter's immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is: A. 12 months. B. 15 months. C. 10 months. D. 14 months.

A. 12 months.

An infant should be immediately evaluated by a physician if which of the following signs or symptoms are present? A. Acting fussier than normal B. Temperature of 37 degrees (98.6 F) C. Refuses a pacifier D. Use of abdominal muscles to breathe

A. Acting fussier than normal

The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure. The nurse notes that the apical rate is 140 beats per minute. Which nursing action is appropriate? A. Administer the digoxin because the apical rate is within normal limits. B. Recheck the apical rate in 1 hour, and administer the medication at that time. C. Notify the health care provider because the apical rate is lower than the normal rate. D. Hold the medication because the apical rate is normal, indicating that the medication is not needed.

A. Administer the digoxin because the apical rate is within normal limits. Rationale: The normal apical rate for a newborn is 120 to 160 beats per minute. Because the apical rate is within normal range, options 2 and 3 are inappropriate. The nurse should hold Digoxin is the infant's apical rate is less than 90 beats per minute. Digoxin is not administered on an as-needed basis, which makes option 4 incorrect.

A child with croup is admitted to the hospital, and the health care provider prescribes a cool-mist tent. The child is fearful and crying. Which nursing intervention is appropriate? A. Ask the mother to bring the child's favorite toy from home. B. Ask the health care provider for a prescription for a mild sedative. C. Obtain a toy from the playroom for the child to bring into the tent. D. Ask the health care provider to change the prescription from the mist tent to oxygen via nasal cannula.

A. Ask the mother to bring the child's favorite toy from home. Rationale: Familiar objects provide a sense of security for the child in a strange hospital environment. The child should be allowed to have a favorite toy or security blanket while in the mist tent (per agency policies). Options 2 and 4 are inappropriate. Option 3 will not provide the child with a favorite toy.

The nurse employed in a well-baby clinic is providing nutrition instructions to a mother of a 9-month-old infant. Which instruction is appropriate? A. Begin to initiate self-feeding. B. Introduce strained fruits 1 at a time. C. Introduce strained vegetables 1 at a time. D. Begin to offer rice cereal mixed with breast milk or formula.

A. Begin to initiate self-feeding. Rationale: Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats, introduced one at a time, can begin at 6 months of age. Self-feeding can be initiated at approximately 9 months of age.

The registered nurse is discussing care of an infant with a patent ductus arteriosus (PDA) with a nursing student. The registered nurse determines that the nursing student needs further teaching regarding a PDA if the student states that which circulatory change is a characteristic of this disorder? A. Blood is shunted to the left side of the heart. B. Blood is shunted to the right side of the heart. C. This shunting results in increased pulmonary blood flow. D. This shunting allows oxygenated and unoxygenated blood to mix.

A. Blood is shunted to the left side of the heart. Rationale: A patent ductus arteriosus (PDA) is a left-to-right shunt. Blood is shunted to the right side of the heart, because the left side is normally functioning at a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow, because the abnormal communication or opening sends more blood to the right side of the heart than normal.

After tonsillectomy, which fluid or food item is most appropriate to offer to the child? A. Green Jell-O B. Cold soda pop C. Butterscotch pudding D. Cool raspberry Kool-Aid

A. Green Jell-O Rationale: After tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits

A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first? A. Heart rate, respiratory rate, and blood pressure B. Recent exposure to communicable diseases C. Number of immunizations received D. Height and weight

A. Heart rate, respiratory rate, and blood pressure The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather the other data later.

A child is hospitalized for diagnostic studies, and a diagnosis of ventricular septal defect is confirmed. The nurse plans care knowing that what is a characteristic of this type of defect? A. It is a left-to-right heart shunt. B. Blood shunts to the left side of the heart. C. Oxygenated and unoxygenated blood do not mix. D. It results in decreased pulmonary blood flow, because the opening sends more blood to the left side of the heart than normal.

A. It is a left-to-right heart shunt. Rationale: Ventricular septal defect (VSD) is a left-to-right heart shunt. In a left-to-right shunt, blood is shunted to the right side of the heart because the left side is normally functioning under a higher pressure than the right side. This shunting allows oxygenated blood and unoxygenated blood to mix. This results in increased pulmonary blood flow, because the abnormal communication, or opening, sends more blood to the right side of the heart through the opening than is normal.

The infant of a substance-abusing mother is at risk for developing a sense of which of the following? A. Mistrust B. Shame C. Guilt D. Inferiority

A. Mistrust Rationale: According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. School agers develop a sense of inferiority when they do not develop a sense of industry.

While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should: A. Notify the doctor B. Look for other signs of abuse C. Recognize this as a normal finding D. Ask about family history

A. Notify the doctor Rationale: Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the doctor promptly of this finding. An open fontanel does not indicate abuse

A 9-year-old girl diagnosed with cystic fibrosis. Which of the following must the nurse keep in mind when developing a care plan for the child? A. Pulmonary secretions are abnormally thick. B. Elevated levels of potassium are found in the sweat. C. CF is an autosomal dominant hereditary disorder. D. Obstruction of the endocrine glands occurs.

A. Pulmonary secretions are abnormally thick. Rationale: A: CF is identified by abnormally thick pulmonary secretions. B: Diagnosis of CF is based on elevated chloride levels detected in sweat. C: It is a chronic, inherited disorder, particularly an autosomal recessive hereditary disorder concerning the exocrine, not endocrine glands. D: The thick mucus blocks the exocrine glands.

