Pediatrics NCLEX Review
The nurse should expect to administer the first dose of the measles, mumps, and rubella (MMR) vaccine at which age? 2 years 4 years 12 months 22 months
12 months
The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than how many cells/mm3? 200,000 mm3 (200 × 109/L) 180,000 mm3 (180 × 109/L) 160,000 mm3 (160× 109/L) 150,000 mm3 (150 × 109/L)
150,000
A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? Anxiety A temper tantrum A hypercyanotic episode The need for immediate primary health care provider notification
A hypercyanotic episode
A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance? Eggs Penicillin Sulfonamides A previous dose of hepatitis B vaccine or component
A previous dose
The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? Pallor Hyperactivity Activity intolerance Gastrointestinal disturbances
Activity intolerance
A child is admitted to the hospital with a diagnosis of acute bacterial meningitis. In reviewing the primary health care provider's prescriptions, which would the nurse question as appropriate for a child with this diagnosis? Administer an oral antibiotic. Maintain strict intake and output. Draw blood for a culture and sensitivity. Place the child on droplet precautions in a private room.
Administer an oral antibiotic
A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? Side or prone Back or prone Stomach with the face turned Back rather than on the stomach
Back rather than on the stomach
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? Hematuria Proteinuria Bacteriuria Glucosuria
Bacteriuria
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? Watery diarrhea Ribbon-like stools Profuse projectile vomiting Bright red blood and mucus in the stools
Bright red blood and mucus in the stools
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis? Hypotension Brown-colored urine Low urinary specific gravity Low blood urea nitrogen level
Brown-colored urine
The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? Increased systolic blood pressure Abnormal posturing of extremities Significant widening pulse pressure Changes in level of consciousness
Changes in level of consciousness
A 12-year-old child with newly diagnosed thalassemia is brought to the clinic exhibiting delayed sexual maturation, fatigue, anorexia, pallor, and complaints of headache. The child seems listless and small for age and has frontal bossing. What should the nurse expect to note on review of the results of the laboratory tests? Macrocytosis and hyperchromia Excessive red blood cell production Excessive mature erythrocyte proliferation Deficient production of functional hemoglobin
Deficient production of functional hemoglobin
The nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which aspect of care? Restricting activity Following a gluten-free diet Following a lactose-free diet Giving medication to manage the condition
Following a gluten-free diet
The mother of an 18-month-old child tells the clinic nurse that the child has been having some mild diarrhea and describes the child's stools as "mushy." The mother tells the nurse that the child is tolerating fluids and solid foods. The most appropriate suggestion regarding the child's diet would be to give the child which items? Applesauce, bananas, wheat toast Mashed potatoes with baked chicken Gelatin, strained cabbage, and custard Fluids only until the "mushy" stools stop
Mashed potatoes with baked chicken
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? Diarrhea Metabolic acidosis Metabolic alkalosis Hyperactive bowel sounds
Metabolic alkalosis
Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. Which beverage is the best option to recommend with iron administration? Milk Water Apple juice Orange juice
Orange juice
The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? Palpating the abdomen for a mass Assessing the urine for the presence of hematuria Monitoring the temperature for the presence of fever Monitoring the blood pressure for the presence of hypertension
Palpating the abdomen for a mass
The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? Positive Negative Inconclusive Definitive and requiring a repeat test
Positive
The nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma and expects to note which finding in the colostomy? Bleeding Gray in color Dark blue in color Red and edematous
Red and edematous
A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. Remain calm. Time the seizure. Ease the child to the floor. Loosen restrictive clothing. Keep the child on her back.
Remain calm Time the seizure Ease the child to the floor Loosen restrictive clothing
The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? Emergency cart Tracheotomy set Padded tongue blade Suctioning equipment and oxygen
Suctioning equipment and oxygen
On assessment during a well-baby visit, the nurse notes that a 6-month-old infant has crossed eyes. Which interpretation would the nurse make based on this finding? The condition will resolve without treatment. The condition is normal up to the age of 2 years. Surgical intervention may be necessary to realign weak eye muscles. Once the child begins to read, eye muscles strengthen and the condition will resolve.
Surgical intervention may be necessary to realign weak eye muscles
The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. What is the nurse's best response? "You need to change the child's diet." "The child probably is infectious again." "The jaundice may worsen before it resolves." "You need to call the primary health care provider."
The jaundice may worsen before it resolves
The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? "We need to encourage our child to drink fluids." "Coughing spells may be triggered by dust or smoke." "Vomiting may occur when our child has coughing episodes." "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."
We need to maintain droplet precautions
A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take? Administer an analgesic. Release the skin traction. Apply ice to the extremity. Notify the primary health care provider (PHCP).
Notify the PHCP
A nurse is caring for a hospitalized child who has hypotonic dehydration. Which serum sodium level would this student expect to observe? 125 mEq/L (125 mmol/L) 135 mEq/L (135 mmol/L) 145 mEq/L (145 mmol/L) 155 mEq/L (155 mmol/L)
125 mEq/L Rationale: Hypotonic dehydration occurs when the loss of electrolytes is greater than the loss of water; in this type of dehydration, the serum sodium level is less than 130 mEq/L (130 mmol/L). Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal at 135 to 145 mEq/L (135 to 145 mmol/L).
The parents of a child with a cleft palate are concerned and ask the nurse when the palate will be repaired. The nurse should plan to base the response on which information about cleft palate repair? A cleft palate cannot be repaired in children. Repair usually is performed by age 8 weeks. Repair usually is performed by 2 months of age. Repair usually is performed between 6 months and 2 years.
