Pedsfinal
a nurse is reviewing the labs of an adolescent who has glomerulonephritis. what finding should be expected
BUN 50
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). on the basis of this finding, which is the most appropriate nursing action? 1. initiate strict enteric precautions 2. move the infant to another room with another child with RSV 3. leave the infant in the present room because RSV is not contagious 4. inform the staff that they must wear a mask, gloves, and a gown when caring for the child.
2. move the infant to another room with another child with RSV
a nurse is admitting an infant who has severe dehydration from acute gastroenteritis. which finding should the nurse expect
3% weight loss
what is the priority nursing intervention for a 6-month-old infants hospitalized with diarrhea and dehydration? a. estimating insensible fluid loss b. collecting urine for culture and sensitivity c. palpating the posterior fontanel d. measuring the infants weight
D. measuring the infants weight
A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant? 1.Diphtheria, tetanus, acellular pertussis (DTaP), Measles, mumps, rubella (MMR), inactivated poliovirus vaccine (IPV) 2.Varicella and hepatitis B vaccines 3.MMR, Hib, DTaP 4.DTaP, Hib, IPV, pneumococcal vaccine (PCV)
DTaP, Hib, IPV, pneumococcal vaccine (PCV)
A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.) Symptoms are continuous throughout the day. Daytime symptoms occur more than twice a week. Nighttime symptoms occur approximately twice a month. Minor limitations occur with normal activity. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.
Daytime symptoms occur more than twice a week. Minor limitations occur with normal activity.
A nurse is planning care for child that is admitting with mumps. Which of the following is an appropriate action for the nurse to take? a. Initiate standard precautions b. Initiate airborne precautions c. Initiate droplet precautions d. Initiate contact precautions
Initiate droplet precautions
A nurse is reviewing lab results in four child. Which of the following values should the nurse report? a. WBC 10,000 b. Lead 2 mcg/dl c. RBC 4.9 d. Iron 38
Iron 38
A nurse is providing teaching to an adolescent who has type 1 diabetes. Which of the following should the nurse include? a. administer glucagon for hyperglycemia b. obtain an influenza vaccine yearly c. inject insulin in the deltoid muscle d. take glyburide with breakfast
Answer: B Glyburide is contraindicated for clients who have type 1 diabetes mellitus.
A nurse is assessing a 1-year-old toddler notices a large abdominal mass and pink-tinged urine in the diaper. Which of the following disorders should the nurse suspect?
Wilms Tumor
A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include? A. "Your baby will receive a hepatitis B vaccine prior to discharge." B. "Your baby should receive the pneumococcal conjugate vaccine on his first birthday." C. "Your baby should receive the MMR vaccine at 6 months." D. "Your baby will receive the first diphtheria, tetanus, pertussis vaccine at the 2 week well-baby visit."
Your baby will receive a hepatitis B vaccine prior to discharge."
A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? a. carotid artery b.. apex of heart c. brachial artery d. radial artery
answer: B
A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes. Which of the following statements by the parents indicates and understanding of the teaching? a. "the onset of low blood glucose usually occurs slowly" b. "my son may complain of feeling shaky when he has low blood glucose" c. "sweating can occur with hyperglycemia" d. "my son might have nausea and vomiting with hypoglycemia"
answer: B
a nurse is preparing to teach about communicable diseases. during which stage/ period is the disease contagious
communicability period
The nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. when obtaining the childs medical history. which manifestation is likely to be noted?
conjunctival hyperemia
a nurse is caring for an infant who has a tracheoesophageal fistula. what findings should the nurse expect?
coughing apnea cyanosis frothy saliva
a child is admitted with a suspected diagnosis of wilms tumor. the nurse should place a sign with what warning over the bed
do not palpate the abdomen
the nurse is collecting data on a child with a diagnosis of rheumatic fever. which question should the nurse initially ask the mother of the child?
has the child complained of a sore throat within the past few months
a nurse is assessing an infant following a motor vehicle crash. which of the following findings should the nurse monitor for identifying increased intracranial pressure?
