pediatric practice questions
the nurse in a provider's office is assessing a client, the nurse determines the client's body mass index is 21.2, this finding is classified as which of the following?
a) underweight b) healthy weight c) overweight d) obese correct-b rationale: BMI range is 18.5-24.9
a nurse is performing a nutritional screening for a 12 year old client who weighs 41 kg (90lb) and has a height of 1.4 m (60in), which of the following values is the client's body mass index?
a) 1.5 b) 3.6 c) 18.2 d) 27.3 correct- c rationale: to calculate the client's BMI, the nurse should divide the client's weight in kg by the square of the client's height in m 41/the square of 1.5 m gives a correct BMI of 18.2
a nurse is assessing a 12 year old child during a well-child checkup, which of the physical findings should the nurse report to the provider?
a) 5 cm (2in) of growth in the past year b) hyperopia c) presence of pubic hair d) weight gain of 3 kg (6.6 lb) in the last year correct-b rationale: the nurse should report hyperopia in a 12 year old child to the provider, farsightedness is an unexpected finding after the age of 7
a nurse is caring for a toddler, which of the following lab findings should the nurse report to the provider?
a) BUN 8mg/dL b) uric acid 3.0 mg/dL c) creatinine 0/9 mg/dL d) urine specific gravity 1.010 correct-c rationale: the expected reference range for a toddler is a creatine level of 0.3-0.7 mg/dL, this child's level is above the expected reference range and should be reported to the provider
a nurse is caring for a 4 mo child who is hospitalized, which of the following toys should the nurse provide for the child?
a) a board book with large pictures b) a toy with movable parts c) a plastic mirror d) push-pull toy correct-c rationale: a 4 mo infant can recognize herself and will also attempt to play with the baby in the mirror, a mirror is a bright object that provide appropriate visual stimulation for this age group, for the infant's safety the mirror must be unbreakable
The nurse is caring for a client who is receiving treatment for DKA and has a current blood glucose level of 250mg/dL, which of the following actions should the nurse take?
a) admin 5% dextrose in 0.9% sodium chloride by continuous IV infusion b) give potassium as a rapid IV bolus c) admin 3 units of ultralente insulin subcutaneously d) obtain an HbA1c level stat correct-a rationale: when the child's blood glucose level falls between 250-300 mg/dL, the nurse should begin IV infusion of % or 10% dextrose in 0.9% sodium chloride, the goal is to maintain blood glucose levels between 120-240 mg/dL, if dextrose is not added, hypoglycemia might occur
the nurse is caring for a school-aged child who had hemophilia and fell on the playground, the child reports a pain level of 4 on a scale of 0-10, which of the following actions should the nurse take?
a) administer NSAID b) perform passive range of motion exercise on the joint c) administer cryoprecipitate d) apply an ice pack to the joint correct-d rationale: immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint
a nurse is obtaining a urine sample from a 5 mo infant by applying a urine collection bag, which of the following actions should the nurse take first?
a) apply the collection bag to the skin at the area of the symphysis pubis b) apply the collection bag to the skin at the area of the perineum c) wash and dry the genitalia, perineum, and surrounding skin d) stroke the muscles on either side of the infant's spine correct-c rationale: the first action is to wash and dry the genitalia, perineum, and the skin in the area to which the urine collection bag will be secured
a nurse is teaching the guardians of an infant who has mild gastroesophageal reflux (GER), which of the following instructions about feeding therapies should the nurse recommend?
a) apply the infant's diaper snugly prior to feeding b) administer nasogastric feedings c) thicken feedings with rice cereal d) place the infant in a lateral position for 1 hr after feedings correct-c rationale: thicken feedings with rice cereal decreases the infant's manifestations of GER and promote weigh gain if needed
a nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse, which of the following actions should the nurse take?
