PED #3 (Chp 44, 51, 52, 53, 56)

10) The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child? 1. 0.9% normal saline (NS) 2. D5 0.2% (¼) normal saline 3. D5W 4. Albumin

1 Explanation: 1. 0.9% normal saline (NS) is an isotonic fluid and maintains Na and chloride at present levels. 2. D5 0.2% (¼) normal saline would not be used initially but later, as maintenance fluids. 3. D5W can lower sodium levels, and so it would not be used to replace fluids in severe isotonic dehydration. 4. Albumin is used to restore plasma proteins.

7) A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a licensed vocational nurse (LVN), cautions the LVN to immediately report which clinical manifestation? 1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia

1 Explanation: 1. A child with hyponatremia is at risk for seizures. 2. Respiratory distress is not a risk of hyponatremia. 3. Hyperthermia is not a risk of hyponatremia. 4. Bradycardia is not a risk of hyponatremia.

5) In the morning, a nurse receives change-of-shift report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the nurse see first? 1. The child with tachypnea and pulmonary congestion 2. The child with hepatomegaly and normal respiratory rate 3. The child with dependent and sacral edema and regular pulse 4. The child with periorbital edema and normal respiratory rate

1 Explanation: 1. A child with respiratory distress should be the first client the nurse checks after receiving a report. 2. The child with hepatomegaly and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion. 3. The child with dependent and sacral edema and regular pulse is more stable than the child with tachypnea and pulmonary congestion. 4. The child with periorbital edema and normal respiratory rate is more stable than the child with tachypnea and pulmonary congestion.

2) Which nursing diagnosis should the nurse include in the plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV)? 1. Activity Intolerance 2. Ineffective Peripheral Tissue Perfusion 3. Acute Pain 4. Decreased Cardiac Output

1 Explanation: 1. Activity Intolerance is a problem because of the imbalance between oxygen supply and demand. 2. Tissue perfusion (peripheral) is not affected by this respiratory disease process. 3. Acute Pain is not usually associated with acute bronchiolitis. 4. Cardiac Output is not compromised during an acute phase of bronchiolitis.

12) A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give? 1. Furosemide (Lasix) 2. Hydrochlorothiazide (Aquazide) 3. Spironolactone (Aldactone) 4. Mannitol (Osmitrol)

1 Explanation: 1. Furosemide (Lasix) is the diuretic used to aid in excretion of calcium. 2. Thiazide diuretics (like hydrochlorothiazide) decrease calcium excretion and should not be given to the hypercalcemic client. 3. Spironolactone (Aldactone) is a potassium-sparing diuretic. While there is a net increase in calcium in the urine, it is not as effective an option as furosemide. 4. Mannitol (Osmitrol) is a diuretic used to decrease cerebral edema and is not routinely used to aid in excretion of calcium.

16) Which is the priority nursing action when preparing a neonate born with a gastroschisis defect for transport to a pediatric hospital for corrective surgery? 1. Covering the exposed intestines with sterile moist gauze 2. Wrapping the newborn warmly in two or three blankets 3. Providing a sterile water feeding to maintain hydration during transport 4. Allowing the parents of the newborn to see their child prior to transport

1 Explanation: 1. It is important to keep the intestine from drying during transport. 2. Placement in a transport isolette would be preferred to wrapping due to the nature of the birth defect. 3. The newborn should be NPO. 4. While it is important for the parents to see their child before transport, this is not the priority nursing intervention.

6) A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate based on the current data? 1. Placing the newborn on a radiant warmer 2. Placing the newborn in an open crib 3. Preparing the newborn for phototherapy 4. Preparing the newborn for a bottlefeeding

1 Explanation: 1. Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The newborn loses heat through the viscera; a warmer is indicated to prevent hypothermia. 2. The crib would not provide adequate maintenance of temperature control. 3. Phototherapy is used to treat hyperbilirubinemia, not an omphalocele defect. 4. The newborn will require surgical correction of the defect prior to initiating bottle or breast feeding.

11) A 6-year-old child is hypokalemic. Which menu choice should the nurse encourage for this child? 1. Pizza with a fruit plate 2. Chicken strips with chips 3. Fajita with rice 4. A hamburger with French fries

1 Explanation: 1. Pizza with a fruit plate should be encouraged because fruits (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination. 2. Chicken strips and chips are not good sources of potassium. 3. The nurse is looking for potassium-rich foods that are attractive to children. This choice does not meet the requirement. 4. A hamburger and French fries do not provide potassium.

10) A child returns from exploratory surgery following a gunshot wound to the abdomen. Which nursing intervention should be excluded for the plan of care? 1. Immediate initiation of oral feedings 2. Assessment of the surgical site 3. Administration of opioid narcotics for pain management 4. Visitation at the bedside

1 Explanation: 1. The child will be NPO after an exploratory abdominal surgery. The nurse should exclude this from the child's plan of care. 2. The surgical site must be visualized frequently for bleeding. 3. Pain management is essential and opioid analgesics are often necessary after exploratory surgery. 4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.

6) The nurse is caring for a child on bed rest who has severe edema in a left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority? 1. Risk for Impaired Skin Integrity 2. Risk for Altered Body Image 3. Risk for Imbalanced Nutrition: Less Than Body Requirements 4. Risk for Activity Intolerance

1 Explanation: 1. The highest priority problem is skin integrity. 2. Body image would not take priority over the integrity of the skin for this scenario. 3. Nutrition would not take priority over the integrity of the skin for this scenario. 4. Activity intolerance would not take priority over the integrity of the skin for this scenario.

13) Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event)? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation.

1 Explanation: 1. This is appropriate monitoring of the infant. 2. Oxygen is a dependent order except under emergency situations. There is no evidence the child needs oxygen. 3. Laboratory tests are not an independent action. 4. There is no indication of a respiratory infection. At this time, contact isolation is not indicated.

12) The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate? 1. Position the newborn in semi-Fowler position. 2. Allow the newborn to be taken to the mother's room for bonding. 3. Offer the newborn formula feeding instead of breastfeeding. 4. Wrap the newborn in blankets and place in a crib by the viewing window.

1 Explanation: 1. This will reduce stomach juices from being aspirated into the lungs. 2. Because an anomaly is suspected, the newborn should remain under visualization until the diagnosis is confirmed and medical orders determined. 3. If an EA/TE fistula is suspected, the feeding should be withheld until the diagnosis is confirmed or cleared. 4. A newborn wrapped in blankets cannot be observed clearly. The child should be placed in an over-bed warmer.

3) A toddler-age client presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided based on the current assessment data? 1. Throat culture 2. Medical history 3. Vital signs 4. Auscultation of breath sounds

1 Explanation: 1. Throat cultures should never be done when a diagnosis of epiglottis is suspected. Manipulation of the throat can stimulate the gag reflex in an already inflamed airway and can cause complete occlusion of the airway. 2. Medical history should be obtained, which assists in diagnosis. 3. Vital signs should always be taken when assessment is done. 4. Assessment of breath sounds is essential for diagnosis.

21) The nurse is assessing a pediatric client who is experiencing metabolic acidosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

1, 2, 3 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

21) Which are the leading causes of pediatric abdominal injuries for which the nurse should provide client teaching during scheduled health maintenance visits? Select all that apply. 1. Motor vehicle crashes 2. Falls 3. Blunt trauma 4. Stabbing 5. Impalement

1, 2, 3 Explanation: 1. Motor vehicle crashes are a leading cause of pediatric abdominal injuries. The nurse should provide education related to proper use of seat belts during health maintenance visits to decrease the incidence of abdominal injuries. 2. Falls are a leading cause of pediatric abdominal injuries. The nurse should include education regarding age-appropriate pediatric fall prevention during health maintenance visits. 3. Blunt trauma is a leading cause of pediatric abdominal injuries. The nurse should include prevention strategies during health maintenance visits. 4. While stabbing can cause abdominal injury, this is not a common cause in the pediatric population. 5. While impalement can cause abdominal injury, this is not a common cause in the pediatric population.

