PEDS HESI practice test questions

A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can expect to grow and be just as tall as all of his friends. What response is best for the nurse to provide?

"Being taller is important to you and taking your injections will help achieve that goal." Rationale: It is important to validate his feelings and reinforce the fact that injections are the only way he can get the medication and achieve growth in height. He will have to take injections three times a week for years.

Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.)

1. Child's height and weight. 2. Nomogram determined mathematical constant. Rationale: The most accurate calculations of pediatric dosages use the child's height and weight. The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in pounds times height in inches divided by 3131, then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose.

A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine(s) should the nurse verify the infant has received? (Select all that apply.)

1. Inactivated poliovirus vaccine (IPV). 2. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP). Rationale: According to the CDC guidelines for immunizations, a six-month-old infant should have received doses 1 & 2 of Hib, IPV, HepB, and DTap.

A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9 F. The nurse determines the daily caloric need for this child is approximately

600 calories per day. Rationale: 10 lbs 15 oz = 10.9 lbs. Convert lbs to kg by dividing pounds by 2.2; 10.9/2.2 = 4.954 kg, rounded to 5 kg. An infant requires 108 calories/kg/day (108 x 5 = 540 calories/day). However, this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day.

The mother of a 2-month-old reports that she often lets the baby cry in the middle of the night instead of going to pick up or sooth the infant. What information should the nurse provide the mother?

A sense of trust is developed in an infant when others respond to the infant's cry. Rationale: According to Erikson, a crucial element in the developmental stage of the infant is, "Trust versus mistrust", which is nurtured when the mother or the primary caregiver is responsive and consistent in responding to the infant's needs and cries.

At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?

Administer PRN prescription of nifedipine (Procardia) sublingually. Rationale: After the nurse has verified the client's elevated blood pressure, the sublingual Procardia should be administered first because it lowers the blood pressure very quickly, before implementing any of the other interventions.

The parents of a child with Asperger's disorder asks the nurse to explain the differences between Asperger's and autism. Which information should the nurse share with the parents about Asperger's disorder that is not characteristic in autism?

Age-appropriate language development. Rationale: Asperger's syndrome is a neurological condition, which falls under the autism spectrum and is considered one of the higher functioning spectrum's of autism. Individuals affected by this condition have a very high functioning of language skills and obsessed over single topics, but demonstrate very weak social skills, have difficulty interacting with others, and are considered emotionally stunted and display ritualistic behaviors.

When assessing the breath sounds of an 18-month-old child who is crying, what action should the nurse take?

Allow the child to initially play with the stethoscope, and distract during auscultation. Rationale: Engaging the child with an interesting activity, such as playing with the stethoscope before its use, often distracts the child long enough to stop crying so, breath sounds can be auscultated accurately.

A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?

Apical heart rate of 60. Rationale: A heart rate of 60 beats per minute is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 beats per minute when awake, and a rate of 70 while sleeping is considered within normal limits.

Which site should the nurse assess to obtain the pulse rate for a 1-year-old child?

Apical. Rationale: Apical pulse rates should be obtained in children less than 2 years of age to assess cardiac function.

A hospitalized 16-year-old male refuses all visits from his classmates because he is concerned about his distorted appearance. To increase the client's social interaction, what intervention is best for the nurse to initiate?

Arrange for an Internet connection in the client's room for email communication. Rationale: Body image and peer acceptance are key concerns for the adolescent. Communication via email allows for social interaction without face to face contact, thus protecting his self-image while also promoting social interaction.

The nurse is caring for a 9-year-old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child?

Ascertain what the child understands about sex. Rationale: School-age children often use correct sexual vocabulary, and yet have no real understanding of what the words mean, so the nurse needs to determine the child's understanding of the concepts used in conversation.

A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?

Assess the child's respiratory status. Rationale: Assessing the airway and the respiratory status is the highest priority since burns to the face and chest place the child at risk for smoke inhalation injury and compromised airway.

The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son's prognosis. Which factor should the nurse include when answering the parent's concern?

Degree of metastasis. Rationale: Ewing sarcoma is the second most common malignant bone tumor of children. Prognosis of this malignant tumor is most significantly related to the degree of metastasis during the early in the course of the disease.

The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis?

Feet and hands. Rationale: Acrocyanosis, nonpathologic cyanosis of the hands and feet, is an expectant finding in the newborns.

Which neurological test should the nurse implement to assess cerebellar function in a 5-year-old with symptoms of hyperactivity?

Finger-to-nose. Rationale: The cerebellum controls balance and coordination and is significant in children with symptoms of hyperactivity or learning difficulty, so difficulty in performing a "finger-to-nose" test indicates poor sense of position (especially with the eyes closed) and incoordination (especially with the eyes opened).

When assessing a preschooler, which finding warrants further assessment by the nurse?

Gains 2 pounds (0.9kg) in 12 months. Rationale: Preschool children gain an average of 5 pounds (2.7kg) per year, so a gain of 2 pounds (0.9kg) is less than half of the expected weight gain and should be investigated further.

Which research finding provides evidence-based practice for an infant's risk for sudden infant death syndrome (SIDS)?

Infants should be positioned supine or supported laterally to sleep. Rationale: Research has shown that placing babies on their backs for sleep reduces the risk of SIDS. A population-based study found the prone sleep position was associated with twice (2.4% odds ratio) the rate of SIDS compared with infants placed supine (on their backs) to sleep.

Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations?

Oven-baked potato chips and cola. Rationale: Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any products containing these ingredients to avoid symptoms such as diarrhea.

Preoperative nursing care for a child with Wilms' tumor should include which intervention?

Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN." Rationale: Prevention of abdominal palpation minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis.

When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?

Record weight daily. Rationale: The most definitive measure of improved nutrition in an infant is obtaining the infant's daily weight at the same time and ideally using the same scale and the infant fully naked.

How should the nurse measure the length of a 14-month-old child?

Supine recumbent position. Rationale: Children younger than 24 to 36 months of age

The nurse calculates a 4 ml dose of prescribed digoxin a 9-month-old infant. What action should the nurse implement?

