Toddler NCLEX, Toddler, Preschool-passp
Which statement by the mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective?
"I've been checking the urine for protein so I'll be able to do it at home."
When teaching the parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?
4. "Try to maintain your child's usual lifestyle to promote normal development."
A 2-year-old child comes to the emergency department with inspiratory stridor and a barking cough. What is the highest priority action by the nurse?
Establish and maintain the airway.
A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress?
Intercostal retractions
Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital?
Side rails in the halfway position
The nurse is caring for a child with a fractured leg. The parents become concerned when visiting they notice the child sucking his thumb, a behavior previously given up. What does this behavior indicate?
The child is responding to stress.
A father expresses concern over his toddler's eating habits. He states the toddler eats very little and consumes only a single type of food for weeks on end. Which instruction is most helpful?
This is normal toddler behavior.
Which I.M. injection site might the nurse use for a 2-year-old child?
Ventrogluteal muscle
A 2-year-old child with status asthmaticus is admitted to the pediatric unit and begins to receive continuous treatment with albuterol, given by nebulizer. The nurse should observe for which adverse reaction?
tachycardia
The parents of a 2-year-old scheduled for surgical repair of an inguinal hernia are fearful and their fears are affecting their child. A play therapist is consulted to help with the child's care. The nurse should explain to the parents that the play therapist will:
use puppets to gain insight into how the child feels about his hospitalization and fears.
The nurse should expect a 3-year-old child to be able to perform which action?
Ride a tricycle
The charge nurse overhears a nurse complaining that she has been assigned to a toddler diagnosed with tetralogy of Fallot for the past 3 days and the mother is very demanding. Which response by the charge nurse is best?
"It's important for the child to have someone assigned to him who's familiar with his care."
Parents of a 15-month-old are concerned that their child says "no" to everything. Which statement by the nurse would be an appropriate response?
"Saying 'no' is part of toddler development and is normal at this age."
The nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is most appropriate?
"The special medicine will feel warm when it's put in the tubing."
A 13-month-old is admitted to the pediatric unit with a diagnosis of gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal that the child is dehydrated. Which nursing interventions are correct to prevent further dehydration? Select all that apply.
-Give clear liquids in small amounts. - Encourage the child to eat nonsalty soups and broths. - Monitor the IV solution per the health care provider's order.
A 2 ½-year-old child, admitted with nephrotic syndrome, has been in the hospital for 24 hours. When the nurse makes her 8 a.m. rounds she notices that no care has been documented for this child since 6 a.m. Which action by the nurse takes priority?
1. Repositioning the child
A 3-year-old child comes to the clinic for a wellness checkup. When the nurse weighs the child, she notes a 10-lb weight gain since his last checkup 1 year ago. The nurse recognizes that this weight gain is:
1. excessive for a toddler, requiring further data collection.
The nurse observes a 2½-year-old child playing with another child of the same age in the playroom on the pediatric unit. What type of play should the nurse expect the children to engage in?
2. Parallel play
When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, doing this helps the child achieve :
2. autonomy.
Which statement by the mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective?
3. "I've been checking the urine for protein so I'll be able to do it at home."
The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size?
3. 23G
What is the best advice for a nurse to give to the parents of a 2-year-old child who frequently throws temper tantrums?
3. Ignore the behavior when it happens.
The nurse should determine a child's body surface area by using:
3. a nomogram.
A 3-year-old child has had surgery to remove a Wilms tumor. Which action should the nurse take first when the parent asks for pain medication for the child?
Assess the child's pain using a smiley face pain scale.
A nurse is reinforcing education with parents on providing adequate nutrition for their toddler who has cerebral palsy. Which observation by the nurse indicates that the education has been effective?
The child eats finger foods independently.
