Peds 4th quarter ch. 28,29, and 30
The nurse is weighing an 18-month-old infant who is in the clinic for a well-child visit. Which of the following actions by the nurse would be most appropriate for weighing this child? a) The nurse should weigh the mother on a standing scale and then weigh her again while the mother is holding the infant. b) The nurse should lay the infant on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. c) The nurse should ask the mother to lightly hold the infant's hands while the infant is sitting on the scale. d) The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
The nurse is caring for a preschooler who is hospitalized with a suspected blood disorder and receives an order to draw a blood sample. Which approach is best? a) "I need to take some blood." b) "Why don't you sit on your mom's lap?" c) "We need to put a little hole in your arm." d) "I need to remove a little blood."
"Why don't you sit on your mom's lap?"
The nurse is setting up a room in the clinic with necessary equipment for a healthy 2 year old. Blood pressure monitoring becomes part of the routine health assessment at what age? a) 4 years b) 2 years c) 1 year d) 3 years e) Birth
3 years
The nurse determines a parent understands a hospitalized toddler's need for transitional objects when the parent states: a) I'd like to get him some toys from the playroom." b) "He insisted on bringing this dirty old blanket with him." c) This stuffed animal makes him feel secure." d) I'm going to buy him a big stuffed animal from the gift shop."
"He insisted on bringing this dirty old blanket with him."
The nurse is caring for a preschooler who requires postsurgical breathing exercises. Which of the following approaches will best elicit the child's cooperation? a) "You need to do the breathing or you could get pneumonia." b) "Do you want to play a breathing exercise game with me?" c) "You will need to cooperate. Otherwise, you might not feel better." d) "Let's see who can blow these cotton balls off the table first."
"Let's see who can blow these cotton balls off the table first."
The nurse is discussing taking a temperature on a child with a group of nursing students in a post-conference setting. Which of the following statements made by the nursing students is most accurate related to taking a temperature? a) "Rectal temperatures should not be taken on a child with diarrhea." b) "A rectal temperature is usually 0.5° to 1.0° lower than the oral measurement." c) "Tympanic temperatures should not be taken on a child who is sleeping." d) "An axillary temperature usually measures 0.5° to 1.0° higher than the oral measurement."
"Rectal temperatures should not be taken on a child with diarrhea."
A nurse is preparing to admit a child for a tonsillectomy. How should the nurse establish rapport? a) "Tell me about your cute stuffed dog you have." b) "Let's take a look at your tonsils." c) "Are you scared about having your tonsils out?" d) "Do you understand why you are here?"
"Tell me about your cute stuffed dog you have."
The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond? a) "Your daughter has acrocyanosis; this is causing her blue hands and feet." b) "This is a vasomotor response caused by cooling or warming." c) "Let's watch her carefully to make sure she does not have a circulatory problem." d) "This is normal; her circulatory system will take a few days to adjust."
"This is normal; her circulatory system will take a few days to adjust."
Normal respiratory rate(per minute) for a 3 year-old is: a) 20-30 b) 40-50 c) 30-40 d) 10-20
20-30
The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which of the following sites to obtain an accurate assessment? a) Brachial pulse b) Apical pulse at the fourth or fifth intercostal space at the midclavicular line c) Radial pulse d) Apical pulse at the third or fourth intercostal space
Apical pulse at the third or fourth intercostal space
The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. Which of the following is the most appropriate way to gather information from the child's caregiver? a) Have the child read the questions to the caregiver and then write down the answers on the form. b) Ask the caregiver if they can read or if they need someone to read the questions on the admission form to them. c) Have the caregiver sit in a quiet room and fill out a questionnaire. d) Ask the caregiver questions and write the answers down.
Ask the caregiver questions and write the answers down.
A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following? a) X-ray b) Inserting air into the tube and listening for sounds in the stomach c) Aspirating stomach contents and checking pH d) It is not necessary to check each time.
