NSG Peds HESI

Which clinical finding should the nurse expect a child with nephrosis to exhibit? A. Elevated blood pressure. B. Blood-tinged urine. C. Elevated temperature. D. Urine protein 3+ to 4+.

-Urine protein 3+ to 4+. Rationale In nephrosis, renal tubules become permeable to proteins, causing massive proteinuria.

The nurse is caring for a client with scoliosis who had a posterior spinal fusion and is in a body jacket cast. Which assessment finding indicates to the nurse that the client is developing superior mesenteric artery syndrome? A. Abdominal distention. B. "Hot spot" felt on cast. C. Diminished pulses in the foot. D. Musty, unpleasant odor to cast.

A. Abdominal distention Rationale Superior mesenteric artery syndrome occurs when the cast is applied too tightly and is compressing the superior mesenteric artery against the duodenum. Abdominal distention, pain, nausea, and vomiting may result.

A 6-month-old infant with congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? A. Apical heart rate of 60. B. Sweating across the forehead. C. Doesn't suck well. D. Respiratory rate of 30 breaths per minute.

A. Apical heart rate of 60. Rationale A heart rate of 60 beats per minute is much lower than normal for a 6-month-old and warrants immediate intervention. The normal heart rate for a 6-month-old is 80 to 150 beats per minute when awake, and a rate of 70 while sleeping is considered within normal limits.

The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is a positive step in the ability to cope with this new situation? A. Endowing the illness with meaning. B. Refusing to believe the child is ill. C. Entertaining an unrealistic future plan for the child. D. Placing complete faith in religion to the point of relinquishing responsibility.

A. Endowing the illness with meaning. Rationale Coping mechanisms are behaviors directed at reducing the tension elicited by a crisis. Approach behaviors are coping mechanisms resulting in movement toward adjustment and resolution of the crisis. The parents' ability to assign the illness meaning within an existing medical, scientific, or spiritual philosophy of life is a long-term coping strategy significantly related to successful family functioning.

A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless, and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture adaptation. B. Lacks the maturity needed in school. C. Refuses to participate in school activities. D. Going through minority group discrimination.

A. Experiencing culture adaptation.

The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis? A. Feet and hands. B. Bridge of nose. C. Circumoral area. D. Mucous membranes.

A. Feet and hands

A nurse reviews the methods for preventing recurring urinary tract infections (UTI) with the parent of a female child. Which response by the parent indicates that further teaching is needed in caring for the child? A. States they will buy the child only nylon underclothes. B. Increases oral fluids and encourages the child to void frequently. C. Provides the child with cotton underwear for daily use. D. Teaches the child to cleanse the perineal area from front to back.

A. States they will buy the child only nylon underclothes Rationale Nylon underwear traps moisture and can contribute to bacterial growth

A newborn who is breastfeeding is diagnosed with galactosemia. Which action should the nurse implement? A. Stop the infant breastfeeding. B. Add amino acids to breast milk. C. Give galactokinase with breast milk. D. Substitute a lactose-containing formula.

A. Stop the infant breastfeeding. Rationale Galactosemia is a rare genetic disorder that involves an inborn error of carbohydrate metabolism in which a hepatic enzyme, galactokinase, involved in the conversion of galactose to glucose is absent. Treatment consists of eliminating all lactose-containing foods, including breast milk, so the infant should stop breastfeeding. Soy protein formula is the feeding of choice during infancy.

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? A. Type of reaction to loud noises. B. Any surgeries on the ears since birth. C. Drainage from the infant's ears. D. Number of ear infections since birth.

A. Type of reaction to loud noises. Rationale Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.

Which sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia? A. Apnea. B. Tachypnea. C. Bradycardia. D. Decreased blood pressure.

B. Tachypnea Rationale Malignant hyperthermia, a potentially fatal autosomal genetic myopathy, can cause a change in vital signs that demands immediate attention in the perioperative period when these individuals are exposed to anesthetic agents. Early symptoms of the disorder include tachycardia and tachyarrhythmia, tachypnea, hypercarbia, and metabolic and respiratory acidosis. An elevated temperature is a late sign of the disorder.

Which site should the nurse use to obtain the pulse rate for a 1-year-old child? A. Radial. B. Apical. C. Carotid. D. Femoral.

B. Apical Rationale An apical pulse should be obtained in children under 2 years

During a well-child assessment, the parents of a 4-year-old express concern that their child often chatters while playing alone. What information should the nurse provide the parents? A. The child is attempting to formulate a secondary language. B. This is an attempt by the child to form an imaginary social base. C. "Private speech" is normal at this age and serves as a problem-solving tool. D. Concern for psychological development is warranted, so further testing is required.

