Peds (NCLEX-PN Book)

A mother of a 3-year-old child tells the nurse that the child has been continuously scratching the skin & has developed a rash. On data collection, which finding indicated that the child may have scabies? 1. Fine, grayish-red lines. 2. Purple-colored lesions. 3. Thick, honey-colored crusts. 4. Clusters of fluid-filled vesicles.

1. Fine, grayish-red lines. Rationale: Scabies appears as burrows or fine, grayish-red lines. They may be difficult to see if they are obscured by excoriation & inflammation. Purple-colored lesions may be indicative of various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo. Clusters of fluid-filled vesicles are seen in clients with herpes virus.

The nurse reviews the results of a tuberculin skin test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. How should the nurse interpret this result? 1. Positive. 2. Negative. 3. Inconclusive. 4. Definitive, requiring a repeat test.

1. Positive. Rationale: An induration that measures 10 mm or more is considered to be a positive result for children who are younger than 4 years old & for those with chronic illness or with a high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for those in the highest-risk groups.

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet? 1. Rice. 2. Oatmeal. 3. Rye toast. 4. Wheat bread.

1. Rice. Rationale: Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, & oats should be eliminated from the diet & replaced with corn & rice. Vitamin supplements, especially fat-soluble vitamins & folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be lifelong, although small amounts of grain may be tolerated after the gastrointestinal ulcerations have healed.

The nurse is assisting to develop 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. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Place the child in a prone position. 5. Move furniture away from the child. 6. Insert a padded tongue blade into the child's mouth.

1. Time the seizure. 3. Stay with the child. 5. Move furniture away from the child. Rationale: During a seizure, the child is placed on his or her side in the lateral position. This type of positioning will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury. The nurse would loosen clothing around the child's neck & ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury & to allow for the observation & timing of the seizure.

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action? 1. Turn the child on the side. 2. Notify the registered nurse (RN). 3. Administer the prescribed antiemetic. 4. Maintain nothing-by-mouth (NPO) status.

1. Turn the child on the side. Rationale: After a tonsillectomy, if bleeding occurs, the child is turned to the side, & the R.N. or H.C.P. is notified. An N.P.O. status would be maintained, & an antiemetic may be prescribed; however, the initial action would be to turn the child to the side.

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease? 1. "The femur is the most common site of this sarcoma." 2. "The child does not experience pain at the primary tumor site." 3. "If a weight-bearing limb is affected, then limping is a clinical manifestation." 4. "The symptoms of the disease during the early stage are almost always attributed to normal growing pains."

2. "The child does not experience pain at the primary tumor site." Rationale: Osteogenic sarcoma is the most common bone tumor in children. A clinical manifestation of osteogenic sarcoma is progressive, insidious intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable amount of pain from the tumor. Options 1, 3, & 4 are accurate regarding osteogenic sarcoma.

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home? 1. Leave diapers off to allow the site to heal. 2. Avoid tub baths until the stent has been removed. 3. Encourage toilet training to ensure that the flow of urine is normal. 4. Restrict the fluid intake to reduce urinary output for the first few days.

2. Avoid tub baths until the stent has been removed. Rationale: After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent the contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test & would most likely expect to note which finding? 1. Hematuria. 2. Bacteriuria. 3. Glucosuria. 4. Proteinuria.

2. Bacteriuria. Rationale: Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, & 4 are not characteristically noted with this condition.

The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome? 1. Hypotension. 2. Generalized edema. 3. Increased urinary output. 4. Frank, bright red blood in the urine.

2. Generalized edema. Rationale: Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, & edema. The urine is dark, foamy, & frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased, & the blood pressure is normal or slightly decreased.

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1. Watery diarrhea. 2. Projectile vomiting. 3. Increased urine output. 4. Vomiting large amounts of bile.

2. Projectile vomiting. Rationale: Signs & symptoms of pyloric stenosis include projectile, nonbilious vomiting, irritability, hunger & crying; constipation; & signs of dehydration, including a decrease in urine output.

The nurse should place the child who had a tonsillectomy in which position? 1. Supine position. 2. Side-lying position. 3. High Fowler's position. 4. Tendelenburg's position.

2. Side-lying position. Rationale: The child should be placed in a semiprone or side-lying position after tonsillectomy to facilitate drainage. Options 1, 3, & 4 will not achieve this goal.

The nurse provides information to the mother of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the mother indicates the need for further teaching regarding this disorder? 1. "Treatment needs to be started as soon as possible." 2. "I realize my child will require follow-up care until full grown." 3. "I need to bring my child back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every few weeks with my child for the casting.."

3. "I need to bring my child back to the clinic in 1 month for a new cast." Rationale: The treatment for clubfoot is started as soon as possible after birth. Serial manipulation & casting are performed as least weekly. If sufficient correction is not achieved withing 3-6 months, surgery is usually indicated. Because clubfoot can recur, all children with the condition require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

The nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? 1. Cracked lips. 2. A normal appearance. 3. Conjunctival hyperemia. 4. Desquamation of the skin.

3. Conjunctival hyperemia. Rationale: During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, & enlargement of the cervical lymph nodes. During the subacute stage, cracking lips & fissures, desquamation of the skin on the tips of the fingers & toes, joint pain, cardiac manifestations, & thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take? 1. Elevate the extremity. 2. Document the findings. 3. Notify the registered nurse. 4. Ambulate the child with crutches.

3. Notify the registered nurse. Rationale: Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding should be reported to the registered nurse or health care provider. Options 1, 2, & 4 are inappropriate & would delay the required & immediate interventions.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position to place this infant at this time is which? 1. A flat position. 2. A prone position. 3. On his or her left side. 4. On his or her right side.

