Pediatric Midterm Redo
When assessing an infant's chest the nurse notes the chest is enlarged on one side. What information is most important to obtain from the family about this finding?
"Has the baby been treated for any health problems?" An infant with a diaphragmatic hernia (intestine herniated into the chest cavity) may have a chest that is enlarged on that side.
The parent of an 8-year-old child requests information from the nurse on proper nutrition for his child. Which is the best statement by the nurse? Calcium Calories Carbs Protein Fat
"An 8-year-old needs 800 to 1,000 mg of calcium daily. will need about 1,400 to 1,600 calories a day. Of these calories, 45% to 65% should come from carbohydrates, 10% to 30% from protein, and 25% to 35% from fat.
Viral Meningitis
(Aseptic) Inflammation of the brain and spinal cord Symptoms: High pitched cry* Seizure Bulging Fontanel Vomit and Fever Photophobia Rash CSF (viral): Clear with negative gram stain Treatment: Acetaminophen for discomfort, HiB and PCV vaccine, seizure precaution, droplet precaution
pyloric stenosis s/s
-olive size mass in RUQ (moveable/firm) -projectile vomiting!** right after feeding - otherwise seems happy/healthy could lead to: -dehydration & metabolic acidosis
A 13-year-old girl has grown rapidly in height over the past 2 years and is taller than most of the boys in class. The girl wonders when the growing will stop. What should the nurse tell the girl as a general guideline for the ages at which most girls stop growing?
16-17 years old
A nurse is assessing an 11-year-old girl. During the assessment, the nurse notices that the girl's breasts have begun to develop. Based on an understanding of adolescent growth and development, the nurse would anticipate that the girl would most likely begin to menstruate within which time period?
2 years
The nurse is collecting data from the mother of a 3-year-old child. What should that child be able to do?
A 3-year-old child should have the ability to copy a circle
rheumatic fever
A bacterial infection that can be carried in the blood to the joints S/S: History of strep (within 2-6 weeks) Chest pain, tachy, murmur** Nontender SubQ nodules on joints** Large painful joints** Rash on trunk** Chorea** Fever
rheumatic fever signs and symptoms
A bacterial infection that can be carried in the blood to the joints systolic murmur, involuntary limb movement, macular rash on the trunk, tender swollen joints, and PALPABLE subcutaneous nodules.
Signs of coarctation of the aorta
A moderately loud systolic murmur at the base of the heart Blood pressure that is significantly higher in the arms than in the legs
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse would place the infant in which room?
A private room near the nurses' station
The school nurse is teaching parents about the effects of bullying on school children. What accurately describes this developmental concern?
Both boys and girls are bullied; boys usually bully boys and use force more often.
A nurse is providing care for a 3-month-old infant diagnosed with bronchiolitis. Which client goal should the nurse prioritize?
Adventitious lung sounds are decreased.
The nurse is providing anticipatory guidance to the parent of a 9-monthold infant during a well-baby visit. Which topic would be most appropriate?
Advising how to create a toddler-safe home
The emergency department nurse is caring for a client with cystic fibrosis who is dyspneic and has a productive cough. Place in order the nursing interventions performed upon arrival to improve breathing Place on oxygen at 2 liters Obtain oxygen saturation reading Place in bed in a semi-Fowler position Instruct on energy conservation measures Assess respiratory status Notify respiratory therapy.
Assess, Place semi fowler, get O2 reading, give oxygen, conserve and teach, then call resp therapy
7 month motor skills
Bears full weight on feet Sits, leaning forward on both hands Moves object from hand to hand
A nurse is reading a journal article about adolescents and major causes of injuries in this age group. The nurse demonstrates understanding of this information by identifying which situation as the major cause of adolescent injuries?
Car Accidents
10 month motor skills
Changes from prone to sitting Grasps rattle by handle
A 15-year-old adolescent admitted for asthma exacerbation is nearing discharge and is requesting to take a shower. The client has had the oxygen discontinued and the continuous pulse oximeter changed to a pulse oximeter completed with vital signs only. A capped intravenous (IV) catheter remains in the client's dominant hand. Which nursing action is most appropriate?
Check the medication administration schedule for upcoming medications.
Parents of an 8-year-old child ask the nurse when they can stop using the booster seat in the car for their child. When responding to the parents, the nurse needs to keep in mind which of the following? Select all that apply.
Child has to be 4ft 9in 8-12 years old
The school-age child develops the ability to recognize that if a block of clay is in a round ball and then is flattened, the shape changes but not the amount of clay. This child has developed an understanding of which of the following?
Conservation
An anxious 12-year-old child receives an injection from the nurse and sighs with relief when it is done. After a moment of reflection, the girl asks the nurse, "Is it hard to give someone an injection?" This child's question is evidence that the child has developed which cognitive skill? conservation accommodation decentering class inclusion
Decentering
A nurse assesses a child experiencing separation anxiety. The nurse understands that the child has a higher likelihood of experiencing long-term effects at which stage? Despair, protest, or denial
Denial Children who progress to denial suffer long-term impaired parental relationships and impaired trust, which can lead to problems in establishing close relationships, attention deficits, self-centeredness, and decreased intellectual functioning.
The nurse is caring for a 7-year-old child who will be in the hospital for several weeks. Which action by the nurse will facilitate the child's psychosocial development?
