Peds NCLEX Q&A Questions

A child is seen in the health care clinic, and the clinic nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen?

"I need to place a piece of transparent cellophane tape lightly over the rectum area as soon as my child awakens and bring it to the clinic for examination."

A child is diagnosed with acute poststreptococcal glomerulonephritis, and renal insufficiency is suspected. Which laboratory result should the nurse expect to note documented in the child's record?

An elevated blood urea nitrogen (BUN) and creatinine

The nurse is creating a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. Which instruction should the nurse include in the plan of care?

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

A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion?

Cerebral palsy is a chronic disability characterized by difficulty with muscle control.

The nurse is providing home care instructions to the parents of an infant recovering from surgical repair of an inguinal hernia. What should the nurse instruct the parents to do to prevent infection at the surgical site?

Change the diapers as soon as they become damp.

The nurse is developing a plan of care for a child who has skin lesions accompanied by a rash and pruritus. What problem has the highest priority when considering health risks?

Diminished skin integrity due to scratching from pruritus

The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?

Assist the child to put on a cotton sleep shirt

A 12-month-old child has just returned from the recovery room after a palatoplasty. The nurse performs an assessment and determines that which finding requires further intervention and indicates a need for follow-up?

Clove-hitch restraints are secured to the arms.

The nursing student is providing care to a preschooler diagnosed with an immunocompromised condition. The nursing instructor is reviewing with the nursing student a list of potential immunizations to be administered to this client. Which immunizations should the nursing student identify as safe to administer to this client? Select all that apply.

DTaP Influenza Meningococcal

The nurse performs an assessment of a child with pertussis (whooping cough). Which finding should the nurse identify as indicative of a potential complication?

Decreased breath sounds in the lung bases

The nurse is caring for an infant admitted to the hospital with a diagnosis of hemolytic disease. Which finding should the nurse expect to note in this infant when reviewing the laboratory results?

Decreased red blood cell count

The nurse is doing discharge teaching with a client diagnosed with sickle cell disease. The nurse instructs the client to avoid which situations that could precipitate a sickle cell crisis? Select all that apply.

Dehydration Exposure to infection High altitudes

The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what?

Deteriorating neurological function

The nurse is assigned to care for a child with a diagnosis of irritable bowel syndrome. The nurse reviews the child's medical record, expecting to note documentation of which assessment finding?

Diffuse abdominal pain unrelated to meals or activity

The nurse creates a plan of care for an infant with bladder exstrophy. The nurse prioritizes the plan of care and selects which as the priority?

Diminished tissue integrity

The nurse is assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup. The nurse notes that the respiratory rate is 30 breaths per minute. Which nursing action is appropriate?

Document the findings

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

Document the findings

The nurse assessing the vital signs of a 3-year-old child hospitalized with a diagnosis of croup notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate?

Document the findings according to facility policies.

The nurse caring for a child diagnosed with kidney disease is analyzing the child's laboratory results and notes a sodium level of 148 mEq/L (148 mmol/L). On the basis of this finding, which clinical manifestation should the nurse expect to note in the child?

Dry, sticky mucous membranes

A school-aged child diagnosed with type 1 diabetes mellitus tells the nurse that his soccer practice will begin soon. The nurse develops a teaching plan for the child regarding food, medication, and exercise. Which instruction should the nurse provide to the child?

Eat an extra snack of carbohydrates before the soccer starts.

The nurse is providing instructions to the mother of a child with a diagnosis of megaloblastic anemia. Which dietary sources of vitamin B12 should the nurse instruct the mother to include in the diet?

Eggs

An infant diagnosed with spina bifida cystica (meningomyelocele type) has had the sac surgically removed. The nurse plans which intervention in the postoperative period to maintain the infant's safety?

Elevating the head with the infant in the prone position

The nurse develops a plan of care for a 1-month-old infant diagnosed with intussusception. Which nursing measure would be most effective to provide psychosocial support for the parent-child relationship?

Encourage the parents to room-in with their infant.

A child diagnosed with type 1 diabetes mellitus becomes flushed, hungry, and dizzy while at school. The child goes to the nurse's office, and the nurse obtains a blood glucose level of 60 mg/dL (3.42 mmol/L). The nurse analyzes the assessment data and determines which intervention to be most appropriate?

Ensure that the child drinks a glass of orange juice.

A 16-year-old client is admitted to the hospital with hyperglycemia from failure to follow a diet, insulin, and glucose monitoring regimen. The client states, "I'm fed up with having my life ruled by doctors' prescriptions and drugs." The nurse identifies that the client is experiencing which problem?

Failure to care for self because of feelings of loss of control

The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?

Hypertrophic pyloric stenosis

The nurse is creating a plan of care for a newborn diagnosed with bilateral club feet. Which information should the nurse plan to include in the parents education?

If casting is needed, it will begin at birth and continue for 12 weeks, at which time the condition will be reevaluated.

The nurse develops a plan of care for an adolescent being admitted to the hospital for treatment of a slipped capital femoral epiphysis (SCFE). What is the appropriate problem for this client?

Impaired mobility and confinement to bed

The nurse is providing discharge instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, what should be the appropriate response to the mother?

In 3 weeks

The nurse is assessing for the presence of bleeding in a child diagnosed with leukemia. A decrease in which laboratory result will assist the nurse in planning appropriate care?

Platelets

The nurse is caring for a child after tonsillectomy. Which positions should the nurse plan to place the child in? Select all that apply.

Prone Left side lying Right side lying

The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?

Prone with the neck hyperextended

An important goal for a child with a deficiency in factor VIII is to relieve pain caused by bleeding into the joints. Which intervention should the nurse expect to be prescribed to achieve this goal?

Provide for joint immobilization.

An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action should the nurse instruct the mother to take to minimize the infant's risk for condition-related injury?

Provide meticulous skin care to the infant and change the infant's diaper after each voiding or stool.

A child with a diagnosis of Reye's syndrome is being admitted to the hospital. The nurse develops a plan of care for the child that includes which priority nursing action?

Providing a quiet environment with dimmed lighting

The nurse is caring for a child with increased intracranial pressure after head trauma resulting from a motor vehicle crash. The child is scheduled for a craniotomy due to a depressed skull fracture. In the preoperative period, the primary nursing action should be to assess which parameter?

Pupillary responses to light

The nurse is caring for a child with osteosarcoma after amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. What is the initial nursing action?

Reassure the child that this is a normal feeling and will go away.

The nurse caring for a 9-month-old child after cleft palate repair has applied elbow restraints to the child. The mother visits the child and asks the nurse to remove the restraints. Which is the appropriate nursing action?

Remove a restraint from one extremity.

he nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?

Report the passage of a normal brown stool to the primary health care provider.

he nurse is caring for a child after cleft palate repair. To reduce the risk of aspiration after feeding the child, what is the best position for the nurse to place the child in?

Right side in semi-Fowler's

The nurse is assisting in the care of a child who underwent a surgical repair of a cleft lip the previous day. Which nursing action should the nurse implement when caring for the surgical incision?