increased sleeping
a nurse is caring for a male infant who has palpable mass in the upper quadrant and stools mixed with blood and mucus. The nurse recognize that which of the following diagnosis in associated with these findings
intussusception
a parent tells the nurse that her toddler drinks a quart of milk a day and has poor appetite for solid foods. the nurse should explain that the toddler is at risk for>
iron deficency anemia
a nurse is caring for a pre0school age child who has epiglottis with barking cough. which acton should the nurse take
monitor oxygen saturation
a nurse in an emergency department is assessing a 3 YO who has a high fever, sever dyspnea, and is drooling. which of the following actions is the nurses priority
prepare for nasotracheal intubation
a nurse is providing teaching to a parent of a child who has celiac-disease. The nurse should include which food choice for the child>
rice
a nurse is assessing a 3 YO at a routine wellness check. which finding should the nurse expect
stands on one foot for a few seconds
a nurse is caring for an infant who has GERD. the nurse should recognize what findings associated with this condition
vomiting weight loss wheezing
a nurse is providing teaching to the parents of a 1 week old infant who has prescription for home oxygen and pulse oximetry monitoring. which of the following statements by the parents indicate an need for further teaching
we will rotate the probe of the pulse oximeter every 24 hours
a 10 year old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. warm dry skin 2. decreased wheezing 3. pulse rate of 90 BPM 4. respirations of 18 breaths/min
2. decreased wheezing
when collecting the history about a child who presents with signs of glomerulonephritis, the nurse should report which most important finding to the health care provider?
Streptococcal throat infection 2 weeks before diagnosis
A nurse is teaching the parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching? A. "You should leave the room while the tantrum is happening." B. "Temper tantrums are the toddler's attempt to gain control of a situation." C. "You should get a psychological consult for the temper tantrums." D. "Temper tantrums are a type of learning disability."
Temper tantrums are the toddler's attempt to gain control of a situation."
the mother of a 4 year old child tells the pediatric nurse that the childs abdomen seems to be swollen. During further assessment of subjective data, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of willms tumor, should avoid doing what during the physical exam? 1. palpating the abdomen for a mass 2. assessing the urine for the presence of hematuria 3. monitoring the temperature for the presence of a fever 4. monitoring the blood pressure for hypertension
1. palpating the abdomen for a mass
the nurse is reviewing a health care providers prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. which prescription documented in the childs record should the nurse question? (SATA) 1. restrict fluid intake 2. position for comfort 3. avoid strain on painful joints 4. apply nasal oxygen at 2L/ min 5. provide a high-calorie high protein diet Did 6. give meperidine, 25mg IV Q 4 for pain
1. restrict fluid intake 6. give meperidine 25mg IV Q 4 for pain
A child hospitalized with pertussis is in the convalescent stage, and the nurse is preparing the child for discharge. The nurse has provided instructions to the parents for home care of the child. Which statement by a parent indicates a need for further teaching? 1. "It is important that my child drinks plenty of fluids." 2. "A quiet environment helps to prevent episodes of coughing spells." 3. "We need to teach the other members of the family how to use good hand washing techniques to prevent the spread of infection." 4. "I need to make sure that the child is isolated from the other children for at least 2 weeks to prevent the spread of the virus to them."
"I need to make sure that the child is isolated from the other children for at least 2 weeks to prevent the spread of the virus to them." Rationale:Pertussis is transmitted by direct contact or respiratory droplets from coughing. The infectious period occurs during the catarrhal stage (from the first to second week until the fourth week). Respiratory isolation is not required during the convalescent stage.
a nurse is caring for an 8-year old child who has rheumatic fever. which of the following assessments is the nurses priority immediately after admission? 1. auscultating the rate and characteristics of the Childs heart sounds 2. using a pain-rating tool to determine the severity of the joint pain 3. identifying the degree of parental anxiety related to diagnosis 4. assessing the Childs erythematous rash
1. auscultating the rate and characteristics of the Childs heart sounds
a nurse is planning care for a 2 month old infant following a surgical procedure. which pain rating scale should be used
FLACC
A nurse is caring for a 3-year-old client whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse contribute to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures.
