pedi evolve

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.

2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

Initiating seizure precautions

The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside?

A bottle of sterile normal saline

The nursing student is presenting a clinical conference and discusses the causative factors related to beta-thalassemia. Which group is at greatest risk of developing this disorder?

A child of Mediterranean descent

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?

A chronic disability characterized by impaired muscle movement and posture

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?

Turn the child to the side

The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern?

infection

The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?

swimming

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure?

Preventing infection at the surgical site

The nurse has just administered ibuprofen to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?

Remove excess clothing and blankets from the child.

The nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig's sign. Which is the appropriate procedure to elicit a Kernig's sign?

Extend the leg and knee and check for pain.

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct?

"BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."

A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following examination, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breastfeeding the infant and asks the nurse if breastfeeding can be continued. Which response is appropriate?

"Breastfeeding can continue, but your breasts should also be treated with nystatin."

The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction?

"Call the primary health care provider if the infant has a high-pitched cry."

The nurse determines that an adolescent client with diabetes mellitus needs further teaching about A1c levels and their purpose if the client made which statement when told that a level will be drawn?

"I already had a complete blood cell count drawn an hour ago, so this test is not necessary."

The nurse is reinforcing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further teaching?

"I am so pleased that I won't have to eliminate oatmeal from my child's diet."

The nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder?

"I need to bring my child back to the clinic in 1 month for a new cast."

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions?

"I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites.

The clinic nurse is reinforcing instructions to an adolescent with type 1 diabetes about administration of insulin. Which statements by the adolescent indicate the need for further teaching? Select all that apply.

"I should give my injections only in my thighs. I should place any unopened insulin vials in the freezer."

A parent with a 6-year-old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching?

"I take away privileges such as TV time when the bed is wet in the morning."

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching?

"I understand that I need to leave the scabicide on for 4 hours before washing it off."

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching?

"I understand that my child needs to wear this brace for 12 hours a day."

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching?

"I understand this whooping cough is viral and I have to let it run its course."

When reinforcing instructions to the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver makes which statement?

"I will allow my child to put cotton balls inside the cast to relieve pressure."

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching?

"I will apply lotion under the brace to prevent skin breakdown.

The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching?

"I will have my child wear dark colored clothing so the tick will not be attracted to the colors

The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching?

"I will insert a glycerin suppository before the dilation."

The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching?

"I will need to give antiseizure medications when my child has a seizure."

The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?

"I will not let my child play with other children who have the flu unless they are taking acetaminophen."

The nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?

"If my baby has a high-pitched cry, I should call the primary health care provider."

The nurse is reinforcing 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. The nurse should make which response to the mother?

"In 3 weeks"

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement?

"In most cases, medication and diet will control fluid retention.

The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy?

"It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."

The nurse assists with providing an instructional session to parents regarding impetigo. Which statement by a parent indicates the need for further teaching?

"Lesions are most often located on the arms and chest."

The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?

"My child will outgrow this by the time he is 2 years old and be able to see just fine."

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching?

"PKU primarily affects the gastrointestinal system."

A child with croup is placed in a cool-mist tent. The mother asks if the child may have her security blanket inside the tent. Which is the most appropriate response by the nurse?

"The child may have the security blanket inside the tent."

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the school children. Which statement, if made by a parent, indicates a need for further teaching regarding this communicable disease?

"The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears.

A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder?

"The disorder means there is no communication from the right atrium to the right ventricle of the heart."

The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching?

"The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."

A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?

"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."

The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse should make which response to the mother?

"This is not an emergency. I will speak to the primary health care provider and call you right back."

The nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. Which nursing response is appropriate?

"This type of breathing is used to mobilize secretions so that they can be easily coughed out."

The nurse is providing discharge teaching regarding skin care to a new mother of a 2-day-old infant. Which statements by the mother demonstrate an understanding of how to care for the infant's skin? Select all that apply.

"We will apply ointments containing zinc oxide to the baby's bottom to prevent diaper rash." 3. "To prevent diaper rash, we will change our baby's diaper as soon as he has pooped or peed."

A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of corticosteroids that are currently being administered every other day. Which therapeutic statements should the nurse make to the child about the cushingoid appearance? Select all that apply.

"Which manifestations of this condition do you find most troublesome?" The signs/symptoms are lessened by taking the prednisone every other day instead of daily." 5. "The cushingoid appearance will gradually disappear once the steroids are tapered and discontinued."

The nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which is the appropriate nursing intervention?