18) Which should the nurse assess to determine oxygenation during the respiratory assessment for a pediatric client? Select all that apply. 1. Mucous membranes 2. Nail beds 3. Skin 4. Sclerae 5. Corneas

1, 2, 3 Explanation: 1. The nurse assesses the mucous membranes to determine oxygenation during the respiratory assessment for a pediatric client. 2. The nurse assesses the nail beds to determine oxygenation during the respiratory assessment for a pediatric client. 3. The nurse assesses the skin to determine oxygenation during the respiratory assessment for a pediatric client. 4. The sclerae are not assessed to determine oxygenation during the respiratory assessment for a pediatric client. 5. The corneas are not assessed to determine oxygenation during the respiratory assessment for a pediatric client.

23) Which factors in the maternal medical history should cause the nurse concern regarding the development of cleft lip or cleft palate during pregnancy? Select all that apply. 1. Cigarette smoking 2. Alcohol use 3. Excessive folate intake 4. Glucocorticoid use 5. Anticoagulant use

1, 2, 4 Explanation: 1. Cigarette smoking during pregnancy is a risk factor for cleft lip and cleft palate. 2. Alcohol use during pregnancy is a risk factor for cleft lip and cleft palate. 3. Excessive folate intake is not a risk factor for cleft lip and cleft palate. A folate deficiency is often the cause for these disorders. 4. Glucocorticoid use is a risk factor for cleft lip and cleft palate. 5. Anticoagulant use is not a risk factor for cleft lip and cleft palate.

3) An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data? 1. Necrotizing enterocolitis (NEC) 2. Ulcerative colitis (UC) 3. Crohn disease 4. Appendicitis

2 Explanation: 1. NEC is usually seen in premature infants and generally not in an adolescent client. 2. Diarrhea and bloody stools are typical symptoms of UC. 3. The teen with Crohn disease might have abdominal pain and diarrhea, but stools usually do not have blood in them. 4. Appendicitis is not associated with bloody stools and usually not with diarrhea.

6) The nurse receives a phone call from the parent of a child who is prescribed rifampin (Rimactane) for treatment of tuberculosis because she saw that the child's urine was orange. Which response by the nurse is accurate? 1. "Encourage your child to drink cranberry juice." 2. "An orange discoloration of urine is expected while your child is on this medication." 3. "Bring your child to the clinic for a urinalysis." 4. "Bring your child to the clinic for a radiograph of the kidneys."

2 Explanation: 1. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 2. Rifampin can color the urine orange, so the parents and child should be taught that this is an expected side effect. 3. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options. 4. Orange urine does not mean the child has a urinary tract infection, and a urinalysis, radiograph, and encouragement of cranberry juice would not be options.

4) Which nursing action is appropriate for the parents of a 4-month-old infant who died due to sudden infant death syndrome (SIDS)? 1. Sheltering parents from the grief by not giving them any personal items of the infant, such as footprints 2. Allowing parents to hold, touch, and rock the infant 3. Advising parents that an autopsy is not necessary 4. Interviewing parents to determine the cause of the incident

2 Explanation: 1. Parents will want any personal items available. 2. The parents should be allowed to hold, touch, and rock the infant, giving them a chance to say good-bye to their baby. 3. The death of an infant without a known medical condition is an indication for an autopsy. 4. The parents need to know that SIDS is not their fault.

1) The mother of a toddler-age client states, "My daughter seems to be at an increased risk for complications associated with respiratory infections." Which response by the nurse is accurate? 1. "You are incorrect in your assessment." 2. "The younger child's airways are smaller and more easily occluded." 3. "Air passages are more likely to become blocked with mucus because younger children make more mucus than older children." 4. "Toddlers do not breathe as deeply as do older children." - Ch 46: Alteration in Respiratory Function - - Start -

2 Explanation: 1. The mother is correct in her statement. 2. Airways are smaller in the younger child and are more easily occluded when mucus is produced. 3. Blockage of air passages with mucus is not related to the age of the child but more to the etiology of mucus production and the continuation of the causative agent. 4. Depth of breathing is not age dependent.

12) Which nursing action is appropriate when providing care to a newborn with a respiratory rate of 102 breaths per minute with lungs that are clear to auscultation? 1. Administering the bath to the neonate in the nursery 2. Transferring to the neonatal intensive care unit for further observation 3. Allowing the neonate to room-in to promote bonding 4. Providing the first feeding in the nursery

2 Explanation: 1. The newborn is tachypneic. Bathing will only add to the respiratory distress and should be avoided. 2. This newborn needs to remain under constant observation due to the respiratory rate. 3. The newborn needs to be monitored. 4. With a respiratory rate this high, aspiration is likely so feeding should be avoided.

13) A nasogastric tube to suction is ordered for a neonate diagnosed with a diaphragmatic hernia. Which complication related to gastric drainage is the priority when planning care for this neonate? 1. Weight loss 2. Metabolic alkalosis 3. Dehydration 4. Hyperbilirubinemia

2 Explanation: 1. Weight loss and inadequate nutrition are not the priority for this client. 2. When large quantities of gastric juice is removed, acid is lost and metabolic alkalosis follows. 3. The volume would not be sufficient to cause dehydration. 4. Hyperbilirubinemia is unrelated to gastric suction.

20) Which pediatric clients would require a nursing assessment for blunt chest trauma? Select all that apply. 1. A preschool-age client who is admitted after a house fire. 2. A toddler-age client who is admitted for injuries sustained in a motor vehicle accident. 3. A school-age client who is admitted for observation after a skateboarding accident. 4. An adolescent client admitted for an asthma exacerbation. 5. An infant admitted to rule out cystic fibrosis.

2, 3 Explanation: 1. A preschool-age client admitted after a house fire would require assessment for smoke-inhalation injury not blunt chest trauma. 2. A toddler-age client admitted for injuries sustained in a motor vehicle accident would require assessment to determine blunt chest trauma. 3. A school-age client admitted for observation after a skateboarding accident would require assessment to determine blunt chest trauma. 4. An asthma exacerbation would not necessitate a nursing assessment for blunt chest trauma. 5. An infant admitted to rule out cystic fibrosis would not necessitate a nursing assessment for blunt chest trauma.

9) Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis? 1. "I will administer this medication 4 times each day." 2. "I will administer this medication twice each day." 3. "I will administer this medication with meals and snacks." 4. "I will administer this medication every 6 hours around the clock."

3 Explanation: 1. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 2. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients. 3. Pancreatic enzymes are administered with meals and large snacks. 4. A scheduled time would not be appropriate because the enzymes are used to assist in digestion of nutrients.

2) Which assessment data would cause the nurse to suspect that a 3-year-old child has Hirschsprung disease? 1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period 3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea

3 Explanation: 1. Clay-colored stools and dark urine are not associated with Hirschsprung disease. 2. The infant with Hirschsprung disease often has delayed meconium stools. 3. These are symptoms of Hirschsprung disease in an older infant or child. 4. Diarrhea is not typical; obstruction is more likely.

1) A 4-year-old child is admitted to the hospital secondary to dehydration. Laboratory tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. Which condition does the nurse suspect based on the current data? 1. Hypernatremia 2. Metabolic acidosis 3. Hypotonic dehydration 4. Isotonic dehydration - Ch 44: Alteration in Fluid, Electrolyte and Acid Base Balance- - Start -

3 Explanation: 1. Hypernatremia is a condition where the body fluids are too concentrated and there is an excess of sodium. 2. Metabolic acidosis refers to a condition where the pH of the blood is acidic. 3. This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water. Serum sodium is below normal levels. Hemoglobin and hematocrit will be high due to the loss of serum water. 4. This occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion.

