PEEDS Quiz #5

A nurse is caring for a child who has Hirschsprung disease. Which of the following findings expect?

Ribbonlike, foul-smelling stools

A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following as an acceptable food choice for this child?

Rice

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?

Skin that is cool to the touch

A nurse is caring for a toddler who has gastroenteritis caused by salmonella. Which of the following action sis the priority for the nurse?

Initiate contact precautions

66.A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? A. Projectile vomiting B. Bile-colored vomit C. Absent bowel sounds D. Fever

A. Projectile vomiting Rationale:Infants who have pyloric stenosis have projectile vomiting, often ejecting vomitus several feet.

92.A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect? A. Polyuria B. Periorbital edema C. Orange-tinged urine D. Hypertension

B. Periorbital edema Rationale: The glomerular membrane is permeable to albumin, which is excreted and changes the colloidal osmotic pressure. Therefore, periorbital edema is a clinical manifestation of nephrotic syndrome.

161.A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula, rather than breast milk." D. "I should move my baby into a side-lying position during sleep."

A. "I will keep my baby in an upright position after feedings." Rationale: The infant should be maintained in an upright position for 1 hr after feedings.

A nurse is caring for a school-age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35 mL of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe?

Low-sodium, fluid-restricted

11.A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate? A. "Bring your infant into the clinic today to be seen." B. "Burp your child more frequently during feedings." C. "Give your infant an oral rehydrating solution." D. "You might want to try switching to different formula."

A. "Bring your infant into the clinic today to be seen." Rationale: The nurse should recognize that projectile vomiting, followed by the child acting hungry afterwards, are indicative of pyloric stenosis. The infant needs to be examined in the clinic as soon as possible by the provider.

133.A nurse is caring for a school-age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35 mL of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe? A. Low-sodium, fluid-restricted B. Regular diet, no added salt C. Low-carbohydrate, low-protein diet D. Low-protein, low-potassium diet

A. Low-sodium, fluid-restricted Rationale:A low-sodium, fluid-restricted diet prevents complications of glomerulonephritis.

A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?

Mucus in stools

240.A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect? A. WBC 17,000/mm3 B. Left lower quadrant abdominal pain C. Hyperactive bowel sounds D. Bradycardia

A. WBC 17,000/mm3 Rationale:A WBC count of 17,000/mm3 is above the expected reference range. An elevated WBC count indicates the presence of infection.

A nurse is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect?

Abdominal mass

150.A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? A. Place the child on a no-salt-added diet. B. Check the child's weight C. Educate the parents about potential complications.ht daily. D. Maintain a saline-lock.

B. Check the child's weight daily. Rationale: The first action the nurse should take using the nursing process is to collect data. Therefore, checking the child's weight daily is the priority.

130.A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse's priority? A. Schedule the child for an abdominal ultrasound. B. Instruct the parent to avoid pressing on the abdominal area. C. Determine if the child is having pain. D. Obtain a urine specimen for a urinalysis.

B. Instruct the parent to avoid pressing on the abdominal area. Rationale: The nurse's priority action is to instruct the parent to avoid pressing on the child's abdomen. These manifestations are associated with Wilms' tumor, and trauma to the mass can cause movement of cancer cells to other sites.

A nurse is caring for a preschool-aged child who has an intussusception of the bowel. Which of the following findings should the nurse report to the physician?

Passage of a formed brown stool

A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?

Periorbital edema

115.A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care? A. Feed the infant half-strength formula for the first 48 hr. B. Remove elbow restraints while the infant is sleeping. C. Keep the infant in a side-lying position. D. Administer pain medication PRN for the first 48 hr.

C. Keep the infant in a side-lying position. D. Administer pain medication PRN for the first 48 hr.

A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?

Projectile vomiting

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority?

Capillary refill 5 seconds

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan?

Check the bag for stool every 4 hours

A nurse is contributing to the plan of care for a school-aged child who has encopresis. Which of the following interventions should the nurse include in the plan of care?

Collect data regarding any recent stress factors in the child's environment

A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?

Projectile vomiting after feedings

A nurse is caring for a school-aged child who has acute poststreptococcal glomerulonephritis. Which of the following manifestations should the nurse expect?

Hematuria

59.A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning? A. "I am scared and I want to go home." B. "I am hungry and thirsty." C. "I'm tired and want to take a nap." D. "My belly doesn't hurt anymore."

D. "My belly doesn't hurt anymore." Rationale:Sudden relief of pain can be an early indication of appendix rupture, which is a surgical emergency. Because the greatest risk to the client is peritonitis secondary to a ruptured appendix, this statement is the most concerning.

136.A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect? A. Drooling B. Increased appetite C. Jaundice D. Mucus in stools

D. Mucus in stools Rationale:Stools with mucus and blood are manifestations of intussusception.

26.A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect? A. Metabolic acidosis B. Effortless regurgitation C. Distended abdomen D. Projectile vomiting

D. Projectile vomiting Rationale:Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine, which does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.

A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

"I will keep my baby in an upright position after feedings."

A nurse is reinforcing teaching with a parent of a 1-month-old-infant who is to undergo the initial surgery to treat Hirschsprung's disease. Which of the following statements should indicate to the nurse that the parent understands the goal of the surgery?