a) ask the child if his parents are responsible for the abuse b) notify the facility's risk manager c) interview the child with his parents present d) report the suspected abuse to local authorities correct-d rationale: the nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement
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 b) plastic stethoscope c) small-piece jigsaw puzzle d) book of short stories correct- b rationale: preschool play centers on imitative activities, providing a stethoscope allows the child to engage in therapeutic play, imitating health care personnel may ease the child's fear of unfamiliar equipment
a nurse is facilitating a group discussion with preschool teachers about child abuse, which of the following examples should the nurse use to illustrate a suggestive finding?
a) bruising of both knees with sutures on 1 b) arm cast for a spiral fracture of the forearm c) consistent bedwetting at nap time d) frequent, vague reports of a stomachache or a headache correct-b rationale: spiral fractures occur from the twisting of an extremity, in most instances, spiral fractures of the arm result from an abusive injury
a nurse is assessing a school age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse, which of the following findings should the nurse investigate further as an indication of child maltreatment?
a) bruising of the right elbow b) dislocated left shoulder revealed by X-ray c) thin, frail extremities d) abrasions on both writs correct-c rationale: thin and frail extremities are related to malnourishment and can indicate child maltreatment, wrist abrasion could be caused by the reins wrapping around the wrists
a nurse is providing teaching to the parent of a child who has CF and a prolapsed rectum, the nurse should identify that which of the following is a cause of this complication?
a) bulky stools b) weakened rectal sphincter c) elevated pancreatic enzymes d) decreased intra-abdominal pressure correct-a rationale: the nurse should identify that bulky stools can cause a child who has CF to develop a prolapsed rectum, the nurse should implement intervention to help decrease the bulk of the child's stools
a nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine, which of the following instructions should the nurse include?
a) common site for an injection of epinephrine are the fatty tissue found in the upper arm and lower abdomen b) administer epinephrine prior to giving your child peanut products in the future c) no further treatment is needed after injected the epinephrine d) you will need to increase the dosage as your child gains weight correct-d rationale: epinephrine is weight-based medication available in 0,15 mg and 0.3 mg, as the child grows, it will be necessary to change the epinephrine dosage that is administered
a nurse is assessing a 6 mo infant who had a cardiac catheterization with right femoral entry to diagnose a possible congenital heart defect, which of the following findings should the nurse report to the provider?
a) cool toes on the right foot b) weak pedal pulses on both feet c) positive babinski reflex on both feet d) erythema on the right foot correct-a rationale: the nurse should monitor the temperature of the infant's right extremity and should report any indication of coolness distal to the entry to the provider because this can indicate an obstruction of an artery
a nurse is teaching the parent of a school-aged child who has celiac disease, which of the following foods selected by the parent indicates an understanding of the teaching?
a) corn-tortilla with black beans b) pizza c) canned soup d) hot dogs correct- a rationale: children who have celiac are placed on a gluten free diet, gluten is found in wheat, rye, and barley selecting products made from corn indicates an understanding of the teaching, as corn and beans are gluten free foods
a nurse is teaching the parent of an infant about food allergens, which of the following is the most common food allergy in children?
a) cow's milk b) wheat bread c) corn syrup d) eggs correct-a rationale: some children are sensitive to the protein casein found in cow's milk, they have difficulty metabolizing casein and are allergic to cow's milk
a nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching?
a) crush the medication and mix it in your child's food b) administer the medication 1 hour before bedtime c) expect your child to have cloudy urine while he is taking this medication d) weigh your child twice per week while he is taking this medication correct-d rationale: the nurse should instruct the parent to weigh the child 2-3 times per week to monitor for weight loss, which is an adverse effect of methylphenidate, parent should report weight loss to provider
a nurse is caring for a child who has electrical burns on the lower arms and hands, which of the following findings indicate the child is experiencing a complication of the injury?
a) dark urine b) 2+ radial pulses c) respiratory rate of 20/min d) minimal pain correct-a rationale: dark urine can be an indication of myoglobinuria, it results from the elimination of waste products from muscle damage and con cause renal failure
A nurse is providing teaching to the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include?