Encourage the child to complete school work and provide guidance.
A parent of a 2-year-old toddler is concerned that the toddler has a hearing deficit because the toddler does not interact with others. After further testing, a diagnosis of hearing loss is confirmed. Which nursing instruction will be beneficial?
Enroll the toddler in early preschool education with others of the same age. These children often benefit from very early preschool education programs, which expose them to interesting and stimulating tasks while their initiative is strongest.
The adolescent with sickle cell disease has been discharged from the hospital and has a need to increase fluid intake daily. What method of instruction would be most effective for the nurse to help the adolescent be compliant with increasing fluid intake?
Establish a contract.
2 month motor skills
Holds hand open Lifts head off mattress
The nurse has just completed an assessment on a child who voices an interest in how things are made and who needs support when they are not successful. The child further reports being involved in clubs and sports outside the home. The nurse is aware that this child is in which of Erikson's states of development?
Industry vs Inferiority
After teaching a group of nursing students about developmental milestones for children, between ages 1 and 4 years, the instructor determines that the teaching was successful when the students identify which of the following as a gross motor developmental milestone that occurs between 2 to 3 years of age?
Jumping in place
If a child in daycare suddenly has a personality change, what can be suspected?
Neglect or abuse has occurred.
Pulse Newborn - School Age
Newborn: 110-160 Infant: 90-160 Toddler: 80-140 Preschool: 70-120 School Age: 60-110
The nurse is observing a 6-month-old boy for developmental progress. For which typical milestone should the nurse look?
Puts down a little ball to pick up a stuffed toy.
The nurse is assessing a child with suspected infective endocarditis. Which assessment finding would the nurse interpret as a sign of extracardiac emboli? - delayed capillary refill - Roth spots - pruritus - erythema marginatum
ROTH SPOTS
iron deficiency anemia
Signs and Symptoms: Decreased Iron and Hgb Tachycardia Pallor, fatigue, weak Brittle spoon nails Craving for ice, dirt, paper* Nursing Care: Increase vitC (OJ), increase iron, limit formula to 32oz Iron Supplement: 1hr before, or 2 hours after meal, stool will be green, will stain teeth.
12 month motor skills
Sits down from standing without help Walks with one hand held Attempts 2 block towers (fails) Can turn many pages in book at one time
Which developmental milestone would the nurse expect an 11-month-old infant to have achieved? Sitting independently Turning a doorknob Building a tower of four cubes Walking independently
Sitting independently
The nurse is collecting information from a 14-year-old adolescent who was brought to the clinic for a well-child visit by the parent. Which techniques would be most beneficial in this process?
Speak directly to the adolescent when making inquiries. Sit down facing the adolescent during the data collection period. Parents stay in room during physical assessment
The nurse has completed an education program on normal communication abilities in the preschool-age child. What should a 5 year old be able to do??
State his name and address
1 month motor skills
Strong Grasp Has head lag
The parent of a 1-month-old infant voices concern about the infant's respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?
The respirations of a 1-month-old infant are normally irregular and periodically pause.
When considering the psychosocial development of a school-aged child, which is the primary developmental task?
establishing a social network
Which intervention would be the most important for the nurse to include in the plan of care for a child with infectious mononucleosis?
moving the child carefully Due to risk of rupturing the spleen
The nurse is teaching a growth and development class to parents of school-age children. What does the nurse teach the parents about the cognitive abilities of their children?
o Class (they can classify objects, objects can belong to more than one classification) o Decenter (They can project themselves into other people's situations) o Accommodate (there can be more than one reason for someone's actions)
A parent and 4-year-old child are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the child doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?
opening drawers in the room, pulling out supplies, and examining them 4 year old like to explore
Which of the following do children over the age of 4 identify as tremendous fears related to hospitalization? Select all that apply
pain discomfort
An infant is hospitalized with a diagnosis of bronchiolitis. What nursing intervention(s) will the nurse perform in this infant's care?
pulse oximetry monitoring fluid replacement oxygen therapy Suction No bronchodilators
The nurse is completing a respiratory assessment hourly. Which assessment finding is of most concern?
quiet chest on auscultation A quiet chest occurs with significantly diminished or absent breath sounds caused when the alveoli are so filled with fluid that little or no air can enter them.
In providing anticipatory guidance related to choking hazards for infants, what items should the nurse include in the teaching?
raw carrots plastic bag propping a bottle
6 month motor skills
rolls from back to front holds bottle
An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent would indicate to the nurse that additional teaching should be done?
"I always keep phenobarbital with me in case of a fever." PHENOBARBITAL = seizure med, not for FEVER
A nurse is providing postoperative care for a newborn diagnosed with hydrocephalus. Which intervention should the nurse include in the plan of care?
Monitor for signs of peritonitis. Daily head circumference Position on nonoperative side
Croup
Most common child respirtatory infection S/S: barking cough, increases at night, stridor Care: Humid O2, racemic epinephrin, Dexamethasone (corticosteroid)
A nurse is preparing a presentation for a group of parents of toddlers and preschoolers. When describing the developmental milestones for this age group, the nurse would include which of the following as typical of a 2-year-old child? How many teeth?