Document the findings.

The mother of a child with Marfan syndrome asks the nurse what can be done at home to help her child. Which are the best responses by the nurse? Select all that apply.

"You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." You will need to make regular eye examination appointments for your child." 5. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 6. "You will need to let the dentist know that antibiotics should be given before any procedure."

A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting with care for the child checks the intravenous (IV) and medication supply area for what?

0.9% normal saline IV infusion

The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action should the nurse take?

Document the findings.

The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder?

Does your infant have foul-smelling, ribbon-like stools?"

A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 am, 12 noon, and at 6:00 pm. What times should the nurse tell the mother to perform postural drainage?

10:00 am, 2:00 pm, and 8:00 pm

An infant, weighing 12 kg, is receiving diuretic therapy, and the nurse is closely monitoring the intake and output. Which is the amount of hourly urine output should the nurse expect as adequate?

12 to 24 mL/hour

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?

Blood cultures

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?

2. Notify the registered nurse (RN)

The nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. Which is the best nursing action?

2. Notify the registered nurse (RN).

Which test would the nurse anticipate for a teenage client who has been treated for vaginal Candida infections repeatedly in the last 6 months to assist in the identification of the underlying chronic pathology?

Blood glucose level

Which finding would indicate that a child had a tonic-clonic seizure during the night?

Blood on the pillow

The nurse caring for an infant with bronchiolitis is monitoring for signs of dehydration. The nurse monitors which method as reliable for determining fluid loss?

Body weight

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?

Calcium and vitamin D

The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid is prescribed for the child. Which nursing action is appropriate?

Consult with the registered nurse to verify the prescription

The nurse is planning care for a hospitalized child with syndrome of inappropriate antidiuretic hormone (SIADH). The primary health care provider has prescribed that the 24-hour fluid maintenance for the child weighing 12 kg be at ¾ of the maintenance. Using the formula shown (refer to figure), which volume of fluid should the nurse plan as the 24-hour maintenance for this child?

825 mL

The school nurse notes that the child has a rash and suspects that it is caused by erythema infectiosum (fifth disease). The nurse bases this determination on the observation that the rash results in which appearance?

A "slapped-face" appearance

The nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse should tell the parents that the infant should be maintained in which position?

A 60-degree angle when supine

A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder?

A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel

The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item should the nurse place at the bedside in preparation for the child's return from surgery?

A cooling blanket

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which finding is noted?

A decrease in urine output to 0.5 mL/kg/hr

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteris

A greater risk of infection than a simple fracture

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic?

A greater risk of infection than a simple fracture

A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which is an unassociated risk factor related to otitis media?

A history of urinary tract infections

The nurse is assigned to care for a child with a diagnosis of Wilms' tumor. The child's mother asks the nurse what kind of tumor this is. What is the best response by the nurse?

A nephroblastoma

The nurse is preparing for the administration of ribavirin to a child with respiratory syncytial virus. Which supplies will the nurse obtain for the administration of this medication?

A pair of goggles

The nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate?

Document the findings.

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?

A side-lying position

The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside?

A suction apparatus and oxygen

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 1 lb in 1 day

The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine?

Allergy to eggs

Following a tonsillectomy, which of the primary health care provider's prescriptions should the nurse question?

Allow ice cream when awake.

The nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this observation as indicating which finding?

An airway obstruction

The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

An elevated temperature

The nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and should expect to note which finding?

An elevated thyroid-stimulating hormone (TSH) level

A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the primary health care provider did not prescribe antibiotics. The nurse makes which response to the mother?

Antibiotics are not indicated unless a bacterial infection is present.

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study should assist in confirming the diagnosis of RF?

Antistreptolysin O titer

The nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which food item should the nurse mix with the medication?

Applesauce

A nursing student is asked to administer a tepid bath to a child with a fever. The student should avoid which action when performing this procedure?

Applies alcohol-soaked cloths over the child's body

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

Apply an ice pack to the injection site

A 6-month-old infant receives a diphtheria, tetanus, and pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which is the appropriate response by the nurse?

Apply an ice pack to the injection site.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply.

Ascites 2. Anorexia Proteinuria Periorbital and facial edema

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?

Assess for any bleeding on the dressing.

An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications should the nurse plan to administer? Select all that apply.

Atenolol Propranolol 4. Methimazole

A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen?

Attaches a urinary collection device to the infant's perineum

The mother of a 5-year-old child brings the child to the emergency department and tells the nurse that the child fell. A fracture is suspected and an x-ray is taken. The results indicate that the child has a comminuted fracture of the right humerus. The mother asks the nurse to describe this type of fracture, and the nurse draws a picture for the mother. Which picture identifies this type of fracture? Refer to figure.

