VNSG 1334: Foundation/Infant Prep U Questions
A 5-year-old boy is scheduled for hospitalization in 2 weeks. Which is the best intervention to help ease the stress of hospitalization in this child?
Encourage the family to participate in the child-life program. Explanation: Many hospitals have a child-life program to make hospitalization less threatening for children and parents. The best way to ease the stress of hospitalization is to ensure that the child has been well prepared, and this can be done with such a program. The other options will help relieve some stress, but the child-life program is the best all-inclusive intervention.
The nurse measures the head circumference of a 6-month-old infant. Which measurement would the nurse interpret as most appropriate?
43.5 Explanation: Head circumference increases rapidly during the first 6 months. In a 6-month-old it is typically 42 to 44.5 cm (16.5 to 17.5 in); at birth it is usually 33 to 35 cm (13 to 14 in); and at 1 year of age it is usually 45 to 47.5 cm (17.7 to 18.7 in).
The parent cannot understand why the 12-month-old can throw a ball but cannot catch the ball. Which statement by the nurse helps the parent understand this?
"Maturation of neurological and muscular functioning has not occurred for this skill" Explanation: The ability to throw a ball is performed with one hand and is a simple activity. Catching the ball is a more complex skill and involves eye hand coordination and occurs in an older child with more maturity. Principle of growth and development in developing skills proceeds from the simple to the complex.
The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which of the following sites to obtain an accurate assessment?
Apical pulse at the third or fourth intercostal space Explanation: For children younger than 2 years of age, the nurse should auscultate the apical pulse with the stethoscope at the point of maximum intensity just above and outside of the left nipple at the third or fourth intercostal space. The radial pulse is difficult to palpate accurately on children younger than 2 years of age because the blood vessels lie so close to the skin surface and are easily obliterated. The brachial pulse is not the best point of auscultation. The point of maximum intensity (PMI) is heard best at the fourth or fifth intercostal space at the midclavicular line beginning around 7 years of age.
The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention?
Continue to assess for bleeding Explanation: Children will have a small amount of blood mixed with saliva following a tonsillectomy. Suctioning or coughing could irritate the surgical site and cause hemorrhage.
The nurse is incorporating nonverbal communication with verbal communication when explaining the treatment plan for a child with type 1 diabetes. What should the nurse do to communicate effectively with this family?
Sit opposite the family and lean forward slightly Explanation: Guidelines for appropriate nonverbal communication include the following: sit opposite the family and lean forward slightly; relax: maintain an open posture, with the arms uncrossed; maintain eye contact; and nod your head to demonstrate interest.
A 2-year-old boy is seen for acute laryngotracheobronchitis. What observation would lead the nurse to suspect airway occlusion?
His respiratory rate is gradually increasing. Explanation: An increasing respiratory rate is a major sign of airway occlusion (breathing faster because less air is received with each breath).
If a urine specimen for analysis is ordered for an 8-month-old girl, which intervention would you use?
Place a urine collector on her just prior to feeding. Explanation: Most infants void following a feeding, so placing a urine collector just before a feeding will usually allow a urine specimen to be obtained.
A child is to receive an IV. The nurse knows that the first step in initiating the procedure is to:
The first step before beginning the procedure is to verify the physician's order. The other steps are necessary but are not the first step.
A nurse is providing skilled home care to a pregnant woman. Which situation best describes this concept?
The woman needs daily fetal heart rate monitoring. Explanation: Home care is considered to be skilled if it includes physician-prescribed procedures such as administration of medication or monitoring of FHR.
When preparing an intravenous infusion for an infant, it would be important to:
add a calibrated fluid pump to the line. Explanation: Because the danger of fluid overload is so great with infants, all intravenous fluid should be infused with an automatic pump.
A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first?
"Have him use his short-acting bronchodilator right away." Explanation: The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.
The nurse is caring for a family who has opposing views on care for their terminally ill preschooler. Which nursing statement best addresses this dilemma?
"I will share with your health care provider that you have questions that make decision making difficult." Explanation: Families may have opposing views on the best treatment plan for a child. The ability to ask questions and have specific answers best enables the family to come to a conclusion regarding care. Open communication enhances understanding of options. The nurse telling the family what is best is inappropriate. Preschoolers are not able to understand the medical situation and, thus, should not be included in important care decisions.
Which statement made by a new nurse demonstrates an understanding of the prevelance of violence and sexual abuse among the population?
"I've come to realize that I need to include questions related to sexual abuse and violence into the assessment of all my clients." Explanation: Nurses will come in contact with violence and sexual abuse no matter what health care setting they work in and among all segments of the population. Nurses must be ready to ask the right questions and to act on the answers, because such action could be lifesaving.
The caregiver of 7-month-old twins tells the nurse that she has noticed that both of her children enjoy playing with a toy by moving the object back and forth between their hands over and over again. Which statement made by the nurse most accurately explains this behavior?
"This is one of the ways that infants develop their fine motor skills." Explanation: Transferring objects is one of the manifestations of fine motor skills development, which is not fully mastered by this early age. References to nerve endings do not address the parent's query.
A mother of a 10-month-old states to the nurse, "I brush my child's teeth every day with flavored kids' toothpaste." Which is the most appropriate response by the nurse?
"Toothpaste is not necessary; it is the scrubbing that is required." Explanation: Toothpaste for infants is not required. The important health technique is the removing of plaque, and that is accomplished through scrubbing of the teeth.
A home visit nurse is providing health promotion on safety to a family of a 1-week-old infant. Which of the following statements by the parents indicates the need for further teaching?
"We will position our infant on his side for sleeping." Explanation: Infants should be placed on their backs for sleeping to reduce the risk of SIDS. All other choices are safe infant practices.
Which measure would be most effective in aiding bronchodilation in a child with laryngotracheobronchitis?
Assisting with racemic epinephrine nebulizer therapy Explanation: A bronchodilator increases the lumen of airways.
A nurse who is caring for a child who has died begins to cry while talking with the family. What is the most appropriate action by the nurse?
Continue to care for the child and family in an unobtrusive manner. Explanation: Families have expressed that seeing the nurse crying shows them how their child has impacted others' lives and helps with the grief process. The nurse should not discuss her personal experiences with death because this does not address the family's grief. The family's beliefs may not allow for touch, so hugging the family may be inappropriate.
Students are reviewing information about family structures and functions. They demonstrate understanding of the information when they identify which of the following as true?
Despite changes in family structure, the nuclear family is still prominent. Explanation: At the beginning of the 21st century, family structures are more varied than in the past. The small, traditional family unit known as the nuclear family remains prominent. The functions of each family differ but do exist to meet some common goals. From 1970 to 2007, married couples in families with children decreased from 93% to 71%. The traditional U.S. family structure is the nuclear family but other structures are common today.
The nurse is instructing a parent group on a child's perception of death. Which factors are included in the teaching plan? Select all that apply.
Developmental age Past experience with death of a pet Family's attitude toward death Explanation: Developmental age, past experiences with death, and family's attitude toward death will influence a child's perception of death. The chronological age of the child may not match the developmental age of the child; therefore, the developmental age plays a greater role in a child's view of death.
The nurse is caring for a 10-year-old boy who is in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. What would be the best intervention?
Enlist the aid of a child-life specialist. Explanation: The nurse should enlist the aid of a child-life specialist to provide suggestions for appropriate activities. Offering the child reading materials or encouraging him to complete his homework would most likely be met with resistance as he has already verbalized his boredom and disinterest in play, reading, and schoolwork. The parents could offer the child life specialist ideas about the boy's likes and dislikes; however, the child life specialist could offer expertise in assisting hospitalized children.
A nursing is preparing to administer vaccines to a 4-month-old infant. Which vaccines will the nurse administer? Select all that apply.
Haemophilus B inactivated poliomyelitis diphtheria, tetanus, and pertussis pneumococcal
A father discusses with the nurse how his daughter, who recently started first grade, is extremely conscientious about her school work and is constantly asking her teachers if she is doing the work correctly. According to Erikson, which of the following developmental tasks is this girl currently learning?
Industry versus inferiority Explanation: Erikson viewed the developmental task of the school-age period as developing industry versus inferiority, or accomplishment rather than inferiority. During school age, children learn how to do things well. A school-age child, while doing a project will ask, "Am I doing this right? Is it okay to use blue?" The developmental task of the preschool period is learning initiative versus guilt or learning how to do things. The new interpersonal dimension that emerges during adolescence is the development of a sense of identity versus role confusion. The developmental task of the toddler is to learn autonomy versus shame or doubt.
Which of the following is a common viral upper respiratory infection in an older child?
Influenza Explanation: Viral upper-respiratory infections that affect children over 3 years of age are influenza, parainfluenza, Epstein-Barr virus, and coxsackievirus. The other choices are viral infections common in children under 3 years of age.
The nurse is caring for a child diagnosed with tonsillitis. Which nursing action is most helpful prior to the tonsilectomy?`
Instruct on salt water gargling. Explanation: Depending upon recurrence of tonsillitis, surgical removal of the tonsils may be recommended. Prior to surgery, salt water gargling is an easy and homeopathic way to limit or eliminate swelling and infection. Tonsillectomies are not performed if an infection is present. Antibiotics not antivirals are also used to treat infections prior to tonsillectomies.
A terminally ill client and family are choosing experimental therapies as a last resort. The nurse recognizes anticipatory grieving in the actions and statements of the family. In which way can anticipatory grieving be beneficial?
It can help a family progress in the grief process. Explanation: Anticipatory grieving occurs when the family begins to mourn in anticipation of the death. This process can shorten the period of acute grief and loss, when death does occur. It is not beneficial to begin to separate from the client when the client is still alive or focus on a cure for the client's terminal diagnosis. It is also best to express feeling with others and not privately.
A nurse needs to ensure an informed consent has been obtained to provide care to a young client. Which aspect would be the most important for the nurse to consider related to the informed consent?
Knowing the laws in the state where care is being provided Explanation: Knowing the laws in the state where care is being given is the most important consideration because laws vary from state to state. Emancipation is a legal consideration that is viewed differently by laws of different states. Establishment of parental competency is a legal consideration that may be judged differently by laws of different states. Contacting the parents prior to giving emergency care is a legal consideration that may be judged differently by laws of different states.
Which socioeconomic change(s) have affected concepts in maternal-child health? Select all that apply.
Large suburban populations A change in the structure of families Consumers demanding more for their money Explanation: Various socioeconomic changes have affected concepts in maternal-child health; including large suburban populations, a change in the structure of families, and consumers who demand more for their money. There has been an increase in the hospital's responsibility for health care and a decrease in the federal fiscal responsibility. Access to care has increased in rural areas, not decreased.
A 5-year-old child has frequent visits to the school nurse's office. Which assessment data should alert the nurse that this child may be a victim of physical neglect?
Malnourished with frequent absences from school Explanation: A neglected child may appear unwashed, thin, and malnourished or be dressed inappropriately, such as without mittens, a coat, or shoes in cold weather. Not requiring a child to attend school, deliberately keeping a child out of school without setting up a home school program, or allowing a child to go unsupervised after school may also be interpreted as neglect. Isolated from classmates with poor self-esteem may be a child who is emotionally neglected. Evidence of bruising on multiple parts of the body might indicate child abuse. Inappropriate knowledge of sexual terms and actions is more likely when a child is sexually abused.
Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child?
Nasal Congestion Explanation: The infant has smaller airways, making it more difficult to breathe when nasal congestion occurs. The older child can tolerate the congestion better than the infant with smaller airways. Depending upon the age of the child, younger infants are afebrile. Vomiting and diarrhea can occur at any age as the mucus from the nasal drainage enters the gastrointestinal tract.
The 2-year-old child is seen in the emergency department (ED) with a sore throat and difficulty swallowing. The ED physician suspects acute epiglottitis. Which of the following interventions should be included in the child's immediate care? Select all that apply.