Suspect dosage error and do not give dose. Rationale: Digoxin narrow margin of safety for an infant should not exceed 1 ml (50 mcg) in one dose. The nurse's calculation indicates a dosage error and should not be given. Digoxin is given without mixing with any other fluids or foods because the infant may refuse to consume the total amount which results in an inaccurate drug dose.

Which clinical finding should the nurse expect a child with nephrosis to exhibit?

Urine protein 3+ to 4+. Rationale: In nephrosis, renal tubules become permeable to proteins, causing massive proteinuria.

The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother?

Walk away from him and ignore the behavior. Rationale: The best approach for a toddler's inappropriate behavior is to ignore the attention-seeking behavior. The parent should be somewhat nearby, within view of the child, but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs.

The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?

"Are you experiencing any type of nervousness?" Rationale: Assessing the client's psychophysiologic state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism. Weight loss (even with a hearty appetite) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority.

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast was applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?

"Call the healthcare provider immediately if his nail beds appear blue." Rationale: Cyanosis indicates impaired circulation to fingers and should be reported immediately.

A 15-year-old girl tells the school nurse that she wants to have a baby. How should the nurse respond?

"Can you tell me how your life will be if you have an infant?" Rationale: Developing a dialogue with the teen is important, and by using open-ended questions the nurse will encourage communication and explanation. Asking the teenager to describe how the infant will affect her life directs the teen to consider real life experiences and allows the nurse to assess the teen's perception and reality orientation.

The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching?

"Dental caries can be prevented through fluoridation of public water." Rationale: Dental caries can be prevented through fluoridation of public water.

During the well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents?

"Private speech" is normal at this age and serves as a problem-solving tool. Rationale: Children chatter to themselves between the ages of 4 and 6 years, and this "private speech" serves as a problem-solving tool for the preschoolers as they try new tasks or work through unfamiliar situations.

A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?

"Use sunscreen when lying by the pool." Rationale: Photosensitivity is a common side effect of tetracycline HCL (Achromycin V) therapy. Severe sunburn can occur with minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen.

A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting. The family wants to begin oral feeding of the child, and asks the home health nurse to feed the child baby food orally. After explaining the risks for aspiration to the family, list in order which actions the nurse should implement. (Rank in the priority order from first action to last action.)

1. Acknowledge the request and then explore with the family the available options for care. 2. Set additional goals for feeding the child with the parents. 3. Refuse to feed the child orally, because the risk is too high. 4. Ask the parents to negotiate a change in feeding methods with the healthcare provider. Rationale: Nurses should respect parental preferences that do not pose a risk for the child, but the risks of aspiration should be explained. Then, the request for oral feeding should be acknowledged, and options should be explored. The nurse and parents should set goals in an atmosphere of mutual respect. If an agreement cannot be reached, written medical prescriptions should be implemented and refusal to feed the child orally substantiated with the risks involved. Lastly, the parents should be directed to negotiate a change in feeding with the healthcare provider.

The nurse notices that the hem of a skirt on a pre-adolescent girl is uneven when she comes to the clinic. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from first on top to last on the bottom.)

1. Ask the girl to remove her shirt but leave on her bra or swimsuit top. 2. Look for asymmetry in the hip area. 3. Instruct the girl to bend at the waist so back is parallel to the floor. 4. Examine for scapular prominence. Rationale: To screen for scoliosis, the girl should first be asked to remove her shirt, wear her bra, or wear a swimsuit top. Then, as she stands erect, observe for asymmetry of the shoulders, back and hips while standing behind the girl. Next, ask her to bend forward so that the back is parallel to the floor, and finally observe from the side and the back, noting asymmetry or prominence of the rib cage and scapulae.

A 14-year-old returns to the pediatric unit after corrective surgery for scoliosis. In the immediate postoperative period, the nurse should include which action(s) in this client's plan of care? (Select all that apply.)

1. Assess bowel sounds every 4 hours. 2. Initiate a logrolling schedule every 2 hours. 3. Give morphine sulfate 2 mg IV every 4 hours PRN. Rationale: Recording intake and output and assessing bowel sounds are critical when determining if the body systems are recovering from the effects of anesthesia. Turning the client using a logrolling technique maintains spinal alignment postoperatively and prevents complications of immobility. Since this is a painful surgery, the nurse should maintain pain control as prescribed. The pain associated is not just due to the incisions of surgery, but due to the manipulation and placement of the spinal hardware and possible muscular pain as the involved muscles adjust to the corrective realignment of the spine. Following corrective surgery for scoliosis, a client should be immobilized without spinal flexion for 24 to 48 hours, and then ambulated by the physical therapist.

An infant weighs 7 lb (3.18kg)at birth. How much should the nurse expect the infant to weigh at age 6-months?

14 lb (6.35kg) Rationale: Due to growth spurts, a healthy infant should double their birth weight by 4 to 6 months and triple it by one year.

A mother tells the nurse that her children are asking questions about divorce, but one male child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibity for the divorce of parents?

4 years. Rationale: Divorce constitutes a major disruption for children of all ages. Behaviors and feelings differ based on children's developmental stages and cover a wide spectrum, with overlap between stages. A preschool-aged child often feels frightened, confused, and may blame themselves for the divorce, or feel it is their personal punishment.

The nurse determines the daily caloric need for a six-month old weighs 15 pounds. Considering an infant requires 108 calories/kg/day, how many calories should the infant be provided throughout the day? (Round at the end of the calculation to the nearest whole number.)

735 calories per day. Rationale: An infant requires 108 calories/kg/day (108 x 6.81= 736 calories/day). Convert pounds to kilograms (kg): 15 pounds / 2.2 pounds per kg = 6.81 kg 108 calories x 6.81 = 735.48 = 735 calories / 24 hours

The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacket cast. Which assessment finding indicates to the nurse the client is developing cast syndrome?

Abdominal distention. Rationale: Cast syndrome occurs when the cast is applied too tightly and is compressing the superior mesenteric artery against the duodenum. Abdominal distention, pain, nausea, and vomiting may result.

What is the priority nursing intervention for a 12-year-old client newly diagnosed with bacterial meningitis?

Administer broad-spectrum antibiotics before results of culture and sensitivity tests are returned. Rationale: Although culture and sensitivity results identify the most effective treatment, prescribed broad spectrum antibiotic therapy should be initiated once the culture is obtained to provide an immediate antiinfectant regimen against the risk of mortality due to bacterial meningitis.

