Nursing Care of Children 1
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly. B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area. - The adhesive on the collection device will not stick to the infant's skin if it is moistened with lubricant. Oil and powder should not be used. C. Avoid placing the scrotum inside the collection bag. - It is acceptable for the nurse to place the infant's penis and scrotum inside the collection bag in order to ensure a snug fit and prevent leaking. D. Wait several hours after positioning the device before checking it. - The urine collector should be checked frequently and removed when urine is obtained. If the infant is active, the adhesive might loosen.
A. Wash and dry the infant's genitalia and perineum thoroughly. This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device.
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing.- The nurse should remove the child's contaminated clothing to prevent further exposure to the substance; however, a different action is the priority. B. Check the child's respiratory status. C. Administer an antidote to the child. - The nurse may administer an antidote if one is available for the substance ingested; however, a different action is the priority. D. Establish IV access for the child. - The nurse should establish IV access because shock is a complication of some poisons; however, a different action is the priority.
B. Check the child's respiratory status. The nurse should apply the ABC priority-setting framework when answering this item. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The nurse observes that the child's lips are edematous and inflamed and that he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway.
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide- The pneumococcal polysaccharide immunization is administered to children between the ages of 2 and 18 years who have a specific high-risk condition that places them at risk for an infection with Streptococcus pneumococci, a bacterium that causes meningitis, otitis media, and pneumonia in clients who have chronic illnesses. B. Meningococcal polysaccharide C. Rotavirus- The final dose of the rotavirus immunization is administered prior to the age of 8 months. An additional booster dose is not recommended. D. Herpes zoster- The herpes zoster immunization is recommended for adults over the age of 60 to prevent an episode of shingles.
B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile - A brightly colored mobile is appropriate for a young infant. It does not meet the activity needs of a preschool-age child. B. Plastic stethoscope C. Small piece jigsaw puzzle - A small piece jigsaw puzzle is too difficult for most preschool-age children and can frustrate them rather than entertain them. D. A book of short stories - A 4-year-old child is not able to read independently. The nurse should provide the child with a picture book instead.
B. Plastic stethoscope Preschool play centers on imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." - The absence of oral or pharyngeal burns does not eliminate the possibility of esophageal burns. The existence and extent of burns depend on the substance and the length of time it has been in contact with tissues. It is possible to have a burn in the esophagus without the existence of a burn in the mouth. B. "Treatment focuses on neutralization of the chemical." - Neutralization can result in heat injury to tissues due to an exothermic reaction. This might result in both chemical and thermal burns of tissues. C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted." - Activated charcoal is not administered to an adolescent who has ingested a corrosive substance, because it can infiltrate any tissue that is burned.
C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury.
A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A - The HPV immunization series is started at the age of 11 years, and the hepatitis A immunization series is started at the age of 12 months. B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) - The first dose of the MMR immunization is administered at 12 to 15 months of age, and the TDaP immunization is administered at 11 to 12 years of age. C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV) - Varicella is not administered to children younger than 12 months, and the LAIV immunization is not administered to children under 2 years of age.
C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The IPV immunization series consists of 4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? A. Grabs feet and pulls them to her mouth - Infants are able to grab feet and pull them to their mouth at the age of 6 months of age. At this age, the infant should also be able to pick up a dropped object and hold her own bottle. B. Posterior fontanel is closed - This is an expected finding in a 6-month old infant. The posterior fontanel closes at approximately 2 months of age. The anterior fontanel is closed by 18 months of age. C. Legs remain crossed and extended when supine D. Birth weight has doubled - Infants should double their birth weight by 6 months and triple their birth weight by 12 months.
C. Legs remain crossed and extended when supine Legs crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the legs flex at the knees when the infant is supine. Crossed and extended legs when supine is a finding associated with cerebral palsy.
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeps on hands and knees- The infant should creep on her hands and knees at the age of 9 months, and begin to stand while holding onto furniture at the age of 10 months. B. Inability to vocalize vowel sounds C. Uses crude pincer grasp- Most infants demonstrate a crude pincer grasp at 9 months of age and the use of a dominant hand is also evident. D. Stands by holding onto support - The ability to stand holding onto support is typically present at 10 months of age.
B. Inability to vocalize vowel sounds The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word.
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head to toe sequence. - It is recommended to start with the least invasive interventions and proceed to the more invasive. The head to toe approach is recommended for preschool-age and older children. B. Minimize physical contact with the child initially. C. Explain procedures using medical terminology. - The nurse should describe procedures using age-appropriate language the child can understand. D. Stop the assessment if the child becomes uncooperative. - If the child becomes uncooperative, the nurse should perform the procedures more quickly.