Obtain a medical and immunization history. Assess vital signs and breath sounds. Obtain and put an endotracheal tray at the bedside. Explanation: Ascertain whether the child has had the Hib B vaccine or has had a beta-hemolytic strep or staph problem, assess for high fever (>102°F), intense sore throat, dysphagia, drooling, increased respiratory and pulse rate and be available to attend to the child's respiratory needs and keep resuscitation equipment and intubation tray at the bedside. Until the child is intubated and the airway is managed nothing is to be put into the mouth—these procedures can cause laryngospasms and a complete airway obstruction may result.
A pediatric nurse caring for children of all ages knows that children learn about themselves, the environment, and relationships best through:
Play Explanation: Throughout the stages of growth and development, the role and types of play differ. Through play, children learn about themselves, their environment, and relationships with others.
The elementary school teacher invites the nurse into the classroom to observe a pupil's interaction when completing an assignment. Which characteristic alerts the school nurse that the child may be the victim of emotional abuse?
The child is fretful and worried about the project. Explanation: When completing group work there can be many dynamics in the classroom; however, the child should not be fretful and worried about the project. This indicates that something else is the cause of the worry. The teacher and school nurse work together to help the child as needed.
A nursing instructor teaching about normal growth and development identifies a need for further instruction when the student makes which of the following statements?
"A growth chart is the best tool to diagnose growth problems." Explanation: A growth chart is used for comparison only, so it is not always the best tool to diagnose a problem. Many times a child will not fall into the "normal" range, and there will not be a problem. All the other statements are correct.
The mother of a 3-month-old infant expresses concern that her infant's head is misshapen. Which would be the most appropriate question by the nurse?
"Do you use "tummy time" with the infant?" Explanation: The appropriate question would be for the nurse to assess whether the mother is placing the infant in the prone position during supervised period of time. This allows for the infant to increase head and neck muscle strength and development of rolling over. It also aids in evening out misshapen or flat heads.
Marcy asks the nurse if her 9-month-old son is drinking the recommended amount of breast milk or formula every day. What would the appropriate response be?
"He needs 7 ounces every 6 hours." Explanation: This response is correct because the recommended amount of milk/breast-milk for an infant 7 to 11 months old is 6 to 8 ounces every 6 to 8 hours. This should be around 32 ounces a day. The other responses do not meet the recommended daily allowance.
The nurse is caring for a 7-year-old child who will undergo an appendectomy. When teaching the child about the procedure, the child tells the nurse, "I'm scared I'm going to die." How should the nurse first respond?
"I understand you're scared." Explanation: Surgery can be very frightening to a child, especially a child who begins to be aware of death and dying. If a child expresses a fear of death or dying, the nurse must first acknowledge the child's fears, in order to make the child feels accepted for his or her feelings. The additional questions/statements may be appropriate; however, only after first acknowledging the child's fears.
The nurse is caring for a 3-year-old child at an outpatient pediatric clinic. The child asks her mother, "What is a hospital?" Which statement by the child's mother requires additional teaching?
"It is where mommies go to have babies." Explanation: It is important that the child understands that hospitals are more than just a place where mommies go to have babies. The child should be told that it is a place where sick people go sometimes, where "boo boo's" are fixed, and where doctors and nurses work.
The nurse is reinforcing teaching with a group of caregivers related to the nutritional needs of the infant. One caregiver asks why her 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?
"Milk won't fully provide your child's needs for iron, which is found in solid foods." Explanation: At about 4 to 6 months of age, the infant's milk consumption alone is not likely to be sufficient to meet caloric, protein, mineral, and vitamin needs. In particular, the infant's iron supply becomes low, and supplements of iron-rich foods are needed. It is true that the child becomes interested in new skills, but this is not the primary rationale for introducing solids. Few parents will understand the "extrusion reflex."
After the nurse provides education to new parents about appropriate sleeping habits for infants, which statement by a parent would indicate to the nurse that teaching needs to reoccur?
"My husband gave the baby a special bear that I will place in the crib." Explanation: The nurse should reinforce that stuffed animals, blankets, pillows, and soft mattresses are suffocation hazards for infants.
The nurse is caring for a child who says, "I'm tired being in the hospital and I miss my own home." Which response by the nurse is most appropriate?
"What can we do to make your room seem more like home?" Explanation: It is important to promote the involvement of the child in the plan of care and involve the child in decision-making to foster his empowerment. The hospitalized child is away from home and should be encouraged to participate in the care and the development of the room's environment. Asking what can be done to promote improved feelings makes the child a part of the team. Telling the child that he will go home when he is better does not address the concerns. Offering sympathy does not attempt to address the concerns. Asking about feelings in this manner is a closed question and does not solicit information from the child.
The nurse prepares to complete a health history. Which question(s) will the nurse use to best assess the child's lifestyle? Select all that apply.
"What grade are you in?" "How many brothers and sisters do you have?" "What kind of foods do you eat?" "What do you like to do for fun?" Explanation: Assessment of the child's lifestyle is an aspect of the client history. School history, social history (including number of siblings), personal history (likes and dislikes), and nutrition history (types of food eaten) are all aspects of the lifestyle assessment. Allergy assessment is not an aspect of the child's lifestyle; rather, this is covered in the allergies, medications, and substance use portion of the assessment.
The nurse is explaining to a school-age child the need to soak the hands twice a day to help with an infection. Which teaching should the nurse provide that would be appropriate for the client's cognitive level?
"Would you like to sit in the chair or stay in bed to soak your hand?" Explanation: Before anyone can be cared for at home, teaching will be required so the family understands the illness and principles of care. Because the patient is a school-age child, the nurse should provide choices so that the patient has a sense of control over the situation. Soaking both hands may or may not be medically necessary. Telling the patient to stay in bed or soaking the hands now does not provide the patient with a sense of control and may lead to resistance or nonadherence to medical treatment.
The health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer?
1/4 to 1/2 inch (0.64 to 1.27 cm) Explanation: The correct distance to insert a rectal thermometer is 1/4 to 1/2 inch (0.64 to 1.27 cm). One-eighth to one-fourth inch (0.32 to 0.64 cm) may not be far enough and further than 1/2 inch (1.27 cm) is too far.
The nurse is caring for a child who weighs 42 lb. The medication ordered for the child has a therapeutic dosage range of 33 mg/kg per day to 48 mg/kg per day. The medication ordered is to be given 3 times a day. Which dosage would be appropriate for the nurse to administer to this child in one dose?
250 mg per dose Explanation:One kilogram equals 2.2 lbs.; therefore, a child weighing 42 lbs. weighs 19 kg. The low dose of this medication would be 19 X 33 = 627 mg, divided by 3 times a day equals 209 mg per dose. The high dose of this medication would be 19 X 48 = 912 mg divided by 3 times a day equals 304 mg per dose. Therefore, a dose of 250 mg per dose would be appropriate.
A mother comes to the clinic and is concerned about the size of her 3-month-old infant's head. She states that the infant's head is larger than his chest. The nurse's response should be based on her knowledge that an infant's head and chest circumference will be approximately equal by what age?
6 months Explanation: An infant's head and chest circumference are approximately equal by 5 to 7 months of age.
The nurse is reviewing the results of a sweat test done a child who is suspected of having cystic fibrosis. Which sweat chloride level would the nurse identify as a positive result?
65 mEq/L Explanation: The sweat test is the definitive test for CF. An elevated sweat sodium chloride level greater than 60 mEq/L is a positive diagnostic result that should be confirmed by a second test at a CF center.
The maternal child health nurse is providing care to the following clients. Which client would the nurse assess as being in the health restoration phase?
A 29-year-old G1P1L1 is assessed for ongoing complications from eclampsia, one week postpartum. Blood pressure is 128/92 mm Hg, heart rate 78 bpm, respiratory rate 22 breaths/min, temperature 98.8° F (37° C). Client states no headaches, no vision changes, and no seizure activity. Explanation: The client who is 1 week postpartum recovering from eclampsia is working to return to a state of wellness and therefore is the individual who is in the restoration phase of health.
The pediatric unit has multiple clients experiencing upper respiratory system complications. Which pediatric client is at the highest risk for respiratory distress?
A 3-year-old with epiglottitis Explanation: Epiglottitis is a medical emergency due to the swelling of the epiglottis covering the larynx. This client needs frequent assessment for respiratory distress. The 3-month-old also will need frequent assessment as the respiratory tract grows and changes until 5 years old. Infants have larger tongues, shorter necks, and narrower airways, which place them at risk for respiratory obstruction. The 3-month-old has a common cold typically from a virus. The 8-year-old has more developed respiratory passages and responds well to treatment for croup. The 16-year-old with asthma has fully developed respiratory airways; however, bronchial constriction and mucus production compromise the airway
The nurse is caring for four clients on the pediatric unit. Which client scenario provides the highest concern of suspected abuse?
A 7 month old with multiple bruises on the legs Explanation: A 7-month-old with bruising would be the most suspicious. A 7-month-old would not be walking and therefore would be unlikely to receive bruises from normal bumps and scrapes. Owning a gun or smoking cigarettes is not related to the incidence of child abuse. It would not be extraordinary to see a 5-year-old with a broken arm accompanied by bruising on the forehead.
Which nurse is most likely to care for patients who are trying to resolve identity versus role confusion?
A nurse who provides care in a large junior high school Explanation: According to Erikson, the crisis of identity versus role confusion is characteristic of adolescence. Consequently, a nurse who provides care in a junior high school is likely to see frequent manifestations of this crisis. Early childhood, middle adulthood, and late adulthood are not typical life stages for the resolution of this crisis.
The nurse is assessing the interaction between the family and their terminally ill 4-year-old child. Which actions suggest that the family is successfully completing unfinished business? Select all that apply.
A parent has taken family medical leave from work. The aunt assisted the siblings in drawing a picture. The child is cuddled when going to sleep. Explanation:Completing unfinished business is an important process in preparing for a death. Completing unfinished business may include spending more time with the child, helping siblings understand the child's illness and be part of the care, and giving family members a chance to show their love. The goal is to feel that the family members have shared their love with the child. Kind and giving gestures are included. The nurse would not be able to judge the status during a weekly phone call. Preparing for the funeral is not focused on time with the child.
Which piece of equipment is most helpful in determining airway obstruction in the client with asthma?
A peak flow meter Explanation: The peak flow meter provides the most reliable early sign of an asthma episode. Most episodes begin gradually, and a drop in peak flow can alert the client to begin medications before symptoms actually are noticeable. A nebulizer and inhaler treat symptoms. An incentive spirometer is used for lung expansion, especially after surgery.
Parents tell the nurse that they will do anything to help their child with leukemia get well, even donating everything they have to charity. How does the nurse respond to this situation?
Acknowledge that this must be very difficult for them. Explanation: The parents are experiencing the bargaining stage of grief and need emotional support. They are unable to deal with the child's prognosis, and they will not see the support group as beneficial yet. They do not need to donate everything to charity as this will not cure their child.
The neonatal intensive care nurse is assessing a neonate and notes the neonate is rigid, irritable, and restless. Which action(s) will the nurse perform in response to the assessment findings? Select all that apply.
Administer the prescribed pain medication Decrease the environmental stimuli Explanation: Research has shown that neonates, infants, and children experience pain. The nurse must be able to recognize signs and symptoms of pain in this population. Rigidity, restlessness, and irritability all indicate pain. Administering the prescribed pain medication decreases the neonate's pain and decreasing environmental stimuli aids in the neonate's rest, which may help with relieving pain. There is no indication that the neonate is hypoxic and would not require supplemental oxygen. Muscle rigidity and irritability is most likely related to pain than muscle spasm in the neonate; therefore, a muscle relaxer is not likely prescribed. Although the health care provider may need to be notified at a further time, the presented information does not require the notification of the health care provider.
A new nurse is caring for a child in the final stages of dying. Which nursing action would require the nurse mentor to intervene?