The parents of a 14-year-old girl tell the nurse that their daughter dresses as a tomboy and plays baseball one day and the next day dresses in feminine clothes and becomes a teenage "drama queen." What information should the nurse use to respond to the parents?

Adolescents try on different roles while seeking their identity. Rationale: As teenagers seek their own identity, they "try on" different roles to see if they fit and which feels more natural and comfortable.

The nurse is collecting a blood sample from a newborn for a screening test for phenylketonuria (PKU). When should the nurse obtain the blood sample?

After ingestion of a source of protein. Rationale: Phenylketonuria (PKU) is a genetic disease caused by the absence of the enzyme needed to metabolize the essential amino acid phenylalanine. The Guthrie blood test is used for early detection of this condition in order to prevent mental retardation as a result of this disease. The blood sample should be collected between 1 - 7 days after birth, with fresh heel blood only, and no sooner than 24 hours after the infant has ingested a source of protein (breastmilk or infant formula). Premature infants and/or sick neonates who haven't been introduce to breastmilk or formula due to medical reasons will have their PKU test adjusted to be taken after they are able to ingest breastmilk or formula regardless of method of delivery (nippling or gavage fed).

A 6-year-old child is admitted to the emergency department with a systolic blood pressure of 58 mm Hg. What action should the nurse take first?

Alert the healthcare provider. Rationale: The lower limit for systolic blood pressure for a child older than 1 year of age is 70 mm Hg plus 2 times the child's age in years, so the healthcare provider should be notified immediately of the child's hypotension and anticipate a prescription for IV fluids.

A 2-year-old is receiving care in the emergency department (ED) for a deep laceration on the head. What action should the nurse implement to facilitate the child's cooperation?

Allow the child to hold a favorite toy or blanket. Rationale: Allowing a child to hold a favorite toy or blanket provides familiarity and comfort which should facilitate the child's cooperation during treatment. Parents should remain with the child, not leave, but stay to calm and reassure a child who may perceive the ED environment as threatening.

The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose?

Applesauce. Rationale: In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications.

A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement?

Apply a Fox shield to the affected eye and any type of patch to the other eye. Rationale: The treatment for a penetrating eye injury is not to remove or manipulate the impaled object, but to apply a Fox shield over the eye, if available (not a regular eye patch) and place an eye patch over the unaffected eye to prevent bilateral eye movement. The child should be transported to the emergency department immediately. If a Fox shield is not available, then tape in place a paper cup over the eye and object.

A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience?

Avoid using jargon, such as "shot," when giving care. Rationale: Using positive terms and avoiding words (jargon) that the toddler may perceive literally in meaning and can assist the preschool-age child in coping with an emergency room experience.

A nurse reviews the methods for preventing recurring urinary tract infections (UTI) with the parent of a female child. Which response by the parent indicates that further teaching is needed in caring for the child?

Bathes the child nightly with liquid bubbles added. Rationale: Bubble baths, especially little girls can be irritating to the urethra, which indicates the need for reteaching.

The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client?

Cardiac arrhythmias. Rationale: An adolescent with bulimia who purges by frequent self-induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increases the risk for cardiac arrhythmias.

An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents?

Check for red areas under the straps three times a day. Rationale: The Pavlik harness, which maintains the hips in abduction, is the most widely used device for developmental dysplasia of the hip. An infant who continuously wears a Pavlik harness is at risk for skin breakdown, so parents should be instructed to check two to three times a day for red areas under clothing and harness straps. To avoid direct contact with the skin, clothing and diapers should be placed under the straps.

The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents?

Children of this age are comfortable with ritualism and display global thinking. Rationale: A 2-year-old is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddlers sensitivity to change is global thinking (change in one small part, such as a minor shift in room arrangement or changes in the whole environment), and the 2-year-olds composure disintegrates.

When plotting a 20-week-old infant's weight on a standardized growth chart, the nurse determines that the child's weight is between the 2nd and 3rd percentile. Based on this finding, which action should the nurse take?

Compare this weight with previous weights recorded in the child's record. Rationale: Evaluation of weight using a growth chart requires comparison of consistency of current weight with previous weight measurements. An infant is defined as having a "failure to thrive" if their height or weight falls below the 3rd percentile, but first the nurse should review the infant's health record to determine the infant's weight history.

An adolescent female's susceptibility to vulvitis is most likely related to which causative factor?

Contact with fabric dyes. Rationale: The most common skin disorder affecting the vulva is contact dermatitis caused by an irritant, such as fabric dyes, soaps or detergents, and feminine hygiene products.

During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate?

Delayed growth and development. Rationale: This child does not demonstrate gross motor or psychosocial skills typical of an 18-month-old toddler, which best supports delayed growth and development.

A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement?

Demonstrate feeding strategies and infant cues that indicate hunger and satiation. Rationale: NFTT most often occurs due to inadequate parent knowledge or a disturbance in maternal-child attachment, but the first goal for infants with NFTT is to provide nutrition to promote "catch-up" growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation.

The nurse observes a 4-year-old boy in a daycare setting. Which behavior should the nurse consider normal for this child?

Demonstrates aggressiveness by boasting when telling a story. Rationale: Four-year-old children are aggressive in their behavior and enjoy "tale telling"

The parents of a 3-week-old infant report that the child eats well but, vomits after each feeding. What information is most important for the nurse to obtain?

Description of vomiting episodes in past 24 hours. Rationale: A description of the vomiting episodes will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant.

While assessing an 18-month-old during a well-child visit, the nurse notes that the toddler has a rounded "pot-belly" abdomen, marked lordosis or swayback, short, slightly bowed legs, and a large head. Based on these findings, what action should the nurse implement?

Document general physical appearance of a normally developed toddler. Rationale: "Toddler lordosis" describes the normal upright posture found at this age, which is characterized by a pot belly, swayback, and short, slightly bowed legs.

What intervention should the nurse implement to help keep a 6-month-old infant calm during a physical assessment?

Encourage the parent to hold the infant. Rationale: Parents should be encouraged to participate by holding the infant as much as possible during an examination to calm and help the infant feel secure.

The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation?