3. On his or her left side. Rationale: After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case, it is best to place the infant on the left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

The nurse is assigned care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? 1. Keeping the weights hanging freely. 2. Ensuring that the ropes are in the pulleys. 3. Placing the bed linens on the traction ropes. 4. Ensuring that the weights are out of the child's reach.

3. Placing the bed linens on the traction ropes. Rationale: Bed lines should not be place on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, & 4 are appropriate measures when caring for a child who is in skeletal traction.

The nurse reinforces instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. The nurse should base the response on which information about mumps? 1. Respiratory isolation is not necessary. 2. Mumps is not transmitted by the respiratory system. 3. Respiratory precautions are indicated during the period of communicability. 4. Respiratory precautions are indicated for 18 days after the onset of parotid swelling.

3. Respiratory precautions are indicated during the period of communicability. Rationale: Mumps is transmitted via direct contact or droplets spread from an infected person & possibly by contact with urine. Respiratory precautions are indicated during the period of communicability. Options 1, 2, & 4 are incorrect.

The day care nurse is observing a 2-year-old child & suspects that the child may have strabismus. Which observation may be indicative of this condition? 1. The child has difficulty hearing. 2. The child does not respond when spoken to. 3. The child consistently tilts his or her head to see. 4. The child consistently turns his or her head to see.

3. The child consistently tilts his or her head to see. Rationale: The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Options 1,2, & 4 are not indicative of this condition.

The nurse reviews the record of a 3-week-old infant & notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which manifestation led the mother to seek health care for the infant? 1. Diarrhea. 2. Projectile vomiting. 3. The regurgitation of feedings. 4. Foul-smelling, ribbon-like stools.

4. Foul-smelling, ribbon-like stools. Rationale: Chronic constipation that begins during the first month of life & that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain & distention, & failure to thrive are also signs & symptoms. This disorder results in a decrease in passage of stool, so diarrhea would no be a presenting manifestation. Hirschbrung's disease affects the colon, so regurgitation & vomiting most often associated with esophageal & stomach pathology would not be presenting manifestations.

A child has been diagnosed with minigococcal meningitis. Which precautionary technique is appropriate to prevent transmission of the disease? 1. Enteric precautions. 2. Neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Isolation precautions for at least 24 hours after the initiation of antibiotics.

4. Isolation precautions for at least 24 hours after the initiation of antibiotics. Rationale: Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun & maintained for at least 24 hours after antibiotics are given. Options 1, 2, & 3 are incorrect.

A child is diagnosed with infectious mononucleosis. The nurse reinforces home care instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider (HCP) if the child develops a fever. 4. Notify the H.C.P. if the child develops abdominal or left shoulder pain.

4. Notify the H.C.P. if the child develops abdominal or left shoulder pain. Rationale: The parents need to be instructed to notify the H.C.P. if abdominal pain (especially in the left upper quadrant) or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until the splenomegaly resolves. Bed rest is not necessary, & children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol).

Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse reinforces instructions to the mother & tells the mother to administer the iron with which best food item? 1. Milk. 2. Water. 3. Apple juice. 4. Orange juice.

4. Orange juice. Rationale: Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Milk may affect absorption of the iron. Water will not assist in absorption. Orange juice contains a greatere amount of vitamin C than apple juice.

The nurse is reviewing the health record of a 1-year-old child who is suspected of having Hodgkin's disease. Which is the primary characteristic of this disease? 1. Fever & malaise. 2. Anorexia & weight loss. 3. Painful, enlarged inguinal lymph nodes. 4. Painless, firm, & movable lymph nodes in the cervical area.

4. Painless, firm, & movable lymph nodes in the cervical area. Rationale: Signs & symptoms specifically associated with Hodgkin's disease include painless, firm, & movable adenopathy in the cervical & supraclavicular areas. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, & malaise are associated with Hodgkin's disease, these manifestations are not the primary characteristics & are seen with many disorders.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? 1. Enteric. 2. Contact. 3. Protective. 4. Respiratory.

4. Respiratory. Rationale: Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory precautions are required, & a mask is worn by those who come in contact with the child. Gowns & gloves are not indicated. Articles that are contaminated should be bagged & labeled. Options 1, 2, & 3 are not indicated for rubeola.

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list? 1. Use anti-lice sprays on all bedding & furniture. 2. Use a pediculicide shampoo & repeat treatment in 14 days. 3. Launder all the bedding & clothing in cold water & dry on low heat. 4. Vacuum floors, play areas, & furniture to remove any hairs that may carry live nits.

4. Vacuum floors, play areas, & furniture to remove any hairs that may carry live nits. Rationale: Thorough home cleaning is necessary to remove any remaining lice or nits. Anti-lice sprays are unnecessary. Additionally, they should never be used on bedding, furniture, or a child. The pediculicide product needs to be used as prescribed, & the parents are instructed to follow package instructions for timing the application & for contraindications for their use in children. Bedding & linens should be washed with hot water & dried on a hot setting.

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child? 1. When the child is sleeping. 2. When changing the child's diapers. 3. When the mother is holding the child. 4. When drawing blood for electrolyte levels.

4. When drawing blood for electrolyte levels. Rationale: Oxygen administration may be prescribed for the infant with H.F. for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching? 1. "I will give my child cough syrup if a cough develops." 2. "During an attack, I will take my child to a cool location." 3. "I can give acetaminophen (Tylenol) if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

1. "I will give my child cough syrup if a cough develops." Rationale: Cough syrups & cold medicines are not to be given because they may dry & thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500-1,000 mL of fluids daily is important for thinning secretions.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. 3. Ensure that the infant's head is in a flexed position. 4. Wear a mask at all times when in contact with the infant. 5. Place the child in a tent that delivers warm, humidified air. 6. Position the infant side-lying, with the head lower than the chest.