An infant is diagnosed with heart failure. Which of the following interventions would be appropriate to promote optimal nutrition for the infant? A. Replacing regular nipples with easy-to-suck ones B. Allowing the infant to feed for at least 1 hour C. Providing large feedings evenly spaced every 4 hours D. Offering formula that is high is sodium and calories

A. Replacing regular nipples with easy-to-suck ones Rationale: A: The nurse should replace regular nipples with easy-to-suck-ones because the infant may tire instantly with regular nipples and thus would not be able to suck sufficiently. B,C: Also to prevent tiring, small frequent feedings lasting no more than 45 minutes, rather than large evenly spaced feedings or ones lasting longer than 1 hour, should be given. D: Typically, the infant receives a low-sodium, high-calorie diet.

Nurse Walter should expect a 3-year-old child to be able to perform which action? A. Ride a tricycle B. Tie the shoelaces C. Roller-skates D. Jump rope

A. Ride a tricycle At age 3, gross motor development and refinement in eye-hand coordination enable a child to ride a tricycle. The fine motor skills required to tie shoelaces and the gross motor skills requires for roller-skating and jumping rope develop around age 5.

To maintain a child's developmental skills while hospitalized, the nurse should encourage what types of activities to a 1-year-old child who was born 2 months earlier than the estimated date of delivery? A. Sitting independently B. Walking independently C. Building a tower of 3 blocks D. Indicating wants by pointing or grunting

A. Sitting independently Rationale: For preterm infants, the nurse needs to calculate the developmental age by deducting the time of prematurity from the age of the child until he or she reaches the age of 2 years. In this case, 2 months need to be subtracted from 1 year, equaling 10 months of age. A 10-month-old can sit independently. By 15 months of age, a child should walk independently and indicate wants by pointing and grunting. By 18 months of age, a child should be able to build a tower of 3 blocks.

Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? A. Susceptibility to respiratory infection B. Bleeding tendencies C. Frequent vomiting and diarrhea D. Seizure disorder

A. Susceptibility to respiratory infection Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

A 5-year-old child is admitted to the hospital for heart surgery to repair the tetralogy of Fallot. The nurse reviews the child's record and notes that the child has clubbed fingers. This finding is indicative of which condition? A. Tissue hypoxia B. Chronic hypertension C. Delayed physical growth D. Destruction of bone marrow

A. Tissue hypoxia Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic tissue hypoxia and polycythemia. Options 2, 3, and 4 do not cause clubbing.

Which of the following instructions would the nurse include in a teaching plan that focuses on initial prevention for a child who is diagnosed with rheumatic fever? A. Treating streptococcal throat infections with an antibiotic B. Giving penicillin to patients with rheumatic fever C. Using corticosteroid to reduce inflammation D. Providing an antibiotic before dental work

A. Treating streptococcal throat infections with an antibiotic Rationale: A: Rheumatoid fever results from improperly treated group beta-hemolytic streptococcal infections, usually pharyngitis. Therefore, prompt treatment of streptococcal throat infections with an antibiotic is a key preventive measure. B: Initial prevention is not possible once the child has rheumatic fever. However, the child will be treated with penicillin to prevent a recurrence of streptococcal infections. C: A corticosteroid may be used to reduce inflammation during treatment of rheumatic fever, not as a preventive measure. D: An antibiotic is given to children with cardiac disease to prevent carditis, not rheumatic fever.

The nurse is caring for a child after tonsillectomy. Which positions should the nurse plan to place the child in? Select all that apply. A. Flat B. With the head of the bed elevated C. Supine D. Left side-lying E. Right side-lying

B, D, E Rationale: The nurse should place the child in position to facilitate drainage (side-lying), and elevate the head of the bed when the child is fully awake

The nurse is providing discharge instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, what should be the appropriate response to the mother? A. "In 1 week." B. "In 3 weeks." C. "Six days after surgery." D. "When the health care provider says it is okay."

B. "In 3 weeks." Rationale: Rough or scratchy foods, as well as spicy foods, are to be avoided for 3 weeks after a tonsillectomy. Citrus juices that irritate the throat need to be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. The mother is instructed to add full liquids on the second day and soft foods as the child tolerates them.

The Andrews family has been taking good care of their youngest child who was diagnosed with asthma. Which of the following statements indicate a need for further home care teaching? A. "He should increase his fluid intake regularly to thin secretions." B. "We'll make sure that he avoids exercise to prevent attacks." C. "He is to use his bronchodilator inhaler before the steroid inhaler." D. "We need to identify what things trigger his attacks."

B. "We'll make sure that he avoids exercise to prevent attacks." Rationale: B: Additional teaching is needed if the family states that the child with asthma should avoid exercise to prevent attacks. Children with asthma should be encouraged to exercise as tolerated. A,C,D: Identifying triggers, using a bronchodilator inhaler before a steroid inhaler, and increasing fluid intake are appropriate measures to be included in a home care teaching program for the child with asthma and his family.

During a well-child visit, a mother states she is frustrated with her 2-year-old son because whenever she asks him whether he wants something to eat he says, "no," but then starts to cry when she does not give him the food. Which statement by the nurse indicates an understanding of psychosocial concepts related to the growth and development of the toddler? A. "Your toddler is only 2 years old and you should not be giving him choices. He is too young." B. "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." C. "Your toddler is still in the stage of trust versus mistrust, and you need to spend more time with him so that he feels more secure." D. "Your toddler is experiencing magical thinking, and with this stage if he says "no," he believes you will know he means the opposite."