Endowing the illness with meaning. Rationale: Coping mechanisms are behaviors directed at reducing the tension elicited by a crisis. Approach behaviors are coping mechanisms resulting in movement toward adjustment and resolution of the crisis. The parents' ability to assign the illness meaning within an existing medical, scientific, or spiritual philosophy of life is a long-term coping strategy significantly related to successful family functioning.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which approach by the nurse is most helpful in establishing communication?

Engage the child through drawing pictures. Rationale: Drawing pictures is a valuable form of non-verbal communication. It is easier for a child to express their emotions and feelings through the process of drawing than to express it verbally. As the nurse and child look at the drawings, a verbal story can be told that projects the child's thinking.

A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation?

Experiencing culture shock. Rationale: An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate.

The nurse is preparing to catheterize an 8-year-old child. Before starting the procedure, which action should the nurse take first?

Explain to the child and the parents that the procedure needs to be done. Rationale: An 8-year-old uses concrete operational thought (Piaget) and can cooperate and should be included in the explanation of the plan of care of the catherization.

What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki disease?

High risk for altered tissue perfusion, cardiopulmonary. Rationale: Kawasaki's disease (KD) is an acute systemic vasculitis that places the child at risk for coronary artery aneurysm, which is most likely to occur during the subacute phase, resulting in reduce cardiac output. Kawasaki disease causes rashes and desquamation of the hands and feet, but this is not as life-threatening as cardiac involvement.

The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC)antihistamine tablets an hour ago. What intervention should the nurse implement?

Initiate gastric lavage. Rationale: Gastric lavage should be implemented within 2 hours of ingestion to ensure gastric removal of a non-corrosive substance, such as an OTC antihistamine.

The nurse at the well-child clinic is advising the parents of an 8-month-old child about health and safety. What information should the nurse provide?

Install stair guards or gates in the home. Rationale: By the age of 8 months, a child is crawling and may be able to pull up to a standing position. The use of stair guards or gates is necessary to prevent accidents, which are the most common cause of injury among children of this age.

What is the best action for the nurse to take when initiating contact with a toddler for the first time?

Kneel in front of the toddler and speak softly to the child. Rationale: The toddler perceives the nurse as a stranger, so a more positive interaction occurs when the toddler perceives the meeting in a non-threatening way. Placing oneself at the toddler's eye level and speaking softly can be less threatening for the child. Asking direct questions, giving your name and telling the toddler you are the nurse or picking a toddler up at an initial meeting are perceived as threatening actions by the child and will more likely result in a negative response from the child.

A mother brings her 6-month-old infant to the clinic for a well-child checkup. She comments, "I want to go back to work, but I don't want my baby to suffer because I'll have less time at home." How should the nurse respond to the mother?

Let's talk about the child care options that are best for the child. Rationale: It is common for mothers to feel torn between their work and child and to have feelings of guilt. The nurse should assist the mother to explore her feelings on the subject while focusing on the optimal, appropriate, safe, and available options for her child.

The mother of a 2-month-old infant who just received the first DTaP asks the nurse what symptoms to expect. What is the best response for the nurse to provide?

Mild reactions are common and most frequently include low-grade fever. Rationale: The most common mild reactions to DTaP include low-grade fever, drowsiness, anorexia, local pain, swelling, and redness. These mild reactions to DTaP are common and are usually managed symptomatically with acetaminophen. Uncommon reactions following DTaP administration may occur. Uncommon reactions such as seizures and rash, which is more likely to occur after the varicella virus vaccine, should be reported to the healthcare provider.

A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding?

Normal growth curve of a breast-fed infant. Rationale: When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed differ from those who are formula fed.

A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?

Nystatin (Mycostatin). Rationale: Nystatin (Mycostatin) is an antifungal drug that is effective in treating thrush, an oral fungal infection.

During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing?

Object permanence. Rationale: Object permanence, learning that objects and people continue to exist even when they are no longer in sight, starts around the age of 7 months, when the infant learns to search for an object that is partially hidden but, does not search for one that is completely out of sight.

The nurse is developing a plan of care for a 10-year-old who is scheduled for a cardiac catheterization. Which intervention should the nurse implement to prepare the child for the procedure?

Obtain a video film of a cardiac catheterization to show to the child prior to the procedure. Rationale: School-age children and adolescents benefit from a description of the cardiac catheterization laboratory and a chronological explanation of the procedure, emphasizing what will seen, felt, and heard. Books, videotapes, or tours of the cardiac catheterization laboratory and procedure is the best option for this age group that is beginning to conceptualize. False reassurance is not therapeutic. Another child nor the parents should explain a medical procedure.

A 5-year-old child who is one day postoperative has bilateral eye patches in place and should be out of bed. What nursing intervention should be implemented first before leaving the bedside?

Orient the child to the immediate surroundings. Rationale: When sighted children temporarily lose their vision, many aspects of the environment becomes bewildering and frightening. To minimize the effects of temporary loss of vision, the child should be oriented immediately to the surroundings and should be told about the nurse's actions and any experiences that are felt or heard during procedures. The child and family should be reassured throughout every phase of treatment and encouraged to be independent (with assistance) in self-care activities, such as eating and bathing.

The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?

Pale bluish coloration of the toes. Rationale: Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the peroneal nerve and arteries that supply the foot. Assessment of adequate circulation, movement, and sensation of the toes and skin distal to the application is made to identify compromised blood flow, so cyanosis of the toes should be reported immediately.

A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement?

Place the child's hand under the examiner's hand while palpating. Rationale: Placing the child's hand on the abdomen with the examiner's hand on top of the child's hand gives the child control and reduces the sensation of tickling. Abdominal palpation is an integral part of the physical assessment and should not be postponed.

The nurse is assessing a child for neurological "soft" signs. Which finding is most likely demonstrated in the child's behavior?

Poor coordination and sense of position. Rationale: There is a gray area in neurologic assessment known as "soft signs," which are findings that are a mild or slight abnormality that is difficult to detect or interpret. Poor coordination and sense of position are classic signs that are consistent with the failure to perform age-specific tasks and represent the persistence of a more primitive neurological response.

The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding?

Poor skin turgor. Rationale: Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor, the skin remains tented or suspended for a few seconds before returning to a normal position.