1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. Rationale: The infant with R.S.V. should be isolated in a private room with another child with R.S.V. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head & chest at a 30-40-degree angle & the neck slightly extended to maintain an open airway & to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, & insensible water loss from tachypnea. Contact precautions (wearing gloves & a gown) reduce the nosocomial transmission of R.S.V.

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea & prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1. Rectal. 2. Axillary. 3. Electronic. 4. Tympanic.

1. Rectal. Rationale: Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis & cause more diarrhea. Axillary or tempanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood & notes colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing. 2. Notify the registered nurse (RN). 3. Document the findings & continue to monitor. 4. Circle the area of drainage & continue to monitor.

2. Notify the registered nurse (RN). Rationale: Colorless drainage on the dressing would indicate the presence of cerebrospinal fluid & should be reported to the R.N. immediately; the R.N. would then contact the health care provider. The colorless drainage should also be checked for evidence of cerebrospinal fluid; on method is to check for the presence of glucose using a dipstick. Options 1, 3, & 4 are incorrect & delay required immediate interventions.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic & the oxygen saturation reading drops to 60%. Which intervention should the nurse preform? Select all that apply. 1. Call a code blue. 2. Notify the registered nurse. 3. Place the infant in a prone position. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask.

2. Notify the registered nurse. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask. Rationale: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, & they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow & communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach to the heart. Toddlers & children squat to get into this position & relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, & intravenous fluids, as prescribed.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record & notes that which finding is associated with the diagnosis of glomerulonephritis? 1. Hypotension. 2. Red-brown urine. 3. Low urine specific gravity. 4. A low blood urea nitrogen (BUN) level.

2. Red-brown urine. Rationale: Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, & hypertension is also common. A mid- to high urinary specific gravity is associated with glo,erulonephritis. B.U.N. levels may be elevated.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of H.F.? 1. Pallor. 2. Cough. 3. Tachycardia. 4. Slow & shallow breathing.

3. Tachycardia. Rationale: The early signs of H.F. include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, & respiratory distress. A cough may occur with H.F. as a result of mucosal swelling & irritation, but it is not an early sign. Pallor may be noted in the infant with H.F., but it is also not an early sign.

The nurse is working in the emergency department & is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction? 1. Nasal flaring & bradycardia. 2. A low-grade fever & complaints of a sore throat. 3. The child thrusts the chin forward & opens the mouth. 4. The child leans backward, supporting himself or herself with the hands & arms.

3. The child thrusts the chin forward & opens the mouth. Rationale: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands & arms with the chin thrust out & the mouth open), nasal flaring, tachycardia, a high fever, & a sore throat.

The nurse is reviewing the health record of a child who has been recently diagnosed with glomerulonephritis. Which finding noted in the child's record is associated with the diagnosis of glomerulonephritis? 1. The child fell off a bike & onto the handlebars. 2. The child has had nausea & vomiting for the last 24 hours. 3. The child had urticaria & itching for 1 week before diagnosis. 4. The child had a streptococcal throat infection 2 weeks before diagnosis.

4. The child had a streptococcal throat infection 2 weeks before diagnosis. Rationale: Group A B-hemolytic streptococcal infection is a cause of glomerulonephritis. The child often becomes ill with strptococcal infection of the upper respiratory tract & then develops symptoms of acute poststreptococcal flomerulonephritis after an interval of 1-2 weeks. The data presented in options 1, 2, & 3 are unrelated to a diagnosis of glomerulonephritis.

The health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of H.I.V. antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray. 2. Western blot. 3. CD+ cell count. 4. p24 antigen assay.

4. p24 antigen assay. Rationale: The detection of H.I.V. in infants is confirmed by a p24 antigen assay, virus culture of H.I.V., or polymerase chain reaction. A chest x-ray evaluates the presence of other manifestations of H.I.V. infection, such as pneumonia. A Western blot test confirms the presence of H.I.V. antibodies. The CD4+ cell count indicates how well the immune system is working.

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching? 1. "I will place a steam vaporizer in my child's room." 2. "I will take my child out into the humid night air." 3. "I will place a cool-mist humidifier in my child's room." 4. "I will place my child in a closed bathroom & allow my child to inhale steam from the running water."

1. "I will place a steam vaporizer in my child's room." Rationale: Steam from warm running water in a closed bathroom & cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended as compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take? 1. Document the findings. 2. Notify the registered nurse immediately. 3. Change the ear tubes so that they do not become blocked. 4. Check the ear drainage for the presence of cerebrospinal fluid.

1. Document the findings. Rationale: After a myringotomy with the instertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, & 4 are not necessary.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child? 1. Drink half a cup of orange juice before soccer practice. 2. Eat twice the amount that is normally eaten at lunch time. 3. Take half the amount of prescribed insulin on practice days. 4. Take the prescribed insulin at noontime rather than in the morning.

1. Drink half a cup of orange juice before soccer practice. Rationale: An extra snack of 10-15 g of carbohydrates eaten before activities & for every 30-45 minutes of activity will prevent hypoglycemia. A half cup of orange juice will provide the needed carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration, & meal amounts should not be doubled.

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Frequent hand washing is important. 2. The child should avoid exposure to other illnesses. 3. The child's immunization schedule will need revision. 4. Kissing the child on the mouth will never transmit the virus. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, & diarrhea are expected to occur & do not require special intervention.