B. "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." Rationale: According to Erikson, toddlers are acquiring a sense of autonomy while overcoming a sense of shame and doubt. They are attempting to relinquish their dependence and asserting independence, which will be present as negativism in their quest for independence. The word, no, is a very strong part of their vocabulary. Therefore, options 1, 3, and 4 are inaccurate.

The nurse is preparing to administer an intramuscular injection to a 10-year-old child in the vastus lateralis muscle. Which value indicates the maximum volume of medication that can be safely administered into this muscle? A. 0.5 mL B. 1.5 mL C. 2.5 mL D. 3 mL

B. 1.5 mL Rationale: In a child ages 6 to 14 years, the maximum volume of intramuscular medication that can be safely administered into the vastus lateralis muscle is 2 mL. The maximum volume of intramuscular medication that can be safely administered into the vastus lateralis is 0.5 to 1 mL

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit? A. Decreased pulse rate B. A sunken fontanel C. Low urine specific gravity D. Increased blood pressure

B. A sunken fontanel Rationale: In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.

A child is diagnosed with coarctation of aorta. While assessing him, the nurse would expect to find which of the following? A. Squatting posture B. Absent or diminished femoral pulses C. Severe cyanosis at birth D. Cyanotic ("tet") episodes

B. Absent or diminished femoral pulses Rationale: B: Absent or diminished femoral pulse is a classic characteristic of coarctation of aorta. C: Severe cyanosis at birth is seen in such defects as transposition of the great vessels. A,D: Tet episodes and squatting are characteristic of tetralogy of Fallot.

Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What's the nurse's best recommendation for helping the mother increase her child's nutritional intake? A. Allow the child to eat at a small table and chair by herself B. Allow the child to feed herself C. Only serve the child's favorite foods D. Use specially designed dishes for children - for example, a plate with the child's favorite cartoon character

B. Allow the child to feed herself Rationale: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices, not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.

When administering a liquid medication to an uncooperative toddler, the nurse should implement which strategy? A. Restrain the child in a high chair. B. Allow the parents to remain in the room. C. Restrain the child in a papoose-type device. D. Remove the child to another room away from the parents.

B. Allow the parents to remain in the room. Rationale: Allowing the parents to remain in the room will promote positive parent-child relationships as well as decrease the irrational fears that are so common in this age-group. Option 4 is incorrect, because separation anxiety will only increase the child's fears. Options 1 and 3 are unnecessarily restrictive and will not increase cooperation.

The nurse is assessing the vital signs of a 3-year-old child and notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate? A. Administer oxygen. B. Document the findings. C. Notify the health care provider. D. Reassess the respiratory rate in 15 minutes.

B. Document the findings. Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.

The registered nurse is discussing care of a child with acute laryngotracheobronchitis (LTB) with a nursing student. The registered nurse determines that the nursing student needs further teaching regarding this disorder if the student states that which finding is a clinical characteristic of LTB? A. Is usually viral but may be bacterial in nature B. Has a sudden onset and usually occurs during the day C. Causes swelling and inflammation of the vocal cords D. Child awakens with a harsh cough and inspiratory stridor

B. Has a sudden onset and usually occurs during the day Rationale: Laryngotracheobronchitis (LTB) typically has a gradual onset and usually occurs at night. Options 1, 3, and 4 are correct descriptions of this disorder.

The nurse is performing an assessment on a preschool child. What should the nurse do in order to facilitate the cooperation of the child? A. Have the parents leave the room. B. Have the child pretend to be the nurse. C. Offer information and answer questions. D. Explain in detail each part of the examination before doing it

B. Have the child pretend to be the nurse. Rationale: According to Erik Erikson, preschoolers are in the initiative stage of development. They pretend, explore, and try out new roles. They primarily look for the fun in activities, not the reasoning behind the activity. Parental involvement is usually important for all ages of children especially during the younger years. The child would not be interested in or understand information or details.

An infant with a patent ductus arteriosus is admitted to the pediatric unit ward. The nurse anticipates which of the following medications will be given to the infant? A. Prednisone. B. Indomethacin. C. Penicillin. D. Albuterol.

B. Indomethacin. Rationale: When surgical ligation is not indicated, prostaglandin inhibitors (e.g., nonsteroid anti-inflammatory drugs [NSAIDs]) are used to close the ductus arteriosus. Options A, C, and D are not used for the management of patent ductus arteriosus.

The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base her response? A. Involuntary movements affecting the legs, arms, and face B. Inflammation of all parts of the heart, primarily the mitral valve C. Tender, painful joints, especially in the elbows, knees, ankles, and wrists D. Red skin lesions that start as flat or slightly raised macules, usually over the trunk, and that spread peripherally

B. Inflammation of all parts of the heart, primarily the mitral valve Rationale: Carditis is the inflammation of all parts of the heart, primarily the mitral valve, and it is a complication of rheumatic fever. Option 1 describes chorea. Option 3 describes polyarthritis. Option 4 describes erythema marginatum.