3) Which parental statement indicates correct understanding of preventive techniques for heat-related illnesses when children exercise? 1. "Wearing dark clothing during exercise is recommended." 2. "Water is the fluid of choice to replenish fluids." 3. "During activity, stop for fluids every 15 to 20 minutes." 4. "Hydration should occur at the end of an exercise session."

3 Explanation: 1. Light-colored, light clothing is best to wear during exercise activities; wearing of dark colors can increase sweating. 2. A combination of water and sports drinks is best to replace fluids during exercise. 3. During activity, stopping for fluids every 15 to 20 minutes is recommended. 4. Hydration should occur before and during the activity, not just at the end.

8) Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client? 1. "We will change the colostomy bag with each wet diaper." 2. "We will expect a moderate amount of bleeding after cleansing the area around the stoma." 3. "We will watch for skin irritation around the stoma." 4. "We will use adhesive enhancers when we change the bag."

3 Explanation: 1. Physical or chemical skin irritation can occur if the appliance is changed too frequently, or with each wet diaper. 2. Bleeding is usually attributable to excessive cleaning. 3. Skin irritation around the stoma should be assessed; it could indicate leakage. 4. Adhesive enhancers should be avoided on the skin of infants. Their skin layers are thin, and removal of the appliance can strip off the skin.

15) Which parental action, observed during a home care visit for an infant diagnosed with gastroesophageal reflux, requires intervention by the nurse? 1. The infant's formula has rice cereal added. 2. The mother holds the infant in a high Fowler position while feeding. 3. After feeding, the infant is placed in a car seat. 4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.

3 Explanation: 1. Rice cereal thickens the formula and helps prevent regurgitation. This is appropriate. 2. This position will help prevent regurgitation and is appropriate. 3. Infant seats are not recommended, as they put pressure on the abdomen and may contribute to regurgitation. 4. Since dosing is small, it is appropriate to use a syringe for accurate measurement.

10) Which should the nurse include in a teaching session for the mother of a 3-year-old client who is concerned about her child choking? 1. Show the mother how to do cardiac compressions and rescue breathing. 2. Recommend the mother perform back blows and chest thrusts. 3. Teach the mother how to perform abdominal thrusts. 4. Tell the mother to do nothing until the child loses consciousness.

3 Explanation: 1. The method of cardiac compressions and rescue breathing is not the first thing that the mother needs to know. 2. This is the treatment for a choking infant, not a child. 3. Giving abdominal thrusts is the correct intervention for a choking child. 4. The mother should respond to the choking child before the child loses consciousness.

17) A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question? 1. Clear liquids today. NPO tomorrow 2. Type and cross-match for 1 unit of packed red blood cells. 3. Rectal temperatures every 4 hours 4. Start an intravenous line with D5NS at 20 mL per hour.

3 Explanation: 1. This is appropriate in anticipation of surgery. 2. Although not always required during surgery, this would not be inappropriate planning for the surgical procedure. 3. Rectal temperatures are avoided due to the fragile state of the rectum. 4. An IV is appropriate for surgical access.

9) A child with croup has an increased PCO2, a decreased pH, and a normal HCO3 blood gas value. Which does the nurse report to the healthcare provider based on these data? 1. Uncompensated metabolic alkalosis 2. Uncompensated metabolic acidosis 3. Uncompensated respiratory acidosis 4. Uncompensated respiratory alkalosis

3 Explanation: 1. Uncompensated metabolic alkalosis has an increased pH, normal PCO2, and increased HCO3. 2. Uncompensated metabolic acidosis has a decreased pH, normal PCO2, and normal HCO3. 3. If the pH is decreased and the PCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis. 4. Uncompensated respiratory alkalosis has an increased pH, decreased PCO2, and normal HCO3.

20) Which pediatric client diagnoses necessitate close monitoring for respiratory alkalosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

3, 4 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

18) Which gastrointestinal defects, often diagnosed shortly after birth, should the nurse include in the assessment process of all newborns? Select all that apply. 1. Pyloric stenosis 2. Biliary atresia 3. Hirschsprung disease 4. Umbilical hernia 5. Diaphragmatic hernia

3, 5 Explanation: 1. Pyloric stenosis is not diagnosed in the newborn nursery, but in the 2- to 4-week-old infant. 2. Symptoms of biliary atresia would not be observable until several weeks of age. 3. Symptoms of Hirschsprung disease may be observable in the newborn nursery. 4. Umbilical hernia cannot be diagnosed at birth. 5. Diaphragmatic hernia will show symptoms immediately after birth due to compression of the lung.

1) The nurse is providing care to a pediatric client, diagnosed with inflammatory bowel disease, who is prescribed daily prednisone. Which parental statement regarding administration of this drug indicates correct understanding of the teaching provided by the nurse? 1. "I will administer this medication between meals." 2. "I will administer this medication at bedtime." 3. "I will administer this medication one hour before meals." 4. "I will administer this medication with meals." - Ch 51: Alteration in Gastrointestinal Function - - Start -

4 Explanation: 1. Prednisone can cause gastric irritation and should not be given on an empty stomach. 2. Prednisone can cause gastric irritation and should not be given before bedtime on an empty stomach. 3. Prednisone can cause gastric irritation and should not be given on an empty stomach one hour before meals. 4. Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.

8) Which assessment data would cause the nurse to suspect that a newborn requires further testing for cystic fibrosis? 1. Rectal prolapse 2. Constipation 3. Steatorrheic stools 4. Meconium ileus

4 Explanation: 1. Rectal prolapse is a complication of the large, bulky fatty stools. 2. Constipation is not a symptom of cystic fibrosis. 3. Steatorrhea and rectal prolapse might be signs of cystic fibrosis seen in an older infant or child. 4. Newborns with cystic fibrosis might present in the first 48 hours with meconium ileus.

4) The nurse is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate? 1. Measuring the girth just below the umbilicus 2. Measuring the girth just below the sternum 3. Measuring the girth just above the pubic bone 4. Measuring the girth around the portion of the stomach

4 Explanation: 1. The circumference below the umbilicus would not be an accurate abdominal girth. 2. The circumference just below the sternum would not be an accurate abdominal girth. 3. The circumference just above the pubic bone would not be an accurate abdominal girth. 4. An abdominal girth should be taken around the largest circumference of the abdomen, just above the umbilicus.

18) Which is the priority nursing assessment when providing care for an infant at risk for dehydration? 1. Urine output 2. Urine specific gravity 3. Vital signs 4. Daily weight

4 Explanation: 1. The infant is unable to concentrate urine and will continue to void dilute urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 2. The infant's kidney is immature and unable to concentrate urine. Therefore, this is not the priority nursing assessment for an infant at risk for dehydration. 3. Pulse will elevate and blood pressure may drop, but the other vital sign findings will remain unchanged. However, this is not the best assessment of dehydration. 4. Daily weights on an infant provide the most accurate assessment of fluid balance.

2) A nurse is taking care of four different pediatric clients. Which child is at greatest risk for dehydration? 1. 7-year-old child with migraine headaches 2. 4-year-old child with a broken arm 3. 2-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea

4 Explanation: 1. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system is at a lower risk than is a toddler with a condition that increases insensible water loss. 2. The pediatric client with an acute condition that does not directly affect electrolytes is at a lower risk than is a client with a condition that increases insensible water loss. 3. The pediatric client with an acute condition, such as a client with cellulitis that does not affect the GI or electrolyte system, is at a lower risk than is a toddler with a condition that increases insensible water loss. 4. The pediatric client with the greatest risk is under 2 years of age and with a condition that increases insensible fluid loss.