When administering a gavage feeding to a school-age child, which action should the nurse implement?

Position the child on the right side after administering the feeding. Rationale: The child should be positioned on the right side with the head of the bed elevated 30 after administering the feeding to facilitate gastric emptying and prevent gastric reflux. Gavage feedings should be given to allow slow gastric filling over 15 to 30 minutes.

The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority?

Potential for fluid volume deficit. Rationale All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid.

A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority?

Prepare a set-up for an endotracheal intubation. Rationale: Diazepam causes respiratory depression, so preparation for endotracheal intubation to protect the airway is the priority intervention at this time.

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first?

Process of glucose testing. Rationale: Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer and to read the number (it is especially helpful if the nurse presents this activity as a game).

The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention?

Prolonged exhalations. Rationale: Prolonged exhalation indicates breathing difficulty, and intervention for this should be taken immediately. According to the American Heart Association- Pediatric Advance Life Support (PALS) algorithm a prolonged expiration in a pediatric client is indicative of lower airway obstruction.

A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent?

Provide clear explanations while encouraging questions. Rationale: Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions should be provided. An adolescent's modesty should be respected, so the presence of the parents at the bedside should be a choice made by the adolescent. An adolescent's ability to think abstractly engages problem solving, so the 14-year-old should be allowed to verbalized decisions about their care.

When caring for a child who has pertussis that is in the paroxysmal stage, which intervention should the nurse implement to support the child's nutritional needs?

Provide small, frequent meals. Rationale: The paroxysmal stage of pertussis is characterized by coughing with vomiting. Frequent small meals are vomited less often than larger meals.

A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement?

Quiet the child and retake the blood pressure. Rationale: When a child is crying, intra-thoracic and abdominal pressures increase and are reflected in an elevation of systemic blood pressure, so the nurse should quiet the child before retaking the blood pressure.

The nurse is developing the plan of care for a school-aged boy with a chronic disability. The child frequently cries about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important for the nurse to implement?

Recommend the use of consistent discipline and reward for acceptable behavior. Rationale: Focusing on the child, and not the condition, is essential in assisting the child to adapt to a chronic disability or illness. Consistent family rules should be used with a chronically ill child, such as setting boundaries for acceptable behavior, requiring participation in household activities, and fulfilling school responsibilities.

The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take when using adhesive tape?

Remove adhesives with water, mineral oil, or petrolatum. Rationale: The use of adhesives should be minimized as much as possible in the treatment of preterm neonates, so adhesives should be removed using water, mineral oil, or petrolatum. Due to the prematurity, the skin of the premature infant is fragile, delicate and thinner as compared to a full term infant and is easily traumatize.

After discussing the introduction of solid foods with the mother of a 6-month-old infant, the nurse determines that the mother understands the information when she states that the first food she gives the infant is from which food group?

Rice cereal. Rationale: Solid foods are usually introduced at about 6-months of age starting with rice cereal, which is the least allergenic. New foods should be introduce one at a time with about 5 days in between the each different food. If the infant has a sensitivity to a particular food item, it will easier to identify which one by spacing out new introduction of the new foods.

A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified?

Secure the antivenin. Rationale: A snake's venom contains neurotoxins which causes muscle paralysis and depression of the respiratory system. Antivenom is essential to the child's survival because the child is showing signs of envenomation. When a bite or envenomation is located on an extremity, the extremity should be immobilized. The use of a tourniquet is not recommended. Envenomation is a potentially life-threatening condition.

A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?

Serum BUN and creatinine levels. Rationale: Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids.

The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration?

Tachycardia. Rationale: In early dehydration (during the first 2 days), fluid loss occurs first from the extracellular and intravascular fluid spaces. so blood pressure falls and heart rate increases in response to a diminished blood volume.

The nurse observes the interactions of a 2-year-old child who says, "No," even when "Yes" is what the child really wants to say. The parent says to the nurse, "We, as parents, are such positive people, why is our child so negative?" How should the nurse respond?

The child is trying to assert autonomy through negativism. Rationale: As a toddler tests autonomy and ego boundaries, young children sometimes clash with parental restrictions, and responds with recital of prompts that parents often say. "No" is a favorite, repeated word and is the child's way of exploring autonomy through negativism.

The father of an 8-year-old child tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father?

The child should be given opportunities to achieve a sense of competency in an area he chooses. Rationale: According to Erickson, the developmental stage "Industry versus inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in. The father who wants his son to play soccer, does not need to decrease his expectations, but should be encouraged to shift the expectation to an activity the child takes pleasure in.

Which finding should the nurse in the emergency department identify as an indicator that a 3-year-old child has been mistreated?

The injury sustained is highly unusual for 3-year-old children. Rationale: An injury that is highly unusual or inconsistent with the age and condition of the child should raise suspicion of child abuse. If the description of the incident the caregivers give does not match the injury sustained or there are too many inconsistencies, then the nurse should be very vigilant in their assessment and documentation while maintaining professionalism with the parents.

What should the nurse assess last when examining a 5-year-old child?

Throat. Rationale: Examination of the mouth, throat, and perineum is considered to be more invasive than other parts of a physical examination, so invasive procedures, such as examination of the throat, should be left to the end of the examination for a preschooler.

Which action by the nurse is most helpful in communicating with a preschool-aged child?

Use a doll to play and communicate. Rationale: Communicating through play with a doll or other toy gives time for the child to feel comfortable with a stranger.

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement?

Use a happy-face/sad-face pain scale. Rationale: A 4-year-old can readily identify with simple pictures to show the nurse how he/she is feeling.

When conducting a hygiene class for adolescent girls, it is important for the nurse to include which instruction about preventing toxic shock syndrome?

Wash your hands before inserting a tampon. Rationale: The single most effective means of preventing infection is handwashing.

A 4-year-old boy is brought to the emergency department by his parent, who reports that the child has been pointing at his stomach and saying, "It hurts so bad." Which pain-assessment tool should the nurse use?

Wong-Baker FACES Scale. Rationale: A pain rating scale using pictures, such as the Wong-Baker FACES Scale, allows the child to choose a facial expression that shows "how much hurt you have now" and should be used for a pre-school-aged child.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that

a tympanic measurement of temperature will provide the most accurate reading. Rationale: A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! Rectal temperature measurement is less accurate because of the possibility of stool in the rectum.