The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care? A. Providing a consistent caregiver B. Protecting the toddler from injury C. Adapting the toddler to the hospital routine D. Allowing the toddler to participate in play and diversional activities

B. Protecting the toddler from injury Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Whereas consistency, adaptation, and diversion are important, protection from injury is the highest priority.

If parents keep a toddler dependent in areas where he is capable of using skills, the toddler will develop a sense of which of the following? A. Mistrust B. Shame C. Guilt D. Inferiority

B. Shame Rationale: According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Infants develop mistrust when their needs are not consistently gratified. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met.

A 9-year-old child is hospitalized for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development? A. Providing a portable media player (MP3) B. Tutoring to keep the child up with schoolwork C. Providing a phone for calling family and friends D. Placing computer games, a television, and videos at the bedside

B. Tutoring to keep the child up with schoolwork Rationale: The developmental task of the school-age child is industry versus inferiority. The child achieves success by mastering skills and knowledge. Maintaining schoolwork provides for accomplishment and prevents feelings of inferiority that may be caused by lagging behind the rest of the class. The other options provide diversion and are of lesser importance for a child of this age.

A family is caring for their youngest child who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition? A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations B. Ventricular septal defect, overriding aorta, pulmonic stenosis, and right ventricular hypertrophy C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle

B. Ventricular septal defect, overriding aorta, pulmonic stenosis, and right ventricular hypertrophy

A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. You should immediately determine whether the patient has: A. delayed capillary refill time. B. stridor. C. the ability to tolerate oral feedings. D. weak pulses

B. stridor.

The nurse in a well-baby clinic is providing safety instructions to the mother of a 1-month-old infant. Which safety instructions are most appropriate at this age? Select all that apply. A. Lock up all poisons. B. Cover electrical outlets. C. Never shake the infant's head. D. Place the infant on the back to sleep. E. Remove hazardous objects from low places.

C and D Rationale: The age-appropriate instructions that are most important are to instruct the mother not to shake or vigorously jiggle the baby's head and to place the infant on his back to sleep. Options 1, 2, and 5 are important instructions to provide to the mother as the child reaches the age of 6 months and begins to explore the environment.

The nurse is caring for a child with a suspected diagnosis of acute laryngotracheobronchitis (LTB). The nurse reviews the assessment data in the child's record, knowing that which findings are characteristic of this disorder? Select all that apply. A. Is always bacterial in nature B. Causes an occasional dry cough C. Associated with inspiratory stridor D. Causes swelling and inflammation of the vocal cords E. Has a gradual onset that usually worsens during the night

C, D, E Rationale: The child presents with a harsh seal-like cough and inspiratory stridor, and it causes swelling and inflammation of the vocal cords. Laryngotracheobronchitis (LTB) has a gradual onset and normally occurs at night. It is usually viral in nature.

The nurse is assessing a child admitted to the hospital with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's mother during the assessment? A. "Has your child had difficulty urinating?" B. "Has your child been exposed to anyone with chickenpox?" C. "Has any family member had a sore throat within the past few weeks?" D. "Has any family member had a gastrointestinal disorder in the past few weeks?"

C. "Has any family member had a sore throat within the past few weeks?" Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks. Options 1, 2, and 4 are unrelated to the assessment findings of rheumatic fever.

A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction? A. "I need to use the back burners for cooking." B. "I need to remain in the kitchen when I prepare meals." C. "I need to be sure to place my cup of coffee on the counter." D. "I need to turn pot handles inward and to the middle of the stove."

C. "I need to be sure to place my cup of coffee on the counter." Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.

A nurse is providing instructions to a mother who has a child with congestive heart failure regarding Digoxin (Lanoxin). Which statement made by the mother indicates further teaching? A. "I will administer the medication 1 hour before or 2 hours after meal". B. "I will use a special dose-measuring spoon or cup, not a regular table spoon for the liquid preparation". C. "If my child vomits after administration, I will repeat the dose". D. "If more than one dose is missed, I will inform the physician"

C. "If my child vomits after administration, I will repeat the dose". Rationale: Digoxin is a cardiac glycoside. The mother needs to be instructed not to repeat the dose once the child vomits it. Options A, B, and D are correct instructions regarding this medicine.

The community health nurse is providing instructions to a group of mothers regarding the safe use of car seats for toddlers. The nurse determines that the mother of a toddler understands the instructions if the mother makes which statement? A. "The car seat should never be placed in a face-forward position." B. "The car seat can be placed in a face-forward position at any time." C. "The car seat is suitable for the toddler until the toddler reaches the weight of 40 pounds." D. "The car seat can be placed in a face-forward position when the height of the toddler is 27 inches."

C. "The car seat is suitable for the toddler until the toddler reaches the weight of 40 pounds." Rationale: The transition point for switching to the forward-facing position is defined by the manufacturer of the safety seat but is generally at a body weight of 9 kg (20 pounds). The car safety seat should be used until the child weighs at least 40 pounds, regardless of age. Options 1, 2, and 4 are incorrect.

The new nurse is caring for a child with cystic fibrosis (CF). The registered nurse asks the new nurse to identify some nonpulmonary manifestations of the disease. Which statement by the new nurse indicates an understanding of these manifestations? A. "The child may have a cough and produce sputum." B. "The child may experience frequent respiratory infections." C. "The child may have steatorrhea and abdominal distention." D. "The child may have chest congestion and exercise intolerance."