The child has 16 temporary teeth
The nurse is caring for a 2-month-old infant with a cleft palate. The infant will undergo corrective surgery at age 3 months. The parent would like to continue breastfeeding the infant after surgery and wonders if it is possible. How should the nurse respond?
"Breastfeeding is likely to be possible, but check with the surgeon."
The nurse is discussing language development with the parent of a 20-month-old toddler. To accurately assess the toddler's language development, which question would the nurse ask the parent?
"Do they understand "no"?
The parents of an 8-month-old infant voice concern to the nurse that their infant is not developing motor skills as the infant should. What question would be appropriate for the nurse to ask in determining if their fears are warranted? "Does the infant move a toy back and forth from one hand to the other?" "Is the infant able to drink with a cup by oneself?" "Is the infant able to hold a pencil and scribble on paper?" "Does the infant place toys into a box or container and take them out?"
"Does the infant move a toy back and forth from one hand to the other?"
The pediatric nurse is assessing a 6-month-old infant for a well-child exam. Which question(s) directed to the client's mother best assesses the infant's development? Select all that apply.
"Has your baby rolled over?" "Can your baby sit up without assistance?"
When caring for children with respiratory issues in relationship to the anatomy and physiology of the child's respiratory system, it is important to recognize which of the following? (size of trach)
The diameter of the child's trachea is about the size of the child's little finger.
The school nurse is teaching a group of 7-year-olds about proper dental hygiene. Which statement made by a 7-year-old indicates a good understanding of dental hygiene? Select all that apply.
"I will brush my teeth twice daily." "It's OK if I eat candy if I brush my teeth good." "I will drink water with fluoride for strong teeth." Visit the dentist every 6 months
A parent calls the hospital nursing hotline and asks, "My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?" What should the nurse's response be to this parent?
"Let me ask you some more questions to see if there are symptoms of colic."
Kawasaki disease
"Lymph node syndrome" 3 phases: acute, subacute and convalescent (6-8 weeks) S/S: Strawberry tongue (inflammation of blood vessles) Cardiac Manifestations Unresponsive Fever Swollen hands and feet Rash Joint Pain Decreased Hemoglobin Nursing Care: Aspirin, IV Gamma Globulin
The nurse is reinforcing teaching with a group of caregivers related to the nutritional needs of the infant. One caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?
"Milk will not fully provide the infant's needs for iron, which is found in solid foods."
The nurse is providing anticipatory guidance to a 12-year-old client and parent regarding psychosocial, cognitive and moral development. Which statement by the parent demonstrates understanding?
"My child will tend to think of oneself as the center of everyone's attention." importance on conformity to peer norms and peer acceptance children would be asking broad, unanswerable questions, such as what is the meaning of life.
A nurse is educating the parents of a toddler diagnosed with spasmodic laryngitis. Which statement made by the parents indicates that the teaching was effective?
"Our child's symptoms will likely resolve with minimal intervention."
The parent of a 12-year-old with Reye syndrome approaches the nurse wanting to know how this happened to the child, saying, "I never give my kids aspirin!" Which response by the nurse would be most appropriate?
"Sometimes it is hard to tell if a product contains aspirin."
The nurse is assessing a 6-month-old infant. The parent asks when the soft area in the infant's head will go away. What is the best response by the nurse?
"The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age."
A parent with a child who has cystic fibrosis asks the nurse how to determine if the child is receiving an adequate amount of pancreatic enzymes. How should the nurse respond? Select all that apply.
"The dose is adequate when your child is only having 1 to 2 stools per day." "The dose is adequate when your child's weight is improving." "When your child starts to eat more quantities of food you will need to adjust the amount of enzyme pills."
The caregiver of 7-month-old twins tells the nurse that she has noticed that both of her children enjoy playing with a toy by moving the object back and forth between their hands over and over again. Which statement made by the nurse most accurately explains this behavior?
"This is one of the ways that infants develop their fine motor skills."
During an admission assessment the nurse is discussing the developmental level of the child with the parents. Which comments by the parents demonstrate a good understanding of developmental expectations of the preschool-aged child?
"We think it is important to have play dates with our friend's preschool children. "Our child attends a wonderful preschool 3 times per week." "We have been talking about enrolling in a morning preschool program since this is our only child."
The parents of a 4-day-old infant report concern about his weight loss. What is the best response by the nurse?
"With appropriate nutrition weight gain will commence with a return to the birth weight within 2 weeks."
During a well-child checkup, the parent of a 5-year-old child reports the child seems much smaller than the 2 older siblings did at this same age. A review of the medical record reveals that the child is 44 inches tall and weighs 42 pounds. What information should be included in the response by the nurse? "The weight of your child at this time is with normal limits for this age but the child is moderately taller than other children this age." "Your child is within the acceptable range for height but the child is significantly smaller in weight for this age." "Your child is within normal limits for weight but the child is slightly shorter in stature than other children this age." "Your child is slightly taller than other children this age but the child's weight is normal."
"Your child is slightly taller than other children this age but the child's weight is normal." Avg 4yr old is 40lb, 40inch
The nurse is caring for a 9-year-old male child who is being seen for a well-child care visit. During the visit, the child's parent reports the child is one of the shorter children in his class. The parent asks how much more the child will grow in the next few years. Which response by the nurse is appropriate?
"Your child should grow approximately 10 in (25 cm) over the next 4 years." From 6 to 12 years of age, children grow an average of 2.5 in (6 to 7 cm) per year, increasing their height by at least 1 ft (30 cm).