6 months to 2 years
The nurse is assisting a primary health care provider (PHCP) during the examination of an infant with developmental hip dysplasia. The PHCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted? A shrill cry from the infant Asymmetry of the affected hip Reduced range of motion in the right and left hip A palpable click during abduction of the affected hip
A palpable click during abduction of the affected hip
Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided? "Administer the antibiotics until they are gone." "Administer the antibiotics if the child has a fever." "Administer the antibiotics until the child feels better." "Begin to taper the antibiotics after 3 days of a full course."
Administer the antibiotics until they are gone
A 9-year-old child with leukemia is in remission and has returned to school. The school nurse calls the mother of the child and tells the mother that a classmate has just been diagnosed with chickenpox. The mother immediately calls the clinic nurse because the leukemic child has never had chickenpox. Which is an appropriate response by the clinic nurse to the mother? "There is no need to be concerned." "Bring the child into the clinic for a vaccine." "Keep the child out of school for a 2-week period." "Monitor the child for an elevated temperature, and call the clinic if this happens."
Bring the child to clinic for vaccine
A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the primary health care provider to prescribe? Increase intake of water with a diet high in carbohydrates. Consume oral rehydration fluid, advancing to a regular diet. Begin fluid replacement immediately with intravenous fluids. Begin a diet of bananas, rice, apples, pears, and toast with juice.
Consume oral rehydration fluid, advancing to a regular diet
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? Cracked lips Normal appearance Conjunctival hyperemia Desquamation of the skin
Conunctival hyperemia
A child is sent to the school nurse by the teacher. On assessment of the child, the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding? A discrete rose-pink maculopapular rash on the trunk Erythema on the face, giving a "slapped cheeks" appearance A highly pruritic, profuse macule-to-papule rash on the trunk A discrete pinkish-red maculopapular rash on the arms and trunk
Erythema on the face, giving a "slapped cheeks" appearance
The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. Administer regular insulin. Encourage the child to ambulate. Give the child a teaspoon of honey. Provide electrolyte replacement therapy intravenously. Wait 30 minutes and confirm the blood glucose reading. Prepare to administer glucagon subcutaneously if unconsciousness occurs.
Give the child a teaspoon of honey Prepare to administer glucagon subcutaneously if unconsciousness occurs
The mother of a 5-year-old child brings the child to the hospital emergency department and tells the nurse that the child fell. A fracture is suspected, and a radiograph is taken. The results indicate that the child has a comminuted fracture. The mother asks the nurse to describe this type of fracture, and the nurse draws a picture for the mother. Which picture identifies this type of fracture? Click on the image to indicate your answer.
Option B, the tibial fracture
The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? Platelet count Hematocrit level Hemoglobin level Partial thromboplastin time
PTT
The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? Supine Side-lying High-Fowler's Trendelenburg's
Side-lying
The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice? The nail beds The skin in the sacral area The skin in the abdominal area The membranes in the ear canal
The nail beds
The mother arrives at a well-baby clinic with her 1-month-old infant. She expresses concern because one of the infant's eyes appears to be crossed. What is the nurse's best response? "The infant will probably need surgery." "This condition is probably permanent." "It requires monitoring because the other eye may do the same thing." "This is normal in the young infant but should not be present after the age of about 4 months."
This is normal in the young infant...
A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth? Infection Paralysis Pressure ulcer Uneven leg growth
Uneven leg growth
The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action? Withhold the medication. Administer the medication. Check the blood pressure and then administer the medication. Check the respiratory rate and then administer the medication.
Withhold the medication
The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother? "You should use a plastic spoon to feed the child." "You need to use an orthodontic nipple on the child's bottle." "You can allow the child to use a pacifier but only for 30 minutes at a time." "You need to monitor the child's temperature for signs of infection using an oral thermometer."
You need to use an orthodontic nipple on the child's bottle
The nurse is performing an assessment on a 10-year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply. Abdominal pain Fever and malaise Anorexia and weight loss Painful, enlarged inguinal lymph nodes Painless, firm, and movable adenopathy in the cervical area
Abdominal pain Painless, firm, and movable adenopathy in the cervical area
A school-age child is seen in the primary health care provider's office for complaints of intense itching mostly at night. The primary health care provider makes a diagnosis of scabies and prescribes permethrin for treatment of the skin condition. Which at-home instruction should the nurse provide to the mother? Retreatment is recommended the next day. The child's bedding and clothing should be washed in cold water. Leave the lotion on throughout the day and rinse off within 6 hours. Apply the lotion liberally to the body and head, avoiding the eyes and mouth.
Apply the lotion liberally to the body and head, avoiding the eyes and mouth
An adolescent with diabetes receives 30 units of Humulin N insulin at 7:00 a.m. The nurse would monitor for a hypoglycemic episode at what time? At bedtime Before supper At midmorning After breakfast
Before supper
A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which primary health care provider prescription would assist in reversing the vaso-occlusive crisis? Monitor pulse oximetry. Begin intravenous fluids. Administer oxygen by face mask. Monitor vital signs and respiratory status.
Begin IV fluids
The nurse is reviewing the laboratory test results for an infant suspected of having hypertrophic pyloric stenosis. The nurse should expect to note which value as the most likely laboratory finding in this infant? Blood pH of 7.50 Blood pH of 7.35 Blood bicarbonate of 22 mEq/L (22 mmol/L) Blood bicarbonate of 27 mEq/L (27 mmol/L)
Blood pH of 7.5
The nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student. Which intervention on the student written plan of care requires correction? Measure circumference of injured joints. Blood transfusion of packed red blood cells. Monitor temperature with oral thermometers. Intravenous administration of recombinant factor.