A 3-year-old child is receiving ampicillin for acute epiglottitis. Which sign would lead the nurse to suspect that the child is experiencing a common adverse effect of this drug?
generalized rash
A 3-year-old child is experiencing distress after having cardiac surgery. Which sign indicates cardiac tamponade
muffled heart sounds
An 18-month-old child comes to the primary health care provider's office for a well-baby checkup. Which foods should the nurse recommend as providing the best sources of dietary iron for the child?
peanut butter, green vegetables, and raisins
A 1-year-old underwent hypospadias repair yesterday; he has a urethral catheter in place and an IV. Which rationale is appropriate for administering propantheline on an as-needed basis?
to prevent bladder spasms while the catheter is present
A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction?
"Give the elixir with water or juice."
A 3-year-old child with Down syndrome, admitted to the pediatric unit with asthma, does not enunciate words well and holds on to furniture when he walks. What question would be appropriate for the nurse to ask the parent?
"How does your child's condition today differ from his normal condition?"
The nurse is reinforcing education with the parents of a 3-year-old child diagnosed with rubella. The mother has just given birth to a second child. Which statement by the parent best indicates an understanding of the implications of rubella?
"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
A 2-year-old hospitalized child is HIV positive with severe thrush. The child's anxious grandparents are at her bedside, continually calling the nurses with various concerns. The staff speak disparagingly about them because they are tired of responding to the frequent call lights. When working with the unit's staff, which response by the nurse manager would be appropriate in creating a more optimal care environment for the child?
"If we stop by the room before the light goes on, they may be less anxious."
A nurse is reinforcing education to the parents of an 18-month-old infant diagnosed with bilateral otitis media about the prescribed medication amoxicillin and clavulanate potassium. Which statement by the parents indicates the education has been effective?
"It can cause diarrhea."
A child, age 15 months, is admitted to the health care facility. During the initial data collection, which statement by the mother most strongly suggests that the child has a Wilms' tumor?
"My child's abdomen seems bigger, and his diapers are much tighter."
An 18-month-old child is admitted to the hospital with full-thickness burns to the anterior chest. The parent asks how the burns will heal. Which statement would the nurse incorporate in the response?
"Surgical closure and grafting are usually needed."
A nurse in a primary health care provider's office is reinforcing education about car seat safety with the parent of a 2-year-old. The parent asks if the child, who weighs 35 lb (15.9 kg), requires a car seat. Which response by the nurse is most appropriate?
"The child should ride in the car seat until he is 4 years old and weighs at least 40 lb."
A 2-year-old child's parent informs the nurse of a concern that the child may have attention deficit hyperactivity disorder (ADHD) because "my child has so much energy, doesn't pay attention for long, and is always getting into things." Which response by the nurse would be best?
"This behavior is normal. The child is exploring and learning about the world."
When teaching the parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?
"Try to maintain your child's usual lifestyle to promote normal development."
At a wellness visit, the parents report that their daughter, age 4, resists going to bed at night. After instruction by the nurse, which statement by the parents indicates effective teaching?
"We'll read her a story and let her play quietly in her bed until she falls asleep."
The nurse suspects that a child, age 4, is being neglected physically. To best collect data on the child's nutritional status, the nurse should ask the parents which question?
"What did your child eat for breakfast?"
A 1-year-old infant is pale, but his physical examination is normal. Blood studies reveal his hematocrit is 24%. Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?
"What's the infant's usual daily diet?"
The nurse is working in a toddlers' playroom providing play therapy. When the toddlers are brought into the room, which scenarios indicate normal toddler play? Select all that apply.
-toddlers playing with toys separately from each other - toddlers wanting the parents to be within sight in the room - toddlers reluctant to crawl to nursing personnel
The nurse is teaching a parent how to administer antibiotics at home to a toddler with acute otitis media. Which statement by the parent indicates that teaching has been successful?
1. "I'll give the antibiotics for the full 10-day course of treatment."
The nurse is trying to determine if the risks associated with lead poisoning are present in a toddler's home environment. Which question should the nurse ask the toddler's mother?
1. "Is your child ever exposed to well water?"
The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her?