Rinse the incision with sterile water after using prescribed solution.

The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?

Rinsing the incision with sterile water after feeding

A community health nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse should stress which action as the first step in the treatment plan?

Shower the child immediately, lathering and rinsing the child several times.

The nurse is caring for a child with Reye's syndrome. On assessment, what should the nurse plan to monitor for first?

Signs of increased intracranial pressure

The nurse is caring for a child with a ventricular septal defect, and the parents ask the nurse about the treatment for this disorder. On what information should the nurse base the response?

Some defects may close spontaneously.

The nurse teaches the parents of a child with celiac disease about foods that need to be avoided because they contain gluten. The nurse tells the parents that which item needs to be avoided?

Spaghetti

After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?

Sterile water

An emergency department nurse is performing an assessment on a child who has a fever of 102° F (38.9° C). Which finding should be of most concern to the nurse?

Stiff neck

he nurse prepares for the admission of the child with a diagnosis of tonic-clonic seizures and plans to place which items at the bedside?

Suction apparatus and oxygen

The nurse is teaching parents of a diabetic child the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse include in the teaching session? Select all that apply.

Sweating Dizziness Trembling

The clinic nurse is providing instructions to the mother of a child with impetigo. The nurse instructs the mother to notify the primary health care provider if which sign occurs?

Swelling around the eyes

The nurse is developing a plan of care for a child diagnosed with hemophilia. Which evaluative statement developed by the nurse indicates a positive outcome for this specific child?

The child experiences no long-term complications from injury or bleeding.

The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?

The child has limited interaction with the environment unless aroused.

A home care nurse visits a child with a diagnosis of celiac disease. Which finding best indicates that a gluten-free diet is being maintained and has been effective?

The child is free of diarrhea.

The camp nurse provides instructions regarding skin protection from the sun to the parents who are preparing their children for a camping adventure. Which statement by a parent indicates a need for further instructions?

"My child won't need the sunscreen on cloudy, hazy days."

The parents of an infant diagnosed with pyloric stenosis ask the nurse why their child developed the disorder. Which statement should the nurse make to the parents to address their concern?

"Pyloric stenosis is caused by a structural problem and there really isn't anything you could have done to prevent it."

The nurse is interviewing the parents of a newborn infant who has spina bifida (myelomeningocele). Which statement by the parent would indicate the need to discuss coping issues?

"Should we tell our friends about the baby?"

A mother states to the nurse, "I am afraid that my child might have another febrile seizure." Which therapeutic statement is best for the nurse to make to the mother?

"Tell me what frightens you the most about seizures."

The nursing instructor is teaching a group of nursing students about mumps. The nursing instructor knows additional teaching is required if a nursing student suggests which intervention be included in the plan of care?

"The client will be given a regular diet."

A nursing student is assigned to care for a child who is in Dunlop traction. The nursing instructor reviews the plan of care with the student. Which statement by the student indicates a need for further teaching?

"The elbow should be flexed at a 30-degree angle with the forearm in a neutral position."

The mother of the child with a diagnosis of hepatitis B calls the health care clinic to report that the jaundice seems to be worsening. Which response should the nurse make to the mother?

"The jaundice may appear to get worse before it begins to resolve."

The nurse has provided information to the parents of a child diagnosed with congenital hypothyroidism about the disorder and care of the child. Which statement by the parents indicates the need for further information?

"The only reason this happened to my child is because I took asthma medicine while I was pregnant."

A child diagnosed with rheumatic fever is admitted to the hospital. The nurse prepares to manage which clinical manifestations of this disorder? Select all that apply.

1. Cardiac murmur 2. Cardiac enlargement 5. Small nontender lumps on bony prominences 6. Purposeless jerky movements of the extremities and face

A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.

1. Edema 2. Proteinuria 4. Abdominal pain 5. Increased weight 6. Hypoalbuminemia

A school-age child has a history of upper respiratory infection (URI) accompanied by a sore throat, and the primary health care provider suspects rheumatic fever. The nurse identifies which of the modified Jones criteria as being used to diagnose rheumatic fever? Select all that apply.

1. Evidence of streptococcal infection 4. The presence of two major manifestations of rheumatic fever 6. The presence of one major and two minor manifestations of rheumatic fever

The nurse is assisting a school-aged client with type 1 diabetes mellitus to plan meals. Which recommendations should the nurse make to this client? Select all that apply.

1. Limit concentrated sweets. 3. Consume snacks between meals and at bedtime. 4. Plan to eat a larger snack during active times of the day.

The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 × 109/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.

1. Monitor stools for blood. 2. Clean oral cavity with soft swabs. 3. Provide appropriate play activities.

Which interventions are appropriate to include in the plan of care for a child after a tonsillectomy? Select all that apply.

1. Offer clear, cool liquids when awake. 2. Administer pain medication as prescribed. 3. Monitor for bleeding from the surgical site. 5. Initially eliminate milk or milk products from the diet.

The nurse is caring for a client with a cervical fracture who has been placed in Crutchfield tongs. Which activities should the nurse implement when caring for the child? Select all that apply.

1. Performs pin care every shift 2. Checks neurological status frequently 3. Logrolls the child when repositioning 5. Checks the tongs for displacement and looseness frequently

The nurse explains to the parents of a child with cystic fibrosis (CF) that which are complications of this disease process? Select all that apply.

1. Pneumonia 2. Pneumothorax 3. Pulmonary infection. 5. Bleb and cyst development in the lungs

A school-aged child sustains a fracture of the femur and was placed in skeletal traction. What interventions should the nurse include when planning care for the child. Select all that apply.

1. Provide pin insertion site care as prescribed. 4. Monitor color, motion, and sensation of the affected extremity. 5. Monitor the insertion sites for redness, swelling, drainage, or increased pain.

The nurse is caring for a child diagnosed with a patent ductus arteriosus (PDA). The nurse reviews the health care record and plans care, knowing that which findings are characteristic of this type of disorder? Select all that apply.

1. Pulmonary blood flow is increased. 3. Oxygenated and unoxygenated blood mix. 5. Blood is shunted to the right side of the heart.

The nurse is assigned to care for a child with a diagnosis of atrial septal defect. The nurse plans care knowing that which description is characteristic of this type of defect? Select all that apply.

1. Right atrial and ventricular enlargement occurs. 2. Signs and symptoms of decreased cardiac output may occur. 4. It is an opening between the two atria and allows oxygenated and unoxygenated blood to mix.

The nurse employed in a well-baby clinic is preparing to administer the scheduled recommended immunizations to a 2-month-old infant. After consultation with the pediatrician, the nurse should prepare to administer which vaccines at this time? Select all that apply.

1. Rotavirus (RV) 2. Pneumococcal (PCV) 3. Inactivated poliovirus (IPV) 5. Haemophilus influenzae type b conjugate (Hib) 6. Diphtheria and tetanus toxoids and acellular pertussis (DTaP)

An adolescent is diagnosed with scoliosis. Which statements regarding scoliosis are correct? Select all that apply.