Blood transfusion of packed red blood cells
The home care nurse is visiting a child newly diagnosed with diabetes mellitus. The nurse is instructing the child and parents regarding actions to take if hypoglycemic reactions occur. The nurse should tell the child to take which action? Administer glucagon immediately if shakiness is felt. Drink 8 ounces of diet cola at the first sign of weakness. Report to a hospital emergency department if the blood glucose is 60 mg/dL (3.4 mmol/L). Carry hard candies whenever leaving home in case a hypoglycemic reaction occurs.
Carry hard candies
The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? "Caution should be used when straddling the infant on a hip." "Vital signs should be taken daily to check for bladder infection." "Catheterization will be necessary when the infant does not void." "Circumcision has been delayed to save tissue for surgical repair."
Circumcision has been delayed to save tissue for surgical repair
A child who sustained a fractured ankle has a short leg cast applied, and the nurse provides home care instructions to the mother. The mother returns to the emergency department 16 hours later because the child is complaining of severe pain. The nurse notes that the child's toes are cool, pale, and puffy, and that the child is agitated and crying loudly. The mother states, "I gave her the pain medication you sent with us just like you told us, and I have kept her foot up on two pillows since we left, except when she gets up to go to the bathroom. I don't understand why she hurts so much. Do something!" What is the most likely clinical situation that occurred? Compartment syndrome Inadequate pain medication Skin breakdown around the cast edges Noncompliance with home care instructions
Compartment syndrome
An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign? Cough Liver failure Watery stool Nuchal rigidity
Cough
The nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus infection. The nurse should include notifying the primary health care provider if which symptom occurs in the child? Fussiness Lethargy Coughing Irritability
Coughing
A 12-month-old child with human immunodeficiency virus infection is currently immunocompromised. The nurse determines that the immunization needs of this child include which action? Withholding the inactivated polio vaccine Recommending against any influenza vaccinations Administering the measles, mumps, and rubella (MMR) vaccine Delaying the administration of the varicella virus vaccine until the child is not immunocompromised
Delaying the admin of varicella virus vaccine
The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure? Paleness of the skin Strong sucking reflex Diaphoresis during feeding Slow and shallow breathing
Diaphoresis during feeding
The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder? "Does your infant have diarrhea?" "Is your infant constantly vomiting?" "Does your infant constantly spit up feedings?" "Does your infant have foul-smelling, ribbon-like stools?"
Does your infant have foul-smelling, ribbon-like stools?
The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. Easy bruising occurs. Gum bleeding occurs. It is a hereditary bleeding disorder. Treatment and care are similar to that for hemophilia. It is characterized by extremely high creatinine levels. The disorder causes platelets to adhere to damaged endothelium.
Easy bruising Gum bleeding It is hereditary Treatment and care are similar to hemophilia The disorder causes platelets to adhere to damaged endothelium
The pediatric nurse educator provides a teaching session to the nursing staff regarding hemophilia. Which statement regarding this disorder should the nurse plan to include in the discussion? Males inherit hemophilia from their fathers. Hemophilia is a Y-linked hereditary disorder. Females inherit hemophilia from their mothers. Hemophilia A results from deficiency of factor VIII.
Hemophilia A results from deficiency of factor VIII
The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? "A balance of rest and exercise is important." "I can apply lotion or powder to the incision if it is itchy." "Activities in which my child could fall need to be avoided for 2 to 4 weeks." "Large crowds of people need to be avoided for at least 2 weeks after surgery."
I can apply lotion or powder to the incision if it is itchy
The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching? "I will wash my hands frequently." "I will keep my child's immunizations up to date." "I will avoid direct unprotected contact with my child's body fluids." "I can send my child to day care if he has a fever, as long as it is a low-grade fever."
I can send my child to day care if he has a fever, as long as it is a low-grade fever
A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction? "The cast may feel warm as the cast dries." "I can use lotion or powder around the cast edges to relieve itching." "A small amount of white shoe polish can touch up a soiled white cast." "If the cast becomes wet, a blow drier set on the cool setting may be used to dry the cast."
I can use lotion or powder around the cast edges to relieve itching
A 6-year-old child with human immunodeficiency virus (HIV) infection has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child? "The pain will go away if you lie still and let the medicine work." "Try not to think about it. The more you think it hurts, the more it will hurt." "I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less." "Every time it hurts, press on the call button and I will give you something to make the pain go all away."
I know it must hurt, but if you tell me when it does, I will try to make it hurt a little less
Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? "Treatment needs to be started as soon as possible." "I realize my infant will require follow-up care until fully grown." "I need to bring my infant back to the clinic in 1 month for a new cast." "I need to come to the clinic every week with my infant for the casting."
I need to bring my infant back to the clinic in 1 month for a new cast
The nurse instructs the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement, if made by the parent, indicates a need for further instructions? "I will take a rectal temperature daily." "I will inspect the skin daily for redness." "I will inspect the mouth daily for lesions." "I will perform proper hand-washing techniques."
I will take a rectal temperature daily
The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? "I will not mix the medication with food." "I will take my child's pulse before administering the medication." "If more than 1 dose is missed, I will call the primary health care provider." "If my child vomits after medication administration, I will repeat the dose."
If my child vomits after medication administration, I will repeat the dose
A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder? "It is an acute bowel obstruction." "It is a condition that causes an acute inflammatory process in the bowel." "It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel." "It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel."