B

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?

Bacteriuria

A child is scheduled for a tonsillectomy in the day-stay surgical unit. On the day following surgery, the mother calls the surgical unit and expresses concern because the child has a very bad mouth odor. The nurse should make which response to the mother?

Bad mouth odor is normal and may be relieved by drinking more liquids."

A primary health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother?

Before the child is 3 years old

The nurse is reviewing the record of a child scheduled for a primary health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which factor when collecting data?

Bladder function

The nurse is planning care for a child with type 1 diabetes. Which items should the nurse plan to use to treat an early mild hypoglycemic episode? Select all that apply.

Candy Orange juice 5. Glucose tablets

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds.

A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period?

Capillary refill, sensation, and motion in all extremities

The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis?

Cat's-eye reflex

A nurse caring for a 2-month-old febrile infant is asked to collect a urine specimen for a culture and sensitivity. The nurse collects the specimen by performing which action?

Catheterizing the infant using the smallest available straight catheter

The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?

Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?

Changes in level of consciousness

The emergency department nurse is gathering initial data on a child suspected of epiglottitis. Which is the nurse's highest priority?

Check for a patent airway.

The nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?

Checking the child's ability to perform range of motion to the shoulder area of the affected extremity

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)?

Chicken tenders and a baked potato with butter

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record?

Choking with feedings

The nurse has reviewed the primary health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to do which?

Collect a 24-hour urine sample.

The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body?

Computed tomography scan

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?

Conjunctival hyperemia

The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the primary health care provider? Select all that apply.

Could you please come assess the child as soon as possible?" 4. "I am concerned that the child is bleeding from the surgical sites." 5. "Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." 6. "Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy."

A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by performing which action?

Covering the bladder with a nonadhering plastic wrap

A mother of a child with cystic fibrosis asks the clinic nurse about the disease. How should the nurse respond to the mother about the disease?

Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands.

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

DTaP, Hib, IPV, pneumococcal vaccine (PCV)

The nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing which?

Decorticate posturing

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The primary health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse should expect which blood pressure readings in the child's legs and arms?

Decreased in the legs and increased in the arms

A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?

Decreased wheezing

The nurse of a well-baby clinic prepares to administer an immunization to a child. The mother of the child tells the nurse that the child has had a fever and is taking antibiotics. The nurse takes the child's temperature and notes that it is 101.5° F rectally. The nurse plans to take which action?

Delay the immunization.

The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, should alert the nurse to the early development of heart failure (HF)?

Diaphoresis during feeding

The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit information about the cause of this disease?

Did your child recently complain of a sore throat?"

A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which nursing intervention should be of highest priority?

Dipstick the urine for protein every 4 hours.

A mother of a child brings the child to a clinic and reports that the child has a fever and has developed a rash on the neck and trunk. Roseola is diagnosed, and the mother is concerned that her other children will contract the disease. Which instruction should the nurse reinforce to the mother to prevent the transmission of the disease?

Disease transmission is unknown

The nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger, and it returns to its original color in 2 seconds. Which action should be taken by the nurse?

Document the findings

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?

Drink a half a cup of orange juice before soccer practice.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse reinforce to prevent another crisis from occurring? Select all that apply.

Drink plenty of fluids. Report a sore throat immediately. Wash hands before meals and after playing.

The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the primary health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding?

Dysfunction in the cerebral hemisphere

The nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume based on which knowledge?

Each gram of diaper weight is equivalent to 1 mL of urine.

An adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse should instruct the adolescent to take which action?

Eat six graham crackers or drink a cup of orange juice before practice or game time.

An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse assisting in caring for the infant should ensure that which action is done to the gastrostomy tube?

Elevated

A child with a brain tumor returns from the recovery room following "debulking" of the tumor. The nurse assigned to care for the child monitors the child for brainstem involvement. Which sign would indicate that brainstem involvement occurred during the surgical procedure?

Elevated temperature

The nurse is assisting in developing a plan of care for a child diagnosed with acute glomerulonephritis. The nurse should include which intervention in the plan of care?

Encourage limited activity and provide safety measures.

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

The nurse is assisting with preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child?

Encourage the child to eat in the playroom.

A mother of a child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child has discomfort on the right side and that the acetaminophen is not very effective. Which is the best suggestion by the nurse?

Encourage the child to lie on the right side.