Administering oral pain medications for pain relief Explanation:A decrease in muscular function leads to severe weakness and fatigue. As the throat muscles become lax, the possibility of aspiration increases. As circulation fails, absorption of a drug from a muscle becomes virtually impossible; if drugs need to be administered, they need to be injected intravenously or often do not have an effect. Therefore, the nurse mentor should intervene and explain that oral medications will not be effective and that IV medications would be best. It is important to explain procedures even if the child is unconscious, as hearing is one of the last senses to go. Mouth dryness will lead to cracking, secondary infection, and pain; prevent this by frequently cleaning the mucous membrane with clear water and with the application of an ointment to the lips. As peripheral circulation fails, less heat is lost from the body and the internal temperature rises. The child's body compensates for this by increased perspiration to increase heat loss through evaporation. This makes the child's skin feel cool and damp. The nurse may need to change linens frequently because of the increased moisture on the skin. Because perfusion of distal body parts is impaired, turn the child slowly to allow the circulatory system to accommodate to the change in position.
A couple reveals that they are going to tell both their biological children and adoptive children they are filing for divorce. Prior to having this family discussion, they met with a couselor about the possible impact this may have on the children. The couselor suggests to be on the lookout for which possible consequences on the adoptive children related to the divorce? Select all that apply.
Adoptive children may feel they are the cause of the divorce. Adoptive children experience insecurity for a second time. Explanation: Divorce of the adopting parents can be devastating if the child views himself as the cause of the separation or as a child unable to find a secure family for a second time.
The nurse is providing anticipatory guidance to the mother of a 9-month-old girl during a well-baby visit. Which topic would be most appropriate?
Advising how to create a toddler-safe home Explanation: The most appropriate topic for this mother would be advising her on how to create a toddler-safe home. The child will very soon be pulling herself up to standing and cruising the house. This will give her access to areas yet unexplored. Warning about small objects left on the floor, telling about safety procedures during baths, and cautioning about using baby walkers would no longer be anticipatory guidance as the child has passed these stages.
Which activity should the nurse encourage a new mother to perform to foster the developmental tasks of a toddler according to Erikson's developmental stages?
Allow the child to pull a talking duck toy. Explanation: The developmental task of the toddler is to learn autonomy versus shame or doubt. Autonomy comes from the toddler's new motor and mental abilities. Children take pride in the new things they can accomplish, and they want to do everything independently. Pulling a talking duck toy will support the development of autonomy. Doing things such as feeding, reading, and watching television does not foster autonomy in the toddler.
The nurse is conducting an educational session at a local community health fair illustrating the various reflexes which are normal in a newborn and how it changes as the infant grows and matures. The nurse determines more education is necessary after a member of the audience points out which finding as an expected occurance?
An extrusion reflex at 9 months of age Explanation:
Which aspect of client wellness has not been a focus of health during the 21st century ?
Analysis of morbidity and mortality Explanation: The focus on health has shifted to disease prevention, health promotion, and wellness. In the last century, much of the focus was on analyzing morbidity and mortality rates.The maternal child health nurse is providing care to the following clients.
The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply.
Around 2 months the infant exhibits a first real smile. Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. Separation anxiety may also start in the last few months of infancy. Explanation: The infant exhibits a first real smile at age 2 months. By about 3 months of age the infant will start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will also mimic the parent's facial movements, such as widening the eyes and sticking out the tongue. Separation anxiety may also start in the last few months of infancy. Around the age of 8 months the infant may develop stranger anxiety. At 6 to 8 months of age the infant may enjoy socially interactive games such as patty-cake and peek-a-boo.
A community-based nurse has a different set of skills than those of counterparts who work in a hospital. Community-based nurses also face unique issues and challenges. What is one of the unique aspects of community-based nursing?
Autonomous Explanation: Community-based nursing practice is autonomous. There are often no other members of the health care team to consult, or no members within the area to consult with. Teamwork is important in community-based nursing, but it is not a unique aspect of this type of nursing. Disease orientation is the medical model of health care. Community-based nursing takes in all aspects of the client, including community aspects such as education—not just the disease process. Therefore, it is more holistic rather than less holistic.
After teaching a class about cystic fibrosis, the nursing instructor determines that the teaching was successful when the students identify the condition as which type of genetic condition?
Autosomal Recessive Explanation: CF is an autosomal recessive genetic condition. In such conditions, the risk of disease transmission is 25% if both parents carry the gene, and the chance that the child will be a carrier of the disease is 50%.
The nurse is assessing a 6-week-old infant in the clinic. Which characteristic represents normal language development for this age?
Babbling Explanation: Cooing begins in the first 4 weeks of life, productions of noises when spoken to and laughing out loud are seen in older infants. Infants begin to babble around 6 weeks of age.
The nurse is making a follow-up visit to the home of a family with a baby newly diagnosed with cystic fibrosis. Which outcome indicates that the parents are adjusting to the child's care needs?
Baby has gained weight Explanation: Children with cystic fibrosis need pancreatic enzyme replacements to help absorb nutrients. The baby gaining weight indicates that these supplements are effective. Foul-smelling stool indicates that additional intervention is needed because fat is not being absorbed. Large stools indicate that nutrients are not being adequately absorbed. Flushing and warmth could indicate a fever or that the home environment is too warm for the child. If children with cystic fibrosis become overheated, they begin to lose excessive sodium and chloride through perspiration and become dehydrated.
A 12-year-old sibling of a child with Down syndrome is overheard telling a friend from school on the telephone, "I don't have any brothers or sisters. I am an only child." What does this child feel about the sibling with Down syndrome?
By having a sibling with Down syndrome, a stigma is attached to him or her. Explanation: Siblings may feel that having a brother or sister with a chronic illness is a stigma, a mark of embarrassment or shame, especially if the ill child has a physical disfigurement or apparent cognitive deficit. Siblings may choose not to tell others about the ill child or may be selective in whom they tell, choosing to tell only those they can trust.
The nurse caring for a 6-year-old enters the room to administer an oral medication in the form of a pill. The dad at the bedside looks at the pill and tells the nurse that his daughter has a hard time swallowing pills. What is the best response by the nurse?
Call the pharmacy and ask if the pill can be crushed Explanation: The father is the best source of knowledge on medication administration for the child. The pharmacy should be called to determine if the pill might be crushed. Asking the child to try swallowing the pill disregards the information the father has just given. Requesting that the physician order the medication in liquid form is not necessary at this point.
The nurse recommends a medical home for a patient with juvenile diabetes. The nurse determines that the medical home has been established when which of the following occurs?
Care is coordinated by a designated physician in a health partnership with the family Explanation: In the medical home concept, care is family-centered and can be provided in various locations such as the physician's office, hospital outpatient clinics, and school-based clinics. The key component in any venue is that care is provided and coordinated by a designated physician who has established a health partnership with the family (AAP, 2007, 2008).
The nurse is preparing a list of abilities of 10-month-olds to use in teaching a parenting group. Which ability should appear at this age?
Cruising around furniture Explanation:At 10 months, this ability appears and is practiced often in preparation for later independent walking. All the rest of the skills take an additional 2 months to develop and appear around age 1 year.
The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which is the most effective anticipatory guidance?
Discouraging the addition of fruit juice to the diet Explanation: Discouraging the addition of fruit juice to the child's diet is the most effective anticipatory guidance. Fruit juice can displace important nutrients from breast milk or formula. Cow's milk is likely to result in an allergic reaction. If breast milk is not available, infant formula may be substituted. Advising fluid intake per feeding of 5 or 6 ounces is too much for this neonate, but is typical for an infant 4 to 6 months of age. Advocating iron supplements with bottle-feeding is unnecessary so long as the formula is fortified with iron.
The nurse is examining the posture of a male toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding?
Do nothing; this is a normal condition for toddlers Explanation: The toddler demonstrates lordosis (swayback) and bowlegs, with a relatively large head and protuberant belly. This is a normal condition and requires no further attention.
The nurse has completed an assessment of a 4-year-old child and the findings include an apical heart rate of 125 beats per minute. What is the nurse's best action?
Document the assessment finding Explanation: This child's heart rate is within reference ranges for his or her age. No further action is indicated.
The nurse is caring for a dying child. Which respiratory assessment findings indicate that the child is approaching death? Select all that apply.
Dyspnea Excess secretions Adventitious breath sounds Cheyne Stokes breathing Explanation: Slowed respirations lead to increased secretions in the lungs and the appearance of rales, the sound of air being pulled through fluid in the alveoli. To compensate for a few minutes of very slow respirations, a child may take several quick or extremely deep inhalations periodically. This is known as Cheyne Stokes breathing. All of these signs signal impending death. Kussmaul respirations is related to diabetes and not to dying. Tachypnea is incorrect, as the breathing slows down instead of getting faste
What is the appropriate time when children should be taught genitalia terminology and about personal privacy?
Early Childhood Explanation: Children in early childhood can identify their sex. Language is progressing and children can learn the appropriate terms to use for body parts. Children explore their body parts and ask questions. This is also the time when children should be taught when exploration of the body is acceptable and who and under what condition may be permitted to touch "private" parts (genitals).
While providing care to a child, the nurse informs the parents about the treatment plans and helps the parents make decisions about the child's care needs. What do this nurse's actions support?
Empowerment Explanation: Nurses promote empowerment of parents and children by respecting their views and concerns, regarding parents as important participants in their own or their child's health, keeping them informed, and helping/supporting them to make decisions about care. The nurse's actions are not being done to support autonomy, accountability, or informed consent.
The family functions as the oldest and most basic social unit in society. What is the primary purpose of the family?
Ensure Survival Explanation:The family's primary purpose is to ensure survival of the unit and its individual members and to continue society and its knowledge, customs, values, and beliefs. Other functions include physical sustenance, emotional support, intellectual stimulation, socialization, and spirituality. However, these are not the primary purpose of the family unit.
The parent of a dying 10-year-old states she is unable to handle watching her child die and starts to leave the unit. What is the priority intervention by the nurse?
Ensure that the child has support during the dying process. Explanation: The child needs to feel supported to lessen anxiety and fears about death. Although caring for the parent is essential, the child would be the priority for the nurse. Nonjudgmental documentation is important but is not the highest priority.
The nurse establishes the following plan of care based on the nursing diagnosis: Caregver role strain related to infant crying throughout night as manifested by parents stating, "We are exhausted." Which nursing interventions are included in the plan of care? Select all that apply.
Establish a quieting ritual for infant before bed. During night awakening, keep interactions minimal. Having one parent awake at a time with infant Explanation: Both encouraging the infant to sleep or providing a time for the parent to sleep decreases caregiver role strain. Bedtime rituals and minimal interactions during night awakening both promote sleep. Also having only one parent awake allows for the other parent to rest decreasing parent exhaustion. Adding rice cereal to bottles does not promote sleeping through the night and isn't recommended. Putting the infant asleep into the crib does not teach the child to self-soothe and fall asleep independently.
The nurse from a rural area moves to a large city to work in a family clinic where there are families from a variety of different cultures. The nurse should prioritize which goal as she begins working in this new environment?
Examine her own feelings concerning cultures Explanation: The nurse must first understand her own feelings and understanding of her own culture, then try to understand the other cultures. In the process the nurse should develop cultural awareness, engaging in self-exploration beyond one's own culture, seeing children from different cultures, and examining personal biases and prejudices toward other cultures. Once this occurs, the nurse can then learn as much about the culture as possible and become familiar with similarities and differences between his or her own culture and the family's culture. The nurse would adapt nursing care to address the practices of the family's culture to provide culturally competent care.
A pediatric nurse caring for an 8-year-old who is having pain would use which of the following scales to assess the child's pain?
FACES scale Explanation: Various tools have been devised to help children express the amount of pain that they feel. These tools include the FACES scale, number scale, and color scale. The number and FACES scales are used primarily for children 7 years and older. The Apgar scale is used immediately after birth to see how well the infant tolerated the birthing procedure. The Braden scale is used to assess the risk of pressure ulcers.
A nurse is teaching a class about families and their functions to a group of colleagues. The nurse determines that the teaching was successful when the group identifies which of the following as true?