1. "It's common for a child to exhibit regressive behavior when anxious or stressed."
The charge nurse overhears a nurse complaining that she has been assigned to a toddler diagnosed with tetralogy of Fallot for the past 3 days and the mother is very demanding. Which response by the charge nurse is best?
1. "It's important for the child to have someone assigned to him who's familiar with his care."
A 14-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the client's room, the nurse anticipates using which traction system?
1. Bryant's traction
A mother brings her 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on his buttocks. Which instruction should the nurse give the mother.
1. Change diapers frequently and use air-drying when possible.
The nurse is teaching parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?
1. Eustachian tubes
When attempting to reduce the risk of impaired skin integrity related to immobility in a toddler, which action should the nurse take?
1. Gently massage the skin with a lubricating substance.
A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to his mother. Which data should the nurse obtain first?
1. Heart rate, respiratory rate, and blood pressure
A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress?
1. Intercostal retractions
The physician prescribes acetaminophen (Tylenol) elixir, 160 mg every 4 hours, for a 14-month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?
1. None because this isn't a safe dose
The nurse should expect a 3-year-old child to be able to perform which action?
1. Ride a tricycle
Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery?
1. Risk for infection
The nurse is admitting a 14-month-old client to the pediatric floor with a diagnosis of croup. Which characteristics would the nurse expect the toddler to have if he is developing normally?
1. Strong hand grasp, 2. Tendency to hold one object while looking for another, 3. Recognition of familiar voices (smiles in recognition), 5. Weight that is triple the birth weight
A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased respiratory rate, and a decreased oxygen saturation level. Which of the following should be the nurse's first action?
1. Suction the tracheostomy.
The nurse is teaching a group of mothers about normal toddler development. When talking about toddlers' play, the nurse should include which point?
1. They play with similar objects nearby other children rather than with them.
Which I.M. injection site might the nurse use for a 2-year-old child?
1. Ventrogluteal muscle
A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:
1. a barium enema.
A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:
1. a barking cough.
A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet-training that the nurse should stress to her is:
1. developmental readiness of the child.
A nurse on the pediatric floor is caring for a toddler. The nurse should keep in mind that toddlers:
1. express negativism.
A parent calls the pediatric clinic to express concern over her toddler's eating habits. She says the toddler eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of:
1. normal toddler behavior.
A nurse observes a parent in a class performing chest compressions on a simulated 2-year-old child. The nurse knows the mother is doing compression correctly when she observes her compression to be approximately how many inches in depth?
2 in (5 cm)
A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction?
2. "Give the elixir with water or juice."
The nurse explains hospice care to the parents of a 15-month-old toddler with terminal neuroblastoma. Which explanation by the nurse is best?
2. "Hospice provides services to improve the quality of life for the child who's suffering from a terminal illness and for his family."
A child with osteomyelitis is to receive nafcillin (Nafcil) I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable?
2. 250 mg every 6 hours
When caring for a toddler, the nurse should understand that a child in this age-group works to achieve which developmental task?
2. Autonomy
An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler?
2. Coin rubbing
The nurse is collecting data on a 3-year-old child who has ingested toilet bowl cleaner. What finding should the nurse expect?
2. Edematous lips
A 13-month-old client is admitted to the pediatric unit with a diagnosis of gastroenteritis. The toddler has experienced vomiting and diarrhea for the past 3 days, and laboratory tests reveal that he is dehydrated. Which nursing interventions are correct to prevent further dehydration?
2. Give clear liquids in small amounts., 4. Encourage the child to eat nonsalty soups and broths., 5. Monitor the I.V. solution per the physician's order.
The nurse is advising a mother about foods to avoid to prevent choking in her toddler. Which foods should she include in her instruction?
2. Large, round chunks of meat such as hot dog
The nurse is teaching parents about accident prevention for a toddler. Which of the following guidelines is most appropriate?