a) instruct the child to ride against the flow of traffic b) instruct the child to walk the bike through intersections c) provide a larger bike that the child will be able to grow into d) ensure the child's helmet covers the ears correct-b rationale: the child should walk the bike through intersections and crosswalk to decrease the risk of injury
a nurse is providing education for the family of the 6mo infant about ways to stimulate language development, which of the following instructions should the nurse include?
a) explain what you are doing to the infant while providing care b) promote fine-motor development for the tongue by offering a pacifier several times each day c) exercise jaw muscles with foods that require chewing, such as hot dogs and carrots d) leave a television playing in the child's room during nap time correct-a rationale: the nurse should instruct the family that exposing the infant to expressive speech is the foundation for the development of expressive skills (the ability to make others understand needs and thoughts) and receptive skills (the ability to understand spoken words)
a nurse is caring for a 1 year old infant who has chronic otitis media, the nurse should identify that which of the following areas is at risk of a delay in development?
a) fine motor skills b) visual acuity c) speech patterns d) hand-to-eye coordination correct- c rationale: speech patterns are developed through auditory experiences, chronic otitis media is a common cause of hearing impairment, which can delay the development of speech
a nurse is providing anticipatory guidance about the 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 b) go to an emergency department c) call the poison control center d) induce vomiting correct-c
a nurse is providing teaching to an adolescent who was recently diagnosed with type 1 DM, which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?
a) hip b) upper arm c) thigh d) lower leg correct-a rationale: vigorous exercise can enhance the absorption of injected insulin from an involved extremity, when participating in vigorous exercise that involves both the arms and les, the client should use a hip as the insulin injection site
a nurse is assessing the gross motor skills of 4 year old preschooler, the nurse should expect the preschooler to perform which of following activities?
a) hopping on 1 foot b) skipping on alternate feet c) jumping rope d) roller skating correct-a rationales: a- 4 year old can hop on 1 foot b, c, d- 5 year old can skip on alternate feet, jump rope, and roller skate
a nurse is caring for a school aged child who has acute post-streptococcal glomerulonephritis, which of the following manifestations should the nurse expect?
a) hypotension b) elevated serum lipid levels c) decreased serum potassium levels d) hematuria correct-d rationale: hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis
a nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace, which of the following responses by the adolescent indicates an understanding of the teaching?
a) i can take my brace off to sleep every night at bedtime b) i can take my brace off for about an hour daily to shower c) i should loosen the straps on my brace if it is rubbing against my skin d) i should place the pads of the brace against my skin with a t-shirt correct-b rationale: the nurse should instruct the child to wear the brace for 23 hours each day and only to remove it for showering or participating in physical therapy
a nurse is providing teaching to the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets, which of the following statements by the parent indicates an understanding of the teaching?
a) i should expect my child to gain weight while taking this medication b) i should expect this medication to decrease my child's HR c) i should crush the medication and put it in my child's food d) i should give this medication to my child half and hour before breakfast correct-d rationale: the parent should admin the medication to the child on an empty stomach
a nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM), which of the following responses by the adolescent indicates and understanding of the teaching?
a) i will breathe in through the mouthpiece, hold my breath for 5 sec, and the exhale b) if i get a reading in the green zone, i will tell my parents immediately so they can call the doctor c) i will slowly exhale through the mouthpiece over a 10 second interval d) i will record the highest reading of three attempts correct-d rationale: after establishing a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3
a nurse is providing postoperative teaching to the parent of a 3 mo infant who is recovering from an umbilical hernia repair, which of the following statements by the parent indicates an understanding of the teaching?
a) i will expect the site to bulge when by baby cries b) i will place a belly band around my baby's abdomen c) i will fold my baby's diaper away from the incision d) i will bathe my child in the bathtub daily correct-c rationale: the prevent infection, the parent should be able to describe and demonstrate proper folding of the diaper to protect the surgical incision from contamination
a nurse is teaching the parent of a preschool-aged child about the treatment for pinworms, which of the following statements by the parent indicates an understanding of the teaching?