1. Scoliosis is an abnormal lateral curvature of the spine. 2. Scoliosis is most typically diagnosed in the adolescent child. 3. Surgical intervention may be necessary when severe curves exist. 6. Selection of instrumentation systems to be used during surgery depends on client needs and surgeon's preferences.

A nursing student is asked to conduct a clinical conference on roseola infantum (exanthema subitum). Which information should the nursing student include in this conference? Select all that apply.

1. The peak age to develop this condition is 6 to 15 months of age. 2. The child displays a high fever for 3 to 4 days, but appears well. 4. The incubation period for this communicable disease is 5 to 15 days. 5. A precipitous drop in fever is followed by the development of a rash.

The nurse provides instructions to the mother of a child diagnosed with an iron deficiency anemia regarding the administration of prescribed oral iron. How should the nurse instruct the mother to administer the iron?

Between meals

The clinic nurse is reviewing the record of a child scheduled for follow-up care. Before the assessment of the child, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans the assessment to focus on which area?

Bladder function

A child is admitted to the hospital with a suspected diagnosis of von Willebrand's disease. On assessment of the child, which symptom would most likely be noted?

Bleeding from the mucous membranes

A child is admitted to the hospital with a suspected diagnosis of bacterial endocarditis. The child has been experiencing fever, malaise, anorexia, and a headache. Which diagnostic study will confirm the diagnosis?

Blood culture

The registered nurse is discussing care of an infant diagnosed with a patent ductus arteriosus (PDA) with a nursing student. The registered nurse determines that the nursing student needs further teaching regarding a PDA when the student states that which circulatory change is a characteristic of this disorder?

Blood is shunted to the left side of the heart

A child was diagnosed with acute poststreptococcal glomerulonephritis and renal insufficiency. Which laboratory result should the nurse expect to note in the child?

Blood urea nitrogen (BUN) 22 mg/dL (7.92 mmol/L) and creatinine levels of 2.1 mg/dL (185 mcmol/L)

A child is admitted to the hospital with a suspected diagnosis of idiopathic thrombocytopenic purpura (ITP) and diagnostic studies are performed. Which diagnostic result is indicative of this disorder?

Bone marrow exam showing increased megakaryocytes

A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?

Bruising behind the ear

The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?

Bulging anterior fontanelle

A 2-year-old toddler has just returned from surgery where a hip spica cast was applied. Which nursing action will best maintain the child's skin integrity?

Changing the toddler's diapers every 2 hours.

A home care nurse visits a child with Reye's syndrome and plans to provide instructions to the mother regarding care of the child. Which measure should the nurse instruct the mother to take?

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

A nurse witnesses a child fall from a moving swing in the playground. The nurse rushes to help the child and on quick assessment suspects an extremity fracture. In order of priority, which actions would the nurse take? Place the actions in order of priority. All options must be used.

Check the extent of the injury and neurovascular status. Immobilize the affected extremity. Elevate the injured extremity. Apply cold packs to the injured area. Transport to the nearest emergency department.

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

Checking the urine for protein every 4 hours

A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis?

Continuous drooling

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). What findings does the nurse anticipate to find during the assessment? Select all that apply.

Cool lower extremities Increased blood pressure in the upper extremities Signs of a recent epistaxis noted when examining the nares

The nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant if which intervention is performed?

Covering the bladder with a sterile, nonadhering moist dressing

A mother brings her 5-month-old daughter into the pediatrician's office with reports that the child has been vomiting during feedings and is sometimes very fussy. What would be the initial action by the nurse?

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

The nurse is caring for an adolescent client with a diagnosis of conjunctivitis. Which instruction is most appropriate for the nurse to relate to the adolescent?

Obtain a new set of contact lenses for use after the infection clears.

The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 a.m., the child suddenly reports being weak and having a headache and blurred vision. Which action should the nurse take immediately?

Obtain blood glucose reading

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

One-half cup of fruit juice

A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority client problem is that the client is at risk for infection because of the immunosuppressed state. Which intervention should the nurse include in the plan of care?

Oral hygiene 4x daily

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

Orange juice Glucose tablets Candy

The nurse is assigned to care for a child diagnosed with hemophilia. When reviewing the results of the prescribed laboratory tests, which test should the nurse anticipate to be abnormal?

PTT

The nurse is admitting an infant with diagnosis of gastroenteritis to the hospital for treatment of dehydration. The nurse notes that the health care provider has documented that the infant is mildly dehydrated. The nurse should expect to note which assessment finding in the infant?

Pale skin color

After hydrostatic reduction for intussusception, the nurse should expect to observe which effective response in the client?

Passage of barium or water-soluble contrast with stools

When obtaining a history from parents of a 5-month-old child suspected of having intussusception, which assessment area should be most important for the nurse to address?

Pattern of abdominal pain

The parent of a toddler diagnosed with acute lymphocytic leukemia (ALL) tells the nurse that the child has developed epistaxis. The nurse advises the parent to immediately take which action?

Place the child in an upright and leaning forward position.

To prepare a school-aged child with cerebral palsy (CP) for school, the nurse should establish goals to help the child achieve maximum potential for locomotion, self-care, and socialization. What action will assist the nurse in achieving these goals?

Placing the child on a wheeled scooter board or similar device to allow independent movement

A nursing instructor is reviewing with a nursing student the postoperative care of a child with a surgical repair of epispadias. The nursing instructor asks the student about postoperative interventions. The nursing instructor determines that further teaching is required if the student includes which intervention?

The nurse will notify the surgeon if there is no urinary output for 3 hours as that may be caused by a kink in the urinary diversion.

The home care nurse is providing instructions to a child with cystic fibrosis about how to perform the "huff" maneuver, and the child asks the nurse about the purpose of this type of breathing. Which information would the nurse give to the child?

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

The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition?

Tissue hypoxia

A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?

To bring the child to the clinic to be seen by the primary health care provider

The nurse is providing discharge instructions to the parents of a child who has had heart surgery. What should the nurse tell the parents?

To call the primary health care provider if the child has difficulty breathing

The nurse provides discharge instructions to the mother of a child who was hospitalized for heart surgery. Which instruction should the nurse provide to the mother?

To notify the primary health care provider if the child develops a fever

A mother brings her child to the emergency department because an insect has flown into the child's ear. The child confirms hearing a buzzing sound in the ear. What should the nurse do first?

Use a flashlight to coax the insect out of the ear.

The nurse is giving instructions to an 8-year-old child regarding measures to take to identify the early signs of an asthma episode. What instruction would be important for the nurse to give the child?

Use a peak flowmeter to measure for a drop in the expiratory flow rate.

A child with a diagnosis of umbilical hernia has been scheduled for surgical repair in 2 weeks. The clinic nurse instructs the parents about the signs of possible hernia strangulation. The nurse tells the parents that which sign requires primary health care provider notification?

Vomiting

The mother of a 4-week-old infant is concerned because the child has been frequently vomiting forcefully after meals. The primary health care provider suspects pyloric stenosis. Which clinical manifestation should the nurse expect to note upon further interview of the mother?