C. "Private speech" is normal at this age and serves as a problem-solving tool. Rationale Children chatter to themselves between the ages of 4 and 6 years. This "private speech" serves as a problem-solving tool as children try new tasks or work through unfamiliar situations.

A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9 F. The nurse determines the daily caloric need for this child is approximately A. 400 calories per day. B. 500 calories per day. C. 600 calories per day. D. 700 calories per day.

C. 600 calories per day. Rationale An infant requires 108 calories/kg/day (108 x 5 = 540 calories/day). However, this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 is 54 and 540 + 54 = 594.

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A. A trial of adrenocorticotrophic hormone injections. B. Frequent stimulation of the cremasteric reflex. C. A trial of human chorionic gonadotrophic hormone. D. Frequent warm baths to gently dilate the scrotal area.

C. A trial of human chorionic gonadotrophic hormone. Rationale A trial of HCG (human chorionic gonadotrophic hormone) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex.

A 6-year-old child is brought to the emergency department with a systolic blood pressure of 58 mmHg. What action should the nurse take first? A. Comfort the child. B. Assess responsiveness. C. Alert the healthcare provider. D. Initiate IV fluid replacement.

C. Alert the healthcare provider. Rationale The lower limit for systolic blood pressure for a child older than 1 year of age is 70 mmHg plus 2 times the child's age in years. The healthcare provider should be notified immediately of the child's hypotension and anticipate a prescription for IV fluids.

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? A. Ability to communicate verbally. B. Response to separation from family. C. Concern for body integrity. D. Socialization with other children.

C. Concern for body integrity. Rationale The preschooler's major stressor is concern for his body integrity. He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity.

The nurse observes a 4-year-old boy in a daycare setting. Which behavior should the nurse consider normal for this child? A. Has a temper tantrum when told he must share his toys. B. Plays by himself most of the day. C. Demonstrates aggressiveness by boasting when telling a story. D. Begins to cry and is fearful when separated from his parents.

C. Demonstrates aggressiveness by boasting when telling a story. Rationale Four-year-old children are aggressive in their behavior and enjoy "tale telling" (C). Behaviors in (A and D) are typical of toddlers. The play of a preschooler is cooperative, so playing alone (B) is not typical.

A 12-year-old male client tells the nurse that he is happy to be taking growth hormones because now he can grow to be as tall as his friends. What response is best for the nurse to provide? A. "You must remember that this treatment regimen is not always effective." B. "Although being tall is important to you, remember there are far more important characteristics than height." C. You will grow with this medicine, and are likely to be taller than anyone in your family." D. "Being taller is important to you and taking your injections will help achieve that goal."

D. "Although being tall is important to you, remember there are far more important characteristics than height." Rationale It is important to validate his feelings and reinforce the fact that injections are the only way he can get the medication and achieve growth in height. He will have to take injections three times a week for years.

When assessing a preschooler, which finding warrants further assessment by the nurse? A. Able to ride a tricycle. B. Talks about an imaginary friend. C. Dresses independently. D. Gains 2 pounds (0.9 kg) in 12 months.

D. Gains 2 pounds (0.9 kg) in 12 months. Rationale Preschool children gain an average of 5 pounds (2.3 kg) per year.

The vital signs of a 4-year-old child with polyuria are: BP 80/40, Pulse 118, and Respirations 24. The child's pedal pulses are present with a volume of +1, and no edema is observed. What action should the nurse implement first? A. Insert an indwelling urinary catheter. B. Start an IV infusion of normal saline. C. Send a specimen to the lab for urinalysis. D. Document the child's vital signs and pulses.

**B. Start an IV infusion of normal saline. Rationale The current blood pressure reading of 80/40 mmHg and the decreased peripheral pulse volume indicates that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume. *Normal range for blood pressure levels for 3-5 year olds according to the American Heart Association and the American Academy of Pediatrics if 104-116/63-74 mmHg dependent on the height and weight of the child.

A nurse who is working in the Poison Control Center receives a telephone call from a parent of a 16-month-old child who drank 2 ounces of acetaminophen elixir. Which action should the nurse recommend to the parent? A. Administer oral syrup of ipecac. B. Give the child a glass of whole milk. C. Transport the child to the emergency department for gastric decontamination. D. Obtain oral activated charcoal tablets from the pharmacy.

. CTransport the child to the emergency department for gastric decontamination. Rationale Each 5 mL of elixir contains 160 mg of acetaminophen. This child has ingested twice the maximum recommended 24-hour dose, which can cause acetaminophen toxicity. The parent should transport the child to the emergency department for gastrointestinal decontamination and the possible administration of the antidote, acetylcysteine. Overdosing of acetaminophen can cause serious liver damage.

