Practice Assessments - Pediatrics

Orthopnea

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect? • Weight loss • Increased urine output • Bradycardia • Orthopnea

Check the catheter tubing for kinks or twisting.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? • Replace the catheter every 3 days. • Check the catheter tubing for kinks or twisting. • Irrigate the catheter once each shift. • Clean the perineal area with an antiseptic solution daily.

Contact the poison control center.

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? • Provide a high-carbohydrate meal. • Give the child syrup of ipecac. • Contact the poison control center. • Bring the child to the office for a rapid infusion of deferoxamine.

Trust vs. Mistrust; Autonomy vs. shame & doubt; initiative vs. guilt; industry vs. inferiority; identity vs. role confusion

A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Place Erikson's stages of psychosocial development in order from birth to adolescence. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) • Autonomy vs. shame and doubt • Industry vs. inferiority • Identity vs. role confusion • Initiative vs. guilt • Trust vs. mistrust

Positive Moro reflex

A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention? • Positive Babinski reflex • Positive Moro reflex • Negative Doll's eye reflex • Negative Crawl reflex

Body weight

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? • Body weight • Skin integrity • Blood pressure • Respiratory rate

2 mL/kg/hr

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance? • 0.5 mL/kg/hr • 2 mL/kg/hr • 7.5 mL/kg/hr • 15 mL/kg/hr

Prior to percussing the abdomen

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? • After palpating the abdomen • Prior to percussing the abdomen • After assessing for kidney tenderness • Prior to inspecting the abdomen

30

A nurse is assessing a female child in an area struck by an earthquake. The child, who is crying, walks well, can state her first name, and repeatedly says "All done" and "Go bye bye now" during the assessment. The child has 24 deciduous teeth and her anterior fontanel is closed. Based on these observations, the nurse should estimate that the child is how many months old? • 12 • 18 • 24 • 30

Muscle tremors

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? • Dry, sticky mucous membranes • Polyuria • Negative Chvostek's sign • Muscle tremors

Lethargy

A nurse is assessing a school-age child whose blood glucose level is 280 mg/dL. Which of the following findings should the nurse expect? • Lethargy • Pallor • Tremors • Shallow respirations

At the end

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? • At the end • At the beginning • Before examining the head and neck • Before auscultating the chest and abdomen

Heat intolerance

A nurse is assessing an adolescent who has an exacerbation of Graves' disease. Which of the following findings should the nurse expect? • Weight gain • Bradycardia • Lethargy • Heat intolerance

Encourage the parents to rock the infant.

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? • Encourage the parents to rock the infant. • Offer the infant a pacifier. • Administer ibuprofen as needed for pain. • Position the infant on her abdomen.

Continue to monitor the client.

A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take? • Notify the provider. • Continue to monitor the client. • Provide oral rehydration fluids. • Perform a bladder scan at the bedside.

Have a parent stay with the child during procedures; Perform the procedure as quickly as possible; Allow the child to keep a toy from home with her

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) • Have a parent stay with the child during procedures. • Cluster invasive procedures whenever possible. • Perform the procedure as quickly as possible. • Allow the child to keep a toy from home with her. • Use mummy restraints during painful procedures.

A needleless syringe and a doll

A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? • A needleless syringe and a doll • A video game • A story book about a child who has diabetes • A period of play in the playroom

It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better.

A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make? • "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." • "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." • "Your child did not seem upset, so I wouldn't worry about it if I were you." • "Why does it bother you that your child has wet the bed?"

Oral electrolyte solution

A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant? • Oral electrolyte solution • Half-strength infant formula • Half-strength orange juice • Sterile water

FLACC

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level? • FLACC • Oucher • FACES • Visual Analog Scale

Cardiovascular

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis? • Cardiovascular • Gastrointestinal • Integumentary • Respiratory

Sudden decrease in abdominal pain

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 child's appendix is perforated? • Sudden decrease in abdominal pain • Absent Rovsing's sign • Flaccid abdomen • Low-grade fever

A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing

A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately? • A who is client 1 day postoperative and has a temperature of 37.5° C (99.5° F) • A client who has a burn injury to an estimated 5% his leg and is crying • A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing • A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation

Placing your child on her back when sleeping will decrease the risk of SIDS.