It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel
The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply. Use the fingertips to lift the cast while it is drying. Keep small toys and sharp objects away from the cast. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity.
Keep small toys and sharp objects away from the cast Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling Contact PHCP if the child complains of numbness or tingling in the extremity
The nurse assists a primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia in whom central nervous system disease is suspected. In which position will the nurse place the child during this procedure? Lithotomy position Modified Sims' position Lateral recumbent position with the knees flexed and chin resting on the chest Prone with knees flexed to the abdomen and head bent with chin resting on the chest
Lateral recumbent
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? Prone position On the stomach Left lateral position Right lateral position
Left lateral position
A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? Limited range of motion in the affected hip An apparent lengthened femur on the affected side Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the examining table
Limited range of motion in the affected hip
A child admitted to the hospital with a diagnosis of gastroenteritis and dehydration weighs 17 lb 2 oz (7.8 kg). The parents state that his preadmission weight was 18 lb 4 oz (8.3 kg). Based on weight alone, what type of dehydration does the nurse expect? Mild dehydration Acute dehydration Severe dehydration Moderate dehydration
Moderate dehydration
The nurse is caring for a child diagnosed with Down's syndrome. Which explanation of this syndrome should the nurse provide the parents? Subaverage intellectual functioning with a congenial nature Above-average intellectual functioning with deficits in adaptive behavior Average intellectual functioning and the absence of deficits in adaptive behavior Moderate to severe intellectual disability and linkage to an extra chromosome 21, group G
Moderate to sever intellectual disability and linkage to an extra chromosome 21, group G
The nurse is reviewing the primary health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question? Suction the child frequently if coughing. Discharge to home when alert and tolerating fluids. Provide clear, cool liquids to the child when awake. Instruct the parent not to give the child milk products.
Suction the child frequently if coughing
The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child? Cyanosis Bronze skin Tachycardia Hyperactivity
Tachycardia
The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply. The child has symptoms of a cold. The child had a previous anaphylactic reaction to the vaccine. The mother reports that the child is having intermittent episodes of diarrhea. The mother reports that the child has not had an appetite and has been fussy. The child has a disorder that caused a severely deficient immune system. The mother reports that the child has recently been exposed to an infectious disease.
The child had a previous anaphylactic reaction The child has a disorder that caused severely deficient immune system
The nurse on the pediatric unit is caring for a child with hemophilia who has been in a motor vehicle crash. Which assessment finding, if noted in the child, indicates the need for follow-up? The child maintains affected joints in an immobilized position and denies pain at this time. The child's urine is noted to be clear and light yellow and is negative for red blood cells. The child maintains bruised joints in an elevated position; the bruises noted are beginning to turn yellow. The child is drowsy and difficult to arouse; previously the child was able to respond to questions effectively.
The child is drowsy and difficult to arouse
A mother brings her 6-year-old child to the clinic because the child has developed a rash on the trunk and scalp. The mother reports that the child has had a low-grade fever, has not felt like eating, and has been tired. The child is diagnosed with chickenpox. The mother inquires about the communicable period associated with chickenpox, and the nurse bases the response on which statement? The communicable period is unknown. The communicable period ranges from 2 weeks or less to 4 weeks. The communicable period is 10 days before the onset of symptoms to 15 days after the rash appears. The communicable period is 1 to 2 days before the onset of the rash to 6 days, when crusts have formed.
The communicable period is 1 to 2 days
The nurse has provided instructions to the mother of a child with cystic fibrosis about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures? "The diet needs to be low in fat." "The diet needs to be low in protein." "The diet needs to be low in calories." "The diet needs to be high in calories."
The diet needs to be high in calories
The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent? The hepatitis B vaccine will not be given to the child. The inactivated influenza vaccine will be given yearly. The varicella vaccine will be given before 6 months of age. A Western blot test needs to be performed and the results evaluated before immunizations.
The inactivated influenza vaccine will be given yearly
The nurse is providing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand care for their child if they make which statement? "We will encourage our child to cough every few hours on a daily basis." "We will make sure that our child participates in physical activity every day." "We will provide comfort measures to reduce any crying periods by our child." "We will be sure to give our child a Fleet enema every day to prevent constipation."
We will provide comfort measures to reduce any crying periods by our child
The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse should modify the client's plan of care based on which interpretation of the client's change? An insignificant finding An improvement in condition Decreasing intracranial pressure Deteriorating neurological function
Deteriorating neurological function
The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? "I need to wash my hands frequently." "I need to clean the eye as prescribed." "It is okay to share towels and washcloths." "I need to give the eye drops as prescribed."
It is okay to share towels and washcloths
A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the primary health care provider, should the nurse question? Obtain a throat culture. Obtain axillary temperatures. Administer humidified oxygen. Administer acetaminophen for fever.
Obtain a throat culture
The nurse is assisting a primary health care provider (PHCP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess? Babinski's sign The Moro reflex Ortolani's maneuver The palmar-plantar grasp
Ortolani's maneuver
A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. Which statement should the nurse educator include in the session? "Treatment includes dietary restriction of tyramine." "Phenylketonuria is an autosomal dominant disorder." "Phenylketonuria primarily affects the gastrointestinal system." "All 50 states require routine screening of all newborn infants for phenylketonuria."