2. Make sure all medications are kept in containers with childproof safety caps.
The nurse is teaching a group of mothers about accident prevention for toddlers. Which point is important for the nurse to emphasize?
2. Making sure outlets are covered with plastic outlet covers that can't be removed by a child
A 16-month-old with a history of hydrocephalus is admitted with an infected ventriculoperitoneal shunt. Which assessment takes priority in this toddler?
2. Monitor for signs of increased intracranial pressure.
A 15-month-old admitted with meningitis develops a rectally obtained fever of 105° F (40.5° C). The registered nurse inserts an I.V. catheter and antibiotics are administered. Which step should be taken next by the licensed practical nurse caring for the toddler?
2. Obtaining an order for an antipyretic and administering it immediately
A 3-year-old client is admitted to the pediatric unit with pneumonia. He has a productive cough and appears to have difficulty breathing. The parents tell the nurse that the toddler hasn't been eating or drinking much and has been very inactive. Which interventions to improve airway clearance should be included by the nurse in the care plan?
2. Perform chest physiotherapy as ordered., 3. Encourage coughing and deep breathing., 5. Perform postural drainage., 6. Maintain humidification with a cool mist humidifier.
The nurse is teaching accident prevention to the parents of a toddler. Which of the following instructions is appropriate for the nurse to tell the parents?
2. Place locks on cabinets containing toxic substances.
An 18-month-old child immobilized with traction to the legs has a nursing diagnosis of Deficient diversional activity related to immobility. The nurse should include which diversional activity in the plan of care?
2. Playing with a pounding board
A 14-month-old is undergoing bone marrow aspiration because leukemia is suspected. A local anesthetic is administered, but the nurse anticipates that a nonpharmacologic comfort measure will also be needed. Which measure is best for a toddler at this age?
2. Reading the toddler a book during the procedure
A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What should the nurse do first?
2. Report the incident to the proper authorities.
The physician prescribes 300,000 U of penicillin G I.M., for an 18-month-old child. What is the best site for the nurse to administer this injection?
2. Thigh (vastus lateralis muscle)
A child's parents state that they childproofed their home for their 2-year-old boy. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which of the following situations displays misunderstanding by the parent?
2. Toy chest in front of a second-story, locked window
The parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment?
2. Using gestures to express desires
The nurse is caring for a toddler who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report:
2. generalized urticaria.
A 2-year-old is admitted to the pediatric unit with fever, seizures, and vomiting. He's awake and irritable. As the nurse is putting a gown on the child, the nurse notices petechiae across the child's chest, abdomen, and back. The nurse should first:
2. initiate droplet precautions.
The best way for the nurse to monitor pain in an 18-month-old child is to:
2. observe for behavioral changes.
An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include:
2. poor hygiene and weight loss.
When caring for a toddler with epiglottitis, the nurse should first:
2. prepare him for tracheotomy.
A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent:
3. "Does your child tug at either ear?"
The nurse in the pediatrician's office is teaching the mother of a 3-year-old about car seat safety. The mother questions the nurse as to why her son requires a car seat when he weighs 35 lb. Which response by the nurse is best?
3. "He should ride in the car seat until he's at least 40 pounds and 4 years old."
A family of four involved in a house fire is brought to the hospital for treatment of burns. The local media arrives at the hospital requesting information about the condition of the family members. Which response by the nurse is most appropriate?
3. "I need to obtain permission from the parents or their representative before I can release any information."
To treat a child's atopic dermatitis, a physician prescribes a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching?
3. "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently."
A child, age 15 months, is admitted to the health care facility. During the initial data collection, which statement by the mother most strongly suggests that the child has a Wilms' tumor?
3. "My child's abdomen seems bigger, and his diapers are much tighter."
After the nurse explains dietary restrictions to the parents of a child with celiac disease, which statement by the parents indicates effective teaching?
3. "Our child must maintain these dietary restrictions for life."
A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching?
3. "We'll go to the physician if our child pulls on his ears or won't lie down."