Vomitus contains sour undigested food but no bile, the infant is constipated, and visible peristaltic waves move from left to right across the abdomen.

The nurse is reviewing a plan of care prepared by a nursing student for an infant being admitted to the hospital with a diagnosis of congestive heart failure. Which intervention should the nurse recognize as needing revision?

Wake the infant for feedings to ensure adequate nutrition.

The nurse is performing an assessment on a child admitted to the hospital with a diagnosis of nephrotic syndrome. What should the nurse expect to note during the assessment?

Weight gain

A child is brought to the emergency department after being bitten on the arm by a neighborhood dog. Which is the priority question for the nurse to ask the parent of the child?

"Are the child's immunizations up-to-date?"

A mother of a child with mumps calls the primary health care clinic to tell the nurse that the child has been very lethargic and has been vomiting. Which is the appropriate response for the nurse to make to the mother?

"Bring the child to the clinic to be seen by the primary health care provider."

The nurse is performing an assessment of a 9-year-old child suspected of having a brain tumor. Which question should the nurse ask to elicit data related to a characteristic sign/symptom of a brain tumor?

"Do you feel sick to your stomach, and do you throw up in the morning?"

The nurse is performing an assessment on a child admitted to the hospital with a diagnosis of rheumatic fever. The nurse asks the mother which initial question when gathering data about the disorder?

"Has any family member had a sore throat or fever within the past few weeks?"

The nurse is collecting data on a child suspected of having rheumatic fever. The nurse plans to obtain specific data regarding recent illnesses in the child and asks the parent which question?

"Has the child had a recent streptococcal infection of the throat?"

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

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

A mother tells the nurse that she refuses to have her child immunized because of a fear that serious injury will result. To assess the basis of the mother's concern, the nurse makes which appropriate response to the mother?

"I can see you are very concerned about your child. What are you afraid that might happen after an immunization is given?"

Which comment made by the parents of a male infant who will have a surgical repair of a hernia indicates a need for further teaching by the nurse?

"I don't know if he will be able to father a child when he grows up."

The nurse caring for a child admitted to the hospital with a diagnosis of viral pneumonia describes the treatment plan to the parents. The nurse determines the need for further teaching when the parents make which statement regarding the treatment?

"It's important that the child isn't allergic to the antibiotic that is prescribed."

A 12-year-old child comes into the clinic for the measles, mumps, rubella (MMR) vaccine for entry into the sixth grade. The nurse asks the mother if the child has had any changes in health since last seen. Which statement by the mother would indicate a potential contraindication to the MMR immunization?

"My child developed hives and difficulty in breathing when prescribed neomycin sulfate for acne."

The nurse provides instructions regarding home care to a parent of a 3-year-old child who has been hospitalized with hemophilia. Which statement by the parent indicates the need for further teaching?

"My child should not have any immunizations."

The nurse provides home care instructions to the mother of a child with glomerulonephritis. Which statement by the mother indicates a need for further instructions?

"I need to be sure to increase my child's intake of fluids."

In the health care clinic, an adolescent is diagnosed with Epstein-Barr virus (infectious mononucleosis). The clinic nurse provides the client's parent with instructions regarding the care of the adolescent. Which statement by the parent indicates an understanding of the care measures?

"I need to call the primary health care provider if my child complains of abdominal pain or left shoulder pain."

The clinic nurse is providing instructions to the parents of a child with a urinary tract infection. The nurse determines that the parents need additional teaching if which statement is made?

"I need to encourage my child to hold the urine and to urinate no more than 4 times a day."

The nurse provides instructions to a mother regarding the care of her 10-year-old child who has pharyngitis. Which statement by the mother indicates a need for further instructions?

"I need to return to the clinic tomorrow for a repeated throat culture."

The nurse provides home care instructions to the mother of an infant with a diagnosis of hydrocephalus. Which statement by the mother indicates an understanding of the care of the infant?

"I need to support my infant's neck and head."

The nurse instructs a mother on measures to take to reduce the incidence of gastroesophageal reflux disease (GERD) in a child. Which statement by the mother indicates a need for further teaching?

"I will buy bottle nipples that have smaller holes for my child."

The nurse is caring for a child who experienced a head injury. The nurse is monitoring the child for signs of increased intracranial pressure (ICP) and informs the mother about the measures to monitor for and prevent increased ICP. Which statement by the mother would indicate a need for further teaching?

"I will encourage my child to drink plenty of fluids."

The nurse is providing instructions to the mother of an infant who is seen in the clinic for recurrent episodes of otitis media. Which statement by the mother should indicate an understanding of the methods to decrease the risk of reoccurrence?

"I will feed my infant in an upright position."

The clinic nurse provides home care instructions to a mother regarding the care of her child who is diagnosed with croup. Which statement by the mother indicates the need for further instructions?

"I will give cough syrup every night at bedtime."

The nurse provides instructions to a mother regarding the care of her child, who is diagnosed with croup. Which statement by the mother indicates a need for further instructions?

"I will give my child cough syrup every night at bedtime so that she will sleep well."

An adolescent client is preparing for discharge after spinal fusion with instrumentation for the treatment of scoliosis. Which statement by the adolescent indicates the need for further teaching?

"I will not be able to go rollerblading for the first few weeks after surgery."

The home care nurse is instructing the mother of a child diagnosed with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which statement, if made by the mother, indicates an understanding of the administration of this medication?

"I will use a medicine dropper to place the iron near the back of the throat."

A 2-month-old infant has just had the recommended immunizations at the pediatrician's office. The nurse provides the mother with home care instructions regarding the immunizations. Which statement by the mother indicates that she needs further teaching?

"If my baby develops a high fever, I will give children's ibuprofen."

The nurse is providing instructions to an adolescent who is taking phenytoin for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication?

"If my gums become sore, I need to stop the medication."

The nurse is providing instructions to the parent of a child who had a myringotomy with insertion of tympanostomy tubes. Which instructions should the nurse provide the parent in case the tubes fall out?

"It is not an emergency, but it is best to call the health care clinic."

A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it has been decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement is most appropriate to assist in alleviating the child's fear?

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

Propylthiouracil is prescribed for a child diagnosed with hyperthyroidism and the nurse provides instructions to the mother regarding the side/adverse effects of the medication. Which statement by the mother indicates a need for further teaching?

"This yellow skin discoloration will disappear when the medication is discontinued."

The nurse implements preventive teaching with the parents of an infant with recurring acute otitis media. Which statement indicates that more teaching is needed?

"We stopped giving the antibiotics to the baby when her fever subsided."

The nurse is caring for a 7-year-old child with glomerulonephritis and discusses the plan of care with the parents. Which statement by the mother indicates a need for further teaching?

"We will remove all salt from our child's diet."

The home care nurse visits the family of a 2-year-old child who was recently discharged from the hospital after treatment for nephrotic syndrome. Which statement by the parents indicates that there is a need for further teaching?

"We're giving him his prednisone whenever he gains more than a pound a day."

