PEDS
Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration? a) Diaphoresis. b) Decreased urine specific gravity. c) Absence of tear formation. d) Deep, rapid respirations.
a - The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fluids. Other typical findings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specific gravity of urine increases with decreased output in the presence of dehydration.
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to: a) Roll from back to side. b) Turn the head from side to side. c) Smile and laugh out loud. d) Hold a rattle briefly.
b - A 1-month-old infant is usually able to lift the head and turn it from side-to-side from a prone position. The full-term infant with no complications has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old.
A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications? a) Toddlers b) Neonates c) Premature infants d) Adolescents
c - Factors related to growth and maturation significantly alter an individual's capacity to metabolize and excrete drugs. Thus, the premature infant is at risk for problems because of immaturity. Deficiencies associated with immaturity become more important with decreasing age. Enzyme systems develop quickly, with most increasing to adult levels within 1 to 8 weeks after birth. Within the first year of life, all are probably as active as they will ever be.
A nurse is assessing an 8-month-old infant during a wellness checkup. Which action is a normal developmental task for an infant this age? a) Feeding himself with a spoon b) Saying two words c) Playing patty-cake d) Sitting without support
d - According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. Saying two words is expected of a 15-month-old infant. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infant should be able to play patty-cake
When preparing to deliver back slaps to an infant who is choking on a foreign body, in which of the following positions should the nurse position the infant? a) Head parallel to the nurse and supported at the buttocks. b) Head down and lower than the trunk. c) Head up and raised above the trunk. d) Head to one side and even with the trunk lower than the head.
b - To deliver back slaps, the nurse should place the infant face down, straddled over the nurse's arm, with the head lower than the trunk and the head supported. This position, together with the back slaps, facilitates dislodgment and removal of a foreign object and minimizes aspiration if vomiting occurs. Placing the infant with the head up and raised above the trunk would not aid in dislodging and removing the foreign object. In addition, this position places the infant at risk for aspiration should vomiting occur. Placing the head to one side may minimize the risk of aspiration. However, it would not help with removal of an object that is dislodged by the back slaps. Placing the infant with the head parallel to the nurse and supported at the buttocks is more appropriate for burping the infant.
After undergoing a barium enema, which of the following indicates that the infant has adequately evacuated the barium? a) Stool guaiac that is negative. b) Absence of fecal mass in the lower abdomen. c) Stools that progress from clay-colored to brown. d) Bowel sounds of 30 per minute.
c - The presence of barium produces white or clay-colored stools. A change in stool color from clay-colored to normal brown is an indication that the barium has been evacuated. Presence or absence of a fecal mass does not give definitive information about the passage or retention of barium. Bowel sounds of 30 per minute suggest normal functioning but do not necessarily indicate passage of barium. A stool guaiac test is done to determine the presence of occult blood, not barium