A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? • "Placing your child on her back when sleeping will decrease the risk of SIDS." • "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." • "SIDS rates have been rising over the last 10 years." • "Sleep apnea is the main cause of SIDS."

Patent ductus arteriosus

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? • Coarctation of the aorta • Patent ductus arteriosus • Tetralogy of Fallot • Tricuspid atresia

6 months

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? • 3 months • 6 months • 9 months • 12 months

Changes in the voice signal the beginning of puberty

A nurse is developing a health program for the parents of school-age boys. Which of the following information about pubescent changes should the nurse include in the program? • Changes in the voice signal the beginning of puberty. • Gynecomastia commonly occurs during late puberty. • Puberty might be delayed if scrotal changes have not occurred by the age of 11 years. • Growth spurts in height occur toward the end of midpuberty.

Creatinine levels are increased in clients who have acute kidney injury.

A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? • Potassium levels are increased in clients who have polyuria. • Specific gravity is decreased in clients who have hypovolemia. • BUN is decreased in clients who have dehydration. • Creatinine levels are increased in clients who have acute kidney injury.

I will wipe from the back to front with the cleansing cloth.

A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? • "I will wipe from the back to front with the cleansing cloth." • "I should not collect a urine sample when I am menstruating." • "I should let the urine cool to room temperature before sending it to the lab." • "I need to urinate a small amount in the toilet before collecting the sample."

Apply the ointment in a thin line into the conjunctival sac.

A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide? • "Apply the ointment in a thin line into the conjunctival sac." • "Ask the child to look down before applying the ointment." • "Always wipe from the outer to the inner canthus when wiping away secretions." • "Use a sterile glove and applicator to apply the antibiotic ointment."

The fever is causing an increase in your baby's heart rate.

A nurse is obtaining vital signs from 2-month-old infant. The infant's heart rate is 190/min and his temperature is 40° C (104° F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate? • "This is within the expected range for your baby." • "The fever is causing an increase in your baby's heart rate." • "As your baby begins to fall asleep, his heart rate will decrease." • "Your baby's heart is beating fast in an attempt to cool down his body."

Apply and release elbow restraints every hour.

A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? • Feed the infant with a spoon for 48 hr. • Apply and release elbow restraints every hour. • Keep the infant supine. • Suction the mouth with an oral suction tube.

Encourage the client to complete school work.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson? • Encourage the client to complete school work. • Vary the child's schedule each day. • Discourage visits from the client's friends. • Provide a daily session with a play therapist.

Apply to intact skin; Apply the medication an hour before the procedure begins; Cleanse the skin prior to procedure; Use a visual pain rating scale to evaluate effectiveness of the treatment.

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply.) • Spread the cream over the lateral surface of both forearms. • Apply to intact skin. • Apply the medication an hour before the procedure begins. • Cleanse the skin prior to procedure. • Use a visual pain rating scale to evaluate effectiveness of the treatment.

5.3 mL

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

0.94

A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

90-110 bpm

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate? ______ /min

Deliver compressions at ⅓ the depth of the chest.

A nurse is preparing to begin chest compressions on an infant. The nurse should perform compressions using which of the following techniques? • Deliver compressions at ⅓ the depth of the chest. • Deliver compressions with the heel of one hand. • Deliver compressions just above the nipple line. • Deliver compressions at a depth of 5 cm (2 in).

The reason why the child is taking the medication; Written information about the medication; The adverse effects of the medication

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.) • The reason why the child is taking the medication • Written information about the medication • Stopping the medication when the child feels better • The adverse effects of the medication • Using a kitchen spoon to administer the medication

Inspection; auscultation; superficial palpation; deep palpation

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) • Inspection • Superficial palpation • Deep palpation • Auscultation

Participates in imaginary play

A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler? • Controls impulsive feelings • Builds a collection of cards • Expresses need for privacy • Participates in imaginary play

Offer the child clear liquids for the first 24 hr.

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include? • Keep the child home for 1 week. • Give the child acetaminophen for discomfort. • Offer the child clear liquids for the first 24 hr. • Assist the child to take a tub bath for the first 3 days.

My son might complain of feeling shaky when he has a low blood glucose level.