A 10-month-old child presents to the clinic with irritability, rubbing and pulling at the right ear, and a temperature of 102.4° F. The primary health care provider diagnoses the child with acute otitis media (OM) of the right ear, prescribes broad-spectrum antibiotics, and provides instructions to the parent, who verbalizes an understanding of the treatment plan. The parent later asks the nurse how to prevent future episodes of OM. Which instructions should the nurse reinforce in parent teaching? Select all that apply.

Ensure the child is not exposed to smoke. Have the child remain in a sitting position while awake. Consider avoiding individuals with upper respiratory infections.

A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion?

Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV).

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which sign as evidence of this disorder?

Evidence of soiled clothing

The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

Exercise intolerance

The nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flow meters. The nurse identifies which goal as appropriate for this child

Expresses feelings of mastery and competence with breathing devices

The nurse reinforces instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which should the nurse include in the instructions?

Feed the infant in an upright position."

The nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? Select all that apply.

Fever 2. Constipation 3. Failure to thrive Abdominal distention 6. Explosive, watery diarrhea

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? Select all that apply.

Fever Increased heart rate Change in the level of consciousness

A mother brings her 15-month-old child to the primary health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, the nurse might suspect that the child has which communicable disease?

Fifth disease

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching?

Fluid overload

The nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is appropriate?

Forty-eight hours after using the antibiotic ointment

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

Frequent hand washing is important. 2. The child should avoid exposure to other illnesses. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing level of consciousness

The nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse would expect which medication to be prescribed?

Furosemide

A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?

Gastric contents regurgitate back into the esophagus.

An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. Which initial nursing intervention is appropriate?

Give the child 6 oz of a regular cola drink.

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dL. Which is the appropriate intervention?

Give the child a glass of fruit juice.

Which interventions should the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.

Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do?

Give the child acetaminophen for the discomfort as per discharge instructions.

An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion? Refer to chart.

Glucose level at 2 am of 65 mg/dL

A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student should include which correct item in the discussion?

HIV virus attacks the immune system by destroying T lymphocytes.

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?

Has the child complained of a sore throat within the past few months?"

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

Has the child had a sore throat or a fever within the past 2 months?"

When checking a child's trochlear nerve function, the nurse should perform which data collection technique?

Have the child look down and in.

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother?

Have the child perform simple isometric exercises during this time.

A child has epistaxis. The nurse understands that which treatment is appropriate for epistaxis?

Have the child sit up and lean forward.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply.

Headache Red-brown urine 4. Periorbital edema

The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs?

Heart failure (HF)

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching?

I will give my child cough syrup if a cough develops."

The nurse is reinforcing discharge instructions to the mother of a child who needs eye drops in the left eye. Which statement by the mother indicates a need for further teaching?

I will give the medication directly on the eyeball.

The nurse is explaining causes and reasons of hemophilia A to the parents of a child with the disease. The nurse should make which statement about hemophilia A?

Hemophilia A results from deficiency of factor VIII."

The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?

Hiccupping and spitting up after a meal

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?

Hip joint laxity

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching?

I can apply lotion or powder to the incision if it is itchy."

A nurse discussing options with a mother of a child with cystic fibrosis (CF) asks if she understands the education. Which statement by the mother indicates a need for further teaching?

I can give my child whatever foods he likes to eat, since he gets enzymes anyway.

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness?

I can remove the harness to bathe my infant."

The nurse is reinforcing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further teaching?

I can use a warm mist humidifier to keep the secretions loose."

The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching?

I hear that the side effects of the medication that my child will be on can cause overeating."

Griseofulvin is prescribed for a child with tinea capitis. The nurse reinforces instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further teaching?

I need to administer the medication 2 hours before meals."

The nurse reinforces discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further teaching?

I need to be sure my child uses soft tissues to blow his nose."

The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?

I need to give frequent, small, nutritious meals if my child starts to vomit

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?

I need to provide a well-balanced, high-fat diet to my child.

The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching?

I need to shampoo my child's hair, apply the medication, leave it on for 10 minutes, and then rinse it out."

The nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further teaching?

I need to use a nipple with a small hole to prevent choking."

The nurse is reinforcing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication?

I need to wash the sites gently before I apply the medication."

The nurse has reinforced discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further teaching?

I should carry my child by straddling the child on my hip."

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching?

I understand I will need to have my baby on antibiotics for this pneumonia."

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

I will place a steam vaporizer in my child's bedroom.

The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching?

I'll let him decide when to return to his play activities."

