Peds Exam 2

The nurse is monitoring an infant for signs of increased intracranial pressure. On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the prioritynursing action?

Notify the primary health care provider.

The nurse is assisting a primary health care provider (PHCP) examine a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess?

Ortolani's maneuver

Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction should the nurse include in the client's teaching plan?

Perform the postural drainage first and then the breathing exercises.

A mother calls the primary health care provider's office requesting an appointment for her 8-year-old child. She states he has asthma and is telling her he had trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the mother?

"Is your child telling you at this time he is having trouble breathing?"

The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF?

A chronic multisystem disorder affecting the exocrine glands

The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching?

"I should place a steam vaporizer in my child's room."

The nurse has provided instructions to the mother of a child with cystic fibrosis about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures?

"The diet needs to be high in calories."

A pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which item should the nurse offer to the child?

Green Gelatin

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. In which position should the nurse place the infant?

Head and chest at a 30-degree angle with the neck slightly extended

The nurse is reviewing the primary health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question?

Suction the child frequently if coughing.

During a clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about CF?

This disease causes dilation of the passageways of many organs

The nursing student is writing a plan of care for a child who presents with an acute head injury. The nursing instructor reviews the plan of care and praises the student for identifying which assessment as a priority?

Airway and breathing

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding?

An airway obstruction

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

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

An ambulatory care nurse is preparing a list of instructions for the parents of a child who is being discharged after a tonsillectomy. The nurse should place which instructions on the list? Select all that apply.

Avoid hot fluids. Avoid raw vegetables. Rest in bed or on a couch for 24 hours.

The nurse reviews the health record of a 2-year-old child. The primary health care provider has documented that the results of a tuberculin skin test have indicated an area of induration measuring 5 mm. How should the nurse interpret these results?

Negative

A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome. The student plans to write on a handout that it is bestto place an infant in which position for sleep?

On the back, or supine

After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position?

Prone

The nurse is caring for a child following a tonsillectomy. The nurse should reposition the child on return from the operating room if the child is in which position?

Supine

A mother arrives at the clinic with her 3-year-old child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, the nurse anticipates that which will be a component of the treatment plan?

Supportive treatment

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis

The nurse creates a plan of care for a child with Reye's syndrome. Which priority intervention should the nurse include in the plan of care?

Monitor for signs of increased intracranial pressure.

The nurse is assisting a primary health care provider (PHCP) during the examination of an infant with developmental hip dysplasia. The PHCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted?

A palpable click during abduction of the affected hip

The clinic nurse is assessing a child suspected of having juvenile rheumatoid arthritis (JRA). Which assessment findings should the nurse expect to note in a child who has been diagnosed with JRA? Select all that apply.

Morning stiffness Painful, stiff, and swollen joints Limited range of motion of the joints History of late-afternoon temperature

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a private room. OR Move the infant to a room with another child with RSV.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and should contact the pediatrician to question which prescription?

Nasotracheal suction as needed.

The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness?

"I will watch for any redness or skin irritation where the straps are applied and call the primary health care provider for red areas."

A child sustains a fall at home and is brought to the hospital emergency department by the child's mother. After a radiographic examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding neurocirculatory assessment and function. Which statement by the mother indicates a need for further instruction?

"If her hand gets real cool and pale, I can apply the heating pad to it."

The nurse caring for a child with suspected absence seizures is collecting data from the parents on how to manage the disorder. Which statement, if made by the parents, indicates the presence of signs congruent with this disorder?

"My child's teacher mentioned that he seems to daydream a lot."

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 should assess the child frequently for which early sign of increased ICP?

Nausea

An alert child who is crying loudly is brought to the hospital emergency department for a simple fracture to the lower right arm that occurred after a fall off a bicycle. What is the nurse's priority assessment?

Neurovascular

The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to caring for their child who has a chronic illness. Which statement, if made by the parents, would indicate a need for further teaching?

"Our child sleeps in our bedroom at night."