B. Minimize physical contact with the child initially. The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold his breath and then blow it out slowly.- This is an example of a distraction strategy. B. Ask the child to describe a pleasurable event. - This is an example of guided imagery. C. Bounce the child gently while holding him upright. - Evidence-based practice indicates that bouncing is not an appropriate action. D. Rock the child in long rhythmic movements.
D. Rock the child in long rhythmic movements. The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements.
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ________ gtt
25 gtt
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min - A respiratory rate of 26/min is within the expected reference range for a 12-month-old infant. C. Blood pressure 88/40 mm Hg - A blood pressure of 88/40 mm Hg is within the expected reference range for a 12-month-old infant. D. Temperature 37.6° C (99.7° F) - A temperature of 37.6° C (99.7° F) is within the expected reference range for a 12-month-old infant.
A. Heart rate 175/min A heart rate of 175/min is above the expected reference range for a 12-month-old infant; therefore, the nurse should report this finding to the provider.
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I lock my medications in the medicine cabinet." B. "I keep my child's crib mattress at the highest level." - The parent should keep the child's crib mattress at the lowest level to prevent the child from climbing or falling from the crib. C. "I turn pot handles to the side of my stove while cooking." - The parent should turn pot handles to the back of the stove while cooking to prevent the toddler from pulling the hot pans off and receiving burns. D. "I will give my child syrup of ipecac if she swallows something poisonous." - Syrup of ipecac is not recommended for the treatment of poisoning in the home. Caustic substances can cause more damage when vomiting is induced.
A. "I lock my medications in the medicine cabinet." Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow for further exploration of the environment and possible access to hazardous substances.
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? A. Follow a nightly routine and established bedtime. B. Encourage active play prior to bedtime. - Active play at bedtime is likely to promote the preschool-age child's resistance to sleep rather than to promote fatigue. C. Let the child remain awake until tired enough to go to sleep. - This approach is likely to result in an overtired child who is awake and unpleasant. Children taught to maintain a bedtime routine at an early age will make the evening more pleasant for everyone, including themselves, and avoid sleep disturbances. D. Reward the child with a food treat just prior to sleep if the child goes to bed on time. - Part of a preschool-age child's bedtime routine should be nightly oral care. Following this with a food treat is inappropriate.
A. Follow a nightly routine and established bedtime. Preschool-age children test limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents. - Pain is a subjective experience even for a 3-year-old child. Asking the parents is not appropriate as pain is considered a personal experience. B. Use the FACES scale. C. Use the numeric rating scale. - The numeric rating scale is appropriate for children who are 5 years of age or older. D. Check the child's temperature. - The child's temperature is not an indicator of pain. While changes in heart rate, BP, and respiratory rate can be indicators of pain, these are not reliable, because pain is a subjective manifestation.
B. Use the FACES scale. Pain is a subjective experience even for a 3-year-old child. The FACES scale can be used to accurately determine the presence of pain in children as young as 3 years of age.
A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "I am not going to let my child play with other children for 2 days." - The child is not contagious to others after receiving the MMR immunization. B. "I will need to return in 2 weeks for my child to receive the varicella immunization." - MMR and varicella immunizations are either administered during the same visit, or at least 1 month apart. C. "I can give my child acetaminophen for discomfort associated with the immunization." D. "My child might have some discharge from the injection site." - There might be swelling and erythema at the injection site; however, drainage should not occur, because the injection is intramuscular.
C. "I can give my child acetaminophen for discomfort associated with the immunization." Parents can give acetaminophen for minor discomforts such as low-grade fever and local tenderness resulting from the administration of the immunization.
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4 ounces of juice to drink each day." - It is recommended to not exceed 4 to 6 oz of juice in children between the ages of 1 and 6 years. It is not recommended to give juice to infants less than 4 to 6 months of age. B. "I will offer my baby dry cereal and chilled banana slices as snacks." - At 12 months of age, infants should be offered finger foods. Finger foods stimulate the pincer grasp, which helps with fine motor development. Cereal is small, but it dissolves with infants' saliva and would not cause an airway obstruction. Chilled banana slices are an appropriate food choice and help with teething. C. "I am introducing my baby to the same foods the family eats." - Introducing infants to foods prepared for the rest of the family is appropriate and helps them feel included. Home-cooked foods also provide infants with the nutrients they need. At 12 months of age, infants are able to eat soft table foods such as mashed potatoes, green beans, bread, and finely chopped meats. D. "My infant drinks at least 2 quarts of skim milk each day."