A preschooler has just been diagnosed with impetigo. The child's mother tells the nurse, "But my children take baths every day." Which therapeutic response should the nurse make to the mother?

"You are concerned about how your child got impetigo?"

The nurse caring for a child diagnosed with patent ductus arteriosus is asked by the parents to provide them with information on the management of this disorder. What is the appropriate nursing response? Select all that apply.

1. "Closure may occur spontaneously." 5. "Indomethacin is sometimes used to promote ductal closure."

The clinic nurse is teaching an adolescent diagnosed with type 1 diabetes mellitus about the proper administration of insulin. Which statement by the adolescent indicates a need for further teaching? Select all that apply.

1. "I should give my injections only in my thighs." 3. "I should place any unopened insulin vials in the freezer."

The nurse is assisting in planning an educational session regarding rubella (German measles) for the parents of school children. What is the incubation period that the nurse should share with the parents?

14 to 21 days

The health care provider has prescribed a continuous insulin infusion to be initiated for a hospitalized child in diabetic ketoacidosis. The prescription is to administer regular insulin at a dosage of 0.1 units/kg/hr. What is the correct dose if the child weighs 44 lb? Fill in the blank.

2 units/hr

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

2. "Which manifestations of this condition do you find most troublesome?" 4. "The manifestations are lessened by taking the prednisone every other day instead of daily." 5. "The cushingoid appearance will gradually disappear once the corticosteroids are tapered and discontinued."

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

2. Atenolol 3. Propranolol 4. Methimazole

The nurse is caring for a child with a diagnosis of atrioventricular canal defect. The nurse plans care knowing that the child will experience which characteristics of this disorder? Select all that apply.

2. Crying-induced cyanosis 3. Mild to moderate heart failure 5. The mixing of oxygenated and unoxygenated blood

Which clinical manifestations are consistently observed in infants who have been diagnosed with congenital hypothyroidism? Select all that apply.

2. Hoarse cry 3. Bradycardia 4. Constipation 6. Excessive sleeping

A mother of a 6-year-old child arrives at the emergency department stating that the child has been complaining of a sore throat. The child has a high fever, and acute epiglottitis is diagnosed. The emergency department nurse plans care knowing that what is a clinical manifestation associated with this disorder? Select all that apply.

2. There is an absence of spontaneous cough. 3. It causes swelling and inflammation of the epiglottis. 5. The client presents with dysphonia, dysphagia, dyspnea, and drooling.

An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client's neurovascular status? Select all that apply.

3. Ability to move all extremities 4. Capillary refill in all extremities 5. Ability to flex and extend the feet 6. Ability to detect sensations in all extremities

The nurse is caring for a child after an inguinal hernia repair. Which finding should indicate that the surgical repair was effective? Select all that apply.

3. Absence of abdominal distention 5. Crying does not result in inguinal swelling

The nurse is caring for a child with a suspected diagnosis of acute laryngotracheobronchitis (croup). The nurse reviews the assessment data in the child's record, knowing that which findings are characteristic of this disorder? Select all that apply.

3. Associated with inspiratory stridor 4. Causes swelling and inflammation of the vocal cords 5. Has a gradual onset that usually worsens during the night

The nurse is caring for a hospitalized child with a documented diagnosis of rheumatic fever. The nurse reviews laboratory results, knowing that which results are indicative of rheumatic fever? Select all that apply.

3. Elevated C-reactive protein 4. Elevated anti-streptolysin O titer 5. Elevated erythrocyte-sedimentation rate

The clinic nurse is assessing a child who was brought to the clinic with reports of severe abdominal pain. The child is suspected of having acute appendicitis. What assessment findings would the nurse expect? Select all that apply.

3. Elevated white blood cell count 4. Rebound tenderness and abdominal rigidity 5. Referred pain indicating the presence of peritoneal irritation

A parent of a 9-year-old child newly diagnosed with diabetes mellitus is very concerned about the child going to school and participating in social events. The nurse creating a plan of care should formulate which goals to address these concerns? Select all that apply.

4. The child and family will integrate diabetes care into patterns of daily living. 5. The child and family will discuss their concerns with the child's teachers and the school nurse.

In planning care for a child diagnosed with contact dermatitis, which client problem would have the highest priority?

Acute pain from skin inflammation

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

825 mL

A child sustains a greenstick fracture of the humerus from a fall out of a tree house. The nurse describes this type of fracture to the parents and should provide them with which picture? Refer to figure.

A

The nurse is monitoring a child diagnosed with type 1 diabetes mellitus for complications of the disorder. Which assessment data would be an indicator of the Somogyi effect in this child?

A 3:00 a.m. blood glucose level of 60 mg/dL (3.42 mmol/L), followed by a 7:00 a.m. blood glucose level of 180 mg/dL (10.2 mmol/L)

The nurse is performing an admission assessment of a 6-month-old infant suspected of having hydrocephalus. Which finding should the nurse expect to note that is associated with this diagnosis?

A bulging anterior fontanel

The nurse is measuring the head circumference of an infant on the fifth postoperative day after surgical placement of a ventricular peritoneal shunt for the correction of hydrocephalus. The nurse notes that the head circumference measurement has increased by 1 cm over the past 24 hours. The nurse analyzes this assessment data as which finding after this surgical procedure?

A complication related to the functioning of the shunt

A child is seen in the emergency department with a diagnosis of possible bacterial meningitis (fulminating meningococcemia). Which finding should the nurse specifically expect to note in this infection?

A fine rash with some bruising

The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?

A gluten-free diet will need to be followed for life.

The nurse is monitoring a child after spinal fusion for the treatment of scoliosis for complications related to the procedure. The nurse prepares to monitor for superior mesenteric artery syndrome by assessing the child for which sign/symptom?

Abdominal discomfort and episodes of vomiting

Which assessment finding should the nurse expect to note in the child hospitalized with a diagnosis of nephrotic syndrome?

Abdominal pain

The mother whose child is generally alert and participates well in classroom activities is concerned that the teacher now reported that the child has frequent periods during the day when he appears to be staring off into space. The nurse should suspect that the child has which problem?

Absence seizures

On assessment, the school nurse notes that the child has a rash. The nurse suspects that the child has erythema infectiosum (fifth disease), because the skin assessment revealed a rash that has which characteristics?

An erythema on the face that has a "slapped face" appearance

The nurse is caring for a child diagnosed with erythema infectiosum (fifth disease). Which clinical manifestation should the nurse expect to note in the child?

An intense fiery red edematous rash on the cheeks

The nurse is caring for a child admitted to the hospital with a diagnosis of viral pneumonia. The nurse describes the treatment plan to the parents and determines the need for further teaching if the parents indicate that which is part of the treatment?

Antibiotics

The nurse is teaching a mother about follow-up care for her 6-month-old child, who just received a third diphtheria, tetanus, and pertussis (DTaP) immunization. The nurse should stress which information to the mother?

Any unusual side effects should be reported immediately to the primary health care provider.

The nurse caring for an infant demonstrating diarrhea should monitor the infant for which early sign of dehydration?