16) Which is the priority nursing action for a child who presents in the emergency department after a motor vehicle accident with a sucking wound of the chest? 1. Placing the child in a Trendelenburg position 2. Beginning rescue breathing for the child 3. Beginning cardiac resuscitation for the child 4. Covering the child's wound with an air occlusive dressing

4 Explanation: 1. This would not be the appropriate response to a sucking chest wound. 2. The child is conscious. Rescue breathing is not appropriate at this time. 3. There is no need for cardiac resuscitation at this time. 4. This prevents more air from entering the chest and is appropriate.

5) Which is the priority nursing diagnosis when planning care for a newborn who is born with esophageal atresia and tracheoesophageal fistula? 1. Ineffective Tissue Perfusion 2. Ineffective Infant Feeding Pattern 3. Acute Pain 4. Risk for Aspiration

4 Explanation: 1. Tissue perfusion is not a primary problem with this condition. 2. The infant is always kept NPO (nothing by mouth) preoperatively, so ineffective feeding pattern would not apply. 3. Pain is not usually experienced preoperatively with this condition. 4. This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea.

7) Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented? 1. "We're glad the dog can continue to sleep in our child's room." 2. "We'll keep the plants in our child's room dusted." 3. "We'll be sure to use the fireplace often to keep the house warm in the winter." 4. "We will replace the carpet in our child's bedroom with tile."

4 Explanation: 1. When possible, pets and plants should not be kept in the home. 2. When possible, pets and plants should not be kept in the home. 3. Smoke from fireplaces should be eliminated. 4. Control of dust in the child's bedroom is an important aspect of environmental control for asthma management.

22) The nurse is assessing a pediatric client who is experiencing metabolic alkalosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply. 1. "Has your child consumed any aspirin?" 2. "Has your child consumed any boric acid?" 3. "Has your child consumed any antifreeze?" 4. "Has your child consumed any baking soda?" 5. "Has your child consumed any antacids?"

4, 5 Explanation: 1. An overdose of aspirin is associated with metabolic acidosis. 2. Consumption of boric acid can cause metabolic acidosis. 3. Accidental consumption of antifreeze can cause metabolic acidosis. 4. Consumption of baking soda is associated with metabolic alkalosis. 5. Consumption of antacids is associated with metabolic alkalosis.

16) As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas? 1. Increased PCO2 and respiratory acidosis 2. Decreased PCO2 and respiratory alkalosis 3. Low pH and low PCO2 4. High pH and high PCO2

Answer: 1 Explanation: 1. Due to inadequate respirations, the child retains CO2 and develops respiratory acidosis. 2. This statement is incorrect as the child retains carbon dioxide. 3. The pH would be acidic, but the pH would be high. 4. The child would have a low pH (acidosis) and high PCO2.

10. In addition to an impaired gas exchange, which other diagnosis will a child in the early stages often have as well? a. Anxiety related to hypoxia b. Fatigue related to air trapping c. Injury related to fatigue and dehydration d. Delayed Development related to hypoxia

a. Anxiety related to hypoxia Feedback: Air trapping is not present in all cases of impaired gas exchange. Delayed development does not occur unless the condition is chronic or acutely damaging. The early phase of impaired gas exchange does not cause injury or dehydration, although fatigue can occur.

11.For what condition does the nurse taking care of a 5-year-old newly diagnosed with Crohn disease teach the parents that their son may be at risk later? a. Cancer b. Malabsorption c. Atresia d. Hepatitis

a. Cancer Feedback: The risk of cancer is greatly increased for the child diagnosed with Crohn disease. Symptoms of Crohn disease include cramped abdominals followed by diarrhea, fever, anorexia, growth failure or weight loss, general malaise, and joint pain. The risks for malabsorption, atresia, and hepatitis do not increase in clients with Crohn disease.

11. The mother of a 2-year-old calls the clinic nurse in a panic, stating, "I think my child swallowed a marble!" Which signs does the nurse know are indicative of a foreign-body aspiration? a. Coughing and dysphonia b. Fear and wheezing c. Hypoxia and choking d. Nasal flaring and crying

a. Coughing and dysphonia Feedback: Clinical manifestations of foreign body aspiration include a sudden onset of choking, spasmodic coughing, shortness of breath, or dysphonia. Fear, wheezing, hypoxia and nasal flaring are later signs of progressing respiratory distress.

8. Which statement by a 17-year-old girl indicates the need for additional counseling regarding the use of medications for TB treatment? a. Isoniazid: "I should take this when I eat." b. Rifampin: "My contact lenses will turn orange." c. Isoniazid: "No more drinking parties for me." d. Rifampin: "I need to stop taking my birth control pills."

a. Isoniazid: "I should take this when I eat." Feedback: Isoniazid should be taken 1 hour before or 2 hours after meals. All of the other statements are correct.

11. Which intervention by the nurse is most important when taking care of a child with severe dehydration? a. Monitor weight daily. b. Monitor for crackles in the lungs. c. Monitor level of consciousness. d. Monitor serum sodium levels. - End of Ch 44 -

a. Monitor weight daily. Feedback: When managing a child with severe dehydration, the nurse must weigh the child daily with the same scale and without clothing to compare past weights and calculate weight loss. A dehydrated child will not have crackles in the lungs. Level of consciousness and serum sodium levels will be monitored, but the priority is hydration.

2. A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis Impaired Gas Exchange? a. Oxygen saturation of 62% b. Heart rate of 100 bpm c. Respiratory rate of 30/min d. Bicarbonate level of 38

a. Oxygen saturation of 62% Feedback: The incorrect options do not contain evidence of abnormal gas exchange values. Pallor, tachycardia, hypertension, and fever can occur with impaired gas exchange but alone do not yield that nursing diagnosis. Bradycardia, lethargy, appearing flushed, and hypothermia could be true in unusual circumstances but are not the typical picture of Impaired Gas Exchange. Elevated bicarbonate, metabolic alkalosis, irritability, and pallor do not reflect gas exchange abnormalities.

7.Which intervention would not be included in the preoperative plan of care for an infant with an omphalocele? a. Push the exposed abdominal contents back into the abdomen. b. Administer intravenous fluids. c. Assess for signs of other congenital anomalies. d. Care for the infant in a radiant warmer.

a. Push the exposed abdominal contents back into the abdomen. Feedback: Care of an infant with an omphalocele (congenital malformation where abdominal contents herniate through the umbilical cord covered by a translucent sac) is aimed at protection of abdominal contents. Aggressive attempts at replacing abdominal contents can lead to numerous problems, including increased abdominal pressure, impaired respiratory status, and bowel perforation. The goals should be to protect the infant from hypothermia, replace fluids, prevent infection, and look for other associated anomalies.

10. A 10-year-old child presents to the emergency department with decreased urinary output, lethargy, and confusion. The nurse suspects hypernatremia. About what condition is the nurse most concerned and how can the hypernatremia be treated? a. Seizures/hypotonic fluid b. Coma/hypertonic fluid c. Confusion/salt tablets d. Anuresis/tap water

a. Seizures/hypotonic fluid Feedback: Seizures can occur when hypernatremia occurs rapidly or is severe. Severe hypernatremia can be fatal. Hypernatremia is treated by intravenous administration of hypotonic fluid. A decreased level of consciousness manifested by confusion, lethargy, or coma can result from shrinking of the brain cells; anuresis may also occur, but the treatments associated with these conditions will be a hypotonic fluid.

9. Which tasks should the nurse perform rather than delegate to an assistant? (Select all that apply.) a. Suctioning a 2-year-old with a tracheostomy b. Changing the diaper of the 3-month-old infant recovering from RSV c. Walking with a 2-year-old who has an IV receiving antibiotics for pneumonia d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable

a. Suctioning a 2-year-old with a tracheostomy; d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet; e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable Feedback: Respirations of 68 are high for an 8-month-old infant. The nurse needs to assess for retractions and wheezing. A 2-year-old who becomes quiet following respiratory distress could be experiencing decompensation and requires an evaluation. Suctioning is a sterile procedure that only the nurse should perform.