A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates an understanding of the teaching? • "The onset of low blood glucose usually occurs slowly." • "My son might complain of feeling shaky when he has a low blood glucose level." • "Sweating can occur with hyperglycemia." • "My son might have nausea and vomiting with hypoglycemia."

I will be sure my child aspirates before injecting the insulin.

A nurse is providing teaching about self-administration of insulin to the parent of a school age child who has a new of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching? • "I will be sure my child aspirates before injecting the insulin." • "The insulin can be injected anywhere there is adipose tissue." • "I will be sure my child rotates sites after 5 injections in one area." • "The insulin should be injected at a 90-degree angle."

I'm glad that my child's ostomy is only temporary.

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? • "I'm glad that my child's ostomy is only temporary." • "I'm glad my child will have normal bowel movements now." • "I want to learn how to use my child's feeding tube as soon as possible." • "I want to learn how to empty my child's urinary catheter bag."

Obtain an influenza vaccine annually.

A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? • Administer glucagon for hyperglycemia. • Obtain an influenza vaccine annually. • Inject insulin in the deltoid muscle. • Take glyburide with breakfast.

A 10-year-old child who has sickle cell anemia who reports severe chest pain

A nurse is reviewing data for four children. Which of the following children should the nurse assess first? • A 10-year-old child who has sickle cell anemia who reports severe chest pain • A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.016 • A 1-year-old toddler who has roseola and a temperature of 39° C (102.2° F) • A 4-year-old child who has asthma and a PCO2 of 37 mm Hg

The teacher says my child has to squint to see the board.

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? • "The teacher says my child has to squint to see the board." • "My child has recently lost both front top teeth." • "My child often cheats when we play board games." • "Sometimes my child acts bossy with his friends."

Our car seat is an infant model and is anchored in the car.

A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? • "Our car seat is an infant model and is anchored in the car." • "Our car seat is front-facing in the back seat." • "I can fit my hand between the baby and the car seat harness." • "The car seat is rear-facing in the front passenger seat."

I will add Polycose to each of my baby's bottles.

A nurse is teaching a parent of an infant who has heart failure about meeting the infant's nutritional needs. Which of the following statements by the parent indicates an understanding of the teaching? • "I will feed my baby on a schedule every 4 hours." • "I will add Polycose to each of my baby's bottles." • "I will allow my baby to take as much time as needed to finish the bottle." • "I will limit my babies crying to 15 minutes prior to each feeding."

Test the urine for ketones.

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? • "Withhold insulin dose if feeling nauseous." • "Notify the provider if blood glucose levels are over 350 milligrams/deciliter." • "Test the urine for ketones." • "Limit fluid intake during meal time."

The rate and rhythm of breath are irregular in newborns

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? • "Newborns are abdominal breathers." • "Newborns do not expand their lungs fully with each respiration." • "Activity will increase the respiratory rate." • "The rate and rhythm of breath are irregular in newborns."

Serve food in small, non-circular pieces; Tie plastic bags in knots before discarding them; Fit the mattress so that it is snug against the sides of the crib

A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) • Serve food in small, non-circular pieces. • Tie plastic bags in knots before discarding them. • Install accordion style gates. • Set the water heater at 65.6° C (150° F). • Fit the mattress so that it is snug against the sides of the crib.

Bring your baby in to the clinic today.

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? • "Bring your baby in to the clinic today." • "Burp your baby more frequently during feedings." • "Give your infant an oral rehydration solution." • "Try switching to a different formula."

Offer the choice of 2 different liquids

A parent reports to the nurse that her two-year-old says "no" whenever he is offered juice and pushes it away. The mother realizes her son needs fluids. Which response from the nurse is most appropriate? • Provide distraction with toys. • Allow the child to see that the mother is upset. • Offer the choice of 2 different liquids. • Take food away until the child drinks.

Tachycardia

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 adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect? • Dry, flushed skin • Deep, rapid respirations • Tachycardia • Polyuria

An 18 month old who only says "no"

When assessing speech development, which child should the nurse refer for further examination? • A 4 month old who cries to express hunger or pain. • A 9 month old who uses a finger to point at things. • A 1 year old who says "oh-oh!" and shakes his head "no". • An 18 month old who only says "no".