All 50 states require routine screening of all newborn infants for phenylketonuria
The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding should the nurse expect to note on assessment of the child? Not easily arousable and limited interaction Loss of the ability to think clearly and rapidly Loss of the ability to recognize place or person Awake, alert, interacting with the environment
Not easily arousable and limited interaction
The pediatric nurse educator is providing a teaching session to nursing staff about hemophilia. Which statement should the nurse educator include? "Acetylsalicylic acid is given for pain control." "Hemarthrosis is the result of synovial cavity aspiration." "Total joint rest along with ice pack application continues for 72 hours after factor VIII is administered." "Affected prepubescent girls should be counseled concerning menorrhagia, which may be life-threatening."
Affected prepubescent girls
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? An infectious disease of the central nervous system An inflammation of the brain as a result of a viral illness A chronic disability characterized by impaired muscle movement and posture A congenital condition that results in moderate to severe intellectual disabilities
A chronic disability characterized by impaired muscle movement and posture
Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? Apply the lotion to areas of the rash only. Apply the lotion and leave it on for 6 hours. Avoid putting clothes on the child over the lotion. Apply the lotion to cool, dry skin at least 30 minutes after bathing.
Apply the lotion to cool, dry skin at least 30 minutes after bathing
The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary health care provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period? Monitor the temperature. Monitor the blood pressure. Reposition the infant frequently. Aspirate the NG tube every 5 to 10 minutes.
Aspirate the NG tube every 5 to 10 minutes
A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen? Catheterizing the infant using the smallest available Foley catheter Attaching a urinary collection device to the infant's perineum for collection Obtaining the specimen from the diaper by squeezing the diaper after the infant voids Noting the time of the next expected voiding and then preparing a specimen cup for the urine
Attaching a urinary collection device to the infant's perineum for collection
A school-age child with Down's syndrome is brought to the ambulatory care center by the mother. The child has bruising all over the body. To work most effectively with this child, the nurse first addresses which complication associated with Down's syndrome? Children with Down's syndrome are more likely to develop acute leukemia than the average child. Children with Down's syndrome fall down easily as a result of hyperflexibility and muscle weakness. Children with Down's syndrome are at risk for physical abuse because of their low intellectual functioning. Children with Down's syndrome scratch themselves a lot because of dry, cracked, and frequently fissuring skin.
Children with Down's are more likely to develop acute leukemia than the average child
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? Clear CSF, decreased pressure, and elevated protein level Clear CSF, elevated protein, and decreased glucose levels Cloudy CSF, elevated protein, and decreased glucose levels Cloudy CSF, decreased protein, and decreased glucose levels
Cloudy CSF, elevated protein, decreased glucose
The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? Cover the bladder with petroleum jelly gauze. Cover the bladder with a nonadhering plastic wrap. Apply sterile distilled water dressings over the bladder mucosa. Keep the bladder tissue dry by covering it with dry sterile gauze.
Cover the bladder with nonadhering plastic wrap
A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? "Has the child complained of back pain?" "Has the child complained of headaches?" "Has the child had any nausea or vomiting?" "Did the child have a sore throat or fever within the last 2 months?"
Did the child have a sore throat or fever within the last 2 months?
The nurse is teaching the parent of a preschool child how to administer the child's insulin injection. The child will be receiving 2 units of Humulin R insulin and 12 units of Humulin N insulin every morning. How should the nurse instruct the parents to prepare the insulin? Draw the insulin into separate syringes. Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe. Draw the Humulin N insulin first and then the Humulin R insulin into the same syringe. Check blood glucose first, and if the result is between 70 and 99 mg/dL (3.9 and 5.5 mmol/L), withhold the insulin injection.
Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe
The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? Enteric Contact Droplet Neutropenic
Droplet
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. Elevated C-reactive protein Elevated antistreptolysin O titer Presence of Reed-Sternberg cells Presence of group A beta-hemolytic strep Decreased erythrocyte sedimentation rate
Elevated C-reactive protein Elevated antistreptolysin O titer Presence of group A beta-hemolytic strep
A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? Elevated antistreptolysin O titer Decreased erythrocyte sedimentation rate Negative result on antinuclear antibody assay Negative result on C-reactive protein determination
Elevated antistreptolysin O titer
The nurse is caring for a child after surgical removal of a brain tumor. The nurse should assess the child for which sign that would indicate that brainstem involvement occurred during the surgical procedure? Inability to swallow Elevated temperature Altered hearing ability Orthostatic hypotension
Elevated temp
The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding? Frequent swallowing A decreased pulse rate Complaints of discomfort An elevation in blood pressure
Frequent swallowing
The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome? Hypertension Generalized edema Increased urinary output Frank, bright red blood in the urine
Generalized edema
The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis? Fear of the complicated treatment regimen Anger at the child for requiring hospitalization Guilt that they did not seek treatment more quickly Depression that the child may not be able to play sports
Guilt that they did not seek treatment more quickly
The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement by one of the parents indicates an understanding of the use of the harness? "I can remove the harness to bathe my infant." "I need to remove the harness to feed my infant." "I need to remove the harness to change the diaper." "My infant needs to remain in the harness at all times."
I can remove the harness to bathe my infant
The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates a need for further teaching? "I cannot place powder under the brace." "I need to place a soft shirt on my child under the brace." "I need to be sure to apply lotion on the skin under the brace." "I need to encourage my child to perform prescribed exercises."
I need to be sure to apply lotion
The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents. Which instruction should the nurse give to the parents? Maintain the child on bed rest for 2 weeks. Maintain respiratory precautions for 1 week. Notify the PHCP if the child develops abdominal pain or left shoulder pain. Notify the primary health care provider (PHCP) if the child develops a fever.