a) i will give my child a dose of albendazole today and again in 2 weeks b) i will collect specimens immediately after my child has a bowel movement c) i will give my child a tub bath twice a day d) i will place my child's bed linens in a sealed plastic bag for 7 days correct-a rationale: instruct the parent to repeat the dose of albendazole in 2 weeks to eradicate the parasite and prevent reinfection
A nurse is teaching a school-aged child who has a new diagnosis of type 1 Dm, which of the following statements should the nurse make?
a) if you take too much insulin, drink a sugar-free cola b) you will need to decreased your insulin dosage when you become a teenager c) you can use a vial of insulin up to 30 days d) stop takin your insulin if you are vomiting correct-c rationale: 28-30 days stored at room temperature or in the refrigerator
a nurse is performing a well-child assessment on a 7 year-old client who take great pride in bringing school paper home, the nurse recognizes that this behavior demonstrates which of the following of Erikson's stages of psychosocial development?
a) initiative vs guilt b) industry vs inferiority c) identify vs role confusion d) autonomy vs shame and doubt correct-b rationale: the developmental task of industry vs inferiority is reflected by a child's level of motivation in relation to personal achievements that build good character during the school-age years 6-12
a nurse is discussing play activities with a group of parents and toddlers, which of the following activities should the nurse recommend for this age group?
a) jumping rope b) pushing a toy lawn mower c) sorting colored marbles d) plating a board game correct-b rationale: the nurse should recommend pushing a toy lawn mower as a play activity for a toddler, toddlers are developmentally ready for pull-push toys, and they enjoy play activities that allow imitation of adults
a nurse is assessing a toddler who has AIDS, which of the following findings is an indication of an opportunistic infection?
a) koplik spots b) peripheral neuropathy c) chancre d) candidiasis correct-d rationale: aka oral thrush results from the overgrowth of Candia albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems, candidiasis appears as cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue, thrush is often the initial opportunistic infection in an HIV positive child who is developing AIDS
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress, which of the following findings should alert the nurse to the possibility of epiglottis?
a) lethargy b) spontaneous coughing c) drooling d) hoarseness correct-c rationale: epiglottitis is a disorder caused by an inflammation of the epiglottis, it results in rapid swelling, which can obstruct breathing, drooling is an expected findings due to the toddler's inability to swallow saliva
a nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy, which of the following interventions should the nurse include in the plan?
a) maintain the child on bed rest b) monitor the child for increased temperature c) administer oxygen to the child d) monitor the child for bleeding correct-b rationale: leukopenia places the child at risk of infection, therefore, the nurse should monitor the child for a fever
a nurse is caring for a child who has been in Buck's traction for 2 days, which of the following actions should the nurse take to prevent complications?
a) manually move the weights to the floor when the child is experiencing pain b) check for pulses in the affected leg every 4 hr c) cleanse the pins every 12 hr d) inform parents to discourage visitors for the child correct-b rationale: traction might lead to neurovascular compromise, the nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours
a nurse is caring for an infant who is experiencing dehydration, which of the following assessments is the nurse's priority?
a) measure the child's weight daily b) check for tears c) palpate the fontanel d) assess skin turgor correct-a rationale: urgent finding- daily weight measurements are the most sensitive indicator of fluid balance in clients of all ages, and are especially critical for infants and children because fluid accounts for a greater portion of body weight
a nurse is caring for a 2 day old infant who has myelomeningocele, which of the following actions should the nurse take?
a) monitor the infant's head circumference b) position the infant supine c) place the infant under a radiant warmer d) tape a piece of plastic over the protruding membranes correct-a rationale: infants with myelomeningocele have an increased risk of hydrocephalus, measuring the infant's head circumference helps determine any increase of fluid
a nurse is teaching the parents of a 3 year old child who has persistent otitis media about prevention, which of the following statements by the parents indicates an understanding of the teaching?
a) my child should not play around others who have ear infections b) we should not smoke around our child c) my child should not swim this summer d) i will encourage my child to blow his nose forcefully when he has a cold correct-b rationale: preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract
a nurse is caring for a child who is postoperative following a tonsillectomy, which of the following findings is the nurse's priority?
