PED Final Exam Course point ?'s Unit 1

The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing?

Moro

The nurse is caring for a newborn infant who has Down syndrome. Which nursing action reflects the nurse's use of the ethical principle of nonmaleficence?

The nurse provides safe, competent nursing care to avoid harming the infant.

The parents of an 8-month-old boy voice concern to the nurse that their child is not developing motor skills as he should. What question would be appropriate for the nurse to ask in determining if their fears are warranted?

"Does he move a toy back and forth from one hand to the other when you give it to him?"

The nurse is interacting with several parents of infants. Which parent statement would alert the nurse to refer the infant for further evaluation by the health care provider?

"My 9-month-old infant is beginning to track objects when we show her favorite objects."

A first-time mother, who is breastfeeding, phones the clinic nurse because she is concerned about her 3-month-old infant's stools. Which statement by the mother would alert the nurse to contact the health care provider?

"The stools are small and hard."

The mother of a 4-year-old is discussing discipline methods with the nurse. She states that she has never tried using "time-outs" with her child and wonders how and if this method works. Which responses from the nurse are appropriate? Select all that apply.

"Time-out is a way of removing positive reinforcement of an unwanted or inappropriate behavior." "If you decide to try this method, be sure to use time-out in a nonthreatening, safe area where no interaction occurs with you." "Time-out is a method that is recognized by many pediatricians and experts in pediatrics."

The nurse is teaching discipline strategies to the parents of a 4-year-old boy. Which response from the parents indicates a need for more teaching?

"We should let him know he makes us angry with bad behavior."

A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?

96.6°F (35.8°C)

Which client will the nurse assess first after receiving 0700 shift report?

A 12-month-old infant with a blood pressure of 60/40 mm Hg

The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age?

An infant's rate is 90 bpm.

The nurse is observing a 6-month-old boy for developmental progress. For which typical milestone should the nurse look?

Puts down a little ball to pick up a stuffed toy.

The nurse is assessing a 12-week-old infant in the clinic at a well-baby visit. Which assessment finding does the nurse predict to assess in this healthy infant?

Smiles at significant others

The nurse is caring for a 5-year-old girl with meningitis. What action by the nurse may be considered ethical behavior?

Starting intravenous fluids even though the child protests

The nurse is assessing a 4-month-old infant during a scheduled visit. Which findings might suggest a developmental problem?

The child does not make sounds in response to voices

The nurse is completing a developmental assessment on a 6-month-old infant. Which findings indicate the need for additional follow-up? Select all that apply.

The infant does not pay attention to noises behind him. The infant has frequent episodes of crossed eyes. The infant seems disinterested in the surrounding environment.

A nurse is talking to and making facial expressions at a 9-month-old baby girl during a routine office visit. What is the most advanced milestone of language development that the nurse should expect to see in this child?

The infant says "da-da" when looking at her father

The parents of a 4-day-old infant report concern about his weight loss. What is the best response by the nurse?

With appropriate nutrition weight gain will commence with a return to the birth weight within 2 weeks."

The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old girl. The nurse understands that falsely high readings may be associated with which situation or condition?

anemia

Which assessment findings if noted in a 4-month-old infant would the nurse recognize as normal growth and development?

holds head up when prone, bears partial weight on legs, reflexes are fading

A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate?

rectal