C. "The child may have steatorrhea and abdominal distention." Rationale: Cystic fibrosis (CF) is a genetic disease that affects many organs and lethally impairs the pulmonary system. It is an autosomal recessive disorder that results in an error in chloride transfer causing excessive mucus production. The child experiences both pulmonary and nonpulmonary symptoms. Pulmonary symptoms include frequent respiratory infections, chest congestion, limited exercise tolerance, cough, sputum production, use of accessory muscles, and decreased respiratory function. Nonpulmonary symptoms include abdominal distention, gastroesophageal reflux, rectal prolapsed, foul-smelling stools, and steatorrhea (excessive fat in stools). Options 1, 2, and 4 indicate pulmonary symptoms. Option 3 identifies the nonpulmonary manifestations.

During a routine well-child checkup for a 2-year-old child, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. What should the nurse expect the child's weight to be at this time? A. 15 pounds 14 ounces B. 23 pounds 13 ounces C. 31 pounds 12 ounces D. 39 pounds 11 ounces

C. 31 pounds 12 ounces Rationale: By the age of 30 months, the toddler should have quadrupled his or her birth weight. The child doubles the birth weight by age 5 to 6 months and triples the birth weight by 1 year of age. Option 3 is quadruple the birth weight.

A child who weighs 44 lb has been given an order for amoxicillin 500 mg b.i.d. The drug text notes that the daily dose of amoxicillin is 50 mg/kg/day in two divided doses. What dose in milligrams is safest for this child? A. 1000 mg B. 750 mg C. 500 mg D. 250 mg

C. 500 mg Rationale: C: First, calculate the child's weight in kg: 44/2.2 = 20 kg. Then calculate the appropriate daily dose according to the drug text: 50 mg/kg/day = 50 mg x 20 kg = 1,000 mg/day. the abbreviation b.i.d. means twice daily; therefore 1,000 divided by 2 equals 500 mg.

Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child's history, the nurse considers which information to be most important? A. A fever that started 3 days ago B. Lack of interest in food C. A recent episode of pharyngitis D. Vomiting for 2 days

C. A recent episode of pharyngitis Rationale: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.

Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first? A. Punish the child for being bad B. Administer ipecac syrup C. Call the poison control center D. Call an ambulance immediately

C. Call the poison control center Rationale: Before interviewing in any way, the parents should call the poison control center for specific directions. Ipecac syrup is no longer recommended. The parents may have to call an ambulance after calling the poison control center. Punishment for being bad isn't appropriate because the parents are responsible for making the environment safe.

Immunization of children with Haemophilus influenzae type B (Hib) vaccine decreases the incidence of which of the following conditions? A. Bronchiolitis B. Laryngotracheobronchitis (LTB) C. Epiglottitis D. Pneumonia

C. Epiglottitis Rationale: C: Epiglottitis is a bacterial infection of the epiglottis primarily caused by Hib. Administration of the vaccine has decreased the incidence of epiglottitis. A: Bronchiolitis is usually caused by respiratory syncytial virus. B: Acute LTB is of viral origin. D: The most common bacterial organisms causing pneumonia in children are pneumococci, streptococci, and staphylococci.

Which of the following respiratory conditions is always considered a medical emergency? A. Asthma B. Cystic fibrosis (CF) C. Epiglottitis D. Laryngotracheobronchitis (LTB)

C. Epiglottitis Rationale: C: Epiglottitis, acute and severe inflammation of the epiglottis, is always considered an acute medical emergency because it can lead to acute, life-threatening airway obstruction. A: Asthma is a chronic disease; however, status asthmaticus and acute attacks require prompt treatment. B: CF is a chronic disease and is not considered an emergency. D: Acute LTB requires close observation for airway obstruction, but this condition is not always an emergency.

Which of the following would the nurse suppose to regard as a cardinal manifestation or symptom of digoxin toxicity to his patient, a child diagnosed with heart failure? A. Headache B. Respiratory distress C. Extreme bradycardia D. Constipation

C. Extreme bradycardia Rationale: C: Extreme bradycardia is a cardinal sign of digoxin toxicity A,B,D: Headache, respiratory distress, and constipation are not related to digoxin toxicity.

Which of the following is an appropriate toy for an 18-month-old? A. Multiple-piece puzzle B. Miniature cars C. Finger paints D. Comic book

C. Finger paints Rationale: Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.

Which of the following organisms is responsible for the development of rheumatic fever? A. Streptococcal pneumonia B. Haemophilus influenza C. Group A β-hemolytic streptococcus D. Staphylococcus aureus

C. Group A β-hemolytic streptococcus

A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder? A. Increased leukocyte count B. Decreased hemoglobin count C. Increased antistreptolysin-O (ASO titer) D. Decreased erythrocyte sedimentation rate

C. Increased antistreptolysin-O (ASO titer) Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.

The nurse is caring for a child with a diagnosis of Kawasaki disease, and the mother of the child asks the nurse about the disorder. Which description of this disorder should the nurse base the response to the mother on? A. It is an acquired cell-mediated immunodeficiency disorder. B. It is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue. C. It is acute systemic vasculitis and is of unknown etiology. D. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.

C. It is acute systemic vasculitis and is of unknown etiology Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute systemic vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus infection. Option 2 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.