D. "My infant drinks at least 2 quarts of skim milk each day." As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids which are needed for growth and development.
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying - The side-lying position may be used during a lumbar puncture. B. Semi-recumbent - A semi-recumbent position is used when performing a gavage feeding. The client's head and chest should be elevated. C. Flexed sitting - The flexed sitting position may be used during a lumbar puncture. D. Supine
D. Supine The client is placed in the supine position, with the client's legs in a frog position.
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. "The PICC line will last several weeks with proper care." B. "The public health nurse will rotate the insertion site every 3 days."- The PICC line is meant to remain in place for the duration of therapy. This is its main advantage over the traditional IV, and why it is the preferred venous access device for moderate term IV therapy, such as the extended antibiotic therapy required for bacterial endocarditis. C. "You will need to make certain the arm board is in place at all times." - The catheters designed for use as PICC lines are highly flexible, so it is not necessary to immobilize the client's arm or limit movement. D. "Your child will go to the operating room to have the line placed." - PICC lines are inserted using a local anesthetic by trained personnel.
A. "The PICC line will last several weeks with proper care." PICC lines are the preferred venous access device for short to moderate term IV therapy. They can remain in place for long periods with proper care.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation? A. The child prefers playmates of the same sex. - Male and female children who are 7 years old prefer to play with peers who are the same gender. B. The child is competitive when playing board games. - School-age children enjoy engaging in various types of competitive games and are learning about the concept of winning. C. The child complains daily about going to school. D. The child enjoys spending time alone. - A 7-year-old child doesn't require the same amount of companionship as older school-age children; therefore, the fact that this child enjoys spending time alone is an expected finding.
C. The child complains daily about going to school. Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children in this stage want to learn and master new concepts. If the child complains daily about going to school, it warrants further evaluation.
A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine - DTaP is used to provide immunity against diphtheria, tetanus, and pertussis in infants and children under the age of 7 years. DTaP is not recommended for wound prophylaxis. B. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) - TIG and DT may be given concurrently for wound prophylaxis, but the nurse should administer these separately using different muscles. DT is given as wound prophylaxis to children under the age of 7 years. C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine - Tdap is given to adults/adolescents who have completed the initial DTaP immunization series, but have not yet received an adult tetanus booster (Td). The minimum age for Tdap is 10 years; however, children between the ages of 7 and 10 years who have not received all recommended doses of DTap should be given a dose of Tdap. Tdap is not recommended for wound prophylaxis. D. Adult tetanus booster (Td)
D. Adult tetanus booster (Td) Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age.
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication. - A PCA device allows the adolescent to be in charge of pain management and is an effective method to control pain. It is inappropriate for the nurse to suggest discontinuing the PCA. B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain. - One of the principles of PCA is that no one other than the client or nurse pushes the button to deliver the medication. An adolescent is capable of maintaining effective pain control using a PCA. C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10.- Moderate (5 to 6) or severe pain (7 to 10) requires the use of opioids for effective pain management. A PCA delivers an appropriate amount of opioid to treat moderate pain and the client should be encouraged to push the PCA button to deliver medication at this time. D. Reinforce teaching with the client about how to push the button to deliver the medication.
D. Reinforce teaching with the client about how to push the button to deliver the medication. The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively.
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination - Playing peek-a-boo does not further refine the infant's fine-motor skills unless the infant is using his hands to locate the hidden object himself. Hand-eye coordination is necessary for fine motor skills. B. Sense of trust - Playing peek-a-boo does not serve to establish a sense of trust. Trust is developed by the consistent care given in the first year of life. C. Object permanence D. Egocentrism - Egocentrism refers to the fact that infants are self-centered and cannot see things from a point of view other than their own. An 8-month-old infant is considered egocentric.
C. Object permanence Object permanence refers to the cognitive skill of knowing an object still exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take? A. Have the toddler wear a disposable gown when in the unit's playroom. - A toddler who requires droplet precautions should not play in common areas, due to the risk of transmitting the infection. The toddler should wear a surgical mask when being transported through public areas. B. Wear sterile gloves when changing the toddler's diapers. - Clean gloves are worn to prevent contact with contaminated body fluids. Urine or stool in the diaper does not carry pathogens that are spread via droplets. C. Wear a mask when assisting the toddler with meals. D. Ask visitors to wear an N-95 mask when entering the room. - An N-95 mask is worn when caring for a client who requires airborne precautions.