Notify the PHCP if the child develops abdominal pain or left shoulder pain
A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen? "I need to collect the specimen after I give my child a bath." "I need to collect the first bowel movement of the day and place it in a sealed container." "I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination." "I need to place a piece of transparent cellophane tape lightly over the anal area after my child has a bowel movement and bring it to the clinic for examination."
I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination
The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching? "I need to purchase the medication from the pharmacy." "After rinsing out the medication, I need to avoid washing my child's hair for 24 hours." "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours." "I need to shampoo my child's hair, apply the medication, and leave it on for 10 minutes and then rinse it out."
I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours
A 3-year-old child with human immunodeficiency virus infection is being discharged from the hospital. The nurse is providing discharge instructions to the mother regarding home care and infection control measures. Which statement by the mother indicates a need for further teaching? "I should discard any unused food and formula immediately." "I need to wash all vegetables carefully before preparing them." "If the nipple becomes soft and sticky, I will discard the nipple." "I will put the clean eating utensils, baby bottle, and dishes in the dishwasher."
I should discard any unused food and formula immediately
The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching? "I should place a steam vaporizer in my child's room." "I will take my child out into the cool, humid night air." "I could place a cool-mist humidifier in my child's room." "I will have my child inhale the steam from warm running water."
I should place a steam vaporizer in my child's room
An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes, and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the mother indicates an understanding of the care measures? "I will call the doctor if my child has abdominal or left shoulder pain." "I need to keep my child on bed rest for 3 weeks to discourage physical activity." "I will notify the primary health care provider if my child is still feeling tired in 1 week." "I need to isolate my child so that the respiratory infection is not spread to others."
I will call the doctor if my child has abdominal or left shoulder pain
The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction? "I'll check his temperature." "I'll give him medication so he'll be comfortable." "I'll check his voiding to be sure there's no problem." "I'll let him decide when to return to his play activities."
I'll let him decide when to return to his play activities
The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse would monitor the child specifically for central nervous system involvement by checking which item? Pupillary reaction Level of consciousness The presence of petechiae in the sclera Color, motion, and sensation of the extremities
LOC
The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? "It is extremely contagious." "It is most common in humid weather." "Lesions most often are located on the arms and chest." "It might show up in an area of broken skin, such as an insect bite."
Lesions most often are located on the arms and chest
The nurse is assessing a client with fragile X syndrome. The nurse anticipates noting which physical assessment finding? Low, straight palate Short, narrow protruding ears Long, narrow face with a prominent jaw Short, rounded face with an indiscernible jaw
Long, narrow face with a prominent jaw
A 2-year-old boy with a diagnosis of hemophilia is admitted to the hospital with bleeding into the joint of the right knee. Which intervention should the nurse plan to implement with this child? Measure the injured knee joint every shift. Take the temperature by rectal method only. Administer acetylsalicylic acid for pain control. Immobilize the joint and apply moist heat to the joint.
Measure the injured knee joint every shift
Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. Monitor the child's weight. Frequent hand washing is important. The child should avoid exposure to other illnesses. The child's immunization schedule will need revision. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.
Monitor the child's weight Frequent hand washing is important The child should avoid exposure to other illnesses Clean up body fluid spills with bleach solution
A child with a diagnosis of sickle cell anemia and vaso-occlusive crisis is complaining of severe pain, selecting number 8 on the 1 to 10 pain scale. Which medication would the nurse expect to be prescribed for pain control? Ibuprofen Meperidine Acetaminophen Morphine sulfate
Morphine sulfate
The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table with the knees pulled up toward the chest. What is the priority nursing action? Collect urine sample for urinalysis. Perform a pain assessment using the FACES scale. Prepare the child for magnetic resonance imaging. Notify primary health care provider of white blood cell count above 10,000 mm3 (10 × 109/L).
Perform a pain assessment using the FACES scale
Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction should the nurse include in the client's teaching plan? Schedule the procedures so they are 4 hours apart. Perform the breathing exercises and then the postural drainage. Perform the postural drainage first and then the breathing exercises. Perform postural drainage in the morning and breathing exercises in the evening.
Perform the postural drainage first and then the breathing exercises
The nurse is reviewing the primary health care provider's prescriptions for a child hospitalized with nephrotic syndrome. Which food should the nurse tell the assistive personnel to remove from the child's food tray? Pickle Wheat toast Baked chicken Steamed vegetables
Pickle
A child is brought to the emergency department after being accidentally struck in the lower back region with a baseball bat. When gathering assessment data, the nurse discovers that the child has hemophilia. The nurse should immediately assess for which data? Slurred speech Presence of hematuria Complaints of headache Change in respiratory rate
Presence of hematuria
The nurse is caring for a child with acquired immunodeficiency syndrome (AIDS) and notes the presence of mouth sores. The nurse provides instructions to the mother regarding maintaining adequate nutritional intake in the child. Which statement by the mother indicates a need for further teaching? "I should weigh my child each morning." "I will offer an iced pop to lick before meals." "Salty foods are very important to maintain an appropriate sodium level in the child." "Milk, juice, or water should really be offered after a meal rather than before a meal."
Salty foods are very important to maintain an appropriate sodium level in the child
A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? "It's very costly, and chemotherapy works just as well." "I'm not sure. I'll discuss it with the primary health care provider." "Sometimes age has to do with the decision for radiation therapy." "The primary health care provider would prefer that you discuss treatment options with the oncologist."