a) nausea b) hoarse voice c) frequent swallowing d) sore throat correct-c rationale: risk for bleeding
a nurse is planning care for a toddler who has acute gastroenteritis and was recently admitted, which of the following should the nurse plan to provide for the child?
a) oral rehydration solution b) bananas or applesauce c) chicken or beef broth d) hypertonic IV solution correct-a rationale: ORS promotes the body's reabsorption of water and sodium and in more effective and less traumatic than the administration of IV fluids for the treatment of dehydration due to diarrhea and emesis
a nurse is caring for a child who is in a skeletal traction, which of the following actions is the nurse's priority?
a) perform PROM for unaffected joints b) massage the child's pressure areas c) increase the child's fluid intake d) encourage the child to use an incentive spirometer correct-d rationale: ABCs, encouraging the client to use an incentive spirometer will promote adequate oxygenation and is the priority nursing action, circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them
a nurse is providing teaching to an adolescent who has fiberglass arm cast, which of the following instructions should the nurse include in the teaching?
a) place a plastic bag over the cast when showering b) insert a dull knitting needle in the cast to rub itchy skin c) exercise fingers every 8 hr for the first 24 hr d) draw on the cast using magic markers correct-a rationale: to keep the cast dry
a nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis, which of the following actions should the nurse take?
a) position the adolescent supine during the procedure b) have the adolescent drink 240 ml (8 oz) of fluid prior to the procedure c) obtain the adolescent's weight prior to the procedure d) monitor the adolescent's vital sign every four hours during the procedure correct-c rationale: obtain baseline weight prior to the initiation of the procedure and again following
a nurse is preparing to assess an 11 mo infant during a well-child exam, which of the following actions should the nurse take?
a) pull the infant's pinna up and back when examining the ears b) palpate and count the infant's radial pulse for 15 seconds c) examine the infant's throat at the end of the examination d) check the infant's blood pressure in both arms correct-c rationale: the nurse should first perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the exam difficult
a nurse is performing a developmental assessment on a 3 year old child, which of the following commands should the nurse expect the child to complete successfully?
a) put your shoes on b) name the days of the week c) cut out this picture with a pair of scissors d) balance on 1 foot with your eyes closed correct- a rationale: children should be able to pull on their shows when they are 3 years old, they typically cannot tie their shows until they are 5 year old
a nurse is caring for a 7 year old child who is in skeletal traction following a complete fracture of the femur, which of the following diversional activities should the nurse offer the child?
a) puzzle with large pieces b) building blocks c) finger paints d) chapter books correct-d rationale: the nurse should offer chapter books as an appropriate diversional activity for a school-aged child who has limited movement due to skeletal traction
a nurse is preparing a school-aged child for a tonsillectomy, which of the following actions should the nurse take?
a) schedule the child for a preoperative visit to the facility b) inform the child he will be put to sleep for the procedure c) read the child a story about a cartoon character having a similar operation d) tell the child the appointment is to have his throat checked correct- rationale: a preoperative visit to the facility allows the child to observe perioperative processes, this education helps the child feel as east prior to the surgical procedure
a nurse in a pediatric clinic is talking with the parent of a toddler who states that her child will not sit the table to eat with the family, she asks the nurse for recommendation for "finger foods" for her child, which of the following foods should the nurse suggest?
a) slices of ripe banana b) popcorn c) slices of hot dogs d) raw carrots correct-a rationale: toddlers should have about 8 oz (1 cup) of fruit of per day, bananas are nutritious and, as long as they are soft, do not present a choking hazard for young children
a nurse is caring for a toddler, which of the following objects should the nurse select from the playroom for this child during hospitalization?
a) small plastic doll with clothes and accessories b) alphabet flash cards c) handheld video game d) 10-piece wooden puzzle game correct-d rationale: appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys - allow for manipulation and exploration
a nurse is caring for a 12 mo infant following the surgical repair of a cleft palate, the nurse should plan to feed the infant using which of the following instruments?