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching?

If my child vomits after medication administration, I will repeat the dose."

A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which characteristic of this disease?

Increased reticulocyte count

The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child?

Prevent tension on the suture

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions should the nurse anticipate to be prescribed? Select all that apply.

Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications.

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which will be prescribed initially?

Insertion of a Foley catheter

The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which intervention in the plan of care?

Inspect the urine for the presence of hematuria at each voiding.

The nurse assists to create a nursing care plan for the child with an arm cast and should include which interventions in the plan? Select all that apply.

Instruct parents to keep the cast clean and dry. 2. Monitor the extremity for circulatory impairment. 3. Instruct the child not to stick objects down the cast. Notify the registered nurse (RN) immediately if circulatory impairment occurs.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply.

Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia

A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct?

Is a type of skin traction that pulls the hip and leg into extension

The nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child?

Is the child allergic to any antibiotics?"

Which criterion should the nurse determine are characteristics of scabies? Select all that apply.

It appears as burrows or fine, grayish-red lines. 3. It is transmitted by close personal contact with an infected person. 4. It is endemic among schoolchildren and institutionalized populations. Household members and contacts of the infected child need to be treated at the same time that the child is being treated

A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?

It involves only the anterior portions of the client's brain."

A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which information?

It is a congenital aganglionosis or megacolon.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease?

It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.

The nurse is teaching first aid measures to a group of adolescents about appropriate treatment for burns. The nurse should anticipate the need for further teaching when one of the adolescents makes which statement?

It is appropriate to place butter on the burn."

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation?

It is negative

A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which on the handout? Select all that apply.

It is transmitted as an autosomal recessive trait. 4. It is a disease that causes mucous formation to be abnormally thick. 5. It is a chronic multisystem disorder affecting the exocrine glands.

The nurse is assisting with collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching?

Our child sleeps in our bedroom at night."

A child seen in the clinic is found to have rubeola (measles) and the mother asks the nurse how to care for the child. Which instruction should the nurse provide to the mother?

Keep the child in a room with dim lights.

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question?

Keep the head of the bed elevated 45 degrees.

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and should avoid which action?

Keeping the child uncovered to assist in reducing the fever

A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. Which is the appropriate nursing action?

Let the mother hold the child and direct a cool mist over the child's face.

The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation

Level of consciousness

The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse monitors the child for central nervous system (CNS) involvement by checking which response?

Level of consciousness (LOC)

The nurse is assisting a school-age client with type 1 diabetes to follow an appropriate diet. Which recommendations should the nurse make for this client? Select all that apply.

Limit concentrated sweets. Consume snacks between meals and at bedtime. 4. Plan to eat a larger snack during active times of the day.

the nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?

Maintain moisture of the normal saline dressing on the gibbus area.

The nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which components should be included in the plan of care? Select all that apply.

Maintain the bed in a low position. Pad the side rails of the bed with blankets. 4. Place the child in a side-lying lateral position if a seizure occurs. 5. Protect the child's head, body, and extremities if a seizure occurs.

The nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings should the nurse expect to note if JIA were present? Select all that apply.

Malaise, fatigue, and lethargy 2. Painful, stiff, and swollen joints 3. Limited range of motion of the joints History of late afternoon temperature, with temperature spiking up to 105° F

A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research?

Males inherit hemophilia from their fathers.

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?

Maximize the child's assets and minimize the limitations.

The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which acid-base disorder would the nurse expect to note in the infant?

Metabolic alkalosis

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as which level of dehydration?

Moderate dehydration

A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse reinforces instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further teaching?

My child will need to be treated with oral antibiotics."

A 3-year-old child has returned to his room following a tonsillectomy. Which finding needs immediate notification of the registered nurse?

Nasal flaring and rib retractions

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?

Nausea

The nurse assists with developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis?

Neurological dysfunction

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the registered nurse and pediatrician regarding necessary follow-up because this infection can be associated with which finding?

Possible sexual abuse

The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which should be a component of the instructions that the nurse reinforces to the mother?

No live virus vaccines should be administered to the child.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Normal saline infusion

A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?

Notify the registered nurse of the finding

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

Notify the registered nurse.

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?

Notify the registered nurse.

The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?

Nuchal rigidity

The nurse has reinforced dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the dietary instructions if she indicates eliminating which products? Select all that apply.

Oatmeal 5. Rye crackers 6. Wheat bread

The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the primary health care provider? Select all that apply.