"I'm glad that the ostomy is only temporary."

A nurse is reinforcing teaching with the parent of an infant who has a newly created colostomy. Which of the following instructions should the nurse reinforce about colostomy care?

"you can choose to use a diaper instead of a collection bag."

5. A nurse is reinforcing teaching with a parent of a 1-month-old-infant who is to undergo the initial surgery to treat Hirschsprung's disease. Which of the following statements should indicate to the nurse that the parent understands the goal of the surgery? A. "I'm glad that the ostomy is only temporary." B. "I'm glad my child will have normal bowel movements now." C. "I want to learn how to use the feeding tube as soon as possible." D. "The operation will straighten out the kink in the intestine."

A. "I'm glad that the ostomy is only temporary." Rationale:A child who has Hirschsprung's disease is missing ganglion cells in a portion of the intestine. The disease usually requires two surgical procedures. The first results in the creation of an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.

174.A nurse is reinforcing teaching with the mother of a toddler who has acute nephrotic syndrome. The nurse should emphasize the need to report which of the following manifestations to the provider? A. Yellow nasal discharge B. Facial edema C. Poor appetite D. Irritability

A. Yellow nasal discharge Rationale:Yellow or green nasal discharge is a sign of an upper respiratory infection. Children who have nephrotic syndrome are at constant risk for infection, so the mother should report this manifestation to the provider who can prescribe appropriate and prompt treatment.

A nurse in an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspiring. Which of the following substances should the nurse administer to the toddler?

Activated charcoal`

A nurse is working with several clients on an acute care pediatric unit. Which of the following clients requires the nurse's immediate attention?

An 8-year-old client who has tonsillectomy and is swallowing frequently

131.A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 hr postoperative following a cleft palate repair. Which of the following interventions should the nurse include in the plan? A. Provide soft foods for the toddler. B. Suction the toddler nose and mouth every hour. C. Maintain elbow restraints on the toddler. D. Give the toddler a hard-tipped sippy cup to drink liquids.

C. Maintain elbow restraints on the toddler. Rationale: The nurse should maintain elbow restraints on the toddler to prevent touching of the mouth. The nurse should monitor the skin under the restraints and remove the restraints periodically to allow the toddler to exercise his arms.

91.A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis? A. Absent bowel sounds B. Increased sodium level C. Projectile vomiting after feedings D. Golf ball-size mass over the left quadrant

C. Projectile vomiting after feedings Rationale:Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the duodenum that results in projectile vomiting.

160.A nurse is caring for a child who has Hirschsprung disease. Which of the following findings should the nurse expect? A. Chronic hunger B. Ridged abdomen C. Projectile vomiting D. Ribbonlike, foul-smelling stools

D. Ribbonlike, foul-smelling stools Rationale: Hirschsprung disease causes an inadequate motility of part of the intestine resulting in ribbonlike, foul-smelling stools.

A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?

Determine if the toddler is voiding

A nurse is reinforcing teaching with an adolescent regarding administration of the Gardasil vaccine. The vaccine provides immunity against which of the following sexually transmitted infections?

Human papillomavirus (HPV)

A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect?

Sodium 125 mEq/L

A nurse is collecting data from a school-aged child who has celiac disease. Which of the following findings should the nurse expect?

Steatorrhea

A nurse is assisting with evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following findings should indicate to the nurse that the surgery was successful?

The color of the infant's stool is yellowish-brown

A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful?

The infant has a total bilirubin level of 0.3 mg/dL.

A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

Urine specific gravity 1.015

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take?

Weigh the child once each day

A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Apply an antibiotic ointment to the suture site. B. Clear oral secretions using a bulb syringe. C. Feed the infant using a spoon. D. Position the infant on her abdomen.

A. Apply an antibiotic ointment to the suture site. Rationale: The nurse should apply an antibiotic ointment to the suture site to help prevent a postoperative infection

178.A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The surgeon prescribes restraints. The nurse should apply which of the following types of restraints to the infant? A. Elbow B. Mummy C. Wrist D. Jacket

A. Elbow Rationale:It is essential to apply elbow restraints immediately after surgery to keep the infant from rubbing the operative site. The nurse should remove the restraints periodically to inspect the skin and allow the infant arm exercise

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?

Assess fluid balance

85.A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding? A. Prone B. Upright C. Left side D. Right side

B. Upright Rationale: The infant should remain in an upright position, usually in an infant chair, for 1 hr after feeding to facilitate emptying of the stomach and prevent reflux.

217.A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first? A. Initiate isotonic fluids with 20 mEq/L potassium chloride. B. Request evaluation of the toddler's serum electrolytes. C. Determine if the toddler is voiding. D. Collect a stool sample from the toddler.

C. Determine if the toddler is voiding. Rationale: The first action the nurse should take when using the nursing process is assessment. The nurse should first determine if the toddler is voiding before proceeding further with any other interventions. When a toddler has a diagnosis of gastroenteritis, the nurse should collect a urine specimen prior to administering potassium. The nurse should anticipate a decreased serum potassium level. However, the nurse should also validate that the kidneys are able to produce urine and excrete potassium. If kidney function is altered, potassium will not be excreted and the toddler will develop hyperkalemia. Administering potassium prior to validating renal functioning can jeopardize the toddler's safety.