Bacterial Meningitis
(Septic) Inflammation of the brain and spinal cord Symptoms: High pitched cry* Seizure Bulging Fontanel Vomit and Fever Photophobia Rash (bleeding under skin) ** indicated sepsis CSF (Bacterial): Cloudy, Increased WBC and protein Treatment: Acetaminophen for discomfort, HiB and PCV vaccine, seizure precaution, antibiotics and dexamethazone for ICP
After teaching a group of parents about ensuring safety for their children, the nurse determines that the teaching was successful when the parents identify which of the following as appropriate? Select all that apply.
- applying sunscreen before the child goes out to play - making sure all pan handles are turned to the back of the stove
A child has been admitted to the inpatient unit to rule out acute Kawasaki disease. A series of laboratory tests have been ordered. Which findings are consistent with this disease?
-Reduced hemoglobin levels -Elevated erythrocyte sedimentation rate (ESR)
The nurse is assessing the apical pulse of a 4-year-old child. The nurse would place the stethoscope at which locations? Select all that apply.
4th intercostal space Midclavicular line
A nurse is working with the local community on promoting physical fitness for children. The nurse encourages the community to develop programs that meet the needs of the school-aged child for physical activity, based on the understanding that this age group requires how much physical activity daily?
60 minutes
The nurse is conducting a physical assessment on a 2-year-old. What steps are important for the nurse to incorporate in this examination?
Allow play with the equipment being used. Have parents remove the clothing. Stand on the scale for height and weight.
The parents of a preschooler are preparing the child to meet all developmental tasks. Which activity best fits at this time?
Allow the preschooler to experiment with Play-Doh. Preschoolers enjoy toys or material that they can manipulate (free-form play) because this helps them learn how things work.
The nurse is assessing if a 20-month-old child is in Piaget's sensorimotor stage of cognitive development. Which observed behavior(s) confirms that the infant has met this developmental stage? The child is imitating others' actions when they are not around. The child is playing school with Bobby, an imaginary friend. The child offers a toy to make a friend feel better. Although it has been 10 minutes, the child states playing with the toy for hours. The child is following instructions on building with legos literally.
Although it has been 10 minutes, the child states playing with the toy for hours. The child is playing school with Bobby, an imaginary friend. The child offers a toy to make a friend feel better.
While assessing a 6-month-old, the nurse notes the posterior fontanel (fontanelle) is open. What action should the nurse take next?
Assess the anterior fontanel (fontanelle). The posterior fontanel should be closed by the end of 2 months. The anterior fontanel (fontanelle) closes by 12 to 18 months. Neither fontanel (fontanelle) should be palpable after these times. The closing of the fontanel (fontanelle) too early or too late can indicate decreased or increased brain or ventricle growth and is therefore a serious finding. After assessing the posterior fontanel (fontanelle) the nurse should then assess the anterior fontanel (fontanelle).
Which assessment findings of the speech of a 5-year-old child warrant further follow-up? It is difficult for people outside of the household to understand the conversation. The child is able to articulate the child's full name. The child is able to count to 15 without prompting. The child is unable to provide the child's address when asked. The child has a vocabulary of an estimated 1,200 words.
Child should know address people should understand them in convo Child should know 2500 words
A child diagnosed with a ventricular septal defect (VSD) is seen in the clinic. The nurse conducts an assessment and reviews the child's recent laboratory results. The nurse suspects the child may have developed heart failure. Which finding is the best indicator of the nurse's suspicion?
Crackles in the lungs
9 month motor skills
Creeps on hands and knees Pulls to standing Pincer grasp more precise
A nurse is conducting a presentation for a community parent group about respiratory conditions in children. The nurse determines that the teaching was successful when the group identifies which as one of the most common conditions seen during early childhood?
Croup
During a routine physical examination of a 13-year-old female the nurse notes the presence of a tender nodule just below the nipple on the right breast. Which action by the nurse is indicated?
Document This finding is normal This is a "breast bud" which is first stage of breast growth
A 6-week-old infant is being assessed for vision acuity. What questions should the nurse ask the parents to ascertain adequate vision? Select all that apply.
Does the baby follow you with her eyes? Do the parents have any concerns? Can the baby focus on a moving object?
Which type of play would the nurse use to prepare a preschool-age child for upcoming surgery to reduce the stress of the event?
Dramatic play (acting out whats going to happen, playing with instruments)
An 8-year-old child is diagnosed with Reye syndrome and laboratory tests are obtained and the results recorded. After reviewing the results, the nurse identifies which result(s) as supporting the diagnosis?
Elevated alanine aminotransferase (ALT) aspartate aminotransferase (AST) ammonia
The nurse is caring for a chronically ill adolescent client. What can the nurse do to maintain stimulation and support the client's sense of identity while hospitalized?
Encourage communicating with friends through social media.