Apical pulse rate of 200 beats per minute

The nurse is caring for a child after a tonsillectomy and notes that increased fluid intake is prescribed. Which fluid is appropriate for the nurse to offer to the child?

Apple juice

The nurse is providing instructions to a parent of a 10-year-old child diagnosed with hemophilia regarding appropriate activities. The nurse tells the mother that which activity should be safe for the child to participate in?

Archery

A child with croup is admitted to the hospital, and the pediatrician prescribes a cool-mist tent. The child is fearful and crying. Which nursing intervention is appropriate?

Ask the mother to bring the child's favorite toy from home.

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

Assessing the anterior fontanel for bulging

The clinic nurse is performing an assessment of a 5-month-old infant suspected of having unilateral developmental dysplasia of the hip (DDH). Which assessment finding should the nurse expect to note in this condition?

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

The nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus (HIV) infection. The nurse instructs the mother to notify the primary health care provider if which occurs in the child? Select all that apply.

Fever Vomiting Coughing

The nurse is planning care for an infant with a diagnosis of an encephalocele located in the occipital area. Which item should the nurse use to assist with positioning the child to avoid pressure on the encephalocele?

Foam half donut

Which action by the nursing student, caring for a child who sustained a head injury from a fall, indicates a need for further teaching?

Forcing fluids

A hospitalized adolescent client diagnosed with type 1 diabetes mellitus is experiencing high glucose levels upon awakening in the morning. The nurse reviews the client's chart and determines that the client is experiencing the Somogyi effect, if which is present? Refer to chart.

Glucose level at 2 a.m. of 65 mg/dL (3.7 mmol/L)

The nurse is developing a plan of care for a child diagnosed with rubella (German measles). In gathering items to provide direct care to the child, what should the nurse obtain? Select all that apply.

Gown Mask Gloves Biohazard bags

The nurse is caring for a child recovering from a tonsillectomy. Which fluid or food item should be offered to the child?

Green Jell-O

The registered nurse is discussing care of a child with acute laryngotracheobronchitis (croup) with a nursing student. The registered nurse determines that the nursing student needs further teaching regarding this disorder if the student states that which finding is a clinical characteristic of LTB?

Has a sudden onset and usually occurs during the day

The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?

Have cool water available to add to the warm bath water.

The nurse has provided instructions to the parents of a child diagnosed with diabetes mellitus about management of hypoglycemia. The nurse determines that the family understands the instructions if they indicate that they will take which action?

Have the child carry LifeSavers with him whenever he leaves the home.

A parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding?

Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.

The nurse is performing an assessment on a child, and the parents report the presence of ribbon-like and foul-smelling stools, episodes of constipation since birth, and poor feeding habits. The nurse notes a distended abdomen. Based on these data, the nurse analyzes these signs/symptoms as indicative of which condition?

Hirschsprung's disease

The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?

Inability to expectorate secretions

The nurse is preparing a plan of care for the child diagnosed with beta thalassemia. Which problem should the nurse identify as a priority for this client?

Inadequate tissue perfusion

The nurse is caring for a child diagnosed with Reye's syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?

Increased ICP

A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?

Increased antistreptolysin-O (ASO titer)

The nurse reviews the plan of care for a child who is hospitalized with a diagnosis of human immunodeficiency virus (HIV). What problem should the nurse identify as the priority in caring for this child?

Infection

The nurse is caring for a hospitalized child with a diagnosis of rheumatic fever who has developed carditis. The mother asks the nurse to explain the meaning of carditis. On which description of this complication of rheumatic fever should the nurse base a response?

Inflammation of all parts of the heart, primarily the mitral valve

A child diagnosed with a malignant brain tumor is admitted for removal of the tumor. The nurse should include which action in the plan of care to ensure a safe environment for the child?

Initiating seizure precautions

A child's fasting blood glucose level ranges from 100 to 110 mg/dL (5.71 to 6 mmol/L) daily. The before-dinner blood glucose levels range from 110 to 120 mg/dL (6 to 6.85 mmol/L) with no reported episodes of hypoglycemia. The child has been taking insulin before breakfast and before dinner as prescribed. The nurse should make which interpretation based on this data?

Insulin doses are appropriate for food ingested and activity level.

The parents of a 6-month-old report that the infant, who has been screaming and drawing the knees up to the chest, has passed stools mixed with blood and mucus that are jelly-like. The nurse recognizes these manifestations as indicative of which disorder?

Intussusception

The nurse is caring for an infant diagnosed with hydrocephalus. Which manifestation should the nurse interpret as the earliest finding of increased intracranial pressure (ICP)?

Irritability

The mother of the child diagnosed with Kawasaki disease asks the nurse about the disorder. On which description of this disorder should the nurse base the response to the mother on?

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

The nurse caring for a child with a diagnosis of human immunodeficiency virus (HIV) plans care based on which description of this disorder?

It is an acquired cell-mediated immunodeficiency disorder.

The nurse is providing instructions to the mother of a child diagnosed with rubeola (measles). What information about the disease's infectious period should the nurse share with the mother?

It ranges from 1 to 4 days before the onset of symptoms to 5 days after the rash appears.

The nurse is performing an assessment of a preschooler who is diagnosed with conjunctivitis. Which sign/symptom prompts the nurse to investigate allergy as the probable cause?

Itching

When an infant is suspected of being human immunodeficiency virus (HIV) positive, the nurse provides information to the parents about appropriate care. Which action on the part of the parents indicates to the nurse that they need further teaching about the care of their HIV-positive infant?

Planning to use rice cereal to help with watery stools when they occur

The nurse witnesses a child getting hit in the nose with a baseball. The nurse rushes to the child who is bleeding from the nose. In order of priority, what actions should the nurse take? Arrange the actions in the order that that they should be performed. All options must be used.

Keep the child calm and quiet. Have the child sit up and lean forward. Apply continuous pressure to the nose with the thumb and forefinger for at least 10 minutes. Insert cotton or wadded tissue into each nostril, and apply ice or a cold cloth to the bridge of the nose if bleeding persists. Document the event, actions, and child's response

A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?

Malodorous

Daily doses of mineral oil have been prescribed for a child with encopresis. Which instruction should the nurse provide to the mother regarding the administration of the mineral oil?

Mix the mineral oil with chilled chocolate milk before administration.

A 3-year-old child is brought to the emergency department. The mother states that the child has had flu-like symptoms with vomiting and diarrhea for the past 2 days. On assessment, the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. What level of dehydration should the nurse interpret that this child has?

Moderate dehydration

A child is admitted to the hospital with a suspected diagnosis of pneumococcal pneumonia. What should the nurse prepare to implement?

Monitor the child's respiratory rate and breath sounds.

The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?

Monitor the intravenous (IV) infusion, intake, output, and weight.

The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?

Monitor the mouth and anus each shift for signs of breakdown.

Before administering the measles, mumps, and rubella (MMR) vaccine, the nurse should ask the parents whether the child has ever had an anaphylactic reaction to which substance?