a) spoon b) straw c) firm nipple d) cup correct-d rationale: the infant should be fed clear liquids using a cup for 7-10 days following a cleft palate repair to prevent trauma and injury to the suture line
a nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side, based on these manifestation, which of the following condition is the infant experiencing?
a) tension pneumothorax b) flail chest c) pulmonary contusion d) fractured rib correct-a rationale: the nurse should identify these manifestations as an indication the infant is developing a tension pneumothorax, the infant might also become cyanotic and show asymmetry of the thorax
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 for several weeks with proper care b) the public health nurse will rotate the insertion site every site every 3 days c) you will need to ensure the arm board is in place at all times d) your child will go to the operating room to have the line placed correct-a rationale: a PICC line is the preferred venous access device for short-to moderate-term IV therapy, it can remain in place for long periods with proper care
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 absense of oral burns excludes the possibility of esophageal burns b) treatment focuses on neutralization of the chemical c) injury by a corrosive liquid is more extensive than by a corrosive solid d) immediate admin of activated charcoal is warranted correct-c rationale: the coating action of liquids permits larger areas of contact with tissues and results in more extensive injury
a nurse is preparing to assess a 2 year old toddler, which of the following behaviors should the nurse expect during the examination?
a) the child prefers to sit on the parents lap during exams b) the child is interested in how the examination equipment works c) the child asks specific questions about body functions d) the child questions how her development compares to other children at the same age correct-a rationale: toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the exam
a nurse is discussing disciplinary technique with the guardian of a preschooler, which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique?
a) the guardian explains to the child why her behavior is unacceptable b) the guardian places the child in time-out after misbehaving c) the guardian allows the child to choose the consequence of her misbehavior d) the guardian assigns an extra chore for the child's misbehavior correct-b rationale: time outs are effective for this age, safe and quiet - 1 minute
a nurse is reviewing the medical record of a 2 mo infant who has rotavirus, the nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%, which of the following statements by the nurse indicates an understanding of the lab values?
a) the infant might be dehydrated b) the infant might be anemic c) the infant might have received too much fluid d) the infant might have leukemia correct-a rationale: the increased hematocrit level indicates dehydration, hematocrit levels rise when blood volume is decreased during dehydration
a nurse is providing teaching about oxycodone to an adolescent who is experiencing a vaso-occlusive crisis, which of the following pieces of information should the nurse include?
a) this medication can cause diarrhea b) this medication can cause an increase in BP c) this medication might cause nausea d) this medication can cause an increase in salivation correct-c rationale: the nurse should instruct the adolescent that nausea is an adverse effect of oxycodone, other adverse effects include dizziness, sedation, and confusion
a nurse is assessing a 9 mo infant, which of the following findings should the nurse report to the provider as a delay in development?
a) using a pincer grasp to pick up blocks b) requiring support to sit for prolonged periods c) turning the head toward the parent's voice d) reaching for the mother and saying mama correct-b rationale: an infant should be able to sit unsupported by the age of 8 months, the nurse should report this finding to the provider because it is an indication of delay in gross motor development
a nurse is assessing the gross and fine motor behaviors of a toddler, which of the following behaviors should the nurse identify as an expected achievement for a 3 year old child?
a) walking backward while moving heal to toe b) standing on one foot for several seconds c) using scissors to cut out shapes d) printing letters with a pencil correct-b rationale: standing on 1 foot for several seconds is an expected behavior for a toddler
a nurse is providing dietary teaching to the parent of a toddler who has phenylketonuria, which of the following foods should the nurse recommend?
a) whole milk b) ground beef c) cooked carrots d) eggs correct-c rationale: offer foods that are low in protein such as cooked carrots an fruit
a nurse is providing teaching the parent of an infant who has HF and a new prescription for digoxin elixir, which of the following pieces of information should the nurse include?