Observe for bleeding. 2. Encourage the child to rest. Assist the registered nurse (RN) with blood transfusions.

The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?

Obtain a blood glucose reading.

A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. Which should be the nurse's initial action?

Obtain a complete history of the child's feeding habits.

A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the primary health care provider's prescription should the nurse question?

Obtain a throat culture.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time?

On his or her left side

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply.

Our child will eventually grow out of this condition It is not necessary to avoid individuals with the common cold.

The nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which information in the conference?

PKU results in central nervous system (CNS) damage.

The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should instruct the mother to do which?

Pad crib rails and table corners.

A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?

Pain

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents?

Pain

In planning care for a child with contact dermatitis, which concern is the highest priority for the child?

Pain

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan?

Palpate the abdomen for a mass.

A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which interventions should the nurse include in the plan of care?

Perform oral hygiene four times a day.

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition?

Peripheral hypoxia

The nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the primary health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which should the nurse expect to note in the child?

Petechiae spots located on the palate

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.

Prepare to administer glucagon subcutaneously if unconsciousness occurs. Give the child a teaspoon of honey.

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first?

Place the child in a knee-chest position.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply.

Place the child on a low-bacteria diet. 3. Change dressings using sterile technique. Perform meticulous hand washing before caring for the child.

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take?

Place the infant in a knee-chest position.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply.

Place the infant in a private room. 2. Place the infant in a room near the nurses' station.

A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chicken pox (varicella). The nurse should take which action to provide safety for all children on the unit?

Place the infected child and any immunocompromised children in isolation.

A primary health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse reinforces instructions to the mother to use which procedure for eye patching?

Place the patch on the left eye

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?

Placing the bed linens on the traction ropes

The nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?

Platelet count

A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. Which should the nurse relay to the mother about primary nocturnal enuresis?

Primary nocturnal enuresis is common, and most children will outgrow bed-wetting without therapeutic intervention.

The nurse reviews the record of a 1-year-old child seen in the clinic and notes that the primary health care provider has documented a diagnosis of celiac crisis. Which symptom should the nurse expect to note in this condition?

Profuse, watery diarrhea

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record?

Projectile vomiting

The nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which intervention is the priority for the child?

Promoting bed rest

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?

Prone

The nurse is assigned to care for a child with hypertrophic pyloric stenosis scheduled for a pyloromyotomy. In which position should the nurse place the child during the preoperative period?

Prone with the head of the bed elevated

The nurse is reviewing the record of a child admitted to the hospital with nephrotic syndrome. Which finding should the nurse expect to note documented in the record?

Proteinuria

A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should include which intervention in the plan?

Provide a quiet atmosphere with dimmed lighting

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply.

Provide adequate nutrition. 2. Restrict fluids, as prescribed. 3. Institute measures to prevent infection. Administer blood products to treat severe anemia. 6. Anticipate the child will have central nervous system involvement.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The parent of the child asks the nurse why the child needs the medication. The nurse correctly responds that the purpose of this medication is which explanation?

Provides adequate oxygen saturation and maintains cardiac output

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which should be included in the plan?

Pull the earlobe down and back before instilling the eardrops.

Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews the laboratory results, knowing that which finding indicates this type of anemia?

RBCs that are microcytic and hypochromic

The nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. Which action should the nurse take?

Reassure the child that this is a temporary condition.

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

Rectal

A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which is associated with this type of cancer?

Reed-Sternberg cells are found on biopsy

The nurse in a primary health care provider's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which instruction should the nurse reinforce to the mother?

Remove the stinger by carefully scraping it out horizontally.

A male child who had surgery to correct hypospadias is seen in a primary health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias?

Renal anomalies

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?

Respiratory disease caused by a virus involving the parotid gland

The nurse is monitoring a child following a tonsillectomy. Which finding would indicate that the child is bleeding?

Restlessness

A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?

Reticulocyte count

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet?

Rice

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

The nurse is developing a plan of care for a child with autism. The nurse should identify which priority problem for this child?

Risk for injury

A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which information in the discussion during the conference?

SIDS usually occurs during sleep and is more common in premature infants.

The nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure which need is met?

Safety with activities

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions should the nurse provide to the mother?

The cast needs to be kept dry because when wet it will begin to disintegrate."

The nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?

Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.

The nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that which are the primary signs/symptoms of meningitis?

Severe headache and neck stiffness

The pediatric nursing instructor asks a nursing student to describe the cause of the symptoms that occur in sickle cell disease. Which is the correct response by the nursing student?

Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow.

The nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room?