The nurse is caring for a child hospitalized with laryngotracheal bronchitis (LTB). Which sign/symptom, if noted in the child, indicates respiratory distress? A. Agitation B. Dehydration C. Nasal flaring D. Brassy respirations

C. Nasal flaring Rationale: Signs of respiratory distress include nasal flaring; the use of accessory muscles; substernal, intercostal, and suprasternal retractions; and restlessness. Option 1 may be an indication of increasing respiratory distress, but it can also indicate several other clinical problems. Option 2 is not a sign of respiratory distress. Option 4 describes an early and classic manifestation of LTB.

When developing a plan care for a hospitalized child, nurse Mica knows that children in which age group are most likely to view illness as a punishment for misdeeds? A. School age B. Infancy C. Preschool age D. Adolescence

C. Preschool age Rationale: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age group, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

During a well-baby visit, Liza asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first? A. Applesauce B. Egg whites C. Rice cereal D. Yogurt

C. Rice cereal Rice cereal is the first solid food an infant should receive because it is easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and finally, meat. Egg whites should not be given until age 9 months because they may trigger a food allergy.

Appropriate intervention is vital for many children with heart disease in order to go on to live active, full lives. Which of the following outlines an effective nursing intervention to decrease cardiac demands and minimize cardiac workload? A. Feeding the infant over long periods B. Allowing the infant to have her way to avoid conflict C. Scheduling care to provide for uninterrupted rest periods D. Developing and implementing a consistent care plan

C. Scheduling care to provide for uninterrupted rest periods Rationale: C: Organizing nursing care to provide for uninterrupted periods of sleep reduces cardiac demand. A: Feeding time should be restricted to a maximum of 45 minutes or discontinued sooner if the infant tires. B: In an attempt to get her own way, the child may cry. Excessive crying should be limited; however, appropriate limit setting should still be observed. D: Developing and implementing a consistent care plan can be important, but it is not related to decreasing cardiac demands or workload.

The nurse employed in a well-baby clinic is collecting data regarding the motor development of an 18-month-old child. What should the nurse expect as the highest level of development in this child? A. The child snaps large snaps. B. The child builds a tower of 2 blocks. C. The child builds a tower of 3 or 4 blocks. D. The child puts on simple clothes independently.

C. The child builds a tower of 3 or 4 blocks.

he nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following observations would be of most concern? A. The baby cannot say "mama" when he wants his mother. B. The mother has not given him finger foods. C. The child does not sit unsupported. D. The baby cries whenever the mother goes out.

C. The child does not sit unsupported. Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say "mama" in the sense that it refers to their mother at this time.

An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure? A. The nurse-manager B. The registered nurse caring for the infant C. The foster mother D. The social worker who placed the infant in the foster home

C. The foster mother Rationale: When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social workers, the nurse, and the nurse-manager have no legal rights to give consent in this scenario.

The nurse is giving instructions to an 8-year-old child regarding measures to take to identify the early signs of an asthma episode. What instruction would be important for the nurse to give the child? A. Perform chest percussion and postural drainage. B. Open the airway passages by using a hand-held nebulizer. C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. D. Deliver a dose of a bronchodilator by a metered-dose inhaler to see if it helps.

C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. Rationale: An asthmatic child older than the age of 4 should be able to measure the expiratory flow. A drop in expiratory flow is the most reliable early sign of an asthma episode. Chest percussion and postural drainage are normally used to clear air passages for children with cystic fibrosis, not asthma. Medications would be administered by a metered-dose inhaler or by a hand-held nebulizer if an asthma attack actually occurs.

Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night? A. "Allow him to fall asleep in your room, then move him to his own bed." B. "Tell him that you will lock him in his room if he gets out of bed one more time." C. "Encourage active play at bedtime to tire him out so he will fall asleep faster." D. "Read him a story and allow him to play quietly in his bed until he falls asleep."

D. "Read him a story and allow him to play quietly in his bed until he falls asleep." Rationale: Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child's going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

At which of the following ages would the nurse expect to administer the varicella zoster vaccine to child? A. At birth B. 2 months C. 6 months D. 12 months

D. 12 months Rationale: The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.

When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done? A. 1 month B. 2 months C. 3 months D. 4 months

D. 4 months Rationale: Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.

Which of the following toys should the nurse recommend for a 5-month-old? A. A big red balloon B. A teddy bear with button eyes C. A push-pull wooden truck D. A colorful busy box

D. A colorful busy box Rationale: A busy box facilitates the fine motor development that occurs between 4 and 6 months. Balloons are contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy.

A 5-year-old girl Hannah is recently diagnosed with Kawasaki disease. Apart from the identified symptoms of the disease, she may also likely develop which of the following? A. Sepsis B. Meningitis C. Mitral valve disease D. Aneurysm formation

D. Aneurysm formation Rationale: Kawasaki disease is a rare childhood illness that affects the blood vessels. 20% to 25% of children can develop aneurysm formation if not intervened. Treatment depends on the degree of the disease, but is often immediate treatment with IV gamma globulin or aspirin. Corticosteroids can sometimes lessen impending complications. Children who experience the disease usually need lifelong follow-up appointments to keep an eye on heart health.

A mother tells the nurse that her child does not want anything to do with toilet training and yells "No!" consistently when she tries to toilet train. The child is 2 years old. According to Erikson, the nurse interprets that the child is experiencing which psychosocial crisis? A. Initiative versus guilt B. Trust versus mistrust C. Industry versus inferiority D. Autonomy versus shame and doubt

D. Autonomy versus shame and doubt Rationale: The crisis of autonomy versus shame and doubt is related to the developmental task of gaining control of self and environment as exemplified by toilet training. Trust versus mistrust is the crisis of the infant. Initiative versus guilt is the crisis of the preschool and early school-age child. Initiative versus inferiority is the crisis of the 6- to 12-year-old child.