Family members usually share the funds that some members earn. Explanation: Family members usually share the funds that some members earn. Couples today are less, not more, concerned about unplanned pregnancies. This is because of the development of the various family planning methods. Reproduction is not a function of all families. It is more often a choice. It is not always the older members who teach the younger members in a family. The younger members may also teach older members about the changing world.
A health care provider has written several prescriptions for a 7-pound newborn with jaundice. Which prescription does the nurse need to question?
IV normal saline 20 mL/hour Explanation: IV fluids should be 2 mL/kg/hour, and this would calculate to 3.2 kg X 2 mL/hr = 6 mL/hour. The prescription for 20 mL/hour is too high for this newborn and would need to be questioned by the nurse. The other prescriptions are within reason.
The nurse is caring for a young child in the hospital who is receiving IV therapy. Part of the routine care for this child will involve monitoring the IV site as frequently as every hour. The nurse will assess the IV for which of the following? Select all that apply.
Induration at the IV site Moisture at the IV site The IV flow rate Swelling at the IV site Explanation: While noting that the mother is at the bedside might be part of the child's assessment, it would not be part of the IV assessment. The other choices are all part of the IV assessment.
The nurse is teaching a 12-year-old with asthma about possible side effects of drug therapy. Which of the following would the nurse identify as a possible side effect of a beta adrenergic agonist used for bronchodilation?
Jitteriness Explanation: Beta adrenergic agonist bronchodilators are associated with increased heart rate and jitteriness. Sedation and dry mouth would be associated with antihistamine used for rhinitis.
Much of the care of the pediatric client has been shifted from the hospital setting to an appropriate community setting. Which community care setting would a nurse point out is appropriate for vision and hearing assessments in children?
Local Schools Explanation: Assessing the vision and hearing of a child is a function of the school nurse, who makes these assessments several times during the course of a child's school career. Vision and hearing centers focus on providing screenings for adults, not children. Pediatric rehabilitation centers are not settings for vision and hearing screenings. Pediatric acute care clinics are for treating acute injuries and illnesses. They are not appropriate settings for routine screenings of a child.
A nurse understands that it is important to help a family adjust to a child's chronic health condition. This is best done by doing which of the following?
Making adjustments in care by doing ongoing interviews Explanation: It is important to help the family adjust to the chronically ill child's condition. This is done best by doing an initial assessment and ongoing interviews. The nurse should never tell a family how to cope but instead give them suggestions about ways to cope. The nurse should encourage the caregivers to discuss needs of the well siblings as well as the sick child. He or she should never tell a family that it will get better over time; doing so is inappropriate and can give false hope.
After teaching a group of nursing students about the developmental variations in a child's respiratory system, the instructor determines that the teaching was successful when the students identify children at which developmental growth stage having a trachea that is 4 cm in length?
Newborn Explanation: Pediatric airways are much smaller in diameter and shorter in length than in adults. For example, a newborn's trachea is 4 cm long, a toddler's is 7 cm long, and a teenager's is 12 cm long.
The nurse is providing anticipatory guidance to the mother of a 2-month-old in relation to interpersonal development. Which behavior is most likely to occur over the next 8 weeks?
Mimicking facial expressions Explanation: Infants will mimic the facial expressions of their parents when they are 3 to 4 months old. Becoming clingy around strangers probably won't occur until the child reaches 6 months. Engaging in peek-a-boo becomes fun between 6 and 8 months. Crying when the mother is out of sight indicates separation anxiety and is common after 6 to 8 months of age.
The nurse is teaching a parenting class to a group of first-time mothers. She recommends which of the following as positive caregiver-infant interactions? Select all that apply.
Mother offers adequate types and amounts of food for the infant. Mother holds the infant in an appropriate position while feeding. Mother burps the baby during and after feeding. Mother provides age-appropriate toys for the infant.
When reviewing the history of an 8-year-old client, which data lead the nurse to recognize Munchausen syndrome by proxy? Select all that apply.
Multiple emergency room visits with lengthy history Difficult to find symptoms on physical examination History of apnea only seen by parent Multiple diagnostic tests without symptom validation Explanation: In Munchausen syndrome by proxy, the caregiver either fabricates or induces illness in the child to get attention. When a caregiver has this syndrome, he or she frequently brings the child to a health care facility and reports symptoms of illness when the child is actually well. The symptoms include descriptions of seizures, abdominal pain, or apnea which cannot be confirmed by physical assessment or diagnostic tests. As a result, the child has multiple emergency room visits and a lengthy history without conclusion. Retinal hemorrhage and soft tissue injury are symptoms of physical abuse such as shaken baby syndrome and child abuse.
A client with a history of type 1 diabetes mellitus is questioning the nurse concerning the best option for the health care provider to assist with her pregnancy and delivery of her newborn. The nurse determines the client needs additional information to make a wise decision when she suggests seeking the care of which specialist?
Neonatologist Explanation:An obstetrician, certified nurse midwife, or perinatologist may be involved in the pregnancy and delivery of a newborn. The neonatologist may be present at the time of birth; however, the neonatologist's focus is to provide specialized care to at-risk newborns.
A new mother asks the nurse when toothbrushing should begin for the baby. Which response is the most appropriate for the nurse to make at this time?
Now Explanation: Toothbrushing can begin even before teeth erupt by rubbing a soft washcloth over the gum pads. This eliminates plaque and reduces the presence of bacteria, creating a clean environment for the arrival of first teeth. Dental care should begin before the age of 12 months, before solid food is eaten, and before the first tooth appears.
A newly admitted school-age child has a temperature of 102°F (38.9°C) and the mother reports that she gave her acetaminophen just before coming to the hospital 2 hours ago. What non-pharmacologic intervention could the nurse implement to help bring the temperature down?
Place the child in a gown or lightweight pajamas. Explanation: Fever is a common problem for children and nurses need to be aware of non-pharmacologic interventions to reduce the fever when medication is not possible. These interventions include dressing the child in lightweight clothing (or just a diaper for infants). Tepid sponge baths are no longer advised because they do not help lower the temperature and make the child uncomfortable. It is a good idea to keep the room cool but turning the room temperature toe 62°F is too cold. The nurse should never place the child under blankets. That will increase the temperature.
What feeding practice used by the parents of an 8-month-old should the nurse discourage?
Placing all liquids given the child in a "no spill" sippy cup Explanation: No-spill sippy cups promote sucking rather than teach cup drinking. Reserve these for times when avoiding spills is a must. The other feeding practices are age appropriate and safe. Soft table and finger foods promote accepting new textures and self-feeding. Reoffering rejected food allows the child to accept it when ready. Including the infant at the family table provides for modeling of eating behaviors and socialization.
After a child plays in the yard, his mother asks him to pick up his toys and put them in the toy bin in the garage. Knowing that he does not want to spend time in his room as a punishment, the child follows his mother's directions. What stage of moral development, according to Kohlberg, is this child demonstrating?
Preconventional level: stage 1 Explanation: The preconventional level is based on external control as the child learns to conform to rules imposed by authority figures. At stage 1, punishment and obedience orientation, the motivation for choices of action is fear of physical consequences of authority's disapproval. At stage 2, instrumental relativist orientation, the thought of receiving a reward overcomes fear of punishment, so actions that satisfy this desire are selected. The conventional level involves identifying with significant others and conforming to their expectations.
The nurse is caring for a client who is seeking care after being raped. What is the primary reason the nurse does not leave the client alone during the emergency room stay?
Promotes the client's sense of safety Explanation: The nurse's first responsibility is to provide the client a safe environment both physically and emotionally. Staying with the client will help promote a sense of safety. Although the other options may result from the nurse's presence, the primary goal is safety.
A nurse is instructing the mother of a newborn about bathing and skin care. When discussing bathing, the nurse includes which of the following besides hygiene as an important reason for bathing?
Promoting parental bonding Explanation: The parents can use bath time for bonding with their infant. This can be done with talking, cooing, and singing. Bath time should be paced and non-stressful.
In providing anticipatory guidance related to choking hazards for infants, what should the nurse include in the teaching? Select all that apply.
Propping a bottle Raw carrots Plastic bags Explanation: The nurse should include teaching related to propping a bottle; foods that are choking hazards such as raw carrots, peanuts, hot dogs, and grapes; and plastic bags and balloons. Any toy or object that the infant can put in their mouth should be considered a choking hazard.
A pediatric nurse observes an infant holding a rattle. Upon dropping the rattle, the baby cannot pick it up with his fingers on his own. The nurse correctly identifies this to be an example of which type of growth?
Proximodistal Explanation: The ability to hold something in the hand before being able to use the fingers to pick up the object is proximodistal growth. Cephalocaudal is the pattern referred to when the child can control the head and neck before the arms and legs. This is neither abnormal growth nor abnormal development.
The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which test as most helpful in determining the extent of the child's hypoxia?
Pulse oximetry Explanation: Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by the nurse for continuous or intermittent monitoring. Pulmonary function testing measures respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and chronic lung disease. Peak expiratory flow testing is used to monitor the adequacy of asthma control. Chest radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion, and abnormal heart or lung size.
The nurse is examining a 5-year-old boy. Which sign or symptom is a reliable first indication of respiratory illness in children?
Rapid, shallow breathing Explanation: Tachypnea, or increased respiratory rate, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing and increasing listlessness are signs that the child's condition is worsening. Cyanosis (a bluish tinge to the lips) or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.
The nurse caring for a preschool child prepares to use therapeutic play to put the child at ease and decrease the child's anxiety. Which game is best for the child, according to the child's
Ring-around the rosy Explanation: Therapeutic play is a play technique used to help the child have a better understanding of what will be happening to him or her in a specific situation. Games played with the child should be appropriate to the child's developmental stage. Ring-around-the-rosy is a game appropriate for the preschooler. I-spy and hangman would be appropriate for an older child. Patty-cake would be appropriate for the infant child.
A nurse places a toy car in front of a 6-month-old girl. She swats at it, and the car flies across the examination table and lands on the floor. She squeals with surprise and delight. When the nurse puts the toy car in front of her again, she immediately swats it again and laughs as it rolls across the table and falls to the floor again. What has the girl demonstrated?
Secondary circular reaction Explanation:By the third month of life, a child enters a cognitive stage identified by Piaget as primary circular reaction. During this time, the infant explores objects by grasping them with the hands or by mouthing them. Infants appear to be unaware of what actions they can cause or what actions occur independently, however. At about 6 months of age infants pass into a stage Piaget called secondary circular reaction. Now when infants reach for an object, hit it, and watch it move, they realize it was their hand that initiated the motion, and so they hit it again. By 10 months, infants discover object permanence. Infants are ready for peek-a-boo once they have gained this concept. They know their parent still exists even when hiding behind a hand or blanket and wait excitedly for the parent to reappear. Binocular vision, which is the ability to fuse two images into one, is demonstrated by 2-month-olds when the follow moving objects with their eyes, although not past the midline.
The nurse caring for a dying pediatric client notices that the parents are sitting at the bedside sobbing. Which nursing action is most appropriate in meeting the parents' immediate needs?
Supporting the parents by appropriately using therapeutic touch Explanation: When a child is close to death, the parents need unobtrusive support by the nurse. A simple touch allows the parents to know that the nurse is present. The parent can communicate any needs at that time. The parents can see that the child is resting peacefully. Performing nursing functions interrupts the last parent-child moments. It will become obvious when the child is no longer breathing. The parents usually call family after the child dies or before the final moments prior to death.
Which type of fracture is most indicative of child abuse?
Spiral Fracture Explanation: Signs of possible evidence of child abuse include spiral fractures of the long bones. A fracture of this nature is not common in children. The other types are not consistent with abuse.