Have a parent stay with the child during procedures. Perform the procedure as quickly as possible. Use mummy restraints during painful procedures.
A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately? a. a client who is 1 day post-op and has a temperature of 99.5 b. a client who has a burn injury to an estimated 5% of his leg and is crying c. a client who's BP changes from 112/60 to 90/54 when standing d. client who has an ankle fracture reports pain level increase from 3 to 5 after ambulation
a client who's BP changes from 112/60 to 90/54 when standing Vital sign ranges for adolescents are similar to those for adults. A drop in the systolic blood pressure of more than 20 mm Hg or a drop in the diastolic of more than 10 mm Hg after standing is considered to be orthostatic hypotension. One of the most common causes of orthostatic hypotension is hypovolemia. The client likely will feel lightheaded and dizzy. This finding should be reported to the provider.
A nurse is caring for a 7 year old child who has an upper respiratory infection and type 1 diabetes. Which of the following statements by the mother indicates a need for further teaching a. "I will encourage her to drink a half cup of water or sugar free fluids every 30 minutes" b. "I will report a change in her breathing or signs of confusion" c. "I will notify the doctor if her temperature is not controlled with acetaminophen" d. "I will continue to check his blood sugar 2 times per day:
answer: D A client who has type 1 diabetes mellitus and is ill is at risk of developing DKA. DKA results in the breakdown of body fat for energy and the presence of ketones in the blood and urine. Because acute illness increases glucose levels, the child's glucose levels and the urine ketones should be checked every 3 hr. Checking the child's blood glucose two times per day is not enough to adequately monitor glucose levels.
a nurse is caring for a child who is having a tonic-clonic seizure and vomiting. which of the following actions is the nurses priority? a. place pillow under head b, position side lying c loosen restrictive clothing d, clear area of hazard
b position side lying
a lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results if the CSF analysis and determines that which of the following results would verify the diagnosis? a. cloudy csf, decreased protein and glucose b. cloudy csf, elevated protein, and decreased glucose c. clear csf, elevated protein, and decreased glucose d. clear csf, decreased pressure, and elevated protein
b. cloudy csf, elevated protein and decreased glucose
a nurse is assessing an adolescent who experienced blunt trauma to the abdomen. which of the following findings is the nurses priority
BP 92/50
The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. which intervention should the nurse perform immediately? 1. reinforce the dressing 2. notify the health care provider 3. document the findings and continue to monitor 4. circle the area of drainage and continue to monitor
2. notify the health care provider
a nurse us admitting a 6 month old who had dehydration. which amount of urinary output should indicate that the treatment has corrected the fluid imbalance>
2ml/kg/hr
the mother of a 6 YO child who has type 1 DM calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the childs urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. hold the next dose of insulin 2. come to the clinic immediatedly 3. encourage the child to drink liquids 4. administer an additional dose of regular insulin
3. encourage the child to drink liquids
The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1."We need to encourage adequate fluid intake." 2."Coughing spells may be triggered by dust or smoke." 3."We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." 4."Good hand-washing techniques need to be instituted to prevent spreading the disease to others."
3."We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."
A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? 1. Eggs 2. Penicillin 3. Sulfonamides 4. A previous dose of hepatitis B vaccine or component
4. A previous dose of hepatitis B vaccine or component
An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply a hot pack to the injection site. 4. Apply a cold pack to the injection site.