The clinic nurse is performing an assessment on a 12-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement if the 12-month-old infant is able to do which task? A. Produce cooing sounds. B. Obey simple commands. C. Produce babbling sounds. D. Begin to use simple words.

D. Begin to use simple words. Rationale: Simple words, such as mama, and the use of gestures to communicate begin when the infant is between 9 and 12 months old. A 1- to 3-month-old infant will produce cooing sounds. Babbling is common in a 3- to 4-month-old infant. Between the ages of 8 and 9 months, the infant begins to understand and obey simple commands, such as "wave bye-bye." The use of single-consonant babbling occurs between the ages of 6 and 8 months.

A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler's fontanels, what should the nurse expects to find? A. Open anterior and fontanel and closed posterior fontanel B. Open anterior and posterior fontanels C. Closed anterior fontanel and open posterior fontanel D. Closed anterior and posterior fontanels

D. Closed anterior and posterior fontanels Rationale: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and the arms. What should the nurse expect the blood pressure child's legs be in comparison to the child's arms? A. Increased in both the arms and the legs B. Decreased in both the arms and the legs C. Increased in the legs and decreased in the arms D. Decreased in the legs and increased in the arms

D. Decreased in the legs and increased in the arms Rationale: Coarctation indicates a narrowing in the aorta. This would indicate an increased pressure proximal to the defect and a decreased pressure distal to the defect. This would result in a lower blood pressure in the legs and a higher blood pressure in the arms, which is indicated in

While performing physical assessment of a 12 month-old, the nurse notes that the infant's anterior fontanel is still slightly open. Which of the following is the nurse's most appropriate action? A. Notify the physician immediately because there is a problem. B. Perform an intensive neurological examination. C. Perform an intensive developmental examination. D. Do nothing because this is a normal finding for the age.

D. Do nothing because this is a normal finding for the age. Rationale: The anterior fontanel typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanel as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate.

A school-age child has a history of upper respiratory infection (URI) accompanied by a sore throat, and the health care provider suspects rheumatic fever. The nurse checks for which if the modified Jones criteria are being used to diagnose rheumatic fever? A. An elevation in antistreptolysin-O antibodies B. A significant decrease in the child's sedimentation rate C. Emotional instability, purposeless movement, and muscular weakness D. Evidence of streptococcal infection and the presence of either two major manifestations or one major and two minor manifestations of rheumatic fever

D. Evidence of streptococcal infection and the presence of either two major manifestations or one major and two minor manifestations of rheumatic fever Rationale: A high probability of rheumatic fever is indicated when there is evidence of at least two of the major or one major and two minor manifestations of the Jones criteria and evidence of a streptococcal infection. An elevation in antistreptolysin-O antibodies indicates a recent streptococcal infection but does not alone diagnose rheumatic fever. The sedimentation rate is normally increased in rheumatic fever. Option 3 identifies clinical manifestations of chorea, which is one major manifestation. However, these alone are not enough to diagnosis rheumatic fever according to the modified Jones criteria.

Which of the following is the best method for performing a physical examination on a toddler A. From head to toe B. Distally to proximally C. From abdomen to toes, the to head D. From least to most intrusive

D. From least to most intrusive When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive. Starting at the head or abdomen is intrusive and should be avoided. Proceeding from distal to proximal is inappropriate at any age.

A 4-year-old child is reluctant to take deep breaths after abdominal surgery. Which measure is most appropriate to implement to encourage deep breathing? A. Give the child colorful latex balloons to blow up. B. Tell the child to exhale forcefully through the peak flow meter. C. Administer chest percussion in several postural drainage positions. D. Have the child pretend he is the big, bad wolf blowing the little pig's house down.

D. Have the child pretend he is the big, bad wolf blowing the little pig's house down. Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flow meter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.

The nurse performs an assessment on a 9-month-old infant. Which finding indicates a physiological problem and the need for follow-up? A. Absence of rooting reflex B. Inability to stand without support C. Creeping or crawling along the floor D. Head lag is noted when pulled to sitting

D. Head lag is noted when pulled to sitting Rationale: Presence of head lag after 6 months suggests neuromuscular dysfunction and indicates a physiological problem in an infant that is 9 months of age. Basic reflexes, such as rooting or startling, predominate the first 3 months and would not be reflexive in late infancy. Standing alone is not expected until 10 to 12 months, and crawling is accomplished by 6 to 8 months of age.

A home care nurse is instructing a mother of a child diagnosed with cystic fibrosis (CF) about the appropriate dietary measures. Which diet should the nurse tell the mother that the child needs to consume? A. Low-calorie, low-fat diet B. High-calorie, restricted fat C. Low-calorie, low-protein diet D. High-calorie, high-protein diet

D. High-calorie, high-protein diet Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and fat-soluble vitamin supplements are administered. Fat restriction is not necessary.

The nurse is caring for a child with a patent ductus arteriosus. The nurse reviews the child's assessment data, knowing that which is characteristic of this disorder? A. It involves an opening between the two atria. B. It produces abnormalities in the atrial septum. C. It involves an opening between the two ventricles. D. It involves an artery that connects the aorta and the pulmonary artery during fetal life.