A 4-year-old child who is ventilator-dependent is receiving tube feedings in the home setting. The family wants to begin oral feeding of the child and asks the home health nurse to orally feed the 4-year-old baby food. What steps should be taken? (Rank in priority order.)

1. Acknowledge the request. 2. Explain the risk of aspiration. 3. Explore available options. 4. Contact the healthcare provider (HCP) and discuss suggested new options for further orders and additional discussion.

The nurse notices that the skirt hem on a preadolescent girl is uneven. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from the first step to the last step.)

1. Ask the girl to remove her shirt but leave on her bra or swimsuit top. 2. Look for asymmetry in the hip area. 3. Instruct the girl to bend at the waist so her back is parallel to the floor. 4. Examine for scapular prominence.

Which neurological test should the nurse implement to assess cerebellar function in a 5-year-old with symptoms of hyperactivity? A. Finger-to-nose. B. Quadriceps reflex. C. Two-point discrimination. D. Ability to follow directions.

A. Finger-to-nose Rationale The cerebellum controls balance and coordination and is significant in children with symptoms of hyperactivity or learning difficulties. Difficulty performing a finger-to-nose test indicates poor sense of position (especially with the eyes closed) and incoordination (especially with the eyes opened).

The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis. The infant has had continuous loose stools since surgery yesterday. Which nursing problem has the highest priority given the infant's condition? A. Fluid volume deficit. B. Alteration in bowel elimination. C. Pain due to postoperative condition. D. Anxiety of parents due to newborn's condition.

A. Fluid volume deficit. Rationale All stated nursing problems are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern for any infant and is even more of an issue for a postoperative infant.

The nurse is caring for an irritable, lethargic 18-month-old child who swallowed several over-the-counter (OTC) antihistamine tablets an hour ago. Which intervention should the nurse implement? A. Initiate gastric lavage. B. Administer naloxone. C. Give a dose of ipecac syrup. D. Encourage oral intake of water or milk.

A. Initiate gastric lavage. Rationale Gastric lavage should be implemented within 2 hours of ingestion to ensure gastric removal of a noncorrosive substance, such as an OTC antihistamine.

The nurse at the well-child clinic is advising the parents of an 8-month-old child about health and safety. What information should the nurse provide? A. Install stair guards or gates in the home. B. Use of a car seat is optional if a lap and shoulder belt is in place. C. Start toilet training with a child-sized potty. D. Give syrup of ipecac in case of accidental ingestion or poisoning.

A. Install stair guards or gates in the home. Rationale By the age of 8 months, a child is crawling and may be able to pull up to a standing position. The use of a stair guard or gate is necessary to prevent accidents, which are the most common cause of injury among children of this age.

The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? A. Prolonged exhalations. B. Thick yellow rhinorrhea. C. Frequent nonproductive cough. D. Oxygen saturation of 95% by pulse oximeter.

A. Prolonged exhalations. Rationale Prolonged exhalation indicates breathing difficulty and requires immediate intervention. According to the American Heart Association's Pediatric Advance Life Support (PALS) algorithm, a prolonged expiration in a pediatric client is indicative of lower airway obstruction.

When caring for a child who is in the paroxysmal stage of pertussis, which intervention should the nurse implement to support the child's nutritional needs? A. Provide small, frequent meals. B. Increase protein intake. C. Maintain a liquid diet. D. Offer the child a regular diet.

A. Provide small, frequent meals Rationale The paroxysmal stage of pertussis is characterized by coughing with vomiting. Frequent small meals are vomited less often than larger meals.

The nurse is developing a plan of care for a school-aged boy with a chronic disability. The child frequently complains about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important for the nurse to implement? A. Recommend the use of consistent discipline and reward for acceptable behavior. B. Allow the child to act out since he is chronically ill. C. Suggest that all the children are included in family decision-making. D. Evaluate the proper use of equipment that is provided to improve the child's lifestyle.

A. Recommend the use of consistent discipline and reward for acceptable behavior. Rationale Focusing on the child, and not the condition, is essential in assisting the child to adapt to a chronic disability or illness. Consistent family rules should be used with a chronically ill child, such as setting boundaries for acceptable behavior, requiring participation in household activities, and fulfilling school responsibilities. Children need solid boundaries, even if chronically ill.

A child is brought to the emergency department with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the type of snake is identified? A. Secure the antivenom. B. Ambulate the child. C. Apply a tourniquet to the leg. D. Reassure the child and parent.