4. Apply a cold pack to the injection site.
The nurse prepares to administer an intramuscular injection to a 4 month old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2. Lateral deltoid 3. Rectus femoris 4. Vastus lateralis
4. Vastus lateralis
a new parent expresses concern to the nurse regarding SIDS. she asks the nurse how to position her new infant for sleep. in which position should the nurse tell the parent to place the infant? 1. side or prone 2. back or prone 3. stomach with the face turned 4. back rater than on the stomach
4. back rather than on the stomach
a nurse is collecting data from an infant at a well-child visit. the nurse should understand that birth weight typically doubles by what age
5 months
A nurse is preparing to administer varicella vaccine to an adolescent. Which of the following questionsshould the nurse ask to determine whether there is a contraindication to administering the vaccine? A. "Do you have an allergy to eggs?" B. "Have you ever had encephalopathy following immunizations?" C. "Are you currently taking corticosteroid medication?" D. "Do you have a hypersensitivity to yeast?"
C. "Are you currently taking corticosteroid medication?"
a nurse is providing teaching to a parents of a child who has a fx of an epiphyseal plate. which statement should the nurse make
normal bone growth will be affected
A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?
Instruct the parent to avoid pressing on the abdominal area.
A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply.) A. Measles,mumpsrubella(MMR) B. Diphtheria, tetanus and acellular pertussis (DTaP) C. Varicella (VAR) D. Rotavirus(RV) E. Human papillomavirus (HPV4)Measles,mumpsrubella(MMR)
Measles,mumpsrubella(MMR) B. Diphtheria, tetanus and acellular pertussis (DTaP E. Human papillomavirus (HPV4)Measles,mumpsrubella(MMR)
A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan? A. discourage a high level of fluid intake B. apply cold compresses to painful, swollen joints C. observe for indications of hypokalemia D. administer meperidine every 4 hours for pain
observe for indications of hypokalemia
a nurse is caring for an infant who has congenital heart defect. which defect is associated with increased pulmonary blood flow
patent ductus arteriosus
a nurse is planning care for a child who has suspected epiglottis. which action should the nurse take
place the child in an upright position
a nurse is caring for a child who is admitted with suspected acute appendicitis. which of the following manifestations should indicate to the nurse that the childs appendix is perforated
sudden decrease in abdominal pain
a nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which action indicated the teaching has been effective?
takes axillary temp
a nurse is obtaining vital signs from 2 month old infant. the infants heart rate is 190 and his temp is 40C the father asks why the infants heart rate is beating so fast
the fever is causing an increase in your babys heart rate
the nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following information should the nurse include in the discharge instructions? SATA the reason why the child is taking the medication written information about the medication stop taking the medication when the child feels better the adverse effects of the medication using a kitchen spoon to administer the medication
the reason why the child is taking the medication written information about the medication
a nurse is preparing to assist with applying a cast to a preschoolers arm. whihc action should the nurse take first>
wrap the arm of the childs doll or toy prior to the procedure
a nurse is assessing a toddler at a well-child visit. at what point in the physical should the nurse examine the childs tympanic membrane
at the end
a nurse is providing teaching about iron deficiency anemia to the parents of a toddler. recommendations to prevent iron deficiency anemia
avoid a diet that consists primarily of milk
a nurse is caring for a 17 year old client who is expecting a relapse of leukemia and is refusing treatment. The client's mother insists that the client receives treatment. which of the following actions should the nurse take? a. initiate the IV per the patients request b. notify the provider of the situation c. administer a sedative to calm the client d. offer the client an antiemetic
b. notify the provider of the situation
the nurse is reviewing the lab results for a child scheduled for a tonsillectomy. The nurse determines that which lab value is most significant to review? a. creatine b. prothrombin time c. sedimentation rate d, BUN
b. prothrombin time
a child with type 1 DM is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. anticipating the plan of care, the nurse prepares to administer which type of IV infusion 1. K infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. normal saline infusion
4. normal saline infusion
The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. which statement should the nurse make to the parent? 1. the immunization schedule will need to be altered 2. the child should not receive any hepatitis vaccines 3. the child will receive all of the immunizations except for the polio series 4. the child will receive the recommended basic series of immunization along with a yearly influenza vaccine
4. the child will receive the recommended basic series of immunization along with a yearly influenza vaccine
A nurse is caring for a child who has Kawaski disease. Which of the following systems should the nurse monitor in response to this diagnosis? a. cardiovascular b. GI c. integumentary d. respiratory
answer: A
the nurse should assess a child who has had tonsillectomy for which of the following as the priority? a. frequenct swallowing b. inspiratory stridor c. swelling of the throat d. abnormal lung sounds
a frequent swallowing
A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates a need for further teaching a. "I will be sure my child aspirates before injecting insulin" b. "the insulin can be injected anywhere where there is adipose tissue" c. "I will be sure by child rotates sites after 5 injections in one area" d. "the insulin should be injected at a 90 degree angle"
a. "I will be sure my child aspirates before injecting insulin"answer: A
a 6-month old infant is due for routine immunizations. The parent reports the infant was exposed to pertussis 2 days ago. The nurse should a. give the 6 month immunization as scheduled b hold the immunization until the next visit
a. give the immunization
a nurse is caring for a child who has a suspected diagnosis of bacterial meningitis what action should the nurse perform
administer antibiotics when available
a nurse is caring for a toddler who is 24 hrs post cleft palate repair. which action should the nurse take?