6. A 4-year-old child with croup is brought to the emergency department. The child is anxious and crying and has a high-pitched stridor, retractions, and a barky cough. After administration of cool mist therapy, which assessment finding would indicate significant improvement in the child's respiratory status? a. The child is less anxious. b. The respiratory rate is decreased. c. Wheezing is less loud. d. The child drinks 8 ounces of fluid.

a. The child is less anxious. Feedback: All responses indicate conditions that are beneficial to the child. Respiratory distress and hypoxia cause anxiety as this vital life function is threatened. When anxiety improves, the nurse knows that the respiratory status must be improving as well, even if signs and symptoms continue.

8. A child is 24 hours postoperative following major trauma, and has received a total of eight units of packed red blood cells during the perioperative period. The child is flaccid, and has diarrhea and peaked T-waves on the electrocardiogram. About which electrolyte abnormality would the nurse call the primary healthcare provider to obtain an electrolyte panel? a. Hypercalcemia b. Hypernatremia c. Hypermagnesemia d. Hyperkalemia

d. Hyperkalemia Feedback: Hypernatremia is associated with dehydration and thirst. Hypercalcemia causes neuromuscular depression and constipation. Etiology is related to malignancy, overintake, and parathyroid disorder. Hypermagnesemia symptoms are similar to hyperkalemia, but the etiology is different. Hypermagnesemia is due to renal failure or administration. This client could be experiencing renal failure but that information is not given.

5. Arterial blood gases results indicate pH 7.33 and PCO2 of 38 mmHg following arrest and subsequent resuscitation of a 3-year-old child. Which nursing intervention should be utilized to attempt to correct this metabolic disorder? a. Assess the effectiveness of the respiratory pattern. b. Determine whether the endotracheal tube is positioned correctly. c. Administer sodium bicarbonate 1 mEq/kg IV. d. Treat the cause of the acidosis.

d. Treat the cause of the acidosis. Feedback: Sodium bicarbonate is used to correct serious metabolic acidosis. Metabolic acidosis is present, but sodium bicarbonate is given only in serious imbalance. We do not have enough information to determine whether that is the case. The medication often complicates acid-base imbalance. Airway always is important to assess, but the PCO2 level indicates that respirations are not contributing to the problem. The best answer is to find and treat the cause of the acidosis.

13) The nurse is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during the shift: Intake: 4 oz of Pedialyte One-half of an 8-oz cup of clear orange Jell-O Two graham crackers 200 mL of D51/2 sodium chloride IV Output: 345 mL of urine 50 mL of loose stool How many milliliters should the nurse document as the client's total intake? Give the numerical answer only. Do not include any units of measurement.

Answer: 440 mL Explanation: 1. The child takes in 120 mL of Pedialyte and 120 mL of Jell-O for a total of 240 mL. With 200 mL of IV fluids, the total intake is 440 mL.

19) Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply. 1. Assessing for respiratory distress 2. Auscultating the lungs for wheezing 3. Prescribing oxygen for low saturations 4. Administering prescribed prophylactic antibiotic therapy 5. Providing support to the family

1, 2, 5 Explanation: 1. A pediatric client who sustained a smoke-inhalation injury is at risk for respiratory distress; therefore, it is appropriate for the nurse to assess this patient for clinical manifestations associated with the phenomenon. 2. Crackles and wheezing are both complications associated with a smoke-inhalation injury. This nursing action is appropriate. 3. It is outside the scope of nursing practice to prescribe oxygen therapy for a pediatric client. The nurse would, however, administer prescribed oxygen for this client. 4. Prophylactic antibiotic therapy is not included in the treatment plan for a pediatric client who sustained a smoke-inhalation injury. 5. The nurse should provide support to the family of a pediatric client who sustained a smoke-inhalation injury.

19) Which pediatric client diagnoses necessitate close monitoring for respiratory acidosis? Select all that apply. 1. Aspiration 2. Epiglottitis 3. Sepsis 4. Meningitis 5. Cystic fibrosis

1, 2, 5 Explanation: 1. Aspiration places the pediatric client at risk for respiratory acidosis. 2. Epiglottitis places the pediatric client at risk for respiratory acidosis. 3. Sepsis places the pediatric client at risk for respiratory alkalosis. 4. Meningitis places the pediatric client at risk for respiratory alkalosis. 5. Cystic fibrosis places the pediatric client at risk for respiratory acidosis.

20) Which statements should the nurse include in a presentation related to the general function of the gastrointestinal (GI) system for parents of pediatric clients? Select all that apply. 1. "The GI tract is responsible for the ingestion and absorption of food." 2. "Newborns have smaller stomachs but increased peristalsis." 3. "All children require smaller, more frequent feedings." 4. "Infants lack certain digestive enzymes which increases the risk for regurgitation." 5. "By the second year of life a child is able to accommodate three meals each day."

1, 2, 5 Explanation: 1. This statement is correct. The GI system is responsible for the ingestion and absorption of food. 2. This statement is correct. Newborns have smaller stomachs but an increased rate of peristalsis. 3. This statement is false. All children do not require smaller, more frequent feedings. This statement is true for newborns and infants. 4. This statement is false. While infants do lack certain digestive enzymes, this does not increase regurgitation but causes abdominal distention due to gas. 5. This statement is true. By the second year of life children are able to accommodate three

15) Which statements should the nurse include in the discharge medication teaching for a child diagnosed with asthma who is prescribed cromolyn sodium (a mast cell stabilizer)? Select all that apply. 1. "The medication works to prevent exacerbations." 2. "The medication should be administered at the first symptom of an asthmatic attack." 3. "The medication should be taken on a daily basis." 4. "The medication should not be administered if the child has a cold." 5. "The medication desensitizes the child against specific allergens."

1, 3 Explanation: 1. This statement is true. Cromolyn sodium is used to inhibit an asthmatic response to allergens. 2. This is incorrect. This medication does not improve the child's condition during an asthmatic attack. 3. This is a preventative medication so doses should not be missed. 4. The medication should be taken daily. 5. This medication does not desensitize the child against allergens.

22) Which topics should the nurse include in discharge instructions related to enhanced safety for a pediatric client who experienced an abdominal injury after a biking accident? Select all that apply. 1. Use of hand signals 2. Age-appropriate use of child safety seats 3. Age-appropriate bicycles 4. Use of a helmet 5. Avoid assigning blame

1, 3, 4 Explanation: 1. Information related to appropriate hand signals when riding a bicycle is an injury prevention strategy that the nurse should include in the teaching session. 2. The use of an age-appropriate child safety seat is not an appropriate discharge instruction for a child who experienced an abdominal injury after a biking accident. 3. Information related to an age-appropriate bicycle is an injury prevention strategy that the nurse should include in the teaching session. 4. Information related to the use of a helmet is an injury prevention strategy that the nurse should include in the teaching session. 5. While the nurse should avoid assigning blame when providing care for a child who experienced an abdominal injury as a result of a biking accident, this is not an appropriate injury prevention topic to include in the discharge teaching session.

11) A neonate is born with a bilateral cleft lip that was not detected during the pregnancy. The parents are distressed about the appearance of their infant. Which nursing actions are appropriate to assist the parents to bond with their newborn? Select all that apply. 1. Calling the newborn by the chosen name 2. Keeping the newborn's lower face covered with the blanket 3. Smiling and talking to the newborn in the parents' presence 4. Showing the parents before and after pictures of other children with cleft lips 5. Discussing positive features of the baby

1, 3, 4, 5 Explanation: 1. This behavior humanizes the child to the parents and is appropriate. 2. This indicates that the infant's appearance is distressing. Although the nurse would want to shield the child from a visitor's stare, the nurse would not want to hide the child from her own family. 3. This indicates acceptance of the infant by the nurse. 4. It is usually not appropriate to show before and after pictures as you cannot predict the success of the surgery on this child. But in the case of cleft lip, the improvement will be significant and it is considered acceptable to show before and after pictures. 5. Statements like, "Your baby is the sweetest thing—she never cries," can help the parents recognize positive features about their baby.