A. Secure the antivenom.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A. Only an RN should be assigned to monitor this child's temperature. B. A tympanic measurement of temperature will provide the most accurate reading. C. The licensed practical nurse should be instructed to obtain rectal temperatures on this child. D. The healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.

B. A tympanic measurement of temperature will provide the most accurate reading. Rationale (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement.

The nurse is caring for a 12-year-old with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication? A. Poor skin turgor resulting from dehydration. B. Changes in level of consciousness. C. Premature aging as the disease progresses. D. Severe edema from an excess of water and sodium.

B. Changes in level of consciousness. Rationale The child must be monitored for signs and symptoms of hyponatremia, which creates secondary central nervous system alterations such as changes in level of consciousness, seizure, and coma.

A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? A. Insert N/G tube for gastric lavage. B. Determine the child's pulse and respirations. C. Assess the child's level of consciousness. D. Administer an IV D5/0.25 NS as prescribed.

B. Determine the child's pulse and respirations.

While assessing an 18-month-old during a well-child visit, the nurse notes that the toddler has a rounded potbelly abdomen, marked lordosis or swayback, short and slightly bowed legs, and a large head. Based on these findings, what action should the nurse implement? A. Refer the findings to the healthcare provider for diagnostic studies for hydrocephalus. B. Document general physical appearance of a normally developed toddler. C. Plot the findings on the growth chart within the parameters of delayed physical maturation. D. Review the dietary intake for indications of a vitamin deficiency or malnutrition.

B. Document general physical appearance of a normally developed toddler. Rationale "Toddler lordosis" describes the normal upright posture found at this age, which is characterized by a potbelly, swayback, and short, slightly bowed legs.

A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine should the nurse verify the infant has received? (Select all that apply.) A. Meningococcal polysaccharide vaccine (MPSV4). B. Haemophilus influenzae type b conjugate vaccine (Hib). C. Inactivated poliovirus vaccine (IPV). D. Hepatitis B virus vaccine (HepB). E. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP). F. Measles, mumps, and rubella vaccine (MMR).

B. Haemophilus influenzae type b conjugate vaccine (Hib). C. Inactivated poliovirus vaccine (IPV). D. Hepatitis B virus vaccine (HepB). E. Diphtheria, tetanus toxoids, and acellular pertussis (DTaP).

Which is a priority nursing problem for a child in the subacute stage of Kawasaki disease (KD)? A. Alterations in skin integrity. B. High risk for altered tissue perfusion, cardiopulmonary. C. Risk for imbalanced body temperature, hyperthermia. D. High risk for fluid volume deficit.

B. High risk for altered tissue perfusion, cardiopulmonary. Rationale KD is an acute systemic vasculitis that places the child at risk for coronary artery aneurysm, which is most likely to occur during the subacute phase resulting in reduced cardiac output. KD causes a rash and desquamation of the hands and feet. This is not as life-threatening as cardiac involvement.

Which research finding provides evidence-based practice for an infant's risk for sudden infant death syndrome (SIDS)? A. Breastfeeding reduces the risk for and the incidence of SIDS. B. Infants should be positioned supine or supported laterally to sleep. C. The prone position should be used when an infant sleeps after feeding. D. The peak incidence occurs between the ages of 1 and 2 months.

B. Infants should be positioned supine or supported laterally to sleep.

When administering a gavage feeding to a school-age child, which action should the nurse implement? A. Administer feedings over 5 to 10 minutes. B. Position the child on the right side after administering the feeding. C. Check the placement of the tube by inserting 20 mL of sterile water. D. Lubricate the tip of the feeding tube with petroleum jelly to facilitate passage.

B. Position the child on the right side after administering the feeding. Rationale The child should be positioned on the right side with the head of the bed elevated 30 degrees after administering the feeding to facilitate gastric emptying and prevent gastric reflux. Gavage feedings should be given to allow slow gastric filling over 15 to 30 minutes.

A 3-year-old boy is brought to the emergency department because of a possible diazepam overdose. He is lethargic and confused. His vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30 mmHg. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C. Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning.

B. Prepare a set-up for an endotracheal intubation. Rationale Diazepam causes respiratory depression. Preparation for endotracheal intubation to protect the airway is the priority intervention at this time.

The nurse calculates a 4 mL dose of prescribed digoxin to a 9-month-old infant. Which action should the nurse implement? A. Mix the dose with juice to disguise its taste. B. Suspect a dosage error and do not give the dose. C. Check the infant's heart rate and administer the dose by placing it to the back and side of the mouth. D. Check the infant's heart rate and administer the dose by letting the infant suck it through a nipple.