When collecting data on an 18-month-old child, the nurse determines that the child's height and weight fall below the 5th percentile on the growth chart. In all previous visits, the child's height and weight fell between the 30th and 40th percentiles. The child's mother expresses concern about the slowed growth rate. How should the nurse respond?
3. "Your child's height and weight should be checked again in 1 month."
A mother brings her child, age 3, to the clinic for an annual checkup. After plotting the child's height and weight on a pediatric growth chart, the nurse identifies which percentile range as normal?
3. 5th to 95th percentile
Before administering a tube feeding to a toddler, which of the following methods should the nurse use to check the placement of the nasogastric (NG) tube?
3. A check of the pH of fluid aspirated from the tube
An 18-month-old male child is admitted to the pediatric unit with a diagnosis of celiac disease. What finding would the nurse expect in this child?
3. A protuberant abdomen
When the physician prescribes an antibiotic to treat a child's ear infection, the nurse checks to see whether the ordered antibiotic could cause ototoxicity. Which of the following options belongs in this category?
3. Aminoglycosides
When assisting in developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate?
3. Arm restraints while asleep
A nurse who's functioning as the team leader on the infant and toddler unit is working with a licensed practical nurse (LPN) and a nursing assistant. The team leader notices that the nursing assistant is sitting at the desk while the LPN is very busy with her assignment and appears frustrated. What action should the team leader take?
3. Ask the LPN why she's frustrated and ask the nursing assistant to help the LPN with her work.
For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority?
3. Avoiding abdominal palpation
For a child with a circumferential chest burn, what is the most important factor for the nurse to monitor?
3. Breathing pattern
A parent brings a toddler, age 19 months, to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?
3. Closed anterior and posterior fontanels
When the nurse collects data on a 2-year-old child with suspected dehydration, which condition should be reported to the physician immediately?
3. Decreased blood pressure
When a toddler with croup is admitted to the facility, the physician orders treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What is the nurse's best approach for gaining the child's cooperation with the treatment?
3. Encourage the parent to stand next to the crib and stay with the child.
A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority?
3. Frequently monitoring the child's level of consciousness (LOC)
A nurse on the pediatric unit who's assigned to the performance improvement committee identifies that admission assessments aren't being completed within the timeframe designated in their standards. Which action should she take first?
3. Notify the nurse-manager so she can identify contributing factors and devise an action plan.
A 2-year-old who's admitted to the pediatric unit for a tonsillectomy is in foster care. The nurse assists the physician in gaining informed consent. Who can legally give informed consent for this elective procedure?
3. Parents or guardian
A toddler is having a tonic-clonic seizure. What should the nurse do first?
3. Remove objects from the child's surroundings.
Which of the following would be the best approach when trying to take a crying toddler's temperature?
3. Talk to the mother first and then to the toddler.
A mother tells the nurse that her 22-month-old child says no to everything. When scolded, the toddler gets angry and starts crying loudly but then immediately wants to be held. What is the best interpretation of this behavior?
3. This behavior is normal in a 2-year-old child.
A 14-month-old child with acquired immunodeficiency syndrome (AIDS) is admitted to the facility with an infection. When assisting in developing a plan of care, the nurse must keep in mind that AIDS in children commonly is associated with:
3. developmental delays
The nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can:
3. hold and rock him and give him a security object.
A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesn't enunciate words well and holds onto furniture when he walks. The nurse should ask the mother:
3. how the child's condition today differs from his normal condition.
The nurse is providing dietary teaching for the parents of a child with celiac disease. This child should avoid:
3. prepared puddings.
The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit:
3. strong food preferences.
The parents of a 2-year-old scheduled for surgical repair of an inguinal hernia are fearful and their fears are affecting their child. A play therapist is consulted to help with the child's care. The nurse should explain to the parents that the play therapist will:
3. use puppets to gain insight into how the child feels about his hospitalization and fears.