1. Frequent hand washing is important. 2. The child should avoid exposure to other illnesses. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). Rationale: A.I.D.S. is a disorder that is caused by the human immunodeficiency virus (HIV) & is characterized by a generalized dysfunction of the immune system. Both cellular & humoral immunity are compromised. The horizontal transmission of H.I.V. occurs through intimate sexual contact or parenteral exposure to blood or body fluids that contain visible blood. Veritical (perinatal) transmission occurs when an H.I.V.-infected pregnant woman passes the infection to her infant. Home care instructions include the following: frequent hand washing, monitoring for fever, malaise, fatigue, weight loss, vomiting, altered activity level, & oral lesions & notifying the health care provider if these occur; monitoring signs & symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight & providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; & avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently & away from food areas, & soiled disposable diapers are folded inward, closed with their tabs, & disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution made up of a 10:1 ratio of water to bleach.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply. 1. Pallor. 2. Edema. 3. Anorexia. 4. Proteinuria. 5. Weight loss. 6. Decreased serum lipids.

1. Pallor. 2. Edema. 3. Anorexia. 4. Proteinuria. Rationale: Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, & pallor. The urine volume is decreased, & the urine is dark & frothy in appearance. The child with this condition gains weight.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumorr. The nurse reviews the plan of care & should question which intervention that is written in the plan? 1. Palpate the abdomen for a mass. 2. Check the urine for the presence of hematuria. 3. Monitor the blood pressure for the presence of hypertension. 4. Monitor the temperature for the presence of a kidney infection.

1. Palpate the abdomen for a mass. Rationale: Wilms' tumor is an intraabdominal & kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor & thus cause the spread of the cancerous cells. Hematuria, hypertension, & fever are signs & symptoms that are associated with Wilms' tumor.

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever? 1. Patasia's sign. 2. Abdominal pain & flaccid paralysis. 3. Dense pseudoformation membrane in the throat. 4. Foul-smelling & mucopurulent nasal drainage.

1. Patasia's sign. Raionale: Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases & in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off & leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous & beefy red in color. Option 2 is associated with poliomyelitis. Option 3 & 4 are characteristics of diphtheria.

The nurse if reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Restrict fluid intake. 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply nasal oxygen at 2 L per minute. 5. Provide a high-calorie, high-protein diet. 6. Administer meperidine (Demerol) 25 mg for pain.

1. Restrict fluid intake. 6. Administer meperidine (Demerol) 25 mg for pain. Rationale: Sickle cell anemia is one of a group of diseases called hemoglobinopathies in which hemoglobin A is partly or completely replaced by abnormal sickle hemogloin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell, & insufficient oxygen causes the cells to assume a sickle shape; the cells become rigid & clumped together, thus obstructing capillary blood flow. Oral & intravenous fluids are important parts of treatment. Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, which is a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, & generalized seizures when it accumulates with repetitive dosing. Therefore, the nurse would question the prescriptions for the restricted fluids & meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, & a high-calorie, high-protein diet are important parts of the treatment plan.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric & will be receiving peritoneal dialysis treatment. The nurse should plan to include with intervention in the care of the child? 1. Restriction of fluids, as prescribed. 2. Administration of analgesics, as prescribed. 3. Monitoring the arteriovenous (AV) fistula. 4. Encouraging the intake of foods that are high in potassium.

1. Restriction of fluids, as prescribed. Rationale: H.U.S. is thought to be associated with bacterial toxins, chemicals, & viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, & central nervous system symptoms. A child with H.U.S. who is undergoing peritoneal dialysis for the treatment of anuria will be on fluid restrictions. Pain is not associated with H.U.S., & potassium would be restricted rather than encouraged if the child was anuric. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

After a tonsillectomy, which fluid or food item would be appropriate to offer to the child? 1. Yellow Jell-O. 2. Cold ginger ale. 3. Vanilla pudding. 4. Cherry Popsicle.

1. Yellow Jell-O. Rationale: After a tonsillectomy, cool liquids should be administered. Citrus, carbonated, & extremely hot or cold liquids need to be avoided because they may irritate the throat. Milk & milk products (pudding) are avoided because they coat the throat & cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided because they give the appearance of blood if the child vomits.

Isoniazid (INH) is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 1. 6 months. 2. 9 months. 3. 15 months. 4. 18 months.

2. 9 months. Rationale: Isoniazid is given to prevent tuberculosis (TB) infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventative therapy. In infants & children, the recommended duration of isoniazid therapy is 9 months. For children with human immunodeficiency virus infection, a minimum or 12 months is recommended.

The nurse is caring for an 18-month-old child who has been vomiting. The appropriate position to place the child during naps & sleep time is which? 1. A supine position. 2. A side-lying position. 3. Prone, with the head elevated. 4. Prone, with the face turned to the side.

2. A side-lying position. Rationale: The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, & 4 will place the child at risk for aspiration if vomiting occurs.

The nurse has reinforced home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicated the need for further teaching? 1. "A balance of rest & exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities during which the child could fall need to be avoided for 2-4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after this surgery."

2. "I can apply lotion or powder to the incision if it is itchy." Rationale: The mother should be instructed that lotions & powders should not be applied to the incision site because these items can affect the skin integrity & the healing process. Options 1, 3, & 4 are accurate instructions regarding home care after cardiac surgery.