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

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

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

"This brace will correct my curve."

The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective?

"We will make appointments for follow-up blood work and care as directed."

The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding should the nurse expect to note on assessment of the child?

Not easily arousable and limited interaction

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the prioritynursing intervention in the preoperative period?

Reposition the infant frequently.

A child must wear a brace for correction of scoliosis. The nurse creates a plan of care knowing the child is at risk for which problem?

Breaks in skin integrity

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which instruction should the nurse provide to the mother?

Check the skin and eyes every day for a yellow discoloration.

An infant is brought to the child care clinic for a follow-up visit. The nurse notes that the infant is wearing this apparatus. The nurse documents that the infant is wearing which device? Refer to figure.

A Pavlik harness for the treatment of congenital hip dislocation

The nurse caring for an infant with a diagnosis of hydrocephalus should monitor the infant for which sign of increased intracranial pressure?

A bulging anterior fontanel

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent swallowing

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side-lying

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make?

"Antibiotics are not indicated unless a bacterial infection is present."

A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate?

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

The nurse is performing an assessment of a 7-year-old child who is suspected of having episodes of absence seizures. Which assessment question to the mother will assist in providing information that will identify the symptoms associated with this type of seizure?

"Does the child have a blank expression during these episodes?"

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?

"Have the child perform simple isometric exercises during this time."

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

"I can remove the harness to bathe my infant."

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

"I can use lotion or powder around the cast edges to relieve itching."

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia

A child with developmental dysplasia of the hip is placed in a Pavlik harness. The nurse should demonstrate to the parents how to place the child in this harness by placing the child's legs in which position?

Abduction

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. Which assessment finding should the nurse expect if this type of posturing is present?

Abnormal extension of the upper and lower extremities with some internal rotation.

A nursing student is assisting a school nurse in performing scoliosis screening on the children in the school. The nurse assesses the student's preparation for conducting the screening. The nurse determines that the student demonstrates understanding of the disorder when the student states that scoliosis is characterized by which finding?

Abnormal lateral curvature of the spine

A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the primary health care provider's prescriptions, which would the nurse question as appropriate for a child with this diagnosis?

Administer an oral antibiotic.

An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction should the nurse provide to the adolescent regarding home care for treatment of the sprain?

Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.

A school nurse is teaching parents about emergency treatment for epistaxis. Which bestaction should the nurse take to assist the parents in understanding the emergency treatment?

Ask the parents to demonstrate, on a mannequin, where to apply continuous pressure if a nosebleed occurs.

The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique should be performed that will best detect the presence of an increase in intracranial pressure?

Assess anterior fontanel for bulging.

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels

A child who sustained a fractured ankle has a short leg cast applied, and the nurse provides home care instructions to the mother. The mother returns to the emergency department 16 hours later because the child is complaining of severe pain. The nurse notes that the child's toes are cool, pale, and puffy, and that the child is agitated and crying loudly. The mother states, "I gave her the pain medication you sent with us just like you told us, and I have kept her foot up on two pillows since we left, except when she gets up to go to the bathroom. I don't understand why she hurts so much. Do something!" What is the most likely clinical situation that occurred?

Compartment syndrome

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What should the nurse document that the child is experiencing?

Decorticate posturing

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing

A child with cerebral palsy is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action?

Placing the child on a wheeled scooter board

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

Positive

A child is scheduled for a tonsillectomy. The nurse plans care, knowing that which condition would be a priority because it presents the highest risk of aspiration during surgery?

Presence of loose teeth

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is mostsignificant to review?

Prothrombin time

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

Providing a quiet atmosphere with dimmed lighting

The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which action to maintain the infant's safety?

Elevating the head with the infant in the prone position

A child has just returned from surgery and has a hip spica cast. What is the nurse's priority action for this client?

Assess the circulatory status.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of 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 notes that an infant with the diagnosis of hydrocephalus has a head that is heavier than that of the average infant. The nurse should determine that special safety precautions are needed when moving the infant with hydrocephalus. Which statement should the nurse plan to include in the discharge teaching with the parents to reflect this safety need?