A physician is administering a medication by intraosseous infusion to a child. Intraosseous drug administration is typically used for a child who is:
3. younger than age 3 in an emergency situation when I.V. access isn't available.
A nurse rescuer knows that chest compressions must be coordinated with ventilations. Which ratio should the nurse rescuer use for a 3-year-old child?
30 compressions to 2 ventilations
An 18-month-old toddler comes into the emergency department after being found face down in the bathtub by his mother. She was able to administer cardiopulmonary resuscitation as instructed by the emergency telephone dispatcher. The toddler fully recovers and is ready for discharge. Which instruction should the nurse include during discharge teaching?
4. "Don't leave your child unattended in the bathtub even for a few minutes."
A 2-year-old is brought to the clinic by his mother for his annual examination. Which statement by the mother alerts the nurse to the toddler's risk for malnutrition?
4. "He drinks a bottle of whole milk several times a day."
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella?
4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
A toddler is in the hospital. Which response to the parents, who are concerned about the seriousness of the child's illness, would be the most appropriate?
4. "It must be difficult for you when your child is ill and hospitalized."
The nurse in a clinic walks into a client's room and finds the mother of a 15-month-old child in tears. The mother states that her child doesn't love her because the child says "no" to everything. Which of the following would be an appropriate response?
4. "Saying 'no' is part of toddler development and is normal at this age."
A mother brings her toddler to the clinic for a wellness checkup. When the nurse asks the mother if she has questions or concerns, the mother tells the nurse she is frustrated because it's so difficult to get her child to bed at night. Which response by the nurse is best?
4. "Toddlers need a consistent bedtime routine, such as having a set bedtime, eating a light snack before going to bed, or reading a book."
A mother asks a nurse about measures for disciplining her toddler. Which recommendation by the nurse is best?
4. "When using a time-out, make sure your child knows the rules ahead of time."
When teaching the mother of a 17-month-old child about toilet training, which instruction would initially be most appropriate?
4. Be sure the child is ready before starting to toilet train.
A toddler with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
4. Droplet precautions
A toddler is brought to the emergency department in cardiac arrest. The physician tries three times to insert an I.V. catheter but is unsuccessful. By which alternate route can the physician administer emergency medications?
4. Intraosseously
What should the nurse do to ensure a safe hospital environment for a toddler?
4. Move the equipment out of reach.
A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most strongly suggests that the child's injuries stem from abuse?
4. Not crying when moved
A toddler is admitted to the facility for treatment of a severe respiratory infection. The child's recent history includes fatty stools and failure to gain weight steadily. The physician diagnoses cystic fibrosis. By the time of the child's discharge, the child's parents must be able to perform which task independently?
4. Performing postural drainage
A toddler requires emergency intervention for an obstructed airway. Which nursing intervention is appropriate?
4. Performing the tongue-jaw lift and removing the foreign object only if it's visible
Which of the following activities should a 2-year-old child to be able to do?
4. Remove a garment.
Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital?
4. Side rails in the halfway position
A 2-year-old is admitted with failure to thrive. The child's mother expresses to the nurse that she doesn't have enough money to buy food for her child. Based on this information the nurse should request from the physician an order to consult which department?
4. Social services
The nurse teaches a mother how to provide adequate nutrition for her toddler, who has cerebral palsy. Which of the following observations indicates that teaching has been effective?
4. The child eats finger foods by himself.
The nurse is caring for a child with a fractured leg. The child's mother becomes concerned when she visits her son and notices him sucking his thumb, a behavior that he had previously given up. What does this behavior indicate?
4. The child is responding to stress.
A toddler is hospitalized for treatment of injuries that the staff believes were caused by child abuse. A staff member states that the parents "shouldn't be allowed to visit because they caused the child's injuries." When responding to this staff member, the nurse should base the comments on which understanding?
4. The parents should be encouraged to visit frequently and should be welcomed by the staff.
Which desired outcome demonstrates effective parent teaching about disciplining a toddler?