4) The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which additional assessment data indicates to the nurse that the infant is experiencing an early to moderate stage of dehydration? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels

2 Explanation: 1. Bradycardia is not a sign of dehydration. 2. Tachycardia is a sign that indicates moderate dehydration. 3. In dehydration, the blood pressure is hypotensive. 4. Fontanels would be sunken in moderate dehydration.

23) Which age-appropriate techniques should the nurse implement in order to encourage a young child to participate in deep breathing exercises? Select all that apply. 1. Showing the child how to use the "blow bottle" 2. Using a pinwheel that the child plays with and asking the child to blow until it turns 3. Asking the child to blow bubbles in a glass of water using a straw 4. Having the child blow scraps of paper across the bedside table with a straw 5. Telling the child that a "shot" will be needed if the child does not follow the nurse's

2, 3, 4 Explanation: 1. A blow bottle is appropriate for an older pediatric client, not a young child. 2. Asking the young child to blow on a pinwheel is an age-appropriate intervention to facilitate deep breathing. 3. Asking the child to blow bubbles into a glass of water is an age-appropriate intervention to facilitate deep breathing. 4. Having the child blow scraps of paper across the bedside table with a straw is an age-appropriate intervention to facilitate deep breathing. 5. Telling the child that an injection will be administered if the nurse's directions are not followed is not therapeutic nor age appropriate.

14) Which statements, made by the adolescent following dietary teaching for Crohn disease, indicate correct understanding of the content presented by the nurse? Select all that apply. 1. "I can promote solid stools by increasing fiber in my diet." 2. "Small, frequent meals are preferred over three meals a day." 3. "I should identify foods that cause distress and eliminate them from my diet." 4. "High-calorie dietary supplement shakes can help me to meet my nutritional requirements." 5. "Socialization during my meal times is important even if my parents do not agree with my food choices."

2, 3, 4 Explanation: 1. Fiber should be decreased, not increased, as diarrhea is one of the symptoms of Crohn disease. 2. This is correct information. 3. This is individualizing the diet and is appropriate. 4. This addition provides an easy way to meet the nutritional needs. 5. Stress should be avoided at mealtimes.

17) Which data collected during the respiratory assessment would indicate the pediatric client is compromised? Select all that apply. 1. Lung sounds clear to auscultation 2. Stridor 3. Substernal retractions 4. Nasal flaring 5. Strong cry

2, 3, 4 Explanation: 1. Lung sounds that are clear to auscultation do not indicate respiratory compromise. 2. Stridor is an adventitious breath sound that may indicate respiratory compromise. 3. Substernal retractions may indicate respiratory compromise. 4. Nasal flaring may indicate respiratory compromise. 5. A weak, not strong, cry may indicate respiratory compromise.

21) Which nursing assessment data would indicate that a pediatric client sustained a large pulmonary contusion in a motor vehicle crash? Select all that apply. 1. Eupnea 2. Dyspnea 3. Hemoptysis 4. Fever 5. Crackles

2, 3, 4, 5 Explanation: 1. Eupnea, or a normal respiratory rate, is not assessment data the nurse expects for a pediatric client who sustained a large pulmonary contusion in a motor vehicle crash. 2. Dyspnea is a clinical manifestation associated with respiratory distress, which can occur for the pediatric client who sustained a large pulmonary contusion in a motor vehicle crash. 3. Hemoptysis is a clinical manifestation associated with a large pulmonary contusion. 4. Fever is a clinical manifestation associated with a large pulmonary contusion. 5. Crackles are a clinical manifestation associated with a large pulmonary contusion.

11) Which positions are appropriate for the nurse to include in a plan of care for the infant who is diagnosed with acute respiratory distress? Select all that apply. 1. Upright 2. Semi-Fowler position 3. Prone position 4. With the infant's head hyperextended 5. With the infant's head in a sniffing position

2, 5 Explanation: 1. An infant cannot be placed in an upright position. 2. The semi-Fowler position elevates the head of bed. This allows better movement of the diaphragm. 3. Prone positioning will not promote respirations. 4. The head should not be hyperextended as that position does not open the airway in an infant. 5. A sniffing position straightens and shortens the airway and is the position that is best.

19) The nurse is providing care to a newborn client who presents in the pediatric clinic for a 2-week health maintenance visit. The parents of the newborn are concerned, as their baby has "gas all the time." Which responses from the nurse are appropriate? Select all that apply. 1. "Your baby has a relaxed lower esophageal sphincter, which is causing the gas." 2. "Your baby lacks the enzyme amylase, which is causing the gas." 3. "Your baby lacks the enzyme insulin, which is causing the gas." 4. "Your baby has an immature liver, which is causing the gas." 5. "Your baby lacks an enzyme that helps to digest fats, which is causing the gas."

2, 5 Explanation: 1. Newborns and infants do have a relaxed lower esophageal sphincter; however, this is not responsible for gas but for frequent regurgitation of small amounts of oral feedings. 2. Newborns and infants lack several enzymes that assist with the digestive process. One of these enzymes is amylase, which assists with carbohydrate digestion. The lack of this enzyme causes abdominal distention due to gas. 3. Insulin is not an enzyme and is not lacking in the newborn. 4. While newborns and infants do have immature livers, that is not what is causing the gas. 5. Lipase is a digestive enzyme that assists in fat digestion. Infants and newborns do lack this enzyme, which would cause abdominal distention due to gas.

9) A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse have on hand for the delivery? 1. Bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Endotracheal tube

4 Explanation: 1. A bag-valve-mask system, or Ambu bag, could push air into the stomach and cause abdominal distension, increase pressure on the diaphragm, and impair breathing. 2. The defect is not external, so sterile gauze and saline are not needed. 3. Soft arm restraints might be necessary but at are not an immediate concern. 4. A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized.

17) Which rationale will the seasoned nurse share with the novice nurse regarding why the specific gravity for infants is lower than for older children? 1. The infant has a greater body surface area. 2. The infant has a higher basal metabolic rate. 3. The infant has a greater percentage of body weight that is water. 4. The infant's kidneys are less able to concentrate urine.

4 Explanation: 1. Although this is true, it does not explain the lower specific gravity. 2. This statement is true but does not explain the specific gravity differences. 3. Although the statement is true, it does not explain the specific gravity differences. 4. This statement is accurate and explains why the specific gravity of the infant's urine is closer to water than an older child's urine specific gravity.

8) A nurse is planning care for a child with hyperkalemia. Which manifestation associated with the documented hyperkalemia requires immediate intervention by the nurse? 1. Hyperthermia 2. Respiratory distress 3. Seizures 4. Cardiac arrhythmias

4 Explanation: 1. Excessive potassium is unrelated to the body temperature. 2. Potassium is needed for contractility of heart and skeletal muscles but not for the muscles of respiration. 3. Seizures are not an adverse outcome of hyperkalemia. 4. A child with hyperkalemia is at risk for cardiac problems that can be life threatening, such as arrhythmias.

7) The nurse is planning care for a school-age client who is postoperative for the surgical removal of the appendix. In addition to pharmacologic pain management, which should the nurse include in the plan of care to address pain? 1. Applying a warm, moist pack every 4 hours 2. Applying EMLA cream to the incision site prior to ambulation 3. Applying a cold, moist pack every 2 hours 4. Applying a pillow against the abdomen to splint the incision site when coughing

4 Explanation: 1. Heat and moisture are not used on the incision area, as they can impair the healing process of the wound. 2. EMLA cream is a medication that requires a prescription. 3. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. 4. A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy.