The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action? respiratory rate of 20 breaths per minute heart rate of 89 beats per minute heart rate of 120 beats per minute respiratory rate of 24 breaths per minute
Heart rate of 120 or above
An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this client? increased temperature and decreased respiratory rate decreased level of consciousness and increased respiratory rate increased pulse rate and decreased blood pressure numbness of fingers and decreased temperature
Increased temperature and decreased respiratory rate
An 8-year-old boy, who says he wants to be a doctor when he grows up, pleads with the nurse to let him put on his own band-aid after receiving an injection. The nurse agrees and watches as the boy very carefully lines the band-aid up with the mark left by the injection and applies it to his skin. Then, he asks, "did I do it right?" and waits eagerly for the nurse's feedback. The nurse recognizes in this situation the boy's attempt to master the primary developmental step of school age, which is what?
Industry
Which would be a nutritional goal for a preschool-aged child? Reduce messiness and spills. Introduce new food gradually and include variety. Eat everything on the plate. Let the child eat only what the child wants.
Introduce new food gradually and include variety.
An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?
It will determine if heart is enlarged
Hirschsprung disease
Lack of ganglion decrease motility and result in obstruction Symptoms/Signs: Absent ganglion cells (do a biopsy to confirm) Distention Palpable Fecal Mass Foul Smelling ribbon stool Nursing Care: Increase protein and calories Decrease fiber
The nurse is completing a care plan for a preschool-age child with the nursing diagnosis of Imbalanced nutrition, less than body requirements. Which interventions should the nurse include? Select all that apply. How much milk, meals and juice?
Limit milk to 16 to 24 ounces per day. Provide at least 3 meals and 2 healthy snacks per day. Weigh child weekly on the same scales at home Juice should be limited to 4 to 6 ounces daily. Feeding the child on a similar schedule
The nurse is providing a class for a group of girls. When discussing the changes surrounding puberty, what information should be included? Select all that apply. (when does menstruation start, When does thelarche start, who gets it earlier)
Most girls begin menstruation between ages 12 and 13. Thelarche occurs as early as age 9 years. Black girls experience menarche earlier than white girls
The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?
Most infants do not sit steadily until 8 months.
A 4-month-old infant is seen at the ambulatory care clinic and diagnosed with nasolacrimal duct obstruction. The parent asks what can be done. What information should be included in the information provided to the parent?
Most of these conditions will spontaneously resolve.
A school-aged child is brought to the emergency room with severe abdominal pain. The nurse performs a physical assessment. Which assessment parameters indicate appendicitis? Select all that apply.
Normal to hyperactive bowel sounds early Hypoactive bowel sounds with perforation Irritation and pain in the right lower quadrant Low-grade fever, nausea, anorexia, and vomiting
The nurse is caring for a 15-year-old male client. The nurse notes the client's height is 47.5 in (120.65 cm) and weight is 112 lb (50.8 kg). Which action will the nurse take next?
Notify The Provider This is very small for 15 year old (avg. 67in, 120lb)
A new mother asks the nurse when she should begin caring for her baby's teeth. Which response is the most appropriate for the nurse to make at this time?
Now
The 2-year-old child is seen in the emergency department (ED) with a sore throat and difficulty swallowing. The ED physician suspects acute epiglottitis. Which of the following interventions should be included in the child's immediate care?
Obtain a medical and immunization history. Assess vital signs and breath sounds. Obtain and put an endotracheal tray at the bedside.
What type of treatment would be given for bronchiolitis?
Oxygen Therapy
The nurse is assessing the level of pain in a preschool-aged child who appears to be experiencing abdominal pain. The nurse uses the Faces scale for pain assessment. The child points to the face indicating "hurts worst." What additional assessment would the nurse complete first?
Parents report of Pain
The nurse is caring for a 1-year-old child with a partial airway obstruction with a foreign body. What intervention(s) will the nurse include in the plan of care?
Place child in a comfortable position. Avoid interventions that cause anxiety. Maintain a quiet environment. Keep parents informed of planned procedures and interventions.
The nurse is caring for a child with history of asthma who presents to the emergency department with wheezing, tachypnea, and dyspnea. What will the nurse do first? Place the child in high-Fowler position Apply oxygen via nasal cannula at 2 liters Ask what may have triggered the attack Assess the child's pulse oximetry reading
Place in High Fowler position
The mother of a 3-year-old is considering the following purchases as a birthday present. Which toy would the nurse suggest as the most age appropriate choice?
Pounding bench The 3-year-old child should have a tricycle, large sturdy toys such as big blocks, active toys like a pounding bench, and musical toys. The preschooler also likes show-and-tell, guessing games (because his or her memory is improving), and big-pieced jigsaw puzzles
The parents are asking their health care provider to give them some advice on how to start toilet training their toddler. Which information is most appropriate to share with this family?
Praise the child every time the child sits on the potty chair and tries to defecate. Don't let the child use the potty chair as a place to sit at the play table since it might confuse the child of its purpose.
A nurse is providing discharge teaching to the family of a child who has undergone a cardiac catheterization. Which instruction is most important for the nurse to stress during the teaching session? Keep all follow-up appointments Administer prescribed analgesics Limit activity for several days Promote adequate hydration.
Promote adequate hydration.
A 14-year-old adolescent and parent are in the office. As the adolescent goes to the bathroom, the parent stops the nurse and asks about the changes that the adolescent is going through. The parent would like to talk to the adolescent about sex and the changes, but the parent is unsure of how to do this. Which suggestion is appropriate for the nurse to provide?
Promote open lines of communication, encourage listening, don't lecture, and share family values.
A 2-year-old child has vomited his oral medication dose 3 minutes after swallowing it. What would the nurse do next?