4. The parents will call immediate attention to undesirable behavior.
A 2-year-old child is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches him. The nurse needs to listen to the child's breath sounds. The best way to approach the 2-year-old child is to:
4. allow the child to handle the stethoscope before listening to his lungs.
The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to:
4. allow the toddler to bathe as much of himself as he can with supervision.
The physician prescribes digoxin (Lanoxin) elixir for a toddler with heart failure. Immediately before administering this drug, the nurse must check the toddler's:
4. apical pulse.
A 3-year-old is to receive 500 mL of dextrose 5% in normal saline solution over 8 hours. At what rate (in milliliters per hour) should a nurse set the infusion pump? Round your answer to a whole number.
63
A toddler is ordered 350 mg of amoxicillin and clavulanate (Augmentin) by mouth, four times per day. The pharmacy sends a bottle with a concentration of 250 mg/5 ml. How many milliliters should the nurse administer per dose?
7
A physician prescribes 150 mg of ibuprofen (Advil) for a toddler whose temperature didn't lower after receiving acetaminophen (Tylenol). The oral suspension available contains 100 mg per 5 ml. How many milliliters of suspension should the nurse administer?
7.5
A 3-year-old child who is unable to make a sound and is cyanotic and lethargic is brought to the emergency department. The parent states that the child swallowed a penny. Which should the nurse do first?
Administer abdominal thrusts.
When assisting in developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate?
Arm restraints while asleep
When caring for a toddler, the nurse should understand that a child in this age-group works to achieve which developmental task?
Autonomy
For a child with a circumferential chest burn, what is the most important factor for the nurse to monitor?
Breathing pattern
How should the nurse prepare a suspension before administration?
By shaking it so that all the drug particles are dispersed uniformly
Parents bring their 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on the buttocks. Which instruction should the nurse give the parents?
Change diapers frequently and air-dry when possible. Correct response:
A mother brings her 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on his buttocks. Which instruction should the nurse give the mother?
Change diapers frequently and use air-drying when possible.
A 2-year-old child is found on the floor next to a toy chest. After first determining unresponsiveness and calling for help, which step should be taken next?
Check for a pulse.
Which method is most reliable for confirming a preschooler's identity before administering a medication?
Check the hospital identification bracelet.
A 4-year-old male is brought to the ambulatory care clinic for well-child care. His height (37 inch [94 cm]) and weight (29 lb [13.2 kg]) are below the 5th percentile for his age and sex. What should the nurse do first in evaluating his growth?
Compare his growth trends with those of his parents and siblings.
A mother states that she is being pressured by family to toilet train her 22 month old. When the nurse is instructing on successful toilet training tips, which point is stressed?
Curiosity of the child
The nurse is caring for a toddler hospitalized with a diagnosis of croup (laryngotracheobronchitis). The health care provider prescribes treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What would be the best approach for the nurse to take to gain the child's cooperation with the treatment?
Encourage the parent to stand next to the crib and stay with the child.
A 2-year-old child comes to the emergency department with inspiratory stridor and a barking cough. What is the highest priority action by the nurse?
Establish and maintain the airway
A 4-year-old child has a tick embedded in the scalp. Which method should the nurse use to remove the tick?
Grasp the tick with tweezers and apply slow, outward pressure.
Which of the following techniques is most effective in preventing nosocomial infection transmission when caring for a preschooler?
Hand washing
A preschool-age child scheduled for surgery in the morning is admitted to the facility for the first time. Which nursing action would ease the child's anxiety?
Having the child act out the surgical experience using dolls and medical equipment
During a well-child visit, the nurse is reinforcing education with the parents of a 2-year-old child. What is the best recommendation a nurse can give to the parents regarding frequent temper tantrums?
Ignore the behavior when it happens.
Which is the most appropriate nursing diagnosis for a preschool child with epiglottitis?
Ineffective airway clearance related to laryngospasm
The mother of a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to which of the following?