A 5-year-old girl who was already admitted to the hospital for an unrelated condition suddenly becomes irritable, restless and anxious. These may be early signs of respiratory distress in a child if accompanied by:
Tachypnea Explanation: Restlessness, irritability, and anxiety result from difficulty in securing adequate oxygen. These might be very early signs of respiratory distress, especially if accompanied by tachypnea (an increased respiratory rate). Retractions can be a sign of airway obstruction but occur more commonly in newborns and infants than in older children. Cyanosis (a blue tinge to the skin) indicates hypoxia, which may be a sign of airway obstruction but would not be the first. Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips. Clubbing would not occur in an acute airway obstruction, as is indicated in the scenario above.
A mother calls the clinic nurse asking for recommendations on comfort measures for her infant who is teething. What recommendation should the nurse make? Select all that apply.
Teething rings and acetaminophen Explanation: The nurse should recommend teething rings that can be refrigerated and acetaminophen dosed by the health care provider. All other items create a choking hazard for the infant.
How would a nurse best advise the family to discuss the seriousness of the diagnosis with their terminally ill 6-year-old?
Tell the child, because the nurse and family are able to help the child with fears. Explanation: A school-age child is able to understand and interpret the seriousness of his or her illness. The child should be told about the diagnosis in an effort to have the child understand what is happening with his or her body and to offer the client support and education. A child has to be aware for therapeutic communication to be effective. Client autonomy depends upon developmental level. Details of the client's diagnosis may be withheld due to developmental level.
The nurse is helping develop a plan of care for a 10-year-old child with a chronic illness. Which of the following would be the goal with the highest priority for this child?
The child will achieve the highest level of growth and development. Explanation: Major goals for the chronically ill child are to accomplish growth and development milestones, perform self-care tasks, decrease anxiety, and experience more social interaction. The highest priority goal is to accomplish the highest level possible in growth and development milestones. An absence of stress of unrealistic.
The nurse is conducting a physical examination of a 5-month-old boy. Which observation may be cause for concern about the infant's neurologic development?
The infant displays an asymmetric tonic neck reflex (fencing reflex). Explanation: The tonic neck reflex normally disappears by age 4 months, the palmar grasp reflex by age 6 months, and the Babinski reflex (fanning of toes when sole of foot stroked) by 12 months. Retaining these primitive reflexes may indicate a neurologic abnormality. The anterior fontanel, which remains open for brain growth, closes between 12 and 18 months of age.
The nurse in a community clinic is assessing a 4-week-old infant. The mother asks if the infant is developing normally. The nurse refers to which finding as suggestive of normal development in infants from birth to 4 weeks of age?
The infant raises head and chest while on stomach Explanation: Infants have gained some neck control and can independently raise head and chest by 4 weeks of age. Appearance of tears, pulling themselves with their arms, and making babbling sounds are appropriate developmental milestones after 6 weeks of age.
An 8-year-old boy is looking at his father's razor and shaving cream in the bathroom medicine cabinet. He watches his father shave daily and asks his father when he will need to start shaving. This child is demonstrating characteristics common during which of Freud's psychoanalytic developmental stages?
The latency stage Explanation: The latency stage (ages 7 to 12 years) makes the transition to the genital stage during adolescence and is characterized by increasing sex-role identification with the parent of the same sex. This stage prepares the child for adult roles and relationships. The anal stage (ages 8 months to 4 years) begins with the development of neuromuscular control to allow control of the anal sphincter. The phallic stage occurs between the ages of 3 and 7 years and the child demonstrates an increased interest in gender differences and his or her own gender. The genital stage (ages 12 to 20 years) is characterized by sexual interest that can be expressed in overt sexual relationships.
The nurse is caring for a hospitalized 8-year-old child whose parents have been divorced. Which of the following is most important for the nurse to do for this child?
The nurse should have clear information about who may contact the child. Explanation: When a child of a divorce is hospitalized, be certain to have clear information about who is the custodial parent, as well as who may visit or otherwise contact the child. The custodial parent's instructions and wishes should be honored.
The nurse is performing an admission of a 10-year-old boy. Which actions will help the nurse establish a trusting and caring relationship with the child and his family? Select all that apply.
The nurse should initiate introductions. The nurse should maintain eye contact at the appropriate level. The nurse should use age-appropriate communication with the child. Explanation: Regardless of the site of care, nursing care must begin by establishing a trusting, caring relationship with the child and family. The nurse should smile, start introductions, give his or her title, and let the child and family know what will happen and what is expected of them. The nurse should also maintain eye contact at the appropriate level, communicate with children at age-appropriate levels, and, with a younger child, start with the family first so the child can see that the family trusts you.
The nurse has been providing support to a family facing the imminent death of their child. How does the nurse know this intervention has been successful?
The parents agree to donate their child's organs after passing away. Explanation: Many parents are able to cope by searching for the meaning of life or death in philosophical, spiritual, or religious terms. For these parents, body organ donation may be a meaningful way to give themselves some solace that their child will in some way continue to live and contribute to others. Researching information about the child's illness may be helpful, but continuing to look for a cure is a form of denial. Siblings are often involved in the care of a dying child, but expressing concern about suffering shows that they need further information. Physical comfort is important during the dying process, but it does not show that parents are coming to terms with the child's imminent death.
A hospice nurse has been preparing parents for the death of their child. How does the nurse recognize that the parents are dealing with anticipatory grief?
The parents have prepared a scrapbook of pictures of their child. Explanation: Reviewing memories and special experiences provides a positive method for coping with grief. Preparing a scrapbook of favorite photos they anticipate will provide solace in the years to come demonstrates they are dealing with anticipatory grief. Remaining at the bedside with their pastor is positive, but it does not necessarily demonstrate coping with grief, and neither does sitting in the family room with their other children or providing care with the nurse. These are typical behaviors for all parents of children who are ill, but they do not demonstrate coping with grief.
Kohlberg's theory is frequently challenged as being male-oriented because his original research was conducted entirely with boys.
True
The pediatric nurse is reviewing statistics on the risks of morbidity and mortality among children. What does the nurse identify as the largest risk to all children and adolescents in the United States?
Unintentional Injury Explanation: Unintentional injury, frequently as the result of motor vehicle accidents, is the largest risk to all children and adolescents in the United States. The remaining answer choices are not the greatest risk to all children and adolescents in the United States.
Which client characteristic is identified as normal behavior when demonstrated by a terminally ill 12-year-old client?
Verbal or physical aggression Explanation:School-aged children may fear a loss of control and express fear through verbal or physical aggression. Magical thinking and ecocentric thinking are characteristic of preschoolers. Exaggerated laughing is not characteristic behavior.
The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately?
Visible peristaltic waves Explanation: Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age.
The mother tells the nurse her daughter has come to the clinic today because she has been having stomach pain. What should the nurse ask the mother? Select all that apply.
When was the last bowel movement? How long has she had pain? Has the child had fever? Where is the pain located? Have you given her any medication for the pain? Explanation: When children are brought to the health care provider the first thing parents want to talk about is the reason they brought their child. This is the chief concern. Once a parent has voiced a chief concern, ask him or her to describe at least six aspects of the problem. These aspects include duration, intensity, frequency, description, associated symptoms and any action taken. Noting the last bowel movement and fever would be associated symptoms. The length of time for the pain would be duration. Asking where the pain is located would be a description. Giving medication for the pain for be considered an action taken.
A 15-year-old client has just given birth and states that she does not want her infant to receive any newborn vaccines. What is the appropriate action for the nurse to take?`
Withhold the vaccines Explanation: The client would frequently be considered emancipated and therefore legally able to make legal decisions regarding the health care of the infant. The nurse should withhold the vaccines but inquire to the reason for no vaccination.
A nurse is preparing a teaching plan for the parents of a newborn. When explaining the neurologic development, how should the nurse point out that this occurs?
center to outside Explanation: Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center-to-outside) pattern. The other choices are the opposite of what happens.
What are possible complications for a child with a vascular access port? Select all that apply.
infection thrombosis hemorrhage air embolism Explanation: Complications of a vascular access port are infection, thrombosis, air embolism, and hemorrhage. Aneurysm and osteomyelitis are not related to having a central venous catheter.
An 8-month-old infant who cries when the parents leave the room has developed the concept of:
permanence Explanation: The infant knows that the parents still exist even though they are out of sight.
A mother of a newborn brings her child to the well child clinic the week after birth. The mother asks the nurse if the child will get any "shots" at the next appointment. The best response from the nurse would be:
"Yes, your child will get 3 shots next time. They will be the polio vaccine (called IPV), Haemophilus influenza B vaccine (called Hib), and hepatitis B vaccine. They will be given in the thigh." Explanation: In older children, the deltoid muscle and the ventrogluteal are acceptable sites. For infants under walking age, use the vastus lateralis for IM injections.
The nurse is providing discharge education to the parents of a 2-year-old who will be taking amoxicillin orally at home. The nurse would include which statement in the teaching?
"Use a dosing cap to measure the dosage." Explanation :When talking to parents about giving medicine, stress that if a medicine comes supplied with a dosing cap, it is best to use that to measure the correct dose (Pham et al., 2011). If there is no dosing cap, then an oral medicine syringe or dropper are the next best methods to measure liquid medicine because kitchen teaspoons are rarely exactly 5 ml. Antibiotics need to be taken for the full course, not until symptoms subside. Mixing the medication with a drink or in food makes it difficult to determine how much the child has taken if the child refuses to finish it all. Amoxicillin comes in a liquid form, so crushing the pills is not appropriate.
An infant is being introduced to drinking fluids from a cup. The nurse instructs the mother that fruit juice can now be added. Which of the following would the nurse suggest the mother try first? Select all that apply.
Apple White grape juice Explanation: Juice is introduced when a cup is introduced to an infant. Usually 4-6 ounces of juice is recommended. Juices that have low-acidity like apple and white grape juice are appropriate. These juices may be diluted to half-strength with water. Orange, grapefruit and pineapple juice are to be avoided.
A nurse is preparing a dose of insulin to give her client. Which action should the nurse take when giving this medication?
Double-check the dose with another RN before giving. Explanation: Insulin is a high-alert medication and must be checked with another RN before giving. Insulin is typically ordered using a sliding scale, so no calculations are needed. Insulin injections do not have to be witnessed. Insulin is not known for having adverse reactions.
A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading?
Have you kept the child up to date on all of the immunizations suggested? Explanation: A leading question supplies its own answer. This questions implies that the child should have had the immunizations and perhaps that the parent is a poor caregiver if he or she gives a different answer than yes. Further, the parent may not be aware of all the current immunizations for the child's age and may inadvertently give an incorrect answer. Asking about the last immunizations is appropriate. Offering to review the immunization record is part of anticipatory guidance.
The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate?
Radial Pulse Explanation: In a child younger than 2 years of age, the radial pulse is very difficult to palpate, whereas the pedal, brachial, and femoral pulses are usually easily palpated.
A novice pediatric nurse learns about the care provided in the pediatric unit. Which action(s) will the nurse demonstrate in regards to care in the pediatric unit? Select all that apply.
Transport the child to the treatment room for any procedures. Serve the child's food outside of his room. Explanation: Children admitted to the pediatric unit are encouraged to wear their own clothing, as appropriate. Meals are often served outside the child's room. Treatments are always provided in a treatment room, ensuring that the child's room is a "safe" place. Family and visitors are encouraged to visit and stay with the child often, which means visiting hours are not always enforced. Because procedures are always performed in a procedure room, the nurse will not encourage family members to stay at the client's bedside during procedures.
Estimating illness in an infant is difficult. To help an infant's parents do this, which of the following would you instruct them to use?
Use her interest in eating as a good gauge. Explanation: A healthy infant eats well, voids adequately, and gains weight.
The nurse is providing discharge planning for a 12-year-old boy with multiple medical conditions. What would be the best teaching method for this child and his family?
Provide a trial period of home care. Explanation :Parents of children with multiple medical needs may benefit from a trial period of home care. This occurs while the child is still in the hospital, but the parents or caregivers provide all of the care that the child requires. The other options are also important teaching methods, but a trial period is the best solution for a child with multiple medical conditions.