Sometimes age has to do with the decision for radiation therapy
The nurse is caring for a child following a tonsillectomy. The nurse should reposition the child on return from the operating room if the child is in which position? Prone Supine Left side-lying Right side-lying
Supine
The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child? Soccer Basketball Swimming Field hockey
Swimming
A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it was decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement is most appropriate to assist in alleviating the child's fear? "The pain medication that I give you will take these feelings away." "This aching and cramping is normal and temporary and will subside." "This pain is not real pain, and relaxation exercises will help it go away." "This normally occurs after the surgery, and we will teach you ways to deal with it."
The aching and cramping is normal and temporary and will subside
A child is brought to the emergency department, and diagnostic x-rays of the child reveal that a fracture is present. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. A plaster of Paris cast is applied to the arm. Which instructions should the nurse provide the mother? Select all that apply. The cast will mold to the body part. The cast should be dry in about 6 hours. Keep the cast elevated on pillows for the first day. Make sure that the child can frequently wiggle the fingers. The cast is water-resistant, so the child is able to take a bath or a shower. The cast needs to be kept dry because it will begin to disintegrate when wet.
The cast will mold to the body part Keep the cast elevated on pillows for the first day Make sure the child can frequently wiggle the fingers The cast needs to be kept dry because it will begin to disintegrate when wet
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? "I have a vase in the utility room, and I will get it for you." "I will get the vase and wash it well before you put the flowers in it." "The flowers from your garden are beautiful but should not be placed in the child's room at this time." "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."
The flowers from your garden are beautiful but should not be placed in the child's room at this time
Cerebral palsy (CP) is suspected in a child, and the parents ask the nurse about the potential warning signs of CP. The nurse should provide which information? Select all that apply. The infant's arms or legs are stiff or rigid. A high risk factor for CP is very low birth weight. By 8 months of age, the infant can sit without support. The infant has strong head control but a limp body posture. The infant has feeding difficulties, such as poor sucking and swallowing. If the infant is able to crawl, only one side is used to propel himself or herself.
The infant's arms or legs are stiff or rigid. A high risk factor for CP is very low birth weight. The infant has feeding difficulties, such as poor sucking and swallowing. If the infant is able to crawl, only one side is used to propel himself or herself.
A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate? "The infectious period occurs after the lesions begin." "The infectious period begins with the onset of the rash." "The infectious period is not known, and it is possible that the children may develop the chickenpox within the next 2 weeks." "The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions."
The infection period begins 1-2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions
After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? Turn the child to the side. Administer the prescribed antiemetic. Maintain NPO (nothing by mouth) status. Notify the primary health care provider (PHCP).
Turn the child to the side
Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which intervention? Restrict oral fluids. Use good hand-washing technique. Give immunizations appropriate for age. Institute strict isolation with no visitors allowed.
Use good hand-washing technique
A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? During sleep When changing the infant's diapers When the mother is holding the infant When drawing blood for electrolyte level testing
When drawing blood for electrolyte level testing
The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? Retake the apical pulse. Administer the medication. Withhold the medication for 1 hour. Withhold the medication and notify the primary health care provider.
Withhold the medication and notify the PHCP
The nurse is counseling the young mother of a small child recently diagnosed with impetigo. The nurse should make which statement that provides the best information about impetigo? "The main treatment while your daughter has impetigo will be to force fluids." "Your daughter probably caught the impetigo because you don't wash her hands enough." "There is no risk of passing impetigo to the other children once you begin the prescribed antibiotics." "You will need to prevent any of the fluid from the blisters from coming into contact with your other children."
You will need to prevent any of the fluid from the blisters from coming into contact with you other children
The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF? Transmitted as an autosomal dominant trait A chronic multisystem disorder affecting the exocrine glands A disease that causes the formation of multiple cysts in the lungs A disease that causes dilation of the passageways of many organs
A chronic multisystem disorder affecting the exocrine glands
The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate? Encourage the child to keep the arm elevated. Report the findings to the primary health care provider. Document the findings and reassess the arm in 4 hours. Tell the child that this is normal while the cast is drying.
Report the findings to the primary health care provider
The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment? Reports of frothy stools and diarrhea Reports of foul-smelling ribbon stools Reports of profuse, watery diarrhea and vomiting Reports of diffuse abdominal pain unrelated to meals or activity
Reports of frothy stools and diarrhea
After hydrostatic reduction for intussusception, the nurse should expect to observe which client response? Abdominal distension Currant jelly-like stools Severe, colicky-type pain with vomiting Passage of barium or water-soluble contrast with stools
Passage of barium or water-soluble contrast with stools
The nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous potassium for the treatment of dehydration. Which assessment finding requires the need to notify the primary health care provider? Weight increase of 0.5 kg Temperature of 100.8º F (38.2º C) rectally Blood pressure unchanged from baseline A decrease in urine output to 0.5 mL/kg/hr
Blood pressure unchanged from baseline (Is what it said was correct, however this is the rationale: The priority assessment is to assess the status of urine output. Potassium should never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium should not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A blood pressure that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data... not sure why it is having the wrong answer as correct here)
A school nurse is teaching parents about emergency treatment for epistaxis. Which best action should the nurse take to assist the parents in understanding the emergency treatment? Tell the parents the steps to take when a nosebleed occurs. Show the parents a video of the steps to take if a nosebleed occurs. Give the parents a brochure about the emergency treatment for nosebleeds. Ask the parents to demonstrate, on a mannequin, where to apply continuous pressure if a nosebleed occurs.
Ask the parents to demonstrate
An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction should the nurse provide to the adolescent regarding home care for treatment of the sprain? Elevate the extremity, and maintain strict bed rest for a period of 7 days. Immobilize the extremity, and maintain the extremity in a dependent position. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.