Latex
What should the nurse do to ensure a safe hospital environment for a toddler?
Move the equipment out of reach.
A nurse has instructions to notify the health care provider if a 44-lb preschooler's urine output drops below 3 mL/kg/hour. The urine output for the previous hour was 30 mL. Which nursing intervention would be the priority?
Notify the health care provider of the child's urine output
A nurse on the pediatric unit who's assigned to the performance improvement committee identifies that admission assessments aren't being completed within the timeframe designated in their standards. Which action should she take first?
Notify the nurse-manager so she can identify contributing factors and devise an action plan.
After collecting data on a newly admitted 5-year-old child, the nurse assists in making the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?
Parents' failure to use available support systems or agencies to assist in coping
Encouraging children to engage in fantasy play and participate in their own care is a useful developmental approach for which pediatric age-group?
Preschool age (3 to 5 years)
A 5-year-old newly diagnosed asthma client is being discharged from the hospital following asthma exacerbation. While providing discharge instructions to an overwhelmed parent, which instruction is essential for home medication use?
Provide the family with the drug's name, dosage, route, and frequency of administration.
When collecting data from a 2-year-old child, which finding would indicate to the nurse the possibility of growth hormone deficiency?
The child had normal growth during the first year of life but showed a slowed growth curve below the 3rd percentile for the second year of life.
Which observation by a nurse indicates that an 18-month-old in Bryant traction is properly positioned?
The hips are slightly elevated off the bed.
The nurse is teaching a group of parents about normal toddler development. When talking about toddlers' play, the nurse should include which point?
They play with similar objects nearby other children rather than with them.
A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth?
Up to 20
A child is seen at the health care provider's office. During the interview period the child's parent reports the child has a grade 1 heart murmur. The nurse is aware that this murmur has which characteristic?
a sound softer than the heart sounds
When collecting data on a child's cultural background, the nurse should keep in mind that:
behavioral patterns are learned within a culture.
A nurse is collecting data on a 3-year-old who has ingested toilet bowl cleaner. What is the priority when gathering data from this child?
evaluating the airway patency and respiratory status
For a child who's admitted to the emergency department with an acute asthma attack, nursing data collection is most likely to reveal:
expiratory wheezing
When obtaining data on a 2-year-old child with croup in respiratory distress, which finding would the nurse expect to observe first?
grunting or head bobbing
What is the best way for a nurse to position a 3-year-old child with right lower lobe pneumonia?
left side-lying
The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position?
lying on one side, with the back curved
A 4-year-old child is admitted to the burn unit with a circumferential burn to the left forearm. Which finding would alert the nurse to a potential complication that should be reported to the health care provider?
numbness of fingers
Which adverse effect can be expected by the parents of a 2-year-old child who has been started on rifampin after testing positive for tuberculosis?
orange body secretions
A nurse is assessing a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?
positive Kernig's sign
The nurse is caring for a toddler admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report?
proteinuria
The nurse is caring for a 20-month-old toddler. The toddler's adoptive parent asks what kind of toy is good to give this child based on the toddler's age. Which toy would the nurse suggest that the parent give based on the growth and development of toddlers?
push-pull toy
The nurse is caring for a 3-year-old client being treated for severe status asthmaticus. After comparing clinical manifestations with laboratory results (reported as shown), a nurse determines that this client has progressed to which condition?
respiratory acidosis
A child is admitted to the pediatric unit with a fractured hip. The physician orders Russell traction. This type of traction is:
skin traction applied to a lower extremity, with the extremity suspended above the bed.
The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit:
strong food preferences.
The nurse at a family health clinic is educating a group of parents about normal infant development. What patterns of communication should the nurse tell parents to expect from an infant at age 1?
understands "no" and other simple commands
When telling a 4-year-old child about an upcoming procedure, the nurse's most important consideration is to:
use simple terms.
A 2-year-old child has been diagnosed with asthma. The parents ask about the most common asthma triggers. What is the nurse's response?
weather