A nurse caring for a 5-year-old who had abdominal surgery yesterday is trying to teach the child how to take deep breaths. The best way that the nurse can accomplish this is by:
Using a pinwheel Explanation:Postoperative care for children includes coughing, turning, and deep breathing every 2 hours. A useful and fun way to teach deep breathing to a child is using a pinwheel. Pursed-lip breathing does not help in deep breathing, nor does a flow meter. Using a spirometer will achieve the goal, but a child will be more inclined to do deep breathing if it involves some type of fun activity.
How will the nurse determine the length of orogastric tubing needed to gavage the 14-month-old infant?
Measure from nose tip to earlobe to end of sternum Explanation: Measuring from the tip of the infant's nose to the earlobe and then to the end of the sternum determines how far the orogastric and nasogastric tubes should be inserted for an infant over age 12 months. Measuring bridge of nose to xiphoid or mouth to umbilicus is not an accurate way to determine length of tube insertion. The tip of the nose to the earlobe to halfway between the end of the sternum and the umbilicus is used for infants younger than 12 months of age.
As the nurse prepares to administer a medication to a preschooler, she realizes that the child is extremely underweight for her age. What action would the nurse take?
Measure her height and weight, and check whether the dose is correct for her. Explanation: Before any medicine is administered, it should be confirmed that the dose is correct for the child's weight and height because of the great variability in these areas.
A school-aged child is scheduled for tonsillectomy in a local outpatient surgery center. Which statement by the mother indicates that further education is needed?
"He will need to spend the night here after the surgery is done." Explanation: Parents need to be taught about preoperative and postoperative care of their children and may not retain everything taught to them initially. Since the surgery is being done at an outpatient surgical center, the child will not be spending the night but will be discharged home.
An anal fissure is observed as the nurse completes a health assessment on an 8-year-old child. What question is most important for the nurse to ask the child?
"How often do you have a bowel movement?" Explanation: In children, the rectum should be inspected for any protruding hemorrhoids or fissures. Fissures may signify chronic constipation, intra-abdominal pressure, or sexual maltreatment. Rectal itching at night might indicate the presence of pinworms. Bleeding and pain are symptoms of the problem, but do not determine the cause.
The nurse instructs the mother of a preschool-aged child on the use of ibuprofen prescribed for a temperature. Which statement indicates that the teaching has been effective?
"I should give this medication with food." Explanation: Because ibuprofen can cause gastrointestinal irritation, it should be given with food or fluids. The medication dosage should be measured by using the device supplied with the medication and not using a kitchen spoon. Fluids should be encouraged when taking this medication because renal failure can occur if the child becomes dehydrated. If the child complains of a stomachache while taking this medication, notify the health care provider. This could be an indication of an adverse effect.
The infant weighs 6 lb 8 oz (2,912 g) at birth. If the infant is following a normal pattern of growth, what would be an expected weight for this child at the age of 4 months?
13 lb (5.9 kg) Explanation: Most infants double their birth weight by 4 months of age and triple their birth weight by the time they are 1 year old.
The infant measures 21.5 in. (54.6 cm) at birth. If the infant is following a normal pattern of growth, what would be an expected height for this child at the age of 6 months?
27.5 in. (69.9 cm) Explanation: Most infants double their birth weight by 4 months of age and triple their birth weight by the time they are 1 year old. By 12 months of age, the infant's length has increased by 50 percent.
Blood pressure monitoring becomes part of the routine health assessment at what age?
3 years of age Explanation: Blood pressure monitoring become part of the routine health exam at age 3.
The nurse is preparing to administer an oral dose of metoclopramide to a 5-year-old child who weighs 40 pounds. The order reads metoclopramide (Reglan) 0.8 mg/kg/day to be given in 4 oral doses. How many milligrams of metoclopramide would the nurse give per dose?
3.65 mg per dose Explanation: The patient's weight in pounds must be converted to kilograms first: 40 divided by 2.2 equals 18.2 kilograms. Then multiply 0.8 mg by 18.2 kg, which equals 14.6 mg per day for the patient's weight. Divide 14.6 mg by 4, the number of doses each day, to arrive at 3.65 mg per dose.
The nurse is caring for a 12-year-old post-appendectomy client who weighs 86 pounds. The child has a temperature of 38.5ºC (101.3ºF). The nurse prepares to give the client a dose of oral Tylenol. The order reads "Tylenol 15mg/kg/dose every 4 to 6 hours PO PRN for fever or pain." How many milligrams of Tylenol should the nurse give the client?
587 mg Explanation: The child's weight must first be converted to kilograms by dividing 86 by 2.2. The result is 39.1 kilograms. Next, the 39.1 kilograms must be multiplied by 15 milligrams. This answer is 587 milligrams.
A 5-month-old is hospitalized for dehydration. What can the nurse make with items found on the unit for an activity to distract the child?
A mobile using gauze and tongue blades Explanation: For an infant, the nurse could make a mobile from gauze and tongue blades. The other options are for older children
The nurse is helping the mother of a 5-month-old boy understand the importance of developmentally appropriate play. Which one of the toys best meets the needs of this child?
A yellow rubber duck for the bath Explanation: The rubber duck is most appropriate. It is safe, visually stimulating while bobbing on the water, and adds pleasure to bath time. A push-pull toy promotes skill for a walking infant. Pots and pans from the kitchen cupboard are played with successfully after sitting is mastered. A 5-month-old does not have the fine motor coordination to use stacking toys.
The nurse is administering a liquid medication to a 3-year-old using an oral syringe. Which action would be most appropriate?
Allow the child time to swallow the medication in between amounts. Explanation :When using an oral syringe to administer liquid medications, give the drug slowly in small amounts and allow the child to swallow before placing more medication in the mouth. The syringe is directed toward the posterior side of the mouth. The toddler or young preschooler may enjoy helping by squirting the medication into his or her mouth.
A nurse is assessing a 3-year-old child in the local health clinic. The child has a persistent cough on examination. Based on the age of the child, which muscle would the nurse view to assess respiratory status?
Abdominal Muscle Explanation: Infants and children younger than age 6 years typically use their abdominal and diaphragm muscles for breathing. When assessing respiration, the nurse should watch for the abdominal muscles to rise and fall.
Which action should the nurse take to ensure an intravenous infusion will be administered safely to an infant?
Add a calibrated fluid chamber to the line. Explanation: Overloading of IV fluid in infants can be prevented by use of fluid chambers, devices that allow only 50 to 100 ml of fluid into the drip chamber at a time. With these in place, even if the pump fails, only the amount of fluid in the drip chamber will be allowed to enter the child's circulation, not the entire contents of the bag suspended above the child's head. A large-bore needle will not ensure that intravenous fluids will be administered safely to an infant. Using a rolled pillowcase instead of a hard arm board also will not ensure that intravenous fluids will be administered safely to an infant. The height of the infusion bag will not ensure that fluids will be administered safely to an infant.
A mother is scheduled for rooming-in with her infant prior to discharge from the hospital. The nurse realizes that rooming-in is done for what purpose?
Allow the caregiver to practice treatments and procedures that will be necessary once the infant is home Explanation: Rooming-in allows parents and caregivers the opportunity, under nursing supervision and guidance, to provide care and perform treatments that will be necessary after discharge. There is no reduction of cost for rooming-in. The caregivers do not take over care of the child and the infant is already bonded to the parent.
A nurse is caring for a pediatric client with leukemia who is experiencing anxiety and fear when his parents leave the unit. Which nursing action(s) will the nurse perform to aid in relieving the child's anxiety and fear? Select all that apply.
Allow the child's parents to stay with the child. Allow for flexibility in the unit's visiting hours. Explanation: Rooming in allows the child's caregiver to participate in the plan of care (bathing, hygiene, etc.). Rooming in decreases the risk for depression and helps to relieve the child's separation anxiety. Because the child has leukemia, he may likely have an increased risk for infection and should not be placed in the room with another child, nor should extra visitors be permitted. However, the normal visiting hours should be flexible, allowing the child's parents or caregivers the opportunity to be at the child's bedside at all times.
What can a nurse do during an emergency admission to alleviate some of the child's and family's fears/anxieties over the situation? Select all that apply.
Ask the family members health history questions while the child is being initially treated. Place an identification bracelet on the child, explaining that this will help the hospital staff know who he or she is at all times. Remain calm, explaining procedures to both the family and the client in a caring manner. Explanation: Children who undergo an emergency admission to the hospital are often frightened and anxious, so the nurse needs to provide education about everything done to the child. Explaining the reason for the identification bracelet, involving the family in providing client information (if they cannot remain with the child), and describing what is being done to the child all help alleviate anxiety and fear in both parents and the child.
A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following?
Aspirating stomach contents and checking pH Explanation: Confirmation of placement by radiologic examination is the most accurate method of verifying placement and position of a feeding tube. Because of the risks of repeated radiation exposure, however, this procedure cannot be used before each feeding. The nurse should verify placement of the tube by aspirating stomach contents and checking the pH. Verifying position by inserting air into the feeding tube and listening for sounds in the stomach is now considered an unreliable method of checking for tube placement.
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child?
Axillary method Explanation: The axillary method may be used for children who are uncooperative, neurologically impaired, or immunosuppressed or have injuries or surgery to the oral cavity. Since the child is crying and uncooperative, the oral method would not be a good choice. The accuracy of the temporal method may be affected by excessive sweating. The rectal route is invasive, not well accepted by children or parents, and probably unnecessary with the modern alternative methods now available.
While performing an assessment on a child, the nurse notes the child's caregiver avoids eye contact with the nurse and is very soft spoken. Which action by the nurse is best?
Continue with the assessment Explanation: The nurse should continue with the assessment because the caregiver's behavior may likely be a cultural behavior. There is no indication that the nurse needs to report or document the caregiver's behavior or ask the caregiver about the behavior.
The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?
Count after the child stops crying and is comfortable. Explanation: Respirations should be assessed when the child is resting or sitting quietly because respiratory rate changes significantly when children cry, eat, or become more active. They also breathe more rapidly when anxious or frightened. Counting respirations for a full minute assures accuracy. Infants' respirations are primarily diaphragmatic; therefore, counting abdominal movements promotes accuracy. Placing a stethoscope to count respirations tends to be seen as invasive by a toddler and will result in movement away or an increase in respirations.
The nurse is caring for a 7-month-old girl during a well-child visit. Which intervention is most appropriate for this child?
Discussing the type of sippy cup to use' Explanation: The cup may be introduced at 6 to 8 months of age. Old-fashioned sippy cups are preferred compared to the new style. The nurse would not advise about increased caloric needs as caloric needs drop at this age. Transition to table meat will not take place until age 10 to 12 months. Tongue extrusion reflex has disappeared at age 4 to 6 months.
A nurse is inspecting the surgical dressing on a school-age child and notes that there is bloody drainage on it. What actions should the nurse take?
Draw a circle around the drainage with a permanent marker, recording the date and time on it. Explanation: If the nurse notes bloody drainage in a surgical dressing, the nurse should draw a line around the drainage with a marker, and record the tie and date of the circle. That way, if further bleeding occurs, there will be evidence of the amount of additional drainage there is and the time frame of the drainage.
A 13-month-old is having a dressing changed on a packed leg wound. Which action from the parents should be encouraged by the nurse during the treatment?
Encourage the father to talk quietly to the child. Explanation: The role of a parent during treatments and procedures should be one of support and comfort.
The nurse approaches a client room and notes a sign stating the client is in droplet isolation. Which precautions would be appropriate for this client?
Gown, gloves, and mask Explanation: A client in droplet isolation has a disease that is spread by coughing and sneezing; anyone entering the room needs protection from the infected droplets. Droplet isolation requires a gown, mask and gloves for all people who enter come in contact with the client room.
The nurse is preparing a school-age child for a diagnostic procedure. What is an important nursing role in relation to obtaining informed consent for this procedure for this client?