a) withhold the medication if the indant's HR is less than 110/min b) mix the medication in 120 mL (4 oz) of infant formula c) expect the infant to vomit frequently while taking this medication d) double the dose if the infant has increased edema correct-a rationale: the pt should withhold the med and notify the provider if the infant's HR is less than 110/min
a nurse is teaching a group of parent of toddlers about growth and development, a parent asks, why does my child's abdomen stick out? which of the following replies should the nurse provide?
a) you should give your child a stool softener daily b) toddlers gain weight at a rapid pace c) you should have your child assessed for a spinal deformity d) toddlers do not have well-developed abdominal muscles correct- d rationale: the ab muscles are immature and minimally developed at this stage, therefore, many toddlers have a pot bellied appearance
a nurse is teaching the parents of a child who has cerebral palsy, which of the following statements should the nurse make?
a) your child will be unable to eat by mouth b) your child will be unable to participate in recreational activities c) your child will need a botulinum toxin A injection to reduce muscle spasticity d) our child will need throw rugs placed over non-carpeted areas correct-c rationale: children who have cerebral palsy have spasticity in their muscles, the child can receive botulinum toxin type A injections into affected muscles, which reduce spasticity
a nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV, which of the following statements should the nurse include in the teaching ?
a) your child's immunization today with be half-doses b) the pneumococcal and influenza vaccines are recommended for your child c) immunization will be delayed until your child tests HIV-negative d) your child will need to restart the immunization schedule once your child's lab values are within the reference range correct-b rationale: immunizations against common childhood illnesses is recommended for all children exposed to and infect with HIV
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 b- explain the sounds the child is hearing c- have the child use a cane when ambulating d- rotate nurses caring for the the child correct- b rationale- the noises in a facility can be frightening to a child who is experiencing a sensory loss, explaining these noises can allay the child's fears
a nurse is caring for a preschooler who has a terminal illness, the nurse should expect the preschooler to have which of the following perspectives about death?
a- believes that her own thoughts can cause death b- has an understanding of the finality of death c- exhibits curiously about what happens to the body after death d- views funeral services as unnecessary correct- a rationale: the nurse should expect preschoolers to believe that their own thoughts or actions can cause death and they might believe that death is a punishment for wrong-doing
a nurse is caring for a 15mo client 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 b- wear sterile gloves when chaning the toddler's diapers c-wear a mask when assisting the toddler with meals d-ask visitors to wear an N-95 when entering the toddler's room correct - c rationale: the nurse should wear a mask within 3-6 ft of the toddler to prevent the transmission of infections that are spread via large-droplet particles expelled in the air
a nurse is assessing a 10mo infant at a well-infant checkup, which of the following assessment findings should the nurse report to the provider?
a- the infant is unable to walk independently b- the infant's Moro reflex is absent c- the infant's anterior fontanel is open d- the infant needs assistance to sit up correct- d rationale: the infant is expected to have the ability to sit up unsupported around 8 months of age, therefore, the nurse should report this finding to the provider
a nurse is performing an annual physical assessment of a preschooler, the parent expresses concern about the child's 1.8 kg (4lb) weight gain over the past year, which of the following responses should the nurse make?
a- this amount of weight gain should likely indicate a serious problem b- this weight change seems to be the result of poor eating habits c- your child should have gained double this amount in a year d- your child's weight change is expected for this age group correct - d rationale: a preschooler should gain about 2-3 kg (4.4-6.6lb) each year, therefore, the nurse should reassure the parent that this child's weight gain is an expected finding for this age group
a nurse is teaching the parents of a 4mo infant who has gastroesophageal reflux, which of the following statements by a parent indicates an understanding of the teaching?
a-I will add 1 tsp of rice cereal per oz to my baby's formula b-I will place my baby on her side when sleeping c-I will decrease the number of feedings by baby receives per day d-i will give my baby loperamide with each feeding correct- a rationale: the parents can give the infant thickened feedings with rice cereal to help decrease reflux, the added calories also can help infants who are underweight due to gastroesophageal reflux
a nurse is assessing a child who is receiving IV chemotherapy, assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions?
stop the infusion elevate the extremity notify the provider remove the IV line