administer opioids for pain
The nurse is preparing to care for a child after a tonsillectomy, The nurse documents on the plan of care to place the child in which position? a. supine b.b side-lying c. high fowlers d. trendelenburg
b. side lying
a nurse is caring for a toddler whos parents states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color
instruct the parent to avoid pressing on the abdominal area
a nurse is caring for a school-aged child who has acute glomerulonephritis with peripheral edema and it is producing 35ml of urine per hour. the nurse should place the client on which diet
low sodium fluid restriction
a nurse is providing health promotion teaching to an adolescent. which of the following info should the nurse teach
your need for sleep will increases during periods of growth
A nurse is assessing a school age child whose blood glucose is 280. which of the following findings should be expected? a. lethargy b. pallor c. tremor d. shallow respirations
answer: A A blood glucose of 280 mg/dL is above the expected reference range indicating hyperglycemia. The nurse should expect the child to appear lethargic, leading to a decreased level of consciousness and confusion.
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask? a."has your son had a sore throat recently?" b. "was your son born with this cardiac defect?" c. "has your child had any injuries recently?" d. "have you given your child aspirin in the last 2 weeks?"
answer: A Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether the child previously had a sore throat.
A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is a priority? a. BP 92/50 mmHg b. HR 72 c. abdominal pain rates as 4/10 d. RR 20/min
answer: A The expected reference range for blood pressure in an adolescent is 110/65 to 120/80 mm Hg. A blood pressure 92/50 mm Hg indicates the adolescent is hypotensive and unstable. Therefore, this finding is the priority. Blunt abdominal trauma can cause internal hemorrhage that leads to hypotension.
A nurse is caring for an 8 year old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission. a. auscultating the rate and characteristic of heart sounds b. using a pain rating tool to determine the severity of the joint pain c. identifying the degree of parental anxiety to the diagnosis d. assessing the client's erythematous rash
answer: A Using the airway, breathing, circulation approach to client care, the nurse should place priority on auscultating the client's heart rate and heart sounds. Rheumatic fever is an inflammatory disease that begins with a strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart valves are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, life-threatening, and life-long complications.
A new nurse is assessing a 3 year old child who has aortic stenosis. Which of the following findings should the nurse expect? a. hypotension b. bradycardia c. clubbing of the nail beds d. weak pulses e. murmur
answer: A, D, E Hypotension with aortic stenosis is a result of decreased cardiac output. Weak pulses with aortic stenosis are a result of decreased cardiac output. Murmur is correct. A narrowing of the aortic valve cause a characteristic murmur in children who have aortic stenosis. A narrowing of the aortic valve cause a characteristic murmur in children who have aortic stenosis.