Aspirating stomach contents and checking pH
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child? a) Axillary method b) Oral thermometer c) Temporal scanning d) Rectal route
Axillary method
The nurse is taking an apical pulse on an infant. The nurse should place the stethoscope at which of the following sites? a) Below the ribs about one half of an inch b) Between the sternum and the left nipple c) Above the clavicle on the left side d) Above the sternum, slightly to the right
Between the sternum and the left nipple
The nurse who wishes to be as supportive as possible to the hospitalized preschooler makes great effort to avoid threatening the 4-year-old's: a) Verbal skills b) Food preferences c) Creativity d) Body integrity
Body integrity
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? a) Closed anterior fontanel and open posterior fontanel b) Open anterior and posterior fontanels c) Closed anterior and posterior fontanels d) Open anterior fontanel and closed posterior fontanel
Closed anterior and posterior fontanels
A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first? a) Family profile b) Details about the fever c) History of past illnesses d) Review of systems
Details about the fever
Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which of the following types of restraints would the nurse most likely use for this child? a) Jacket restraint b) Clove hitch restraint c) Elbow restraints d) Mummy restraint
Elbow restraints
A pediatric nurse caring for an 8 year old who is having pain would use which of the following scales to assess the child's pain? a) FACES scale b) Color scale c) Apgar scale d) Braden scale
FACES scale
Anna, a 4-year-old is brought to the clinic by her mother complaining of ear pain. Which of the following would the nurse most likely do when examining Anna's ears? a) Grasp the pinna and look inside. b) Grasp the pinna and pull down and back c) Grasp the pinna and pull up and back d) Grasp the pinna and pull forward
Grasp the pinna and pull up and back
The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which of the following behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? a) He forms superficial relationships with his caregivers. b) He cries uncontrollably whenever they leave. c) He sits quietly and is uninterested in playing and eating. d) He ignores his parents when they return to his room.
He sits quietly and is uninterested in playing and eating.
The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which of the following statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child? a) Include the child in all parts of the examination; speak to the caregiver before and after the examination. b) Address the child by name; speak to the caregiver and do the most invasive parts last. c) Keep up a running dialogue with the caregiver, explaining each step as you do it. d) Speak to the child using mature language and appeal to his or her desire for self-care.
Include the child in all parts of the examination; speak to the caregiver before and after the examination.
How will the nurse determine the length of orogastric tubing needed to gavage the 14-month-old infant? a) Measure from nose tip to earlobe to end of sternum b) Measure from nose tip to earlobe to halfway between xiphoid and umbilicus c) Measure from mouth to umbilicus d) Measure from bridge of the nose to tip of the xiphoid
Measure from nose tip to earlobe to end of sternum
The nurse is helping the care provider with a scalp venipuncture on an infant. Which of the following restraints would be the most appropriate for this procedure? a) Clove-hitch restraint b) Elbow restraint c) Mummy restraint d) Jacket restraint
Mummy restraint
The nurse is caring for an 11-year-old admitted with a respiratory condition. Which of the following methods of oxygen administration would likely be used for this child? a) Nasal prongs b) Tent c) Mask d) Hood
Nasal prongs
A nurse receives a physician's order to collect a specimen for the diagnosis of respiratory syncytial virus. How should the nurse collect this specimen? a) Obtain a urine specimen. b) Obtain a stool specimen. c) Obtain a throat culture. d) Obtain a nasal washing.
Obtain a nasal washing.
A 6 year old will be hospitalized for a surgical procedure. How can the nurse best ease the stress of hospitalization for this child? a) Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital. b) Have another child talk with the child to be hospitalized. c) There is no way to adequately prepare a child for an impending hospitalization. d) Tell the parents to bring toys for the child from home.
Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital.
The nurse is caring for a 10-year-old girl who is in an isolation room. Which of the following interventions would be a priority intervention for this child? a) Provide age-appropriate toys and games. b) Discourage visits from family members. c) Reduce noise as much as possible. d) Put on mask prior to entering the room.
Provide age-appropriate toys and games.
The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate? a) Radial b) Pedal c) Femoral d) Brachial
Radial
A nurse is unsure whether the nasogastric (NG) tube just placed is properly positioned in the child's stomach. How can the nurse most accurately verify the location of the tube? a) Seek radiologic confirmation b) Inject air and listen with a stethoscope for a "whoosh" c) Aspirate enteral fluid and check pH d) Measure length of tubing extending from the naris
Seek radiologic confirmation
Where is the point of maximal impulse (PMI) found in Lucy who is 5 years old? a) The PMI is at the clavicle. b) The PMI is at the third intercostal space. c) The PMI is at the fourth intercostal space. d) The PMI is at the sternum.