When assessing a child with asthma, the nurse should expect intercostal retractions during

inspiration. Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways when a child is experiencing an asthma exacerbation.

When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it

stresses the suture line. Rationale: Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair.

A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?

"The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her." Rationale: The baby is at 35% FiO2 which is much more than room air (21% FIO2) and at this time the baby should not be moved from under the oxyhood. The nurse should offer the parents an alternative such as to stroke the infant and talking to the baby. The baby should recognize the parent's voices because at 5 months gestation in utero, the sense of hearing is developed. Even though, holding sick babies is beneficial and recommended for the infant and the parents, the infant's need for oxygenation has a higher priority at this time.

The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates a need for further teaching?

"Using a teaspoon will help me measure this correctly." Rationale: The prescribed medication is 4 ml per dosage and is measured with the most accuracy using an oral syringe, so if the parent uses a teaspoon, which is equivalent to 5 ml, further teaching is indicated.

Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?

A thin stratum corneum that increases topical absorption. Rationale: Infants have a thin outer skin layer (stratum corneum), so the nurse should monitor the infant for a prompt onset and response to the application of topical medication.

When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?

Cessation of growth in a child that had been normal. Rationale: Since the thyroid gland is responsible for metabolism, cessation of growth which was previously within normal range, is the most common sign for hypothyroidism in children.

The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?

Changes in level of consciousness. Rationale: The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma.

The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's repeated hospitalizations. Which is the best response that the nurse should offer?

Encourage the mother to have the children visit the hospitalized sibling. Rationale: Siblings of a sick child will often be scared, concerned or confused. Needs of a sibling will be better met with factual information and contact with the ill child, so sibling visitation should be encouraged. Children may have difficulty expressing concerns, so the support of parents and other caregivers are needed to help alleviate their fears.

A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization?

Explain hospital schedules to the child, such as mealtimes. Rationale: Altered daily schedules and loss of rituals are upsetting to school-aged children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules and establishing an individual schedule familiarizes the child to the hospital environment and should decrease the child's anxiety.

A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?

Explain that menarche varies and occurs between the ages of 12 and 18 years. Rationale: The nurse should provide a factual and reassuring explanation that focuses on individual variations of menarche, which can normally occur between 10 and 17 years of age.

During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?

Eye exams. Rationale: Visual changes leading to blindness can occur in children with juvenile idiopathic arthritis (JIA). The most common eye problem for clients with JIA is uveitis which can lead to glaucoma, cataracts, and permanent visual damage. These complications can be prevented if detected early, so it is important the parents are educated about the importance of eye exams for their child diagnosed wit JIA.

The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?

Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. Rationale: Familiarizing the child and mother with the department by visiting the cath lab and meeting the personnel there prior to the procedure day should help decrease anxiety of the child and mother (who may have more anxiety than the child).

What preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?

Observe for projectile vomiting. Rationale: In pyloric stenosis, the valve between stomach and small intestine enlarges blocking the passage of food. The nurse needs to ensure suctioning equipment is closed by to help prevent aspiration from the projectile vomiting episodes and monitor for the state of metabolic alkalosis, which is a classic sign of pyloric stenosis.

The nurse is planning care for school-aged children at a community care center. Which activity is best for the children?

Playing follow-the-leader. Rationale: School-aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader.

To take the vital signs of a 4-month-old child, which order will give the most accurate results?

Respiratory rate, heart rate, then rectal temperature. Rationale: The respiratory rate should be taken first in infants, since touching them or performing unpleasant procedures usually makes them cry, elevating the heart rate and making respirations difficult to count. Rectal temperature is the most invasive procedure, and is most likely to precipitate crying, so should be done last.

An 18-month-old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?

Ribbon-like and brown. Rationale: Hirschsprung's disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results from failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constipation and small diameter, brown-colored stools. Foul-smelling and fatty stool is associated with cystic fibrosis. Bile-colored and watery stool is common in gastroenteritis. Semi-solid and yellow stool is normal in breastfed neonates.

The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?

Risk for infection. Rationale: Chemotherapy (CT) suppresses phagocytotic neutrophils and places the child at risk for infection, which is the priority nursing diagnosis at this time.

The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?

Tympanic and oral temperatures are equally accurate. Rationale: A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies. The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media.

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?

Type of reaction to loud noises. Rationale: Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant.

The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation?

Use a colorful straw. Rationale: A liquid iron preparation should be administered through a straw to help prevent staining of the teeth and may help the child to accept the medication since young children consider drinking from a colorful straw fun.

The nurse is giving preoperative instructions to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?

"I understand that I will be in a body cast and I will show you how you taught me to turn." Rationale: Outcome of learning is best demonstrated when the client not only verbalizes an understanding, but can also provide a correct return demonstration.

The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?

12 to 15 months. Rationale: The first measles, mumps, and rubella (MMR) immunization should be given no sooner than 12 months of age, and ideally between 12 and 15 months of age. The second dose of MMR is routinely administered at 4 to 6 years old, providing that the first MMR immunization was administered between 12-15 months of age.

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider?

A 6-month-old with failure to thrive that has a closed anterior fontanel. Rationale: At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. Premature closure of the fontanels is a condition called "craniosynostosis". The only treatment for this condition is surgery to reopen the fontanels, to allow and accommodate the infant's growing brain, otherwise if not surgical corrected, the infant will suffer severe neurological damage.

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate?

A trial of human chorionic gonadotrophic hormone. Rationale: A trial of HCG (human chorionic gonadotrophic hormone) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex.

The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?

Administer aerosol therapy followed by postural drainage before meals. Rationale: Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and one hour before meals and/or at least 2 hours after eating to prevent nausea and vomiting and potential aspiration. Postural drainage uses gravity to promote mucous removal after the nebulization treatments has liquefied the secretions, therefore helps open the airways. Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily.

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?

Concern for body integrity. Rationale: The preschooler's major stressor is concern for his body integrity. He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity.

During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?

Ask the child if he/she has had a cold, runny nose, or any ear pain lately. Rationale: More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of history and related signs and symptoms is indicated for accurate interpretation of the findings.