A 4-year-old child sustains a fall at home & is brought to the emergency department by the mother. After an x-ray, it is determined that the child has a fractured arm, & a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further teaching? 1. "The cast may feel warm as it dries." 2. "I can use lotion or powder around the cast edges to relieve itching." 3. "A small amount of white shoe polish can touch up a soiled white cast." 4. "If the cast becomes wet, a blow-dryer set on the cool setting may be used to dry it."

2. "I can use lotion or powder around the cast edges to relieve itching." Rationale: The mother needs to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast because they can become sticky or caked & cause skin irritation. Options 1, 3, & 4 are appropriate instructions.

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child & the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching? 1. "Frequent hand washing is important." 2. "I need to provide a well-balanced, high-fat diet to my child." 3. "I need to clean contaminated household surfaces with bleach." 4. "Diapers should not be changed near any surfaces that are used to prepare food."

2. "I need to provide a well-balanced, high-fat diet to my child." Rationale: The child with hepatitis should consume a well-balanced, low-fat diet to allow the liver to rest. Options 1, 3, & 4 are components of the home-care instructions to the family of a child with hepatitis.

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching? 1. "I need to use proper hand-washing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions."

2. "I need to take my child's rectal temperature daily." Rationale: The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, & 4 are appropriate teaching measures.

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicated the need for further teaching? 1. "I need to have my child wear a soft fabric under the brace." 2. "I will apply lotion under the brace to prevent skin breakdown." 3. "I need to encourage my child to perform the prescribed exercises." 4. "I need to avoid applying powder under the brace, because it will cake."

2. "I will apply lotion under the brace to prevent skin breakdown." Rationale: The use of either lotions or powders should be avoided because they can become sticky or cake under the brace, thus causing irritation. Options 1, 3, & 4 are appropriate statements regarding the care of a child with a brace.

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply. 1. Administer a Fleet enema. 2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications. 6. Place a heating pad on the abdomen to decrease pain.

2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications. Rationale: During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix & reluctant peritonitis. Intravenous fluids would be started, & the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

The nurse, reinforcing home care instructions, prepares a list 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. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys & sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Place a heating pad on the lower end of the cast & over the fingers if the fingers feel cold. 5. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. 6. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling.

2. Keep small toys & sharp objects away from the cast. 5. Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. 6. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling. Rationale: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentation in the cast could occur & cause pressure on the underlying skin. Small toys & sharp objects are kept away from the cast, & no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, & the H.C.P. should be notified. The extremity is elevated to prevent swelling, & the H.C.P. is notified immediately if any signs of neurovascular impairment develop.

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother? 1. "Avoid all exercise during painful periods." 2. "The R.O.M. exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing the R.O.M. exercises.

3. "Have the child perform simple isometric exercises during this time." Rationale: During painful episodes, hot or cold packs, splinting, & positioning the affected joint in a neutral position help to reduce the pain. Although resting the extremity is appropriate, is it important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement.

The nurse is reinforcing discharge instructions to the mother of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the mother indicated that further teaching is needed? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be comfortable." 3. "I'll let him decide when to return to his play activities." 4. "I'll check his voiding to be sure there are no problems."

3. "I'll let him decide when to return to his play activities." Rationale: All vigorous activities should be restricted for 2 weeks after surgery to promote healing & prevent injury. This will prevent dislodging of the suture, which is internal. Normally 2-year-old children will want to be very active. Therefore, allowing the child to decide when to return to his play activities may prevent healing & cause injury. The parents should be taught to monitor the child's temperature; provide analgesics, as needed; & monitor the urine output.

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye, as prescribed." 3. "It is okay to share towels & washcloths." 4. "I need to give the eyedrops, as prescribed."

3. "It is okay to share towels & washcloths." Rationale: Bacterial conjunctivitis is highly contagious, & infection control measures should be taught; these include frequent hand washing & not sharing towels & washcloths. Options 1, 2, & 4 are correct measures.

A child is scheduled to receive a measles, mumps, & rubella (MMR) vaccine. The nurse, preparing to administer the vaccine, reviews the child's record. Which finding should make the nurse question the health care provider's prescription? 1. Recent recovery from a cold. 2. A history of frequent respiratory infections. 3. A history of an anaphylactic reaction to neomycin. 4. A local reaction at the site of a previous M.M.R. vaccine injection.

3. A history of an anaphylactic reaction to neomycin. Rationale: The M.M.R. vaccine contains minute amounts of neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to the M.M.R. vaccine. The general contraindication to all immunizations is a severe febrile illness. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is treated with cool packs for the first 24 hours after injection, & this is followed by warm or cool compresses if the inflammation persists.

A 6-month-old infant receives a diphtheria, tetanus, & acellular pertussis (DTap) immunization at the well-baby clinic. The mother returns home & calls the clinic to report that the infant has developed swelling & redness at the site of injection. Which instruction by the nurse is appropriate? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply an ice pack to the injection site. 4. Leave the injection site alone, because this always occurs.

3. Apply an ice pack to the injection site. Rationale: Occasionally tenderness, redness, or swelling may occur at the site of injection. This can be relieved with cool packs for the first 24 hours & followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention, but it is not specific to the subject of this question.

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1. Fats. 2. Zinc. 3. Calcium. 4. Thiamine.

3. Calcium. Rationale: Lactose intolerance is the inability to tolerate lactose, which is the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources or calcium &, if the child is an infant, protein & calories.

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1. Incessant crying. 2. Coughing at nighttime. 3. Choking with feedings. 4. Severe projectile vomiting.

3. Choking with feedings. Rationale: Any child who exhibits the "3 C's" - coughing & choking during feedings & unexplained cyanosis - should be suspected of having T.E.F. Options 1, 2, & 4 are not specifically associated with T.E.F.