A nurse is caring for an infant who has a congenital heart defect. Which of the following is associated with increased pulmonary blood flow? a. coarctation of the aorta b. patent ductus arteriosus c. tetralogy of fallot d. tricuspid atresia
answer: B
A nurse if providing teaching to a school-age child who has a new diagnosis of type 1 diabetes. Which of the following statements by the child indicates an understanding of the teaching? a. "my morning blood glucose should be between 90 and 130" b. "I should eat a snack half an hour before playing soccer" c. "I should not take my regular insulin when I am sick." d. "I can store unopened bottles of insulin in the freezer".
answer: B Exercise lowers blood glucose levels. The child should eat a snack half an hour prior to physical activity. If the exercise is prolonged, the child might require a snack during the activity. Insulin should be stored at room temperature or in a refrigerator. Freezing insulin causes it to become inactive.
A nurse is providing discharge teaching instructions to the parent of a 10 year old child following cardiac catheterization. Which of the following should be included? a. keep the child home for one week b. give the child acetaminophen for discomfort c. offer the child clear liquids for the first 24 hours d. assist the child to take a tub bath for the first 3 days
answer: B The child might have minor discomfort at the puncture site. The parent should offer either acetaminophen or ibuprofen due the risk of Reye syndrome associated with taking aspirin.
A nurse is obtaining vital signs from a 2 month old. The HR is 190/minute and temperature is 104. The father asks the nurse why the infant's heart is beating so fast. Which of the following responses is most appropriate. a. this is within the expected range for your baby b. the fever is causing an increase in the heart rate c. as your baby begins to fall asleep, the HR will decrease d. your baby's heart is beating fast in an attempt to cool down his body.
answer: B The expected reference range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to 37.2° C (98.9° F). This infant has a fever that is causing the infant's heart rate to increase. The expected reference range for heart rate in a 2 month-old infant is 121 to 179/min.
A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the blood glucose and it is 55. Which of the findings should the nurse expect? a. dry, flushed skin b. deep, rapid respirations c. tachycardia d. polyuria
answer: C
A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include? a. withhold insulin dose if feeling nauseous b. notify the provider if blood glucose levels are over 350 c. test the urine for ketones d. limit fluid intake during meal time
answer: C The parent or child should test the urine for ketones and report the presence of them in the urine. Ketonuria can indicate that the child does not have enough glucose for energy and is breaking down fats to provide glucose to cells. The nurse should instruct the school-age child and his parent to notify the provider if his blood glucose levels are greater than 250 mg/dL in order to initiate treatment before injury can occur.
A nurse is assessing a 3 year old child at a routine wellness checkup. Which of the following findings should be expected? a. skips and hops on one foot b. has a vocab of 1500 words c. walks backwards heel to toe d. stands on one foot for a few seconds
answer: D
The nurse is caring for a child with a suspected diagnosis of rheumatic fever, the nurse reviews the lab results. which lab study should assist in confirming the diagnosis of RF?
antistreptolysin O titer
a nurse is caring for a 2 YO who is hospitalized and throws a tantrum when his parents leave, which of the following toys should the nurse provide to alleviate the Childs stress? a. set of building blocks bb. toy hammer and pounding board c. picture book about hospitals d, stuffed animals
b. toy hammer and pounding board
a nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. The nurse should recognize these findings as
bronchiolitis
a nurse is assessing an 11 month old infant. which finding is associated with CNS infection?
bulging fontanel
a nurse is caring for a child who is 2 hours post op following a tonsillectomy. which of the following fluid items should the nurse off the client at this time?
crushed ice
the clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. which, if identified by the parents as a precipitating factor, indicated the need for further instruction? a. stress b. trauma c. infection d. fluid overload
d. fluid overload
a nurse in a pediatric clinic is caring for a child who had iron deficiency anemia and a new prescription for ferrous sulfate. which of the following instructions should the nurse provide the parents regarding administration of this medication>
give with orange juice
a parent of a toddler ask a nurse at a well child visit how the childs frequent temper tantrums can best be handled. which actions should the nurse suggest to the parent
ignore the temper tantrums
a nurse is caring for an infant who had GERD. the nurse should place the infant in which position following a feeding
in the infant car seat