Ensure the child understands and assents to the test. Explanation: Although the parents are the ones who sign the consent form, it is important to ensure that the child understands the procedure and assents to accept the proposed care. It is the healthcare provider's responsibility to inform the parents of all benefits and risks. Presenting education and preparation to the parents is inappropriate unless the child is an infant because children need information to prepare them as well. Children do not determine the timing of procedures.
The nurse is about to place a gastrostomy tube in an infant. After gathering the supplies, which is the first step in the procedure?
Explain the procedure to the parents Explanation: The procedure should be explained to the parents first. The nurse then proceeds with hand washing and commences the procedure.
A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding?
Fanning of the infant's toes Explanation: A Babinski reflex is part of the neurological assessment of a newborn. When the newborn is touched or stimulated along the lateral side and ball of the foot, the toes fan.
A nurse is preparing to apply heat therapy to a client who has a back abscess. Heat has which of the following benefits? Select all that apply.
Increases circulation Causes vasodilation Promotes muscle relaxation Explanation: Local application of heat increases circulation by vasodilation and promotes muscle relaxation, thereby relieving pain and congestion. It also speeds the formation and drainage of superficial abscesses.
All infants should have their head circumference measured at health-assessment visits. This measurement is made from:
Just above the eyebrows through the prominent part of the occiput. Explanation: Measuring heads consistently from above the eyebrows to the occiput allows measurements at different visits to be compared.
The nurse in a community clinic is caring for a 6-month-old boy and his mother. Which intervention is the priority to promote adequate growth?
Monitoring the child's weight and height Explanation: Monitoring the child's weight and height is the priority intervention to promote adequate growth. Encouraging a more frequent feeding schedule, assessing the child's current feeding pattern, and recommending higher-calorie solid foods are interventions when the nursing diagnosis is that nutrition level does not meet body requirements.
The mother of a 3-month-old baby is concerned because the child is not able to sit independently. How should the nurse respond to this mother's concern?
Most babies do not sit steadily until 8 months. Explanation: An 8-month-old child can sit securely without any additional support. Babies are not able to sit steadily at age 3 or 4 months. Sitting ability does not correspond with tooth eruption.
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse?
Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Explanation:Whether enteral catheters should be passed through the nares or the mouth is controversial. Because newborns are obligate nasal breathers, passing a catheter through the nose may obstruct their breathing space, and repeated insertion of a nasal gastric tube can cause inflammation and obstruction of the nose; thus most tubes are inserted orally in small infants. Orogastric insertion can also decrease the possibility of striking the vagal nerve in the back of the throat and causing bradycardia, whereas nasogastric tubes increase the possibility of striking the vagal nerve.
A nurse receives a physician's order to collect a specimen for the diagnosis of respiratory syncytial virus. How should the nurse collect this specimen?
Obtain a nasal washing. Explanation: To diagnose respiratory syncytial virus, a nasal washing may be done. A small amount of saline is instilled into the nose; then the fluid is aspirated and placed into a sterile specimen container.
A 3-year-old boy has developed otitis media and requires antibiotics. In order to increase the chance that the boy will take his prescribed medication, the nurse should:
Offer a choice between liquid and chewable medications, if possible. Explanation: Preschoolers are often uncooperative during drug administration. Strategies for enlisting cooperation include offering choices (e.g., between liquid medicines or chewable tablets) when feasible. This is preferable to forcibly administering a medication. Teaching is unlikely to influence a 3-year-old child's reluctance. A central IV line would not be a preferred strategy if oral medications are available.
A novice nurse is instructed to collect a urine specimen from a 3-week-old. Which method of collection would an experienced nurse suggest first?
Placing cotton balls in the diaper and squeezing out urine Explanation: To collect a urine specimen from an infant, the nurse places cotton balls in the diaper and squeezes urine from the cotton ball. Catheterization is not recommended. A pediatric urine bag is used with older infants and toddlers. A midstream specimen would not be possible to collect in an infant.
A child has been admitted to the pediatric unit with vomiting and diarrhea. The physician orders strict monitoring of intake and output. The mother asks the nurse what fluids she will need to measure. The nurse responds that fluid intake can include which of the following? Select all that apply.
Popsicles Gatorade Jello IV fluids Explanation: Applesauce is a food item and not counted as liquid intake. IV fluids, jello, gatorade, and popsicles are all considered liquid intake.
A preschool teacher calls the hospital and wants to introduce the concept of a hospital to her preschool class in case they ever get sick and need to be admitted. What resources could the child life specialist provide for this group to aid in their learning? Select all that apply.
Provide a room for the class with hospital gowns, masks and equipment used on children. Tour the hospital, including the playrooms on the pediatric floors. Let the children lie in the beds, use the call lights and practice being a patient. Explanation:Preschoolers are curious and love to manipulate the equipment used at the hospital. By making admission to the hospital less frightening for them, they will adjust better if they have to be admitted. Mentioning people not leaving the hospital indicates they died; this is scary to the children and inappropriate for this session. Children are never allowed to play with needles or syringes - it is too dangerous.
A parent brings the child into the clinic and states that the child cannot hear well. Which characteristics in the child may indicate hearing difficulty? Select all that apply.
Responding inappropriately in conversation Speaking loudly Not speaking clearly Not responding when spoken to Explanation: A high activity level in the child is most likely normal and would not indicate any hearing difficulty. The other choices are all associated with hearing difficulty and would warrant audiometry.
A nurse is unsure whether the nasogastric (NG) tube just placed is properly positioned in the child's stomach. Which action confirms the location of the tube?
Review of the radiologic report Explanation: Radiologic confirmation is the only sure way to determine the location of an NG tube. The nurse would review the report returned. Aspiration and acidic pH are useful clinical verifications. Auscultating for air helps confirm but is less valid. Measuring tubing extending from the naris is a safety check used after tube placement is verified post placement and can alert to tube migration.
Development should continue during hospitalization. What play activities will the nurse choose for toddlers to accomplish this? Select all that apply.
Stacking blocks Pulling a toy train Putting together a large-piece puzzle Explanation: Pulling a toy train encourages movement and the development of gross motor skills important to the toddler. Stacking blocks and putting together a puzzle uses fine motor skills and an understanding of shapes and space and are stimulating cognitively. Watching a mobile is appropriate for infants and may be unsafe if the toddler could reach it. Balloons are inappropriate in the hospital setting (latex sensitivity) and are an aspiration risk. Mylar balloons may be considered safe, although attached long strings or ribbons are not.
What is a definitive test for cystic fibrosis?
Sweat Chloride Explanation: The definitive test in diagnosing cystic fibrosis is the sweat chloride test. This test is performed by stimulating a small patch of sweat glands on the inner aspect of the forearm. There must be two positive tests and clinical symptoms to confirm the diagnosis. The other choices are routine diagnostic tests.
The nurse is caring for a 4-week-old girl and her mother. Which is the most appropriate subject for anticipatory guidance?
Telling how and when to introduce rice cereal Explanation: Telling the mother how to introduce rice cereal is the most appropriate subject for anticipatory guidance. Since this mother is already breast- or bottle-feeding her baby, educating her about these subjects would not inform her about what to expect in the next phase of development.
The nurse is assessing a 4-month-old infant during a scheduled visit. Which findings might suggest a developmental problem?
The child does not vocally respond to voices. Explanation: The fact that the child does not vocally respond to voices might suggest a developmental problem. At 4 to 5 months of age most children are making simple vowel sounds, laughing aloud, doing raspberries, and vocalizing in response to voices. The child is too young to babble, squeal, yell, or say dada or mama.
The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which topics might the nurse include? Select all that apply.
The child's toileting habits Use of car seats and other safety measures Use of supplements and vitamins Explanation: The functional history should contain information about the child's daily routine, such as toileting habits, safety measures, and nutrition. Problems with growth and development would be covered in the developmental history. Prenatal and perinatal history is assessed in the past health history and the child's race and ethnicity is part of the demographics.
The nurse is weighing a 20-month-old who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. Explanation: The toddler who is able to sit can be weighed while sitting. Keep a hand within 1 inch of the child at all times to be ready to protect the child from injury.
The nurse is administering a tube feeding to a child. The nurse aspirates the stomach contents as part of the process for checking placement of the tube. Which action is correct for the nurse to do with the aspirated stomach contents?
The nurse should measure and replace the residual stomach contents. Explanation: Aspirate, measure, and replace the residual stomach contents at the beginning of the procedure.
A child has been admitted to the pediatric unit with diarrhea. The nurse must collect a stool specimen for ova and parasites. The nurse knows that the proper procedure must be followed for detection of the ova and parasites. The proper procedure includes:
Transport the stool specimen to the laboratory promptly. Explanation: The stool specimen must go to the laboratory immediately so that it does not have to be redone. Refrigeration destroys ova and parasites. Urine should not be in contact with the stool, and the stool needs to be in a clean container. Stools are collected from diapers as well as bedpans.
The nurse notes that parents accompanying their child for a procedure appear tense and nervous. What intervention by the nurse will best assist the young child to relax?
Use measures to reduce the parents' anxiety. Explanation: Reducing the parents' anxiety will also reduce the child's anxiety. Anxious parents transmit their anxiety to the child and are less effective in providing support. The other nursing interventions are helpful, but relaxed parents are the key.
The public health nurse is choosing to focus community education for parents of young children about awareness of the hospital. When is the best time to educate the children about the hospital?
When the children are capable of understanding basic functions of community resources Explanation:The best time to educate the children about awareness of the hospital is when the children are capable of understanding the basic function of community resources. Children do not fully understand death and dying until later in childhood and it is not necessary to know in order for younger children to understand hospitals. Showing interest and recognizing emergency workers and vehicles does not mean the children are capable of understanding the function of the hospital.
The nurse who wishes to be as supportive as possible to the hospitalized preschooler makes great effort to avoid threatening the 4-year-old's:
body integrity Explanation:Preschoolers are very concerned about physically intrusive procedures. They lack understanding of the way in which the body works and feel extremely threatened by all that could possibly cause bodily harm. Preschoolers are creative, have useful verbal skills, and often have very particular food preference. All of these characteristics and abilities should be recognized and supported by the nurse, but are not as anxiety-producing when threatened as is body integrity.
The nurse is testing the pH of contents aspirated from a gavage feeding tube to confirm placement. Which finding indicates likely intestinal placement?
pH 7.0 Explanation: A pH over 6 indicates an alkaline environment and likely intestinal placement; a pH less than 5 points toward gastric placement.
A parent must administer a medication in syrup form to a 2-month-old infant. The nurse suggests:
placing the medicine in an empty nipple without an attached bottle. Explanation: The young infant should naturally and easily suck the medicine through an empty nipple, getting the entire dose. Formula and rice cereal are essential foods for the infant and the desirability of them should not be altered by the taste of the medication. In addition, a 2-month-old is not developmentally ready for spoon feeding of rice cereal or medication from a medicine spoon.
A nurse is conducting an assessment of a 13-month-old. The mother notes that the infant cannot pull herself into a standing position. Which assessment should the nurse conduct to gather more information to report to the health care provider?
symmetry of gluteal skin folds assessment Explanation: By assessing for symmetry of gluteal skin folds the nurse would be assessing for signs of developmental dysplasia of the hip. It is expected that by about 10 months of age infants can pull themselves into a standing position.
A preschool child has been admitted to the hospital. Which prescription should the nurse question?
tap water enema 500 mL Explanation: Tap water is not used in enemas with children because, as it is not isotonic, it causes a rapid shift of fluid in body compartments, possibly leading to water intoxication. The nurse would want to question the health care provider about the prescription for a large tap water enema. The other prescriptions could be completed safely for a preschool child.
The nursing students are learning how to perform a health assessment on a pediatric client. The nursing instructor identifies a need for further teaching when a student states:
"I should take blood pressure on a child beginning at age 2 years." Explanation: When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years.
The nurse is teaching a parent how to administer otic medications to her 4-year-old child. Which comment from the mother would indicate the need for further teaching?