Which laboratory result would verify the diagnosis of bacterial meningitis? 1. Clear cerebrospinal fluid with high protein & low glucose levels. 2. Cloudy cerebrospinal fluid with low protein & low glucose levels. 3. Cloudy cerebrospinal fluid with high protein & low glucose levels. 4. Decreased pressure & cloudy cerebrospinal fluid with a high protein level.

3. Cloudy cerebrospinal fluid with high protein & low glucose levels. Rationale: A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, & a low glucose level.

The nurse, caring for a child with aplastic anemia, is reviewing the laboratory results & notes a white blood cell (WBC) count of 6,000 cell/mm3 & a platelet count of 20,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care? 1. Encourage naps. 2. Encourage a diet high in iron. 3. Encourage quiet play activities. 4. Maintain strict isolation precautions.

3. Encourage quiet play activities. Rationale: Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, & abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the W.B.C. count was low. Naps & a diet high in iron are unrelated to the risk of bleeding.

A mother of a 6-year-old child with type 1 diabetes mellitus calls the clinic nurse & tells the nurse that the child has been sick. The mother reports that she checked the child's urine & it showed positive ketones. Which should the nurse instruct the mother to do? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3. Encourage the child to drink liquids. Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to help with clearing them. The child should be encouraged to drink liquids. It is not necessary to bring the child to the clinic immediately, & insulin doses should not be adjusted or changed.

The nurse reviews the record of a child who was just seen by a health care provider (HCP). The H.C.P. has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate? 1. Pallor. 2. Hyperactivity. 3. Exercise intolerance. 4. Gastrointestinal disturbances.

3. Exercise intolerance. Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, & dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 & 4 are not related to this disorder.

Which represents a primary characteristic of an autism spectrum disorder? 1. Normal social play/ 2. Consistent imitation of others' actions. 3. Lack of social interaction & awareness. 4. Normal verbal & nonverbal communication.

3. Lack of social interaction & awareness. Rationale: A primary characteristic of an autism spectrum disorder is a lack of social interaction & awareness. Social behaviors include a lack of or an abnormal imitation of others' actions & a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication & markedly abnormal nonverbal communication.

The nurse assists in planning care for a child who sustained a burn injury. The nurse plans care based on which accurate statement? 1. Scarring is not as severe in a child as in an adult. 2. Children are at a lower risk of infection than adults because of their strong immune system. 3. Lower burn temperatures & shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. 4. Infants & children are at decreased risk for protein & calorie deficiency because they have smaller muscle mass & less body fat than adults.

3. Lower burn temperatures & shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. Rationale: Lower burn temperatures & shorter exposure to heat can cause a more severe burn in a child than an adult because a child's skin is thinner. Scarring is more severe in a child; additionally, disturbed body image will be a distinct issue for a child or adolescent, especially as growth continues. An immature immune system presents an increased risk of infection for infants & young children. Infants & children are at increased risk for protein & calorie deficiency because they have smaller muscle mass & less body fat than adults.

The nurse is assigned care for a child after a spinal infusion for the treatment of scoliosis. The child complains of abdominal discomfort & begins to have episodes of vomiting. On data collection, the nurse notes abdominal distention. Which action should the nurse take? 1. Administer an antiemetic. 2. Increase the intravenous fluids. 3. Notify the registered nurse (RN). 4. Place the child in a side-lying Sims' position.

3. Notify the registered nurse (RN). Rationale: A complication after the surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents that can result from the lengthening of the child's body. It results in a syndrome of emesis & abdominal distention that is similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting among children with body casts or among those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Therefore, the remaining options are incorrect.

The nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which should be the appropriate nursing action? 1. Initiate strict enteric precautions. 2. Wear a mask when caring for the child. 3. Plan to move the infant to a room with another child with R.S.V. 4. Leave the infant in the present room, because R.S.V. is not contagious.

3. Plan to move the infant to a room with another child with R.S.V. Rationale: R.S.V. is a highly communicable disorder, but it is not transmitted via the airborne route. It is usually transferred by the hands, & meticulous hand washing is necessary to decrease the spread of organisms. The infant with R.S.V. is isolated in a single room or placed in a room with another child with R.S.V. Enteric precautions are not necessary; however, the nurse should wear a gown when the soiling of clothing may occur.

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure? 1. Measuring intake & output. 2. Administering anticholinergics. 3. Preventing infection at the surgical cite. 4. Applying cold, wet compresses to the surgical site.

3. Preventing infection at the surgical cite. Rationale: The most common complications associated with orchiopexy are bleeding & infection. The parents are instructed in postoperative home care measures, including the prevention of infection, pain control, & activity restrictions. The measurement of intake & output is not required. Anticholinergics are prescribed from the relief of bladder spasms; they are not necessary after orchiopexy. Cold, wet compresses are not prescribed. The moisture from a wet compress presents a potential for infection.

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which should be included in the plan? 1. Wear gloves when administering the eardrops. 2. Pull the ear up & back before instilling the eardrops. 3. Pull the earlobe down & back before instilling the eardrops. 4. Hold the child in a sitting position when administering the eardrops.

3. Pull the earlobe down & back before instilling the eardrops. Rationale: When administering eardrops to a child who is younger than 3 years old, the ear should be pulled down & back. For children who are older than 3 years old, the ear is pulled up & back. Gloves do not need to be worn by the parents, but hand washing needs to be performed before & after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

The nurse is reviewing the record of a child with increased intracranial pressure & notes that this child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities. 2. Adduction of the arms at the shoulders. 3. Rigid extension & pronation of the arms & legs. 4. Abnormal flexion of the upper extremities & extension & adduction of the lower extremities.