5) Which immunization should the nurse include in a teaching session for parents of a toddler-age client to decrease the risk for epiglottitis? 1. Hepatitis B 2. Polio 3. Measles, mumps, and rubella (MMR) 4. Haemophilus influenzae type B (HIB)

4 Explanation: 1. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis. 2. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis. 3. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis. 4. The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis.

14) Which is the priority nursing action for a premature neonate who is experiencing apnea? 1. Administering oxygen 2. Performing back blows and chest thrusts 3. Calling a code blue 4. Providing stimulation by stroking the back

4 Explanation: 1. If the infant is not breathing, oxygen will not help. 2. This is intervention for choking, not apnea. 3. A code is not the initial response. If the nurse is unable to restart breathing, then a code should be initiated. 4. Tactile stimulation is often sufficient to restart the infant's respirations. Apnea of prematurity is due to immaturity of the respiratory center.

3.Which assessment finding would lead the nurse to suspect esophageal atresia in an infant? a. Hypotonicity b. Excessive crying c. Abdominal distention d. Excessive drooling

d. Excessive drooling Feedback: The classic symptoms in an infant with esophageal atresia are excessive drooling often accompanied by cyanosis, choking, and coughing. Low blood pressure, excessive crying, and hypotonicity are not common signs of esophageal atresia.

14) A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg and is estimated to have lost 7% of his normal body weight. The nurse is double-checking the IV rate the healthcare provider prescribed. The formula the healthcare provider used was for maintenance fluids: 1000 mL for 10 kg of body weight plus 50 mL for every kilogram over 10 for 24 hours. Replacement fluid is the percentage of lost body weight × 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, which hourly IV rate will the nurse implement for 24 hours? 1. 88 mL/hr 2. 86 mL/hr 3. 81 mL/hr 4. 83 mL/hr

Answer: 2 Explanation: 1. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1,150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. 2. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. 3. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour. 4. Maintenance need for 13 kg is 1000 + (50 [×] 3), or 1150 mL/24 hours. Add to this the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1150 + 910 = 2060 for 24 hours. 2060/24 = 86 mL per hour.

15) A 9-month-old infant is hospitalized with vomiting and diarrhea. The mother questions why her child needed hospitalization since her school-age nephew had the same symptoms and was treated at home. Which should the nurse include in the explanation to the infant's mother? Select all that apply. 1. Infants have a lower proportion of their body weight as water. 2. The percentage of extracellular fluid is higher in the infant than the school-age child. 3. School-age children have a larger body surface area. 4. The school-age child's kidneys are more mature and better able to conserve water. 5. The metabolic rate of the school-age child is higher.

Answer: 2, 4 Explanation: 1. Infants have a higher percentage of body weight as water. 2. This statement is accurate. 3. Body surface area (BSA) is an assessment of skin surface. BSA compares the height and weight of the child and is greatest in infancy. 4. This statement is accurate. 5. Infants have a higher metabolic rate than a school-age child.

7. The nurse is caring for a school-age child who has chronic fluid overload with edema, and teaches the parents about skin care for their child. Which statement by the parents indicates the need to review the material further? a. "Pajamas sound ideal for clothes." b. "Places where the skin rubs together are risk areas for breakdown." c. "It is best to buy clothes that are loose-fitting, so they do not rub the skin." d. "We should check the skin daily to look for any red areas."

a. "Pajamas sound ideal for clothes." Feedback: The statement "Pajamas sound ideal for clothes" indicates further review is necessary. Dressing the child in pajamas promotes the sick role, singles the child out, and does not promote self-esteem. Body image is a concern with edema. The remaining statements are appropriate.

12. The nurse is teaching a prenatal class about respiratory infections. Which statement by a parent indicates that further teaching is necessary? a. "When my newborn has a stuffy nose, he will be okay because newborns are obligatory mouth breathers." b. "Children's narrower airways cause them to breathe harder when they are congested." c. "The only time a newborn breathes through the mouth is when he's crying." d. "I should keep my newborn's nose clean so he can breathe and eat without difficulty." - End of Ch 46 -

a. "When my newborn has a stuffy nose, he will be okay because newborns are obligatory mouth breathers." Feedback: Newborns are obligatory nose breathers. The only time newborns breathe through the mouth is when they are crying. The other statements by the parent are correct.

4. Following a motor vehicle accident and successful cardiopulmonary resuscitation, arterial blood gases are drawn from a 13-year-old client. What will the nurse identify as the result of this test? a. Acid-base balance b. Prognosis c. Capillary metabolic exchange d. Carbonic acid level

a. Acid-base balance Feedback: The test provides information about immediate status of the client's acid-base balance. It will not provide data that can predict future outcomes. Capillary blood gases are done on newborns and infants to decrease the amount of blood used, but that is not the test referred to in this question. Carbonic acid contributes to the acid-base balance, but is not measured specifically in this test as a percentage.

4. An 8-year-old child is diagnosed with viral pneumonia and sent home from the clinic without an antibiotic prescription. The symptoms worsen, and the child returns to the clinic a week later with signs of a higher fever, listlessness, and a harsh, productive cough. The child's mother states, "I knew a prescription for antibiotics was needed." Which response by the nurse is the most appropriate? a. "It is better to wait to make sure so we don't use antibiotics unnecessarily. This approach also saves healthcare dollars." b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." c. "You do not want to expose your child to medication unnecessarily. Now it is necessary, because it is bacterial pneumonia." d. "Sometimes we just do not know. I'm glad you came back in."

b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." Feedback: The nurse responds with the most informative, accurate response. The decision not to use antibiotics for viral pneumonia was based on sound rationale about the etiology of the illness, not cost.

1.The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than older children are. Which parent comment would indicate that further education is needed? a. "Compared to an adult, an infant has little body water for reserve." b. "Infants maintain their temperature by losing heat through their heads." c. "Infants have a higher metabolic rate than older children do." d. "Infants lose water through their skin, and they have a larger proportion of skin surface area than older children do."

b. "Infants maintain their temperature by losing heat through their heads." Feedback: Incorrect answers indicate the parents understand the lesson taught, and do not require further education. A correct answer indicates the parents do not understand the lesson, and require further education. Losing heat through their heads will have minimal affect on fluid loss in infants. A parent who makes this comment will require further education.

8.The nurse is caring for a group of infants in the neonatal intensive care unit. Which infant would require preparation for immediate surgery due to risk of life-threatening respiratory distress? a. An infant with an umbilical hernia b. An infant with a diaphragmatic hernia c. An infant with a cleft palate d. An infant with gastroesophageal reflux

b. An infant with a diaphragmatic hernia Feedback: Gastroesophageal reflux, cleft palate, and umbilical hernia do not cause respiratory distress and are not considered surgical emergencies. A diaphragmatic hernia will cause the abdominal organs to extend into the chest, causing pressure on the thoracic cavity. Only 50% of afflicted infants survive.

2. A 6-month-old infant is admitted with severe dehydration. Effectiveness of therapy is evaluated with which assessment measures? (Select all that apply.) a. Documenting abdominal girth every shift b. Documenting mucous membrane moisture every shift c. Daily weights each day on a rotating shift d. Recording intake and output accurately e. Evaluating level of consciousness continuously

b. Documenting mucous membrane moisture every shift; d. Recording intake and output accurately; e. Evaluating level of consciousness continuously Feedback: All of the choices represent assessment measures that evaluate the effectiveness of therapy except abdominal girth, which does not provide information regarding hydration status, and daily weights on a rotating schedule. Daily weights should be done, but they must be completed on the same scale at the same time each day while the infant is wearing no clothing.

6. A school nurse teaches a coaching staff about heat-related illnesses. Which action by a coach indicates to the nurse that teaching was effective? a. Sleep 2-3 hours in the middle of the day during all-day practice. b. Have cell phones or other mechanisms to call for emergency assistance. c. During activity, stop for fluids every 30 minutes. d. Allow 1-2 hours' rest during the middle of the day, with fluids and food provided.

b. Have cell phones or other mechanisms to call for emergency assistance. Feedback: Rest 2-3 hours during the day of all-day practice, but sleep is not required. Stop for fluids every 15-20 minutes. It is essential to have a means of communication in case of emergency.