B. Suspect a dosage error and do not give the dose. Rationale Digoxin's narrow margin of safety for an infant should not exceed 1 mL (50 mcg) in one dose.

A 14-year-old returns to the pediatric unit after corrective surgery for scoliosis. In the immediate postoperative period, the nurse should include which action in this client's plan of care? (Select all that apply.) A. Record intake and output every 8 hours. B. Elevate the head of the bed 30 degrees. C. Assess bowel sounds every 4 hours. D. Initiate a logrolling schedule every 2 hours. E. Ambulate for 5 minutes, 12 hours postoperative. F. Give morphine sulfate, 2 mg IV every 4 hours PRN.

C. Assess bowel sounds every 4 hours. D. Initiate a logrolling schedule every 2 hours. F. Give morphine sulfate, 2 mg IV every 4 hours PRN. Rationale Recording intake and output and assessing bowel sounds are critical when determining if the body systems are recovering from the effects of anesthesia. Using a logrolling technique to turn the client maintains spinal alignment postoperatively and prevents complications of immobility. Since this is a painful surgery, the nurse should maintain pain control as prescribed. The pain associated is not just due to the incisions of surgery, but also to the manipulation and placement of the spinal hardware and muscular pain as the involved muscles adjust to the corrective realignment of the spine. Following corrective surgery for scoliosis, a client should be immobilized without spinal flexion for 24 to 48 hours, and then ambulated by the physical therapist.

The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement? A. Reassure the parents that 3-year-olds are cooperative and therefore are less likely to be anxious. B. Obtain a video film of a cardiac catheterization to show to the child prior to the procedure. C. Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there. D. Obtain a cardiac catheter and demonstrate the procedure by pretending to put the catheter in a doll or stuffed animal.

C. Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.

The nurse is assessing a child for neurological soft signs. Which finding is most likely demonstrated in the child's behavior? A. Presence of vertigo. B. Loss of visual acuity. C. Poor coordination and sense of position. D. Inability to move the tongue in all directions.

C. Poor coordination and sense of position. Rationale There is a gray area in neurological assessment known as soft signs, which are findings that are a mild or slight abnormality that is difficult to detect or interpret. Poor coordination and sense of position are classic signs that are consistent with the failure to perform age-specific tasks and represent the persistence of a more primitive neurological response.

During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? A. Start another IV of dextrose solution and stay with the child. B. Continue the transfusion and monitor the child's vital signs. C. Stop the infusion immediately and notify the healthcare provider. D. Slow the transfusion and assess for cessation of symptoms.

C. Stop the infusion immediately and notify the healthcare provider. Rationale The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A. Remove all blackheads and follow with an alcohol scrub. B. Use medicated cosmetics only to help hide the blemishes. C. Wash the hair and skin frequently with soap and hot water. D. Encourage her to see a dermatologist as soon as possible.

C. Wash the hair and skin frequently with soap and hot water. Rationale Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne.

The nurse is collecting a blood sample from a newborn for a phenylketonuria (PKU) screening test. When should the nurse obtain the blood sample? A. At birth from cord blood. B. Fourteen days after birth. C. Before oral feedings are initiated. D. After ingestion of a source of protein.

D. After ingestion of a source of protein. Rationale PKU is a genetic disease caused by the absence of the enzyme needed to metabolize the essential amino acid phenylalanine. The Guthrie blood test is used for early detection of this condition in order to prevent mental retardation as a result of this disease. The blood sample should be collected between 1 to 7 days after birth, with fresh heel blood only, and no sooner than 24 hours after the infant has ingested a source of protein (breast milk or infant formula).

A 4-year-old is brought to the emergency department with a laceration on the right foot. Which action should the nurse implement to help the child cope with the emergency department experience? A. Avoid the use of bandages to keep wounds open to air. B. Remind the preschooler how big children should act. C. Give the child some time after explaining procedures. D. Avoid using jargon, such as "shot," when giving care.

D. Avoid using jargon, such as "shot," when giving care.

What is the best action for the nurse to take when initiating contact with a toddler for the first time? A. Ask the toddler to point to where it hurts. B. Tell the child your name and that you are the nurse. C. Call the child by name while picking up the toddler. D. Kneel in front of the toddler and speak softly.

D. Kneel in front of the toddler and speak softly.

The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son's prognosis. Which factor should the nurse include when answering the parent's concern? A. Age of onset. B. Gender of child. C. Appearance on x-ray. D. Degree of metastasis.

Degree of metastasis Rationale Ewing sarcoma is the second most common malignant bone tumor of children. Prognosis is most significantly related to the degree of metastasis during the early course of the disease.