3. Rigid extension & pronation of the arms & legs. Rationale: Decerbrate (extension) posturing is characterized by the rigid extension & pronation of the arms & legs. Option 1 is incorrect. Options 2 & 4 describe decorticate (flexion) posturing.

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible hernial strangulation. The nurse tells the parents that which manifestation requires health care provider (HCP) notification by the parents? 1. Fever. 2. Diarrhea. 3. Vomiting. 4. Constipation.

3. Vomiting. Rationale: The parents of a child with a hernia need to be instructed about the signs or strangulation. These signs include vomiting, pain, & an irreducible mass. The parents should be instructed to contact the H.C.P. immediately if strangulation is suspected. Fever, diarrhea, & constipation are not associated with strangulation of a hernia.

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates an understanding of this disorder? 1. "P.K.U. is an autosomal-dominant disorder." 2. "P.K.U. primarily affects the gastrointestinal system." 3. "Treatment of P.K.U. includes the dietary restriction of tyramine." 4. "All 50 states require routine screening of all newborns for P.K.U."

4. "All 50 states require routine screening of all newborns for P.K.U." Rationale: P.K.U. is an autosomal-recessive disorder. Treatment includes the dietary restriction of phenylalanine intake (not tyramine intake). P.K.U. is a genetic disorder that results in central nervous system (CNS) damage from toxic levels of phenylalanine in the blood.

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of R.F.? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or a fever within the past 2 months?"

4. "Did the child have a sore throat or a fever within the past 2 months?" Rationale: Rheumatic fever (RF) characteristically presents 2-6 weeks after an untreated or partially treated group A B-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines if the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, & 3 are unrelated to R.F.

The nurse reinforces home-care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicated the need for further teaching? 1. "I will supervise my child closely." 2. "I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." 4. "I will avoid immunizations & dental hygiene treatments for my child."

4. "I will avoid immunizations & dental hygiene treatments for my child." Rationale: The nurse needs to stress the importance of immunizations, dental hygiene, & routine well-child care. Options 1, 2, & 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma (especially trauma that involves the joints), & they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement by a parent indicates the need for further teaching? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the health care provider." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose." Rationale: The parents need to be instructed that if the child vomits after the digoxin is administeredm they are not to repeat the dose. Options 1, 2, & 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed & it is not noticed until 4 hours later, the dose should not be administered.

The parents of a newborn have been told that their child was born with bladder exstrophy, & the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy? 1. "It is a hereditary disorder that occurs in every other generation." 2. "It is caused by the use of medications taken by the mother during pregnancy." 3. "It is a condition in which the urinary bladder is abnormally located in the pelvic cavity." 4. "It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."

4. "It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall." Rationale: Bladder exstrophy is a congenital anomaly that is characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is unknown, & there is a higher incidence among males. Options 1, 2, & 3 are not characteristics of this disorder.

A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for H.I.V. infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get H.I.V. Which response by the nurse is appropriate? 1. "I'm also pleased that everything has turned out fine." 2. "Since symptoms have not developed, it is unlikely that the infant will develop H.I.V. infection. 3. "Everything looks great, but be sure that you return with your infant next month for the scheduled visit." 4. "Most children infected with H.I.V. develop symptoms withing the first 9 months of life, & some become symptomatic at some point before the age of 3 years.

4. "Most children infected with H.I.V. develop symptoms withing the first 9 months of life, & some become symptomatic at some point before the age of 3 years. Rationale: Most children who are infected with H.I.V. develop symptoms within the first 9 months of life. The remainder of these infected children become symptomatic sometime before the age of 3 years. Children, with their immature immune systems, have a much shorter incubation period than adults. Option 1, 2, & 3 are incorrect responses.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system. 2. An inflammation of the brain as a result of a viral illness. 3. A congenital condition that results in moderate to severe retardation. 4. A chronic disability characterized by impaired muscle movement & posture.

4. A chronic disability characterized by impaired muscle movement & posture. Rationale: Cerebral palsy is a chronic disability characterized by impaired movement & posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

A nursing student is assigned to help administer immunizations to children in a clinic. The nursing instructor asks the student about the contraindications to receiving an immunization. Immunization is contraindicated in the presence of which condition? 1. A cold. 2. Otitis media. 3. Mild diarrhea. 4. A severe febrile illness.

4. A severe febrile illness. Rationale: A severe febrile illness is a reason to delay immunization but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea are not contraindications to immunization.

Acetylsalicylic acid (asprin) is prescribed for a child with rheumatic fever (RF). The nurse should question this prescription if the child had documented evidence of which condition? 1. Arthralgia. 2. Joint pain. 3. Facial edema. 4. A viral infection.

4. A viral infection. Rationale: Anti-inflammatory agents, including asprin, may be prescribed by the health care provider for the child with R.F. Asprin should not be given to a child who has chickenpox or other viral infections such as influenza because of the risk of Reye's syndrome. Option 1 & 2 are clinical manifestations of R.F. Facial edema may be associated with the development of a cardiac complication.

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation & thus the need to notify the registered nurse? 1. Bradypnea. 2. Diaphoresis. 3. Decreased blood pressure (BP). 4. A weight gain of 1 lb in 1 day.

4. A weight gain of 1 lb in 1 day. Rationale: A weight gain of 0.5 kg (1 lb.) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, & report the weight gain. Tachypnea & an increase B.P. would occur with fluid accumulation. Diaphoresis is a sign of H.F.; but it is not specific to fluid accumulation, & it usually occurs with exertional activities.