C. Wear a mask when assisting the toddler with meals. The nurse should wear a mask when within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large droplet particles expelled in the air.
A nurse is teaching a parent of a 12-month old child about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." - A toddler's use of the appropriate pronoun when referring to self does not occur until 30 months of age. B. "A toddler's interest in looking at pictures occurs at 20 months of age." - A toddler develops an intense focus and interest in pictures at 15 months of age. C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." - Most toddlers have bowel and bladder control during the daytime by 30 months of age. The nurse should teach the parent not to expect the toddler to accomplish this task by the age of 24 months. D. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
D. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months." The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively.
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper- Most 2-year-old children do not have the coordination abilities to cut with scissors. This activity is appropriate for a 3-year-old child. B. Drawing stick figures using crayons - The ability to draw stick figures is an appropriate activity for a 4-year-old child. The 2-year-old child will draw vertical lines and make circular strokes. C. Riding a tricycle - Riding a tricycle is an appropriate activity for a 3-year-old child. Most 2-year-old children do not have the strength or the gross motor ability to ride a tricycle. D. Building towers of blocks
D. Building towers of blocks Building towers of blocks is an appropriate activity for a 2-year-old child. It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization.
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height - The head circumference of a school-age child decreases when compared to full height due to skeletal lengthening. C. Increased leg length related to height - Body proportion varies with a slimmer appearance and longer legs in the school-age child. Leg length increases and waist circumference decreases when related to height in this age group. D. Presence of a loose, central incisor - The deciduous teeth are being shed at this age, starting with the lower central incisors at approximately the age of 6.
A. Presence of sparse, fine pubic hair The development of sexual characteristics prior to the age of 9 years in boys, and 8 years in girls, is an indication of precocious puberty and requires further evaluation.
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. - A stationary infant walker is recommended. Wheeled infant walkers can quickly move across uneven surfaces and result in injury. B. Place soft pillows around the edge of the infant's crib. - Soft pillows and cushions should not be used in cribs due to the increased risk of suffocation. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F).
C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F) Infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines As the infant begins to crawl and becomes more mobile, the risk of falls increases. To prevent a burn injury, the temperature of the water heater should not exceed 49° C (120° F).
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero. - Vitamin C does not influence absorption or excretion of lead, and intake does not need to be reduced for a child who has a blood lead level of 3 mcg/dL. Over time, this can result in a vitamin C deficiency. B. Administer a folic acid supplement to the child each day. - A 3-year-old child does not need a folic acid supplement. This will not influence absorption or excretion of lead. C. Give pancreatic enzymes to the child with meals and snacks. - Pancreatic enzymes are administered to children who have cystic fibrosis, not an elevated blood lead level. D. Ensure the child's dietary intake of calcium and iron is adequate.
D. Ensure the child's dietary intake of calcium and iron is adequate. A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child. - Children who experience a loss of vision should be encouraged to participate in self-care activities, such as feeding, as much as possible. Items on the meal tray should be organized and the child oriented to their location. Finger foods should be offered. B. Explain sounds the child is hearing. C. Have the child use a cane when ambulating. - Children who have a temporary vision loss are not accustomed to using a cane. A child who has permanent vision loss can use a cane for ambulation and activities during hospitalization. D. Rotate nurses caring for the child. - Providing consistency in the child's environment promotes safety and security for the child. The same nurse offers comfort and reassurance to the child, and promotes increasing independence by building upon the child's skills and abilities during hospitalization.
B. Explain sounds the child is hearing. The noises in a facility can be frightening to a child who is experiencing a sensory loss. It is important to explain these noises to allay the child's fears.
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Head lags when pulled from a lying to a sitting position B. Absence of startle and crawl reflexes - The startle reflex disappears by the age of 4 months, and the crawl reflex disappears around the age of 6 weeks. C. Inability to pick up a rattle after dropping it - At the age of 5 months, the infant can visually follow a dropped object, but the infant is unable to pick the object up until around the age of 6 months. D. Rolls from back to side - The infant should be able to roll from her back to her side at the age of 4 months.
A. Head lags when pulled from a lying to a sitting position At the age of 5 months, the infant should have no head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.
A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 - Children between the ages of 6 months and 5 years are more vulnerable to the stress of hospitalization than a 10-year-old child. B. First hospitalization- Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization. C. Male gender D. Calm, quiet demeanor - Children who demonstrate irritable and difficult temperaments are at increased risk for stress-related reactions to hospitalization.