Readminister the medication right away.
A child is refusing to use the potty and having accidents, even though he has achieved toilet training. This is an example of which type of behavior?
Regression
A parent brings the 4-year-old child for a check-up. Which finding would concern the nurse? Ectomorphic body type Resting pulse rate of 120 Weight gain of 5 lb (2.27 kg) in the past year No increase in appetite compared with that in toddler years
Resting pulse rate of 120
A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement, to "get the infant used to eating solid food." The parent felt that the popcorn would be safe because it is soft on the infant's gums. What should be the primary Concern?
Risk for aspiration related to feeding the infant an inappropriate food
Reflexes and when they disappear
Rooting: 4 months Palmar: 4 months Plantar: 8 months Moro: 6 months Tonic Neck: 3-4 months Babinski: 1 year Stepping: 4 weeks
When describing play by the school-aged child to a group of nursing students, the instructor would emphasize the need for which of the following?
Rules
The nurse is teaching a 14-year-old child on the proper use of a metereddose inhaler to control symptoms of asthma. Which teaching points should the nurse include in these instructions?
Shake, activate while taking a deep breath, hold 5-10 seconds
The nurse is providing education to a parent about the 20-month-old child's growth. The parent says the child seems to have such a big head. What information should the nurse include in the response?
Share that the heads of children at this age are large in proportion to the rest of their body.
Reye's syndrome Signs and Symptoms Treatment Medication
Syndrome which causes swelling of the brain and liver dysfunction. Usually follows a viral illness & linked to intake of aspirin. S/S: increased ammonia levels, increased liver enzymes, extreme vomiting, seizure, confusion, lethargy Treatment: elevate HOB, seizure precaution, monitor for hemmorrhage Medication: Mannitol (to decrease brain edema)
A nurse is preparing an educational seminar about the moral and spiritual development of preschoolers. When describing this topic, which information would the nurse include?
Tendency to do good out of self-interest They determine right/wrong based on the rules
The nurse is assessing an infant at the 6-month well-baby check-up. The nurse notes that at birth the baby weighed 8 lb (3.6 kg) and was 20 in (50.8 cm) in length. Which finding is most consistent with the normal infant growth and development?
The baby weighs 18 lb (8.2 kg) and is 26 in (66.0 cm) in length. The average infant's weight doubles at 4 months and will triple at 1 year of life. The infant's length will increase by 50% by the first year.
A 5-year-old is getting a cardiac catheterization. When describing this procedure to the parents, which of the following would the nurse most likely include?
The child's temperature will be monitored continuously through the procedure by a rectal probe. The child will need to lie still for several hours after the procedure.
The nurse is examining the heart and peripheral perfusion of an 8-year-old. The nurse will assess the apical impulse at which location?
The fifth intercostal space lateral to the left midclavicular line
The nurse is assessing the respiratory system of a newborn. Which anatomic differences place the infant at risk for respiratory compromise? (alveoli, Larynx, nose)
The nasal passages are narrower. There are significantly fewer alveoli. The larynx is more funnel shaped.
A 16-year-old female adolescent reports to the nurse that she is trying to improve her diet to lose weight. Proper amounts of each? -Calcium -calories -fat % -Iron
The recommended calcium intake for female adolescents is 1,300 mg/day. The average caloric intake is approximately 2,000. Fat intake should comprise 20% to 35% of the daily diet. Daily iron intake for female adolescents should be approximately 15 mg per day.
A 15-month-old toddler has been brought to the clinic because the toddler is pale and listless. Which finding or observation would lead the nurse to suspect iron-deficiency anemia as the cause of the clinical manifestations?
The toddler drinks 32 oz (1 L) of milk per day.
A parent brings the 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse? Prominent abdomen Forward curve of the spine at the sacral area Increase in height of 5 inches in the past year Total weight gain of 15 lb in the past year
Total weight gain of 15 lb in the past year
A nurse is assessing a 3 year old at a well-child visit. Which developmental milestones would the nurse expect to assess?
Undresses self without difficulty Stacks a tower of blocks Rides tricycle Draws a circle
The nurse is teaching the parents of an infant with a cleft palate about strategies for feeding. What should the nurse include in the teaching? Select all that apply. Use a squeezable bottle. Provide a referral to an orthodontist. Use a regular nipple for bottle feeding. Keep the head upright at 45 degrees. Review feeding devices.
Use Squeeze bottle, Keep head up at 45 degrees, review feeding devices, refer to ortho
Which objective data provide the basis for documenting that this child has progressed from the 15-month-old to the 18-month-old developmental level?
Uses an 8-word vocabulary. Follows simple commands such as "sit down." Uses a spoon to feed self.
When assessing a child for the probable cause of acute bronchiolitis, the nurse focuses on which factor? Environmental allergies Bacterial infections Prenatal complications Viral infections
Viral Infections
The parents of a 5-year-old call the nurse for advice about night terrors. The child has had them nightly for almost 2 weeks. What is the most appropriate intervention?