A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information?

Children need to retain a sense of initiative without impinging on the rights and privileges of others. Rationale: Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others.

A full-term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited?

Choking, coughing, and cyanosis. Rationale: "Choking, coughing, and cyanosis" includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea. Esophageal atresia is a congenital birth defect in which there is no connection between upper esophagus and the lower esophagus and stomach. The upper esophagus ends in a blind pouch.

A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?

Congenital heart disease. Rationale: Congenital heart disease is the most common associated defect in children with Down syndrome. Clients with trisomy 21 are diagnosed with Down Syndrome. Clients affected by trisomy 13 are affected by a syndrome called "Patau's Syndrome" and clients with trisomy 18 are affected by a syndrome called "Edward's Syndrome". All three of these trisomy syndromes have some form of congenital cardiac anomalies present with these chromosomal defects.

While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is phasic with respirations, increasing during inspiration and decreasing with expiration. What action should the nurse take?

Continue the cardiac examination. Rationale: Sinus arrhythmia is characterized by phasic irregularity of the heart rate that occurs with changes in intrathoracic pressure during respiration and is a common phenomenon during childhood and adolescence. No intervention is required, and the nurse should continue with the cardiac exam.

A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first?

Determine the child's pulse and respirations. Rationale: The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs, in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary.

Which restraint should be used for a toddler after a cleft palate repair?

Elbow. Rationale: Elbow restraints prevent children from bending their arms and bringing their hands to the oral surgical site.

The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits?

Half of child's speech is understandable. Rationale: Between approximately 15 and 24 months of age, a child's speech is only half understandable. A child can begin counting and name colors usually between 3 and 5 years of age. And a child is capable of two - four word sentences between 18 months to 24 months of age.

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?

Have a bulb syringe readily available to remove secretions. Rationale: A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and having suction equipment at the crib side the highest priority to maintain a patent airway.

A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's?

Head and neck. Rationale: A child's head and neck are proportionately larger to their body than an adult's. The standard "Rule of Nines" is inaccurate for determining burned body surface areas with children, and must be modified for use with children. Specially designed charts for children are commonly used to determine body surface area involvement.

The nurse is assessing a 2-year-old child. What behavior indicates that the child's language development is within normal limits?

Is capable of making a three word sentence. Rationale: Normal language skills within the toddler development period is the ability of making two to three word sentences.

The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take?

Pass the information on in the report. Rationale: The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report.

The nurse must prevent a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?

Place elbow restraints on the child's arms. Rationale: Elbow restraints prevent arm flexion and the ability to reach to scratch the involved areas, but do not inhibit use of the hands for play activities.

A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care?

Plenty of fluids should be consumed daily. Rationale: Adequate fluid intake decreases the viscosity of the blood which helps decrease the incidence of vasocclusive crisis.

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?

Store all toxic agents and medicines in locked cabinets. Rationale: The only reliable way to prevent poisonings in young children is to make them inaccessible by storing them out of reach of children in locked cabinets.

Which class of antiinfective drugs is contraindicated for use in children under 8 years of age?

Tetracyclines. Rationale: Tetracyclines cause enamel hypoplasia and tooth discoloration in children under 8 years of age.

A nurse who is working in the Poison Control Center receives a telephone call from a parent of a 16-month old child who drank 2 ounces of acetaminophen (Children's Tylenol) elixir. What action should the nurse recommend to the parent?

Transport to emergency center for gastric decontamination. Rationale: Each 5 ml of Children's Tylenol Elixir contains 160 mg of acetaminophen, and this child has ingested twice the maximum recommended 24-hour dose, which can cause acetaminophen toxicity. The parent should transport the child to the emergency center for gastrointestinal decontamination and the possible administration of the antidote, acetylcysteine. Overdosing of Tylenol can cause serious liver damage.

What sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia?

Tachypnea. Rationale: Malignant hyperthermia, a potentially fatal autosomal genetic myopathy, can cause a change in vital signs that demands immediate attention in the perioperative period when these individuals are exposed to anesthetic agents. Early symptoms of the disorder include tachycardia and tachyarrhythmia, tachypnea, hypercarbia, and metabolic and respiratory acidosis. An elevated temperature is a late sign of the disorder.

An 8-year-old boy who is recently diagnosed with diabetes mellitus is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which nursing action has the highest priority?

Initiate an intravenous infusion. Rationale The priority for a child with DKA, an emergency life-threatening situation, is to obtain venous access for administration of fluids, electrolytes, and insulin. The child should be placed on a cardiac monitor and have serum electrolytes and glucose levels obtained, but not before initiating venous access.

A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take?

Administer tetanus toxoid booster. Rationale: After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered.

A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?

All the immunizations with the influenza vaccine given at a separate site from any other injection. Rationale: At 6-months of age, the routine immunizations include Hepatitis B, DTaP, Hib (Haemophilus influenza type b) , PCV (Pneumococcal), IPV (inactivated poliovirus) and influenza. To ensure the infant receives the influenza vaccine, it should be given that same visit, at a separate site from any other injection site.

All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child?

Assessing fontanels. Rationale: All of these interventions are used to evaluate fluid status in infants, but with a 20 month old, assessing the fontanels would not be appropriate. The posterior fontanel should be closed at 2 months and anterior fontanel closed by 18 months of age.

Which behavior would the nurse expect a two-year-old child to exhibit?

Display possessiveness of toys. Rationale: Two-year-old children are egocentric and unable to share with other children. Toddlers demonstrate "parallel" play where they will play alongside with others, but not with others.

The mother of a preschool-aged child asks the nurse if it is all right to administer bismuth subsalicylate (Pepto Bismol, Bismylate) to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?

Do not give if the child has chickenpox, the flu, or any other viral illness. Rationale: Pepto Bismol, Bismylate contains subsalicylate and if used in the presence of a viral illness, there is the potential of developing Reye's syndrome, a sometimes fatal condition for children.

The low-birth-weight (LBW) infant requires a neutral thermal environment. What action should the nurse implement?