C. Male gender Male clients are at increased risk for hospitalization-related stress compared to female clients.
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children? A. Cow's milk B. Wheat bread - The nurse should instruct the parent that some children have an allergy or sensitivity to wheat; however, evidence-based practice indicates that another food allergy is more common. C. Corn syrup - The nurse should instruct the parent that some children have an allergy or sensitivity to corn syrup, especially among children who have eczema; however, evidence-based practice indicates that another food allergy is more common. D. Eggs - The nurse should instruct the parent that some children have an allergy to eggs because they contain albumin, which is a protein that some clients are unable to metabolize; however, evidence-based practice indicates that another food allergy is more common.
A. Cow's milk According to evidence-based practice, the nurse should instruct the parent that cow's milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow's milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow's milk.
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? A. Stepping - The stepping reflex, in which the infant takes reflexive steps when placed on his or her feet in an upright position, disappears by the age of 4 weeks. B. Babinski C. Extrusion - The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months. D. Moro - The Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.
B. Baninski The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine. - Administering the medication to the infant while she is supine can cause the infant to choke and aspirate. B. Give the medication at the side of the infant's mouth. C. Add the medication to a full bottle of the infant's formula. - Medication should never be mixed into an infant's regular formula to be given through a bottle. Using this method makes it difficult to ensure that all the medication has been administered and might cause an infant not to take the bottle or formula in the future if the infant associates it with an unpleasant taste or activity. D. Administer the medication slowly while holding the nares closed. - An infant's nasal passages should never be blocked to assure that oral medications are swallowed. Young infants are obligatory nose breathers and holding the nares closed can increase an infant's distress. This method of administration increases the risk of aspiration.
B. Give the medication at the side of the infant's mouth. When administering medications to an infant, a needleless oral syringe or medicine dropper is placed in the side of the mouth (buccal cavity alongside the tongue) to prevent gagging and aspiration.
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete - This is an expected finding in a 30-month-old toddler. At this age, the toddler should have all 20 deciduous teeth. B. Unable to hop on one foot - The skill of hopping on one foot is not developed until around the age of 4 years. C. Birth weight is tripled D. Able to state first and last name - This is an expected finding in a toddler at the age of 30 months. At this age the toddler should be able to state his first and last name.
C. Birth weight is tripled The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? A. Copies a circle B. Cuts foods using a table knife - The nurse should explain that cutting food using a table knife is a fine-motor skill expected of 7-year-old children. C. Begins writing in cursive - Initial use of cursive writing is an expected skill for an 8- to 9-year-old child. D. Prints first and last name clearly - The nurse should explain that children will print their first name around the age of 5 years.
A. Copies a circle The nurse should explain that copying a circle is a skill achieved by the age of 4 years.
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk.- The nurse should instruct the parents that it might be recommended to give the toddler milk to drink, but this will depend on the poison that is ingested. Evidence-based practice indicates that the nurse should take a different action first. B. Go to an emergency department. - The nurse should instruct the parents that it might be recommended that they take the toddler to the emergency department, but this will depend on the poison and amount that is ingested. Evidence-based practice indicates that the nurse should take a different action first. C. Call the poison control center. D. Induce vomiting. - The nurse should instruct the parents that it might be recommended to induce vomiting, but this will depend on the poison that is ingested. Evidence-based practice indicates that the nurse should take a different action first. For many poisons, such as corrosives, inducing vomiting is an inappropriate action because it can cause additional harm by causing burns.
C. Call the poison control center. According to evidence-based practice, the nurse should instruct the parents to first call the poison control center, which will then identify what further actions the parents should take.
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. C. Follow the child's cues as to when food and fluids are provided. - A consistent structured routine of feeding the child at the same time and place is used to promote weight gain. A child who has failure to thrive might not offer feeding cues. D. Sit beside the child's high chair when feeding the child. - Caregivers should sit directly in front of the child to maintain a face-to-face position during feeding and promote eye contact. The emphasis is on encouraging feeding. E. Play music videos during scheduled meal times. - A quiet, stimulation-free environment should be provided at meal times to avoid distractions and focus attention on food intake.
A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to his body after death. - A school-age child is interested in post-death services and what happens to the body after death due to an improved ability to comprehend what is happening. C. The child recognizes that death is permanent. - Preschool-age children have difficulty understanding the concept of time and are therefore not likely to believe that death is permanent. They perceive death as reversible. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.
A. The child views death as similar to sleep. -Preschool-age children might make this comparison. D. The child believes his thoughts can cause death. - Preschool-age children believe that their thoughts and wishes can make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age. E. The child thinks death is a punishment. - Preschool-age children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought.