6. The nurse is preparing a pediatric client for a barium enema. Which diagnosis would support the need for this diagnostic test? a. Gastroschisis b. Intussusception c. Appendicitis d. Pyloric stenosis

b. Intussusception Feedback: Intussusception occurs when the intestine invaginates into another, causing pain with vomiting and passage of brown stool. The stools eventually can resemble currant jelly. Pyloric stenosis is a stenosis between the stomach and duodenum. Gastroschisis is a congenital defect where there is herniation of abdominal contents outside the abdominal wall. Appendicitis is an inflammatory process of the appendix

12. An 8-year-old is admitted to the emergency department with an injury to the abdomen with single organ involvement. Which type of injury does the nurse suspect? a. High-velocity blunt trauma b. Sports-related trauma c. Penetrating trauma d. Bike-related trauma - End of Ch 51 -

b. Sports-related trauma Feedback: Sports-related abdominal trauma is often associated with a direct blow to the abdomen, and a single organ is usually injured. High-velocity blunt trauma usually involves multiple organs. Blunt trauma may not be apparent in penetrating traumas and would have to be assessed to determine what injury lies beneath the skin surface. Bike-related traumas can result in serious abdominal injuries.

9. The nurse notes several changes in the past 24 hours in a child with heart failure. Which finding is the most significant in assessing the child for fluid volume overload? a. Presence of lung crackles b. Weight gain of .4 kg c. Bounding pulse d. Jugular venous distention

b. Weight gain of .4 kg Feedback: All are signs of fluid volume overload. However, an increase of weight is always the best indicator of an increase in fluid. The other options indicate heart failure as a result of the increase in fluid.

5. A nurse is discharging an infant after a pyloric stenosis repair. Which statement by the mother would indicate the need for further instructions prior to discharge? a. "I should call the doctor if my infant's temperature rises above 101 degrees." b. "I should fold the diaper down so it does not irritate the incision." c. "My infant's incision will need to be observed for redness, swelling, or discharge." d. "If my infant vomits, I should hold feedings for 6 hours."

d. "If my infant vomits, I should hold feedings for 6 hours." Feedback: It is normal for an infant to vomit occasionally after having surgery for pyloric stenosis. The infant should be fed on a normal feeding schedule. All other statements about checking the incision site, folding the diaper, and calling the doctor if there is a fever are true.

1. A nurse explains why a 4-year-old presenting with respiratory distress has retractions. Which statement by the parent indicates that the teaching was understood? a. "When distress occurs, children swallow air, leading to expansion of the rib cage and retractions." b. "Retractions occur in all children, because their ribs are soft and pliable. They are not related to respiratory distress." c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." d. "Children breathe primarily with the muscles between the ribs, so when distress occurs, the extra work of breathing causes retractions."

c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." Feedback: Up to the age of 6 years, children breathe primarily with their diaphragm. The intercostal muscles assist by increasing the chest diameter. When distress occurs, the intercostal muscles of the rib cage work with extra effort to move air through narrow airways. This causes retractions.

9. Which instruction should be provided to the parents of an infant with gastroesophageal reflux? a. "Feed every 4-5 hours to prevent overfeeding." b. "Place in a seated position for 10 minutes after feedings." c. "Elevate the head of the crib at all times." d. "Burp every 3-4 ounces with feeding."

c. "Elevate the head of the crib at all times." Feedback: Management of gastroesophageal reflux includes administering small, frequent feedings and burping every 1-2 ounces. Elevating the head of the bed and holding the infant upright for 30 minutes after feeding help minimize the reflux. Putting the infant in a seated position can increase the pressure on the abdomen, causing reflux to increase. 10.In obtaining a nursing history on an 18-month-old with diarrhea, which questions might help to identify the cause of the problem? (Select all that apply.) a. Has the child taken diphenhydramine in the past week? b. Do any other family members have diarrhea? c. Has the child been on antibiotics recently? d. Does the child have any food sensitivities? e. Has the child traveled recently? Answer: b. Do any other family members have diarrhea?; c. Has the child been on antibiotics recently?; d. Does the child have any food sensitivities?; e. Has the child traveled recently? Feedback: A complete history of the child with diarrhea is important to finding the cause. Questions should cover recent travel, medication use, exposures, and foods eaten. Diphenhydramine is an antihistamine that does not cause diarrhea. Similar symptoms in other family members suggest infectious etiology.

3. A school nurse initiates an asthma action plan after checking a student's peak expiratory flow averages after three readings. Which peak expiratory flow average indicates that no action be taken? a. 35% b. 65% c. 85% d. 40%

c. 85% Feedback: A reading of 80% to 100% of peak expiratory flow is green, or best. A reading of 50% to 80% is yellow, or a warning. In order to prevent the symptoms from increasing, action must be taken. Less than 50% is red, or a warning. This emergency requires medical care.

4.Which client would the nurse suspect to have pyloric stenosis? a. A 7-month-old with choking episodes b. An 11-year-old with an olive-shaped abdominal mass c. A 5-week-old infant with projectile vomiting d. A 2-year-old with a harsh cough

c. A 5-week-old infant with projectile vomiting Feedback: The most likely incidence of pyloric stenosis is in a 2- to 8-week-old infant. The common symptoms are nonbilious projectile vomiting, irritability, and failure to gain weight.

5. In which child does the nurse anticipate a potential respiratory arrest following an assessment? a. A 5-month-old infant with RSV who is sleeping and has a respiratory rate of 24 b. A 2-year-old with epiglottitis who was intubated in the emergency department c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds d. A 4-year-old, status post-tension pneumothorax from a motor vehicle accident with a chest tube in place, who complains of pain

c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds Feedback: All of the children are acutely ill. A child with asthma who was wheezing and now has decreased breath sounds is acutely ill. This child's ability to move air is decreasing and is approaching respiratory arrest. Intubation protects the airway from closing in epiglottitis and a chest tube is the treatment for tension pneumothorax in a different room; therefore, these children are stable. The infant with RSV is sleeping with a normal respiratory rate, so there is no immediate danger here.

7. Which comments by the parents of a 7-year-old child with asthma indicate comprehension of instructions regarding medication use for control of the illness? a. The medications are too complicated for a 7-year-old to understand. b. If a spacer is used, a whistling sound indicates that the medication is being inhaled correctly. c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. d. Dry powder inhalers are for adult use only.

c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. Feedback: A 7-year-old is at an age when medication administration responsibility ought to be initiated. The spacer whistle is significant, although its significance varies with each type of spacer. Children may use dry powder inhalers when they are old enough to have a rapid inhalation.

2. Which intervention would the nurse include in the care of an infant following surgical repair of a cleft lip? a. Let the infant touch the suture lines as a means of self-comforting. b. Position the infant in the supine position for feedings to avoid aspiration. c. Administer pain medications as ordered. d. Use a special feeding device with shorter nipples.

c. Administer pain medications as ordered. Feedback: Special feeding devices with long nipples usually are used, and the infant is fed in the sitting position to avoid aspiration. Some soft restraints may be used to prevent the infant from touching the suture line.

3. A nurse obtains a history from a single, breastfeeding mother with a small but hydrated 3-month-old infant who is listless following what the mother describes as a seizure. Which question would be most important for the nurse to ask? a. "Did you have gestational diabetes during pregnancy?" b. "Is this your first baby?" c. "Are you sure you didn't hurt the baby?" d. "Has your baby had seizures before?"

d. "Has your baby had seizures before?" Feedback: "Are you sure you didn't hurt the baby?" is judgmental and closed-ended. Questions should be open-ended. The nurse should be nonjudgmental in attitude and expressions.