Maintain a high-humidity atmosphere. Rationale: A neutral thermal environment with high humidity provides adequate warmth so the LBW infant can maintain a normal core temperature with minimum oxygen consumption and calorie expenditure. LBW infants are especially vulnerable to temperature instability due to they are usually premature and neurologically have difficulty maintaining their temperature and their skin has not mature enough to provide the adequate protection from heat and water-loss. A high-humidity atmosphere in an incubator contributes to body homeostasis by reducing evaporative heat loss and insensible water loss.

Which finding in a 19-year-old female client should trigger further assessment by the nurse?

Menstruation has not occurred. Rationale: Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs between the ages of 10 to 17, so the fact the client is 18 years old and has not experience menarche, should prompt further investigation to determine the cause of this primary amenorrhea.

A mother expresses concern to the nurse about the behavior of her 15-year-old adolescent who is frequently finding fault and criticizing her. What information should the nurse provide?

Teens create psychological distance from parents in order to separate from them. Rationale: Although a mutually respectful parent-adolescent relationship is important, an adolescent may use critical and fault-finding behavior as a mechanism to separate from the parent. Between the ages 15-17 years old, adolescents tend to have conflicts with their parents as they struggle with issues of independence and control as they mature towards late adolescence of 18-20 years old.

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take?

Tell the student to proceed directly to his regularly scheduled class. Rationale: This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100 F is normal for this student at this time. The student should attend class since no further nursing action is required.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?

Wash the hair and skin frequently with soap and hot water. Rationale: Washing the hair and skin with soap and hot water removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. Removing all blackheads and following with an alcohol scrub is contraindicated. The use of medicated cosmetics to help hide the blemishes should be used sparingly to avoid further blocking sebaceous gland ducts. A visit with the dermatologist may be encouraged if healthcare recommendations are not successful.

A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?

Wash the wound gently with mild soap and water. Rationale: A small, superficial laceration to the skin should be washed gently with mild soap and water for several minutes, followed by thorough rinsing. Washing the superficial laceration will help prevent an infection and/or tetanus. Hydrogen peroxide should be avoided because it can irritate the already injured tissue.

A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?

Sequestration. Rationale: The findings support a sequestration crisis, where blood pools in the spleen and sometimes in the liver, and is characterized by abdominal pain and anemia.

The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first?

Start an IV infusion of normal saline. Rationale: The current blood pressure reading of 80/40 mmHg and the decreased peripheral pulse volume indicates that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume. Normal range for blood pressure levels for 3-5 year olds according to the American Heart Association and the American Academy of Pediatrics if 104-116/63-74 mmHg dependent on the height and weight of the child. The other vital signs for the child are considered within normal limits; normal heart rate for a 3-4 year old at rest while awake is (80-120 beats per minute) and respirations for a 3-6 year old is (22-34 respirations per minute).

A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?

Steatorrhea. Rationale: Steatorrhea is defined as stools with an abnormally high fat content that are usually foul smelling and float on water. Cystic fibrosis is an autosomal recessive gene condition that affects the secretory glands and can affect many parts of the body. The digestion system is affected by blockage of the glands involved in digestion such as the pancreas and gall bladder which results in the presence of steatorrhea stools reflective of the fats not digested and absorbed in the child's intestines.

A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement?

Stop the infant breastfeeding. Rationale: Galactosemia is a rare genetic disorder that involves an inborn error of carbohydrate metabolism in which a hepatic enzyme, galactokinase, involved in the conversion of galactose to glucose is absent. Treatment consists of eliminating all lactose-containing foods, including breast milk, so the infant should stop breastfeeding. Soy protein formula is the feeding of choice during infancy.

During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?

Stop the infusion immediately and notify the healthcare provider. Rationale: The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified.

A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.)

1. Monitor the the infant's weight and number of wet diapers per day. 2. Increase the infant's intake per feeding by 1 to 2 ounces per week. 3. Allow the infant to rest and refeed on demand or every 2 hours. 4. Use a softer nipple or increase the size of the nipple opening. Rationale: Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day. A one-month old infant should ingest 2 to 4 ounces (60-120mL) of formula per feeding and progress to about 30 ounces (900mL) per day by 4-months of age. Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake. A softer (preemie) nipple or a larger slit in the nipple helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula because it is difficult to ensure that the total dose is consumed.

A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?

Apply pressure and ice for bleeding while elevating and resting the extremity. Rationale: Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression, and elevation (RICE).

The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit?

Clubbed fingers. Rationale: Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes due to tissue hypoxia. Tachycardia, not bradycardia , is a manifestation of congenital heart disease. A machinery murmur is a classic sign of ventricular septal defect. Weak pedal pulses are a characteristic of coarctation of the aorta.

A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child?

Remove restraints one at a time and provide range of motion exercises. Rationale: Removing restraints one at a time is safer than removing all of both at once. The child needs to exercise and should not be kept in restraints at all times and skin assessments and neurovascular checks should be done.

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family?

Polyuria and polydipsia. Rationale: Signs and symptoms of diabetes or hyperglycemia need to be reported. Clients who are receiving growth hormones should be monitored to detect elevated blood sugars and glucose intolerance.

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?

Prevent the return of oxygenated blood to the lungs. Rationale: VSDs are a common congenital heart defect which means there is a hole in the septum wall separating the left and right ventricles. Dependent upon the size of the hole, will impact how much of oxygenated blood is shunted over to the right ventricle of the heart, decreasing amount of oxygenated blood pumped out to the rest of the body. The closure of VSDs will stop the oxygenated blood from being shunted from the left ventricle to the right ventricle.

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan?

Consistently follow a set mealtime routine. Rationale: A 2-year-old child is comforted by consistency, so following a set mealtime routine and ensuring the child remains upright at least two hours after eating to reduce symptoms should help in alleviating the child's fear of experiencing GERD after eating.

When discussing discipline with the mother of a 4-year-old child, the nurse should include which guideline?

Parental control should be consistent. Rationale: Discipline should be a positive and necessary component of childrearing that is started in infancy and should teach socially acceptable behavior, help children protect themselves from danger, and channel undesirable behavior into constructive activity. Misbehavior may result from inconsistent rules or messages, so parental attention should be clear, reasonable, and consistent. The most important aspect of parenting is being consistent when raising a child, so it helps them to establish structure and boundaries. Structure and boundaries that are consistently followed through will help a child feel more secure and less anxious than no boundaries or consistency.