"I will pull the pinna down and back." Explanation: If the child is older than 2 years of age, the parent should pull the pinna of the ear up and back. Ear drops must always be used at room temperature or warmed slightly because cold fluid may exacerbate pain and may also cause severe vertigo as it touches the tympanic membrane. The parent should turn the child or ask the child to turn onto his or her back, or use restraint as necessary, and then turn the child's head to one side and administer in the ear as prescribed.
When teaching an infant's mother about bathing her, it would be important to instruct her that:
Bath time provides an opportunity for play. Explanation: Infants do not need a daily bath as long as the diaper area is washed with diaper changes. Soap is actually drying to an infant's skin. Washing the hair with soap can help remove excess oil.
A new mother asks for advice from the nurse about bathing her infant. Which of the following should the nurse tell her?
Be sure to wash the infant's face, hands, and diaper area daily Explanation:Except in very hot weather, an infant does not need a bath every day. If a parent is tired and would not enjoy bath time or if some days are just too rushed, a complete bath can be omitted, with only the infant's face, hands, and diaper area washed. Some infants do need their head and scalp washed frequently (every day or every other day) to prevent seborrhea, a scaly scalp condition often called cradle cap. If seborrhea lesions do develop, they adhere to the scalp in yellow, crusty patches. The skin beneath them may be slightly erythematous. The patches can be softened by oiling the scalp with mineral oil or petroleum jelly and leaving it on overnight. The crusts can then be removed by shampooing the hair the next morning. A soft toothbrush or fine-toothed comb can be used to help remove them.
David, age 2, is diagnosed with stomach flu and is suffering from vomiting and diarrhea. What is the most important factor in determining the correct dosage for his infection?
Body surface area Explanation: A drug dose for a child can be determined by using the standard formula for finding the body surface area of the child. The ratio of the body surface area to weight is inversely proportional to its length. Body surface area also can be determined by using a nomogram. Drug dosages cannot be based on age or memorized because child weights may vary considerably. Child dosage cannot be based on adult dosage, because a child's body is small and immature.
A new mother tells the nurse that she a bought car seat for her infant at a garage sale when she was pregnant but that a friend recently told her that she should buy a new one. Which instruction would the nurse give initially?
Check the expiration date on the car seat Explanation: Initially, the nurse would instruct the client to check the car seat for an expiration date. Expiration dates are now placed on all car seats. The seat identifies when the seat was manufactured. Expiration dates allow for routine updates. If the expiration date had expired, the nurse would instruct to discard the car seat. The other options would be considered if the expiration date was in the future.
Place in order the steps the nurse would implement when gathering the following physical data for an infant?
Count respirations Count the apical pulse Examine the infant's genitalia Measure the infant's chest and head circumferences. Obtain the infant's axillary temperature Look into the ears and mouth Explanation: Infants do not like having their body touched or manipulated. The first thing the nurse should do is observe the infant and count the respirations, which is easy because infants are abdominal breathers. Next, the nurse would gently place a stethoscope on the infant's chest and listen and count the heart rate. After gathering vital signs, examine the genitalia. The next data gathered would be the measurement of the head and chest circumference, which is minimally invasive. Following that, the nurse would obtain a temperature and lastly would be examination of the mouth and ears. Always go from least invasive to most invasive.
A toddler requires 1.5 mL (.05 oz) of an antibiotic given intramuscularly (IM). How will the nurse administer this medication?
Divide the dose. Administer 0.75 mL (0.25 oz) IM in each vastus lateralis. Explanation: The recommended amount of solution a toddler should receive in one IM injection should not exceed 1 mL (0.33 oz). Dividing the dose is necessary even though two injections will cause additional stress. These could be given simultaneously by two nurses. Seeking an oral route could be explored, but may not be feasible. The manufacturer's directions regarding the amount of diluent should be followed to ensure safety.
A new mother is concerned about the risk of her 6-month-old aspirating and choking. Which of the following should the nurse recommend to her? Select all that apply.
Don't prop up the baby's bottle when feeding him Use only clothing without decorative buttons Explanation: Aspiration is a potential threat to infants throughout the first year. Educate parents who feed their infant formula not to prop bottles. By doing this, they are overestimating their infant's ability to push the bottle away, sit up, turn the head to the side, cough, and clear the airway if milk should flow too rapidly into the mouth and an infant begins to aspirate. Using clothing without decorative buttons, and checking toys and rattles to ensure they have no small parts that could snap off or fall out are good steps for parents to follow. A test of whether a toy could be dangerous if an infant puts it inside the mouth is whether it fits inside a toilet paper roll. If it does, it is small enough to be aspirated. Children under about 5 years should not be offered popcorn or peanuts because of this danger of aspiration. If parents are going to offer an infant a pacifier, they should use one that has a one-piece construction with a flange large enough to keep it from completely entering the child's mouth.
Mike, age 8, is going home on medication after surgery. The nurse is preparing to review the discharge instructions with the mother. What basic information and/or instructions should be given to her to continue the drug therapy at home? Select all that apply.
Generic and trade names of drugs Schedule and duration of administration Description of the intended therapeutic drug effect Explanation: A crucial step in administering pediatric drug therapy is educating the parents and other family members or caregivers, especially when the child returns home. Providing honest and detailed explanations and rationales helps reassure those caring for the child. The nurse should also provide age-appropriate explanations. Referring to books or imparting knowledge of the position papers will not help Mike's mother take care of her son at home.
The nurse is caring for an 11-year-old admitted with a respiratory condition. The child requires occassional administration of low-flow oxygen. Which of the following methods of oxygen administration would likely be used for this child?
Nasal Prongs Explanation: Depending on the child's age and oxygen needs, many different methods are used to deliver oxygen. Nasal prongs or a nasal cannula are used appropriately for an 11-year-old child, especially if the child has modest needs for supplementation.
The nurse is caring for a 10-year-old girl who is in an isolation room. Which intervention would be a priority intervention for this child?
Provide age-appropriate toys and games. Explanation: Children in this setting may experience sensory deprivation due to the limited contact with others and the use of personal protective equipment such as gloves, masks, and gowns. The nurse should stimulate the child by playing with her with age-appropriate toys/games. Reducing noise would be appropriate for sensory overload. The nurse should encourage the family to visit often, introduce himself or herself before entering the room, and allow the child to view his or her face before applying a mask.
An adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate?
Providing detailed explanations of the procedure at least a week in advance of the procedure Explanation: The adolescent needs a detailed explanation about the procedure at least 7 to 10 days beforehand. Waiting until the morning of the procedure would be inappropriate. However, information could be clarified and additional questions could be answered at this time. Having the parent stay with the adolescent is something that the adolescent would need to decide; he may or may not want a parent present. Referring the adolescent to the surgeon for his questions is inappropriate and ignores the adolescent's desire for control and information.
Colin, age 1, has been admitted for an injury on his head that requires sutures to be placed. He is crying and trying to sit up when he is placed on the examining table. To keep him safe during the procedure, the nurse would choose which method to restrain him?
Restrain him with a mummy restraint and release it as soon as the procedure is completed. Explanation: Restraints often are needed to protect a child from injury during a procedure or an examination, or to ensure the infant's or child's safety and comfort. A mummy restraint can be used for an infant or small child during a procedure. This device is a snug wrap that is effective when performing a scalp venipuncture, inserting a nasogastric tube, or performing other procedures that involve only the head or neck.
The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this client?
Rhonchi Explanation: Rhonchi are snoring sounds that are made by air moving through mucus in the bronchi. This is a normal sound. Stridor is a crowing sound being made through a constricted larynx. This is an abnormal sound. Crackles are sounds made by air moving through fluid. This is an abnormal sound. Wheezing is a whistling sound made by air moving through a narrow bronchus. This is an abnormal sound.
Which finding would the nurse interpret as least significant when assessing a child's lungs?
Rhonchi Explanation: Rhonchi is the sound of air passing over mucus in the airway. Stridor and wheezing denote a constricted airway. Crackles denote fluid in alveoli, which is the mark of pneumonia.
The pediatric nurse is caring for a group of children. Which clinical situation will the nurse identify as being a safety concern?
Sleepy mother holding sleeping child at the child's bedside Explanation:Safety is the priority for the pediatric nurse. The nurse should not allow a sleepy family member to hold a sleeping child because the family member may accidentally drop the child. Friction toys should not be allowed when supplemental oxygen is used; and a rubber ball would not be considered a friction toy. The infant who can stand should be placed in a crib with the top on it to prevent climbing out and an infant in a crib should have all railings in the up position.
A 3-year-old who has just been admitted with pneumonia needs to have an intravenous (IV) line inserted for antibiotic therapy. What is the best nursing action?
Take the patient to the treatment room to have the IV inserted. Explanation: Treatments should be performed in a treatment room, not in the child's room. Using a separate room to perform procedures promotes the concept that the child's bed is a safe place. Having the mother hold the child is helpful but not the best action in this case. Telling the patient that it will feel like a bee sting would only make the child more apprehensive.
The nurse is caring for a 4-month-old infant who is running fever. The mother questions what can be done to get the child's temperature down. Which of the following are acceptable methods to manage fever in an infant? Select all that apply.
Use a hypothermic blanket. Encourage the infant to drink fluids. Use acetaminophen or other antipyretics. Prevent overdressing the infant. Explanation: Infants should not be placed in a cool bath to lower body temperature. The nurse should recommend giving antipyretics and fluids, using a hypothermic blanket if necessary, and avoiding overdressing.
A nurse is administering a liquid oral medication to a 5-month-old. Which nursing action provides the correct dosage? Select all that apply.
Using a medicine dropper Gently restraining the child's arms and head Administering the medicine such that it flows slowly into the child's mouth Explanation: In infants, oral medication can be given with a medicine dropper or a unit dose syringe (without a needle). The nurse would not choose a medicine cup for administration. Never give medicine with the child lying completely flat; otherwise, a child could choke and aspirate. Instead, gently restrain the child's arms and head by holding the child against your body with the head raised. A crying child is already opening the mouth for you; otherwise, gently open the mouth by pressing on the child's chin. Press the bulb of the medicine dropper or use the plunger of the syringe so that the fluid flows slowly into the side of the child's mouth. Be certain the end of the syringe or dropper rests at the side of the infant's mouth to help prevent aspiration.
Which safety and legal responsibilities does the nurse need to maintain when performing or assisting with procedures on children? Select all that apply.
Verify that an informed consent is obtained, as needed. Utilize the electronic health record to verify the prescription for the procedure. Explain the procedure to the child and parents to ensure both are well informed. Coordinate and collaborate with other health care providers to ensure the safety and efficacy of all procedures. Assess a child's response to the procedure. Document the outcome of the procedure and the child's reaction to the procedure. Explanation: When performing or assisting with procedures on children, the nurse must maintain safety and legal responsibilities for care. The nurse should perform the following actions: verify that an informed consent is obtained, as needed: utilize the electronic health record to verify the prescription for the procedure; explain the procedure to the child and parents to ensure both are well informed; schedule the procedure; prepare the child physically and psychologically; obtain necessary equipment for the procedure; accompany the child to a treatment room or hospital department where the procedure will be performed; coordinate and collaborate with other health care providers to ensure the safety and efficacy of all procedures; provide support during the procedure, using the least amount of restraint possible; ensure adherence to standard infection precautions; assess a child's response to the procedure; provide care to a child and specimens obtained once the procedure is completed; and document the outcome of the procedure and the child's reaction to the procedure.
The nurse is caring for a child who has a gastrostomy tube in place. The nurse is about to give a feeding when it becomes evident that the tube is filled with dark brown fluid. The nurse's best action would be to:
report to the primary care provider that a complication may be occurring. Explanation: A potential complication of gastrostomy tubes is that they may migrate through the pyloric valve into the duodenum and cause obstruction. Brown fluid suggests this has happened, because the tube is filled with feces. An alkaline pH suggests the complication has occurred, because bowel secretions are alkaline, while stomach secretions are acidic.