Side-lying

The nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests which position for the infant?

Side-lying position

The nurse reviews the plan of care for a child with Reye's syndrome. Which priority complication should the nurse plan to monitor?

Signs of increased intracranial pressure

The nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which immediate problem as the priority for the infant?

Skin disruption

The nurse and a mother are discussing care of her child's iron deficiency anemia. The nurse should suggest including which foods in the child's diet that are highest in iron? Select all that apply.

Spinach 2. Apricots 3. Raisins

The nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. How should the nurse plan to administer the vaccine?

Subcutaneously in the outer aspect of the upper arm

A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question?

Suction via the nasotracheal route as needed.

A camp nurse is reinforcing instructions to the parents of the children who are attending a daytime camp for the summer. The nurse instructs the parents to check their child daily for the presence of tick bites and tells the parents that if a tick is found to do which action first?

Suffocate the tick with a substance such as nail polish.

A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which component of the treatment plan should the nurse anticipate?

Supportive treatment

A child has been diagnosed with bacterial conjunctivitis. Which clinical manifestations of bacterial conjunctivitis should the nurse expect to note? Select all that apply.

Swollen lids 4. Inflamed conjunctiva Crusting on eyelids, especially in the morning

The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child?

Tachycardia

The nurse teaches a child with cystic fibrosis how to perform the "huff" maneuver. Which instructions should the nurse tell the child?

Take a deep breath and then exhale rapidly, whispering the word huff.

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Take temperature measurements rectally. 4. Start clear liquid diet after 8 hours postoperative.

A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately?

Temperature 100.9° F

When checking a child's glossopharyngeal nerve function, the nurse should perform which data collection technique?

Test sense of sour or bitter taste on the posterior segment of the tongue.

A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. Following x-ray examination, it has been determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates a need for further teaching?

The cast will feel warm when it is dried."

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease?

The child does not experience pain at the primary tumor site."

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse about radiation therapy because it was not prescribed as a part of treatment. Which is the most appropriate response to the mother?

The child is too young to have radiation therapy.

The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation should the nurse expect to make during data collection of the child?

The child sleeps unless aroused and, once aroused, interacts poorly with the environment.

A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, which information does the nurse plan to give to the parents of the child?

The child will need to be hospitalized for observation.

The nurse is reinforcing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother?

The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?

The child's cervical spine

The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction should the nurse give the mother?

The child's towels and washcloths should not be used by other members of the household

A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?

The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.

The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome?

The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G)

The nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which are characteristics of this illness? Select all that apply.

The cough is harsh and metallic. 2. Inspiratory stridor may be present. 3. Symptoms usually worsen at night and are better during the day. It is usually preceded by several days of upper respiratory infection symptoms.

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examination?

The dislocated femoral head pops back into the acetabulum

The nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which statement should the nurse make to the mother?

The fluid retention should be controlled by medication and diet."

The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement should the nurse include in the instructions? Select all that apply.

The foot should be kept elevated for the first 24 to 48 hours. Reposition the infant every 2 to 4 hours until cast is thoroughly dried." 5. "The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."

The nurse reinforces instructions regarding the use of permethrin 1% to the parents of a child who has been diagnosed with pediculosis capitis. Which statements by the parents indicate they understand the instructions? Select all that apply.

The hair should not be shampooed for 24 hours after treatment." 3. "The medication can be obtained over the counter in a local pharmacy. The medication is applied to the hair after shampooing, left on for 5 to 10 minutes, and then rinsed out.

The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?

The harness needs to be removed to check the skin and for bathing.

The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed?

The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier."

A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder?

The infrequent and difficult passage of dry stools

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching?

The mother administered the iron with milk.

A 1-year-old child is seen in the primary health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?

The mother states the child had purulent discharge from the ear last night.

The nurse is checking the status of jaundice in a child with hepatitis. Which location should the nurse check to ascertain if the child is jaundiced?

The mucous membranes

The nurse is reinforcing the teaching of parents of a diabetic child on the differences between type 1 and type 2 diabetes mellitus. Which statements by the parents indicate understanding of the teaching? Select all that apply.

The onset of diabetes is sudden with type 1." Type 2 diabetes can often be managed with diet only. "Three symptoms of type 1 diabetes are polyuria, polydipsia and polyphagia."

An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which indicates to the nurse that the parents need further teaching about the care of their HIV-positive infant?

The parents plan to use rice cereal to help with watery stools when they occur.