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

The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse should modify the client's plan of care based on which interpretation of the client's change?

Deteriorating neurological function

The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure?

Elevated temperature

The nurse is assessing for Kernig's sign in a child with a suspected diagnosis of meningitis. Which action should the nurse perform for this test?

Raise the child's leg with the knee flexed and then extend the leg at the knee and assess for pain.

A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the primary health care provider, should the nurse question?

Obtain a throat culture.

The nurse is assigned to care for a child with a brain injury who has a temporal lobe herniation and increasing intracranial pressure. Which signs should the nurse identify as indicative of this type of injury? Select all that apply.

Flaccid paralysis Ipsilateral pupil dilation Shifting of the temporal lobe laterally across the tentorial notch

The nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse should immediately test the discharge for the presence of which substance?

Glucose

A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be the prioritybefore transferring the child to the hospital emergency department?

Immobilize the arm.

The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem?

Infection

The nurse assists a primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia in whom central nervous system disease is suspected. In which position will the nurse place the child during this procedure?

Lateral recumbent position with the knees flexed and chin resting on the chest

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

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

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition?

Limited range of motion in the affected hip

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Notify the primary health care provider (PHCP).

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 primary health care provider (PHCP).

The nurse is caring for a child with a head injury. The nurse observes decerebrate posturing. What is the nurse's best action?

Notify the primary health care provider.

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

Place the infant in a private room. Wear a mask, gown, and gloves when in contact with the infant. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

Russell's traction is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse about the purpose of the traction. The nurse explains to the mother that which is the primary action of this type of traction?

Reduces or realigns a fracture site

The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate?

Report the findings to the primary health care provider.

The community health nurse is providing information to parents of children in a local school regarding the signs of meningitis. The nurse informs the parents that the classic signs/symptoms of meningitis include which findings?

Severe headache, fever, and a change in the level of consciousness

After a tonsillectomy, the nurse reviews the surgeon's postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours.

The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside?

Suctioning equipment and oxygen

A child is brought to the emergency department, and diagnostic x-rays of the child reveal that a fracture is present. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. A plaster of Paris cast is applied to the arm. Which instructions should the nurse provide the mother? Select all that apply.

The cast will mold to the body part. Keep the cast elevated on pillows for the first day. Make sure that the child can frequently wiggle the fingers. The cast needs to be kept dry because it will begin to disintegrate when wet.

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out.

Cerebral palsy (CP) is suspected in a child, and the parents ask the nurse about the potential warning signs of CP. The nurse should provide which information? Select all that apply.

The infant's arms or legs are stiff or rigid. A high risk factor for CP is very low birth weight. The infant has feeding difficulties, such as poor sucking and swallowing. If the infant is able to crawl, only one side is used to propel himself or herself.

Which nursing actions apply to 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. Place the child in a lateral side-lying position.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

Time the seizure. Stay with the child. Move furniture away from the child.

The nurse enters a child's room and discovers that the child is having a seizure. Which actions should the nurse take? Select all that apply.

Turn the child on her side. Loosen any restrictive clothing. Check the child's respiratory status.

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the child to the side.

A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth?

Uneven leg growth

The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child?

Yellow non-citrus Jell-O

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

"I need to be sure to apply lotion on the skin under the brace."

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

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

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

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

The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which statement by the mother indicates a need for further teaching?

"I will have to use a heat lamp to help the cast dry."

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

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

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.

Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity. Keep small toys and sharp objects away from the cast.

The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse should monitor for which sign of a serious complication associated with this type of traction?

Elevated temperature

The pediatric nurse educator provides a teaching session to the nursing staff regarding juvenile idiopathic arthritis (JIA). Which action by a nursing staff member in the care of a child with JIA indicates a need for further education?

Emphasizes the importance of rising quickly in the mornings

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lie on the right side.