Wake the child up nightly 30 to 45 minutes after going to sleep for 7 days
11 month motor skills
Walks while holding onto something Neat pincer grasp Deliberately drops things to have them picked up Places objects in containers
3 month motor skills
Will raise head and shoulders in prone position Slight head lag Keeps hands loosely open
The health care provider prescribes an abdominal radiograph for a newborn to check for Hirschsprung disease. The nurse examines the newborn and finds which symptoms that are indicative of this disease? Select all that apply
abdominal distention absence of stool in the rectum enterocolitis (bowel inflammation) bilious vomiting (green vomit)
A nurse is assessing a 15-month-old and his gross motor ability. Which of the following would the nurse expect to assess?
ability to stoop and recover ability to throw a ball
A nurse working at a pediatric clinic includes an adolescent history for every child aged 11 to 18 years when the child is new to the office. Which issues should the nurse address when the parents are not in the room? Select all that apply.
abuse/domestic violence sexual activities
The nurse is evaluating the plan of care for a 2-year-old child with heart failure. Which outcome(s) demonstrates that the plan of care has been effective for the child?
adequate calorie intake balanced intake and output
A nurse is providing care to a child with Kawasaki disease. Which medication(s) would the nurse expect the health care provider to prescribe?
aspirin IV immunoglobulin
cystic fibrosis
autosomal recessive disorder that affects the lungs and digestive system of the individual Symptoms: Salty skin Fatty Stool Decreased vitamin absorption Clubbed Fingers Barrel Chest Nursing Care: Increase Sodium, calories, protein and pancreatic enzymes Give Dornase Alfa
The nurse is reviewing the health history of an infant who is demonstrating developmental delays. Which finding would be considered a possible risk factor?
being raised by a single adolescent mom
A nurse is working with a preceptor in a well-baby clinic that deals with children aged birth to 12 years old. During the routine physical assessment of a 2-year-old child, the nurse identifies which finding as being abnormal for this age group? respiration rate of 20 bpm abdominal breathing noted blood pressure of 116/80 mm Hg heart rate of 92 beats/min regular wears diapers since not potty trained
blood pressure of 116/80 mm Hg
A group of nursing students are reviewing information about the different types of hearing impairment. The students demonstrate understanding of the information when they identify which of the following as a possible cause of a conductive hearing impairment? Select all that apply.
cerumen blockage fluid in the middle ear tympanic membrane scarring
The nurse is assessing a child with aortic stenosis. Which findings would the nurse most likely assess? Select all that apply.
chest pain with activity dizziness with prolonged standing thrill palpated at base of heart
A child is being treated for pertussis and is prescribed azithromycin by the health care provider. Which finding is most important for the nurse to report to the health care provider before administering this drug?
child has had previous episodes of supraventricular tachycardia (SVT) Azithromycin is recommended for use to treat pertussis in infants older than 1 month of age and children. It should, however, not be used in children at risk for cardiovascular events.
Hypertrophic Pyloric Stenosis (HPS) S/s Nursing Care
constriction of pyloric sphincter with obstruction of gastric outlet Signs and Symptoms: palpable as an olive like mass in the upper abdomen, Projectile vomit right after feeding Prep for Surgery Feed Q4-6 hours post op
When assessing a infant born at 32 weeks' gestation, which finding would lead the nurse to suspect that the infant has a patent ductus arteriosus (PDA)? weak, thready pulse continuous murmur on auscultation decreased pulse rate high diastolic arterial pressure
continuous murmur on auscultation
The nurse is caring for a 5-year-old child with laryngotracheobronchitis (LTB). Which intervention will the nurse prioritize in the child's plan of care?
corticosteroids as prescribed administer corticosteroids as prescribed to help reduce airway inflammation (anti-inflammatory)
The nurse suspects that an infant is experiencing intussusception. What did the nurse assess in this infant? Select all that apply.
crying as if in severe pain sudden drawing up of the legs stool that looks like currant jelly leg drawing up, and the infant's crying repeats every 15 minutes
A nurse is carrying on a conversation with a 7-year-old child during an office visit. Which is an example of the level of language development the nurse should expect in this child? - fascination with bathroom language - difficulty understanding the concept of "half past" in reference to time - ability to carry on an adult conversation - inability to speak in full sentences
difficulty understanding the concept of "half past" in reference to time
The nurse is assessing the pain level of a school-aged child who is cognitively impaired using the r-FLACC pain tool. The nurse determines the child scores 10 points on the assessment. Which symptom(s) did the nurse assess to achieve this score?
distressed looking face head banging and breath holding refusing any comfort measures
A group of students is reviewing information about adenovirus infections and the development of upper respiratory infections in children. What is not a common time for the infection to occur?
early fall
The nurse is assessing a 3-year-old child. Which assessment finding would the nurse identify as abnormal? pedals tricycle without assistance unscrews a bolt on a toy falls when bending over to touch toes builds a tower of 10 cubes
falls when bending over to touch toes
The nurse is developing a teaching plan for the parents of a 12-year-old boy with cystic fibrosis. For which piece of equipment should the nurse prioritize education?
flutter valve device
The nurse is teaching the mother of a 5-month-old boy who is concerned about thumb sucking. What should be included in the teaching plan?