D. It involves an artery that connects the aorta and the pulmonary artery during fetal life. Rationale: Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. Options 1, 2, and 3 are not characteristics of this cardiac defect.

While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected? A. A strong Moro reflex B. A strong parachute reflex C. Rolling from front to back D. Lifting of head and chest when prone

D. Lifting of head and chest when prone Rationale: A 3-month-old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months.

Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is learning forward and drooling? A. Auscultate his lungs and place him in a mist tent. B. Have him lie down and rest after encouraging fluids. C. Examine his throat and perform a throat culture D. Notify the physician immediately and prepare for intubation

D. Notify the physician immediately and prepare for intubation Rationale: The child is exhibiting classic signs of acute epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal.

The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever. The nurse notes that the health care provider has documented the presence of erythema marginatum. Based on this documentation, which signs and symptoms should the nurse expect to note in the child? A. Involuntary movements affecting the legs, arms, and face B. Inflammation of all parts of the heart, primarily the mitral valve C. Tender painful joints, especially the elbows, knees, ankles, and wrists D. Red skin lesions that start as flat or slightly raised macules over the trunk

D. Red skin lesions that start as flat or slightly raised macules over the trunk Rationale: Erythema marginatum is characterized by red skin lesions that start as flat or slightly raised macules, usually over the trunk, that spread peripherally. Option 1 identifies chorea. Option 2 identifies carditis. Option 3 identifies polyarthritis

The adolescent's inability to develop a sense of who he is and what he can become results in a sense of which of the following? A. Shame B. Guilt C. Inferiority D. Role diffusion

D. Role diffusion Rationale: According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-aged children develop a sense of inferiority when they do not develop a sense of industry.

The nurse is caring for a child with a ventricular septal defect, and the parents ask the nurse about the treatment for this disorder. On what should the nurse base the response? A. It is treated by medications alone. B. Surgical closure is done immediately. C. Surgical closure is done at ages 5 to 6. D. Some defects may close spontaneously.

D. Some defects may close spontaneously. Rationale: In ventricular septal defects, some defects may close spontaneously. If spontaneous closure does not occur, moderate or large defects require surgical closure before school age. If pulmonary hypertension is present, closure is necessary by age 1. Open heart surgery is done for closure.

Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation? A. Aortic stenosis (AS) B. Coarctation of aorta C. Patent ductus arteriosus (PDA) D. Tetralogy of Fallot

D. Tetralogy of Fallot D: Tetralogy of Fallot consists of four major anomalies: ventricular septal defect, right ventricular hypertrophy, pulmonic stenosis (PS), aorta overriding the ventricular septal defect. PS impedes the flow of blood to the lungs, causing increased pressure in the right ventricle, forcing deoxygenated blood through the septal defect the left ventricle. As a result of this decreased pulmonary flow, deoxygenated blood is shunted into the systemic circulation. The increased workload on the right ventricle causes hypertrophy. The overriding aorta receives blood from both the right and left ventricles. This is the definition of defect with decreased pulmonary blood flow where unoxygenated blood is shunted into the systemic circulation. A,B: Coarctation of aorta and AS are obstructive defects where obstruction, not shunting, is the problem. C: With PDA, blood flows from the aorta through the PDA and back to the pulmonary artery and lungs (shunting of oxygenated blood to the pulmonic system), causing increased pulmonary vascular congestion.

The well-baby clinic nurse is assessing the motor developmental of a 30-month-old child. Which is the highest level of development that the nurse should expect to note in the child? A. The child opens a doorknob. B. The child unzips a large zipper. C. The child builds a tower of two blocks. D. The child puts on simple clothes independently.

D. The child puts on simple clothes independently. Rationale: At age 15 months, the nurse would expect that the child could build a tower of two blocks. A 24-month-old would be able to open a doorknob and unzip a large zipper. At age 30 months, the child would be able to put on simple clothes independently.

An 11-year-old child scheduled for a diagnostic procedure will have an intravenous line inserted and will receive an intramuscular injection. What form of communication should the nurse use in preparing the child for the procedure? A. Reassuring the child that he or she will not feel any pain B. Teaching the parents so that they can explain everything to the child C. Telling the child not to worry because the doctors take care of everything D. Using pictures, concrete words, and demonstrations to describe what will happen

D. Using pictures, concrete words, and demonstrations to describe what will happen

When administering an I.M. injection to an infant, the nurse in charge should use which site? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis

D. Vastus lateralis Rationale: The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.

The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of heart failure (HF). Which intervention should the nurse recognize as needing revision? A. Elevate the head of the bed. B. Provide oxygen during stressful periods. C. Limit the time that the infant is allowed to bottle-feed. D. Wake the infant for feedings to ensure adequate nutrition.

D. Wake the infant for feedings to ensure adequate nutrition. Rationale: Awaking the child is not therapeutic in this situation. Measures that will decrease the workload on the heart include limiting the time that the infant is allowed to bottle-feed or breast-feed, elevating the head of the bed, allowing for uninterrupted rest periods, and providing oxygen during stressful periods.

A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. The first step in treatment is to: A. administer a nebulizer treatment with a beta-agonist medication. B. deliver bag-valve-mask ventilations. C. suction the oropharynx for secretion. D. administer humidified oxygen via blow-by method

D. administer humidified oxygen via blow-by method