Apply ice
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition? Full range of motion in the affected hip An apparent short femur on the unaffected side Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
Asymmetry of the gluteal skin folds
The nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing and notes the presence of dried blood on the back of the dressing. The child is alert and oriented, and the vital signs and neurological signs are stable. Which nursing action is most appropriate initially? Prepare to change the dressing. Recheck the dressing in 1 hour. Check the operative record to determine whether a drain is in place. Document the findings and notify the primary health care provider immediately.
Check the operative record to determine whether a drain is in place
The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? Increase the dose of ibuprofen. Increase the frequency of ibuprofen. Encourage the child to lie on the left side. Encourage the child to lie on the right side.
Encourage the child to lie on the right side
The parents of a newborn have been told that their child was born with bladder exstrophy, and the parents ask the nurse about this condition. Which explanation, given by the parents, indicates understanding of this condition? "It's a hereditary disorder that occurs in every other generation." "It is caused by the use of medications taken by the mother during pregnancy." "It is a condition in which the urinary bladder is abnormally located in the pelvic cavity." "It's an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."
Extrusion of the urinary bladder to the outside of the body
The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? Fine grayish red lines Purple-colored lesions Thick, honey-colored crusts Clusters of fluid-filled vesicles
Fine grayish red lines
After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position? Prone Supine High-Fowler's Trendelenburg's
Prone
The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness? "I know that the harness must be worn continuously." "I will bring my child back to the orthopedic office in a month or two so the straps can be checked." "I realize that I will also need to put two diapers on my child so that the harness will stay dry and does not get soiled." "I will watch for any redness or skin irritation where the straps are applied and call the primary health care provider for red areas."
I will watch for any redness or skin irritation
The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child? "Has the child had any sore throats?" "Has the child been eating properly?" "Is the child allergic to any antibiotics?" "Has the child been exposed to any infections?"
Is the child allergic to any antibiotics?
A mother calls the primary health care provider's office requesting an appointment for her 8-year-old child. She states he has asthma and is telling her he had trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the mother? "Is your child crying and irritable?" "Does your child have a productive cough?" "Did he have a temperature last night of greater than 100º F (37.8º C)?" "Is your child telling you at this time he is having trouble breathing?"
Is your child telling you at this time he is having trouble breathing?
An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? "I should obtain new contact lenses." "I should not wear my contact lenses." "My old contact lenses should be discarded." "My contact lenses can be worn if they are cleaned as directed."
My contact lenses can be worn if they are cleaned as directed
The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the pediatrician's prescriptions and should contact the pediatrician to question which prescription? Obtain daily weight. Provide clear liquid intake. Nasotracheal suction as needed. Maintain a patent intravenous line.
Nasotracheal suction as needed
A 14-year-old child is admitted to the hospital with a diagnosis of acute lymphocytic leukemia. She is receiving a combination chemotherapeutic regimen that includes cyclophosphamide. The nurse plans care understanding that which are associated with this medication? Select all that apply. It is platelet sparing. It causes constipation. It causes hemorrhagic cystitis. It causes bone marrow depression. Increased fluid intake is necessary.
Platelet spraing Hemorrhagic cystitis bone marrow depression increased fluids
The nurse is initiating nasogastric tube feedings in a child. What is the nurse's best action? Microwave the formula. Place the child in a prone position. Encourage the child to point the head downward. Position the child with the head slightly hyperflexed.
Position the child with the head slightly hyperflexed
The nurse is assigned to care for a child following surgery to correct cryptorchidism. Which priority action should the nurse include in the plan of care following this type of surgery? Prevent tension on the suture. Monitor urine for glucose and acetone. Force oral fluids, and monitor intake and output. Encourage coughing and deep breathing every hour.
Prevent tension on the suture
The nurse is caring for a child with hemophilia and is reviewing the results that were sent from the laboratory. Which result should the nurse expect in this child? Shortened prothrombin time (PT) Prolonged PT Shortened partial thromboplastin time (PTT) Prolonged PTT
Prolonged PTT
Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? Elevated hemoglobin level Decreased reticulocyte count Elevated red blood cell count Red blood cells that are microcytic and hypochromic
Red blood cells that are microcytic and hypochromic
Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. Maintain the child in a semiprivate room. Reduce exposure to environmental organisms. Use strict aseptic technique for all procedures. Ensure that anyone entering the child's room wears a mask. Apply firm pressure to a needle-stick area for at least 10 minutes.
Reduce exposure to environmental organisms Use strict aseptic technique Ensure that anyone entering the child's room wears a mask
An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? Test the urine for protein. Reposition the infant frequently. Provide a stimulating environment. Assess blood pressure every 15 minutes.
Repositions the infant frequently
The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? Restrict fluids as prescribed. Care for the arteriovenous fistula. Encourage foods high in potassium. Administer analgesics as prescribed.
Restrict fluids as prescribed
During a clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about CF? CF causes mucus that is formed to be abnormally thick. It is a condition transmitted as an autosomal recessive trait. This disease causes dilation of the passageways of many organs. It is a chronic multisystem disorder affecting the exocrine glands.
This disease causes dilation of the passageways of many organs
The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective? "We're glad we only have to give our child the medication for 30 days." "We will make appointments for follow-up blood work and care as directed." "We're glad there are no side effects from taking the antiseizure medications." "After our child has been seizure free for 1 month, we can discontinue the medication."
We will make appointments for follow-up blood work and care as directed