A corticosteroid cream is prescribed by a health care provider for a child with atopic dermatitis (eczema). The nurse reinforces instructions to the mother regarding how to apply the cream. Which instruction is appropriate? 1. Apply the cream over the entire body. 2. Apply a thick layer of cream to affected areas only. 3. Avoid cleansing the area before applying the cream. 4. Apply a thin layer of cream, & rub it into the area thoroughly.

4. Apply a thin layer of cream, & rub it into the area thoroughly. Rationale: Corticosteroid cream should be applied sparingly & rubbed into the area thoroughly. The affected area should be cleansed gently before application. The cream should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

Permethrin (Elimite) is prescribed for a 4-year-old child with a diagnosis of scabies. The nurse reinforces instructions to the mother regarding the use of this treatment. Which instruction is appropriate? 1. Apply the lotion & leave it on for 4 hours. 2. Apply the lotion to the hair, face, & the entire body. 3. The child should wear no clothing while the lotion is placed. 4. Apply the lotion to cool, dry skin at least half an hour after bathing.

4. Apply the lotion to cool, dry skin at least half an hour after bathing. Rationale: Permethrin is applied from the neck downward, with care taken to ensure that the soles of the feet, the areas behind the ears, & the areas under the toenails & fingernails are covered. The lotion should be kept on for 8-14 hours, & then the child should be given a bath. The lotion should be applied at least 30 minutes after bathing, & it should be applied only to cool, dry skin. The child should be clothed during treatment.

The nurse is caring for a child with a diagnosis of intussusception. Which manifestation should the nurse to expect to note in this child? 1. Watery diarrhea. 2. Ribbon-like stools. 3. Profuse projectile vomiting. 4. Blood & mucus in the stools.

4. Blood & mucus in the stools. Rationale: The child with intussusception classically presents with severe abdominal pain that is crampy & intermittent & that causes the child to draw in his or her knees to the chest. Vomiting may be present, but is not projectile. Bright red blood & mucus are passed through the rectum & commonly described as currant jelly-like stools. Ribbon-like stools are not a manifestation of this disorder.

The nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which is the priority when performing this procedure? 1. Taking the temperature. 2. Taking the blood pressure. 3. Checking the apical heart rate. 4. Checking the peripheral pulse in the affected arm.

4. Checking the peripheral pulse in the affected arm. Rationale: The neurovascular check for tissue perfusion is performed on the toes or fingers distal to an injury or cast & includes checking peripheral pulse, color, capillary refill time, warmth, motion, & sensation. Options 1, 2, & 3 may be components of care, but they are not the priority in this situation.

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis? 1. Veggie salad & a caramel apple. 2. Strawberry jelly sandwich & pretzels. 3. Plate of nachos & cheese & a cupcake. 4. Chicken tenders & a baked potato with butter.

4. Chicken tenders & a baked potato with butter. Rationale: Children with C.F. are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, & fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. Chicken tenders & a baked potato with butter provide a high-calorie & high-protein meal that includes fat.

The nurse reinforces instructions to the mother of a child with sickle cell disease regarding the precipitating factors related to pain crisis. Which, if identified by the mother as a precipitating factor, indicates the need for further teaching? 1. Stress. 2. Trauma. 3. Infection. 4. Fluid overload.

4. Fluid overload. Rationale: Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5-2 times the daily requirements to prevent dehydration.

The nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. Which action would best assist in determining the cause of the seizure? 1. Testing the child's urine for specific gravity. 2. Asking the child what happens during a seizure. 3. Obtaining a family history of psychiatric illness. 4. Obtaining a history regarding factors that may occur before the seizure activity.

4. Obtaining a history regarding factors that may occur before the seizure activity. Rationale: Fever & infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5 years old. Dehydration & electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.

The nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, which is a priority intervention? 1. Taking the apical pulse. 2. Taking the blood pressure. 3. Testing the urine for protein. 4. Palpating the anterior frontanel.

4. Palpating the anterior frontanel. Rationale: A full or bulging anterior frontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse & blood pressure changes & proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

A child is diagnosed with Reye's syndrome. The nurse assists to develop a nursing care plan for the child & should include which intervention in the plan? 1. Assessing hearing loss. 2. Monitoring urine output. 3. Changing body position every 2 hours. 4. Providing a quiet atmosphere with dimmed lighting.

4. Providing a quiet atmosphere with dimmed lighting. Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness & is characterized pathologically by cerebral edema & fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring & managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue & neuron responses. Hearing loss & urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema & promote drainage of cerebrospinal fluid.

The nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The H.C.P. performs the Ortolani maneuver. Which best describes the reason for performing the Ortolani maneuver? 1. Determining the extent of range of motion. 2. Checking for asymmetry on the affected side. 3. Pushing the unstable femoral head out of the acetabulum. 4. Reducing the dislocated femoral head back into the acetabulum.

4. Reducing the dislocated femoral head back into the acetabulum. Rationale: With the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive Ortolani maneuver is a palpable clunk as the femoral head moves over the acetabular ring. Option 1 & 2 are data collection techniques for the identification of the clinical manifestations of hip dysplasia, but they do not describe the Ortolani maneuver. When performing the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum.

A child has a basilar skull fracture. Which health care provider's prescription should the nurse question? 1. Restrict fluid intake. 2. Insert an indwelling urinary catheter. 3. Keep an intravenous (IV) line patent. 4. Suction via the nasotracheal route as needed.

4. Suction via the nasotracheal route as needed. Rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake & output. An I.V. line is maintained to administer fluids or medications, if necessary.