Neomycin

The nurse provides discharge instructions to the mother of a child who was hospitalized for heart surgery. Which instruction should the nurse provide to the mother?

Notify the primary health care provider if the child develops a fever greater than 100.5° F (38° C).

A pediatrician is evaluating a school-aged child after the teacher reports that the child is not paying attention during class. The teacher reports that the child appears to be daydreaming and staring off into space 40 or 50 times during the day and that the child is otherwise alert and participates in classroom activity. The nurse assisting the pediatrician expects the pediatrician to note which on physical examination?

The child is probably experiencing absence seizures and will need to have an electroencephalogram (EEG) to confirm this diagnosis.

The home care nurse visits a child with a diagnosis of hepatitis B. On assessment, the nurse notes that the child's weight has increased and the child is lethargic and confused. Based on these assessment findings, what conclusion should the nurse make?

The child must be seen by the primary health care provider.

A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation?

The most significant symptoms are headache and vomiting.

A 1-year-old child is seen in the pediatrician's office with reports of an elevated temperature the preceding night. When gathering subjective assessment data from the mother, which statement would most likely indicate that the child has an acute otitis media infection?

The mother noted purulent discharge from the child's ear last night.

Intravenous immune globulin (IVIG) therapy is prescribed for a child diagnosed with idiopathic thrombocytopenic purpura (ITP). What are the expected results of this medication?

White blood cell count 18,000 mm3 (18 × 109/L) and platelets 355,000 mm3 (355 × 109/L)

The nurse is planning discharge instructions for the mother of a child after orchiopexy, which was performed on an outpatient basis. Which should be a priority in the plan?

Wound care

The school nurse is visiting a kindergarten classroom to teach the students the importance of hand washing. During the teaching session, she notices that one girl is scratching her head. On inspection, the nurse determines that the child has pediculosis capitis. When teaching the mother about care of this condition, which statement by the mother indicates that she needs further teaching regarding this condition?

"I must call a carpet cleaning service to clean all my carpets in the house."

The nurse is providing home care instructions to the mother of a child receiving radiation therapy. Which statement by the mother indicates a need for further teaching?

"I need to be sure that my child gets plenty of sun."

The nurse is providing instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement by a parent indicates a need for further instructions?

"It isn't safe for my child to receive the common childhood immunizations."

A child with juvenile idiopathic arthritis (JIA) is seen in the clinic for a routine visit. The child tells the nurse that she has a difficult time getting out of bed in the morning because of early morning stiffness. Which response to the child is appropriate?

"It might help to use a sleeping bag at night to stay warm."

The nurse has completed discharge teaching with the parents of a child diagnosed with glomerulonephritis. Which statement by the parents indicates that further teaching is necessary?

"It'll be so good to have our child back in tap-dancing classes next week."

The emergency department nurse is providing instructions to the mother of a child who had a plaster cast applied to a lower arm. Which statement by the mother indicates a need for further teaching?

"The fingers of the casted arm will probably be cooler than those of the other arm, and this is normal for the first few days."

The nurse is talking to the parents of a child with acute lymphocytic leukemia (ALL) who has come out of remission twice, and is discussing the treatments for the disease. The nurse determines that the parents understand the treatments if the parents make which statement?

"We know that a bone marrow transplant may not work; however, we will have to go ahead with the treatment because chemotherapy has not helped."

The nurse is preparing to care for a child diagnosed with acute gastroenteritis who is having diarrhea. What interventions should the nurse implement in the care of the child? Select all that apply.

3. Sending stools to the laboratory for culture 4. Monitoring intake and output (I&O) hourly 5. Weighing the diaper after each bowel movement

A preliminary medical diagnosis is made for a 3-year-old child with acute lymphoblastic leukemia (ALL). What should the nurse expect to find with a complete blood count (CBC) of the child?

A white blood count (WBC) of 35,00 (3.5 × 109/L)

A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother whether the child has had any recent infections. The mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?

Antistreptolysin titer

A 3-year-old admitted to the hospital with a diagnosis of acute lymphocytic leukemia (ALL) cries and tells the nurse, "My knees hurt." Which intervention should the nurse provide for the child?

Apply cold packs to the knees

The clinic nurse is providing home care instructions to the mother of a child diagnosed with human immunodeficiency virus (HIV) infection. Which statement by the mother indicates a need for further teaching?

I should delay the polio virus vaccine."

A child is admitted to the hospital with a diagnosis of acute rheumatic fever. The nurse analyzes the laboratory results and determines that which finding would confirm the likelihood of acute rheumatic fever?

Increased antibody level

The nurse is providing instructions to the mother of a child with a diagnosis of exercise-induced asthma (EIA). What is the best sport or activity for the nurse recommend to the mother and child?

Indoor swimming

The nurse is preparing to care for a child with cancer who has received an allogenic bone marrow transplant (BMT). With this type of transplantation, what is the priority concern in the child's care?

Potential for infection

The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?

Prone with the head of the bed elevated

The nurse is providing home-care instructions to a mother of a 12-month-old infant with mild diarrhea. Which should the nurse instruct the mother to do?

Provide an increased intake of water.

Which signs and symptoms should the nurse expect to note in a child with rheumatic fever demonstrating erythema marginatum?

Red skin lesions that start as flat or slightly raised macules over the trunk

Which instruction should the nurse provide to the mother inquiring about the proper method for removing a bee stinger?

Remove the stinger by carefully scraping it out horizontally.

child is admitted to the hospital with a suspected diagnosis of bacterial endocarditis. Which diagnostic study should the nurse plan for to confirm this diagnosis?

Sedimentation rate

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

Tachycardia

The nurse provides discharge instructions to the parents of a child treated for sickle cell crisis. Which statement by the parents indicates a need for further instructions on measures to prevent a repeat of the crisis?

"We need to increase the dose of the analgesic as soon as the pain begins."

An infant has been diagnosed with acute chalasia. During the nursing history, the mother tells the nurse, "I am concerned that I am somehow causing my infant to vomit after feeding her." Considering this statement, which concern should the nurse identify for the mother?

An unrealistic expectation of herself

An infant crawling on the floor of the playroom suddenly begins to cough and make loud, high-pitched, wheezing sounds when breathing. The nurse immediately considers which problem?

Aspiration resulting from ingestion of a foreign object

The nurse is preparing to teach the parents of a child diagnosed with anemia about the dietary sources of iron that are easy for the body to absorb. Which food items should the nurse include in the teaching plan as the best source of absorbable iron? Select all that apply.

Fish Poultry

The nurse reviews the admission assessment data of an infant admitted with a diagnosis of pyloric stenosis. Which assessment findings should the nurse observe in this infant?

Forceful and projectile vomiting

The nurse is creating a plan of care for a child with juvenile idiopathic arthritis (JIA). Which evaluative statement should the nurse formulate that indicates a positive outcome for this child?

The child will experience relief from pain, as evidenced by resting more comfortably and demonstrating increased levels of self-care.

Which activity by the family of an infant with severe respiratory syncytial virus (RSV) who is receiving ribavirin would indicate that there is a need for further teaching about the management of the disease process?