A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Several diagnostic studies are performed to determine the presence of this disease. When evaluating the diagnostic results, the nurse should expect to note which evidence if this child has Hodgkin's disease?

The presence of Reed-Sternberg cells

A child is scheduled for a tonsillectomy. Which should present the highest risk of aspiration during surgery?

The presence of loose teeth

The parents of a child with sickle cell disease ask the nurse why their child is always anemic. What is the best response by the nurse?

The sickle cells are very fragile and break easily, which leads to anemia."

The nursing instructor assigns a student nurse to present a clinical conference to the student group about brain tumors in children. Which statement by the student is accurate about brain tumors in children?

The significant symptoms are headaches and morning vomiting.

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?

The symptoms increase in severity after the rash appears.

The nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?

The synthetic cast allows for greater mobility than a plaster cast.

The nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, which instruction should the nurse provide the mother?

Thicken the feedings by adding rice cereal to the formula.

A 13-year-old child is diagnosed with osteogenic sarcoma of the femur. Following a course of chemotherapy, it is decided that leg amputation is necessary. Following the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which statement made by the nurse will best assist in alleviating the child's fear?

This aching and cramping are normal and temporary and will subside."

The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made?

This brace will correct my curve."

A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need for further research of this disorder?

This disease is twice as likely to occur in boys as in girls.

The nurse should implement which actions in the care of a child who is having a seizure? Select all that apply.

Time the seizure. Stay with the child Loosen clothing around the child's neck.

A parent calls the clinic nurse to schedule an appointment for her child's diphtheria, tetanus, and pertussis vaccination. The parent tells the nurse that her child had a swelling at the injection site and low-grade fever after the last diphtheria, tetanus, and pertussis (DTaP) vaccination. Which instructions should the nurse give to the parent to lessen this type of reaction to the upcoming vaccination?

To administer an appropriate dose of Tylenol 45 minutes before the appointment

The nurse is observing a nursing student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes which intention?

To apply continuous suction when inserting the catheter

The nurse receives a call from the mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse should give which response?

Touch the object gently with a moistened sterile cotton swab, and lift it out.

The nurse is reinforcing instructions regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which points should the nurse include in the session? Select all that apply.

Tuck pant legs into socks. 2. Wear closed shoes when hiking. 3. Apply insect repellent containing DEET. 4. Cover the ground with a blanket when sitting.

The nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?

Urinary output is increased.

A primary health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child should check which highest priority item before administration of the potassium?

Urine output

The nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?

Using pillows to elevate the head and shoulders

The nurse is attempting to ensure the parent is able to safely administer the prescribed ear drops to the 2-year-old client at home. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. Have the child lie on his or her back with the affected ear facing u Straighten the ear canal by pulling the pinna of the affected ear down and back. Slowly instill the number of drops prescribed by the primary health care provider into the ear. Massage the area anterior to the ear to facilitate entry of the drops.. Keep the child in the same position for 2 to 3 minutes.

Antibiotics are prescribed for a child and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement made by a parent would indicate that the instructions were understood?

We will administer the antibiotics until they are gone."

The nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand these measures if they make which statement?

We will provide comfort measures to reduce any crying periods by our child."

A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?

Weighing the diapers

The nurse reinforces home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further teaching?

When I'm feeling better, I'm returning to the soccer team."

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child?

When drawing blood for electrolyte levels

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

When picking up your infant, support the infant's neck and head with the open palm of your hand."

The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms should be noted in determining this finding? Select all that apply.

oliguria Slightly sunken fontanels 5. Very dry, mucous membranes

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?

White sacs attached to the hair shafts in the occipital area

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position?

With the head and chest at a 30-degree angle, with the neck slightly extended

The nurse is preparing to administer digoxin to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication

The nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the priority in the plan of care?

Wound care

The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be appropriate? Select all that apply.

You feel like there's nothing else you can do to cure your acne. You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."

A client has been prescribed valproic acid for the treatment of generalized seizures, and the nurse reinforces instructions to the child about the potential side effects of the medication. Which statement by the client would indicate a need for further teaching?

i am so glad that I won't lose any of my hair. I was worried what my friends would think."

A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which is a characteristic of this disorder?

invagination of a section of the intestine into the distal bowel

A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. To meet these goals, which action should the nurse take when working with the child?

place the child on a wheeled scooter board.

A child with croup is being discharged from the hospital. The nurse reinforces home care instructions to the mother and advises the mother to bring the child to the emergency department if the child develops which symptom?

stridor

The nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. Which supplement should the nurse give the child to treat the reaction?

½ cup of fruit juice