form of self-comfort won't cause malocclusion (crooked teeth) thumb sucking occurs more often during periods of stress this behavior usually decreases by 6 to 9 months of age
When obtaining an toddler's history to determine appropriate anticipatory guidance, which upcoming milestone correlates with safety and poisoning concerns? sitting without additional support oral fascination rolling over gaining motor skills
gaining motor skills
The nurse is caring for a child with a gastrointestinal disorder and measuring intake and output. The nurse observes that the child is demonstrating symptoms of adequate hydration when the child has which findings? Select all that apply fontanels (fontanelles) with normal tension loose stools adequate skin turgor pink and moist mucous membranes oral intake
good skin turgor, moist membranes, normal fontanelles
The nurse is conducting a well-child checkup for a 4-year-old child. At the child's 3-year-old checkup, the child weighed weighs 34 lb (15.4 kg), was 35 in. (0.89 m) tall, had 20 teeth and was developmentally on target. What would be the expected findings for this visit? Select all that apply.
height of 38 in. (0.96 m) able to climb steps with alternating fee Preschoolers grow at a rate of 4 to 5 lb (1.8 to 2.3 kg) and about 2.5 to 3.0 in (6.3 to 7.8 cm each year)
A nurse is beginning to examine a 4-month-old infant. The nurse takes the infant from the parent's arms and places the infant in which manner?
in the crib facing the parent
The developmental task of the school-aged period, according to Erikson, is gaining a sense of
industry versus inferiority.
A child has been admitted to the acute care facility for the management of dehydration. The nurse is preparing to administer intravenous fluid replacement to the child. Which fluids are suitable for use?
isotonic solutions for dehydration and burns = normal saline and LR
The nurse is providing health-promotion teaching to a group of parents of preschool-aged children at a local day care. What information would the nurse include in this education session? - Preschool-age children are capable of taking a bath independently. - Encourage children to select their own clothing to wear each day. - Preschool-aged children only need to wear bicycle helmets if they are going on long rides. - Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing. - Parents will need to supervise tooth-brushing and be responsible for flossing.
let kids pick our their own clothes Treat any toileting accidents in a matter-of-fact manner and assist the child in getting dry clothing Parents will need to supervise tooth-brushing and be responsible for flossing.
The nurse is completing a physical assessment of a 15-month-old child. Which objective data would the nurse document as normal findings? heart rate of 100 beats per minute waddling gait sunken abdomen predominance of baby fat lordosis
lordosis (sway back) waddle HR 100 BPM
A nurse is obtaining the history from a parent of a child who experiences absence seizures. Which would the nurse expect the parent to describe?
loss of motor activity accompanied by a blank stare
An infant with a high respiratory rate is NPO and is receiving IV fluids. What assessment(s) will the nurse make to assure this infant is hydrated? Select all that apply.
measure skin turgor palpate anterior fontanel (fontanelle) determine urine outpu
Which finding(s) is a major criterion used to help the health care provider diagnose acute rheumatic fever in a child? Select all that apply.
painless nodules located on the wrists pericarditis with the presence of a new heart murmur MINOR Criteria: Elevated temp elevated erythrocyte sedimentation rate
The nurse performing an abdominal examination on a client auscultates the abdomen and documents high-pitched, hyperactive bowel sounds. The nurse is aware that this is indicative of:
partial intestinal obstruction.
In developing a plan of care for the child diagnosed with rheumatic fever, the nursing intervention that takes highest priority for this child is to: - promote rest periods and bed rest - provide age-appropriate diversional activities - position the child to relieve joint pain - monitor the C-reactive protein and erythrocyte sedimentation rate (ESR) levels.
promote rest periods and bed rest.
The nurse is assessing a 12=year-old boy. Which assessment finding(s) are consistent with the child's age?
pubic hair spreading to the sides enlargement of the testes longer extremities relative to trunk
A nurse is performing a physical assessment on a child who is having an asthma attack. Which would the nurse most likely observe?
retractions
4 month motor skills
rolls from back to side grasps objects with both hands
5 month motor skills
rolls from front to back uses palmar grasp dominantly
The nurse is conducting developmental surveillance of an adolescent. Which of the following would the nurse focus on as the primary goal for this age group?
self-advocacy
The nurse is caring for an infant with an atrial septal defect. Which finding(s) will prompt the nurse to anticipate surgery in the child's plan of care? Select all that apply.
signs of heart failure failure to thrive tiring easily surgery is indicated for the child with a large atrial septal defect
8 month motor skills
sits unsupported begins using pincer grasp
intussusception - s/s - treatment
telescoping of the intestines -Pulls knees to chest -Screaming cry Q15 -Sausage shaped mass -Currant Jelly Stool - Tender Abdomen Treatment: Air Enema
During a complete physical assessment of a preadolescent boy, the nurse correctly recognizes which finding as being the first change of puberty?
testicular enlargement
A group of nursing students are reviewing information about growth and development during infancy. The students demonstrate understanding of the information when they identify which as characteristic of a 10-monthold infant? Select all that apply. Stands alone Exhibits stranger anxiety Tilts head backward to see up Understands the word "no" Waves hands
understands the word "no", tilts head backward to see up, stands alone
A 12-year-old girl has recently begun menstruating and is well into puberty. The child is visiting the health care provider today for a routine physical examination. Which finding should cause concern in the nurse?
vulvar irritation
The nurse is assessing a 2-month-old formula-fed infant who is experiencing colic. Which type of bowel movements should the nurse expect to occur with this health problem?
yellow and semisoft With colic, bowel movements are normal. For an infant who is formula-fed, this means the stool will be yellow and semisoft.