The infant's pregnant aunt visits while the infant is receiving treatment with ribavirin.

After instructing a mother on how to feed an infant who has a cleft palate, the nurse observes the mother feeding the child. Which observation indicates a need for further teaching?

The mother often interrupts the feeding to check for choking.

A child has an arteriovenous (AV) fistula created for hemodialysis. The nurse recognizes the need for further teaching to the mother when the mother makes which statement?

"When we return next week, the AV shunt will be ready to be used for the dialysis procedure."

The nurse is providing instructions to the parents of a child with a hernia regarding measures that will aid in reducing the hernia. Which statement by the parents should lead the nurse to determine that the parents understand these measures?

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

A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.

1. Increase fluid intake. 2. Administer oxygen. 4. Perform frequent pain assessment. 5. Administer intravenous (IV) fluids.

The nursing instructor asks a nursing student to distinguish between the rashes presented by scarlet fever (scarlatina) and erythema infectiosum (fifth disease). The nursing instructor identifies that the student has an understanding of the difference when the nursing student makes which statements? Select all that apply.

2. "The rash of scarlet fever is a red, fine, sandpaper-like rash." 4. "The rash of fifth disease presents as a 'slapped face' appearance."

A child is being admitted to the hospital with the tentative diagnosis of pertussis (whooping cough). As the child is being admitted to the nursing unit, what should the nurse plan to do first?

Place the child on a pulse oximeter and a cardiorespiratory monitor.

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

Assess for any bleeding on the dressing.

An adolescent with juvenile idiopathic arthritis (JIA) is being admitted to the hospital. Which initial intervention should the nurse plan?

Assess the adolescent's perception of the chronic illness.

Levothyroxine sodium is administered to a hospitalized infant diagnosed with congenital hypothyroidism. The infant vomits 10 minutes after administration of the dose. What is the most appropriate nursing action at this time?

Contact the pediatrician

The parents of a child with mumps express concern that their child will develop orchitis as a result of having mumps. What characteristic of this complication should the nurse discuss with the parents?

Fever

A mother brings her 15-month-old child to the primary health care provider's office concerned that the child has suddenly developed a bright red rash on both cheeks. The child has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, what might the nurse suspect the child's diagnosis to be?

Fifth disease

The nurse caring for a child diagnosed with a patent ductus arteriosus should base planning on which fact concerning this disorder?

It involves an artery that connects the aorta and the pulmonary artery.

A child is diagnosed with glomerulonephritis, and the mother asks the nurse what the diagnosis means. What information should the nurse base her response on?

It is characterized by inflammation of the capillaries contained in the glomerulus.

A child is hospitalized with a diagnosis of atrial septal defect. The nurse plans care knowing that what are the characteristics of this type of defect? Select all that apply.

It's a L to R heart shunt Oxygenated and unoxygenated blood mix Left side of the heart is experiencing higher pressure than the right side.

A child is sent home from school by the school nurse with a diagnosis of rubeola (measles), and the mother asks the nurse how to care for the child. Which information is most appropriate for the nurse to provide to the mother?

Keep the child in a room with dim lights to protect the child's eyes.

A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?

Lack of social interaction and awareness

The nurse is reviewing the primary health care provider's prescriptions for a child admitted to the hospital with a diagnosis of sickle cell crisis. The nurse should contact the primary health care provider if what intervention is prescribed?

Meperidine hydrochloride

The nurse is caring for a child hospitalized with laryngotracheobronchitis (croup). Which sign, if noted in the child, indicates respiratory distress?

Nasal flaring

An infant with Tetralogy of Fallot becomes hypoxic and cyanotic and the nurse determines that the infant is experiencing a hypercyanotic spell (blue spell or tet spell). In order of priority, which actions would the nurse take? Arrange the actions in order of priority. All options must be used.

Place the infant in a knee-chest position. Prepare to administer 100% oxygen. Prepare to administer morphine sulfate. Prepare to administer fluids intravenously. Document occurrence, actions taken, and the infant's response.

A client and her infant have been diagnosed as being positive for human immunodeficiency virus (HIV). When the mother is observed crying, the nurse determines that which intervention will meet the client's initial needs?

Sitting quietly with the mother as she talks and cries

The registered nurse is developing a plan of care with a nursing student for a child returning from the operating room after a tonsillectomy. The registered nurse determines that the nursing student needs further teaching if the student suggests placing which inappropriate nursing intervention in the plan of care?

Suction every 4 hours

A mother and family of a 5-year-old newly diagnosed with diabetes mellitus are very concerned about the child going to school and participating in social events. What would be an appropriate goal to address this concern?

The child and family will integrate diabetes care into patterns of daily living.

The nurse is reviewing the primary health care provider's prescriptions for a child who was admitted to the hospital with vaso-occlusive pain crisis resulting from sickle cell anemia. Which primary health care provider prescription should the nurse question?

Meperidine hydrochloride

The home care nurse is providing instructions to the mother of a child diagnosed with roseola exanthem subitum. When asked about measures to help reduce the skin irritation to facilitate comfort, the nurse should encourage which intervention?

Mittens or socks

The nurse is caring for a child with celiac disease. According to the mother, the child has experienced a poor appetite for the past few months. Which assessment finding supports poor nutritional intake?

Muscle wasting in the extremities

The nurse is providing discharge instructions to the parents of a child who underwent a myringotomy with insertion of tympanostomy tubes to treat otitis media. What should the nurse include in the instructions?

Notify the primary health care provider if the child complains of any pain or has a fever.

The pediatric nurse specialist teaches nursing students about mumps. Which clinical manifestation will the specialist identify as the most common complication of this disease?

Nuchal rigidity

The nurse is caring for an 8-month-old infant with a diagnosis of febrile seizures. In planning care, the nurse should anticipate the need for which item?

Padded sides of the crib

The nurse is preparing to discharge a toddler newly diagnosed with hemophilia. What instruction should be included in the teaching plan for home care of this child?

Padding crib rails and table corners

Which nursing assessment finding indicates the presence of an inguinal hernia on a child?

Painless groin swelling noticed when the child cries

The nurse is providing instructions to the mother of a preschool child diagnosed with hemophilia. What instruction should the nurse give to the mother to promote a safe environment while allowing for normalcy?

Examine toys and the play area for sharp objects.

The nurse is providing dietary instructions to the mother of a child diagnosed with lactose intolerance. Which food item should the nurse instruct the mother to include in the child's diet?

Green leafy vegetables

The nurse is performing an assessment on a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching at night, and the nurse teaches the mother about measures that will prevent an alteration in skin integrity. Which statement by the mother indicates that teaching was effective?

"I need to place white gloves on my child's hands at night."

The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which result should the nurse most likely expect to note?

Elevated blood pH

The nurse is assigned to care for a child diagnosed with juvenile idiopathic arthritis (JIA). What is the child's priority problem?

Acute pain

The nurse prepares to administer digoxin to a newborn with a diagnosis of heart failure. The nurse notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?

Administer the digoxin because the apical rate is within normal limits.