The PMI is at the fourth intercostal space.
What is the primary purpose for rooming-in on pediatric units? a) The caregiver can help with basic care. b) The caregiver is there for the patient when the nurse is busy. c) The caregiver provides security and stability. d) The caregiver can assist the nurse during staff shortages.
The caregiver provides security and stability.
The nurse is collecting subjective data when doing which of the following? a) The nurse is weighing and measuring the child. b) The nurse is interviewing the child's caregiver. c) The nurse is taking the child's vital signs. d) The nurse is reinforcing teaching with the child's caregivers.
The nurse is interviewing the child's caregiver.
The mother of 2-year-old triplets is anxious and worried because one of the children, Emily, does not seem to be at the same developmental level as her siblings. If the following findings were found when doing a physical exam, which finding might indicate a need for further diagnostic testing to rule out intellectual disability in this child? a) She blows her nose frequently. b) The tops of her ears are below the corners of her eyes. c) She speaks loudly when asked a question. d) The fontanels on her head are closed.
The tops of her ears are below the corners of her eyes.
A nurse is preparing to start an intravenous (IV) line on a 5 year old. Where does the nurse understand the procedure should be performed so that the child's "safe place" will not be disrupted? a) The emergency department b) The child's room c) The treatment room d) The operating room
The treatment room
The nurse is performing a physical examination on a sleeping newborn. Which of the following body systems should the nurse examine last? a) Lungs b) Abdomen c) Throat d) Heart
Throat
All infants should have their head circumference measured at health-assessment visits. This measurement is made from a) the middle of the forehead through the parietal prominences. b) just above the eyebrows through the prominent part of the occiput. c) the center of the forehead to the base of the occiput. d) the hairline in front to the hairline in back.
just above the eyebrows through the prominent part of the occiput.
On the first postoperative day, a 4 year old who was hospitalized for an emergency appendectomy has begun to cry relentlessly, will not let the nurse touch her, and keeps asking for her mother. The pediatric nurse is aware that this patient is in which stage of separation? a) protest b) despair c) grief d) denial
protest
A urine specimen has been ordered for a 2-year-old girl who has not been potty trained. Which of the following methods would be the best way for the nurse to obtain this urine specimen? a) Give the child some water or juice, leave off her diaper, and ask the caregiver to call you when the child needs to void and obtain the specimen in a sterile container. b) Get down on the child's level and speak to her explaining that you need her to tell you when she needs to use the bathroom and when she does, obtain the specimen. c) Clean the child's genital area thoroughly and when she has urinated, squeeze the urine from her diaper into a specimen cup. d) Place a sterile cotton ball into the child's diaper then after child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab.
Place a sterile cotton ball into the child's diaper then after child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab.
The nurse is interviewing an adolescent. Which of the following should the nurse recognize as an important aspect of interviewing the adolescent? a) The adolescent will not likely share information related to sexual relationships or to use of substances. b) The adolescent will share more about themselves in a private conversation. c) The adolescent should be asked if they would like a peer in the room during the interview. d) The adolescent will talk more openly if their caregivers are in the same room.
The adolescent will share more about themselves in a private conversation.
An adolescent is scheduled to have the present gastrostomy tube replaced with a gastrostomy button. What advantage of the button over the tube will the nurse emphasize? a) The button will be smaller and less visible when not in use. b) Aspiration for residual is unnecessary. c) The button will not need flushing. d) Replacement of the button on a regular basis is rarely needed.
The button will be smaller and less visible when not in use.
The nurse working on the pediatric unit is talking with the child-life specialist. The nurse asks the specialist what the technique is called in which activities are used to help the child have a better understanding of what will be happening to him or her in a specific situation. Which of the following best describes what the nurse is discussing? a) Play therapy b) Cooperative play c) Onlooker play d) Therapeutic play
The nurse working on the pediatric unit is talking with the child-life specialist. The nurse asks the specialist what the technique is called in which activities are used to help the child have a better understanding of what will be happening to him or her in a specific situation. Which of the following best describes what the nurse is discussing? a) Play therapy b) Cooperative play c) Onlooker play d) Therapeutic play
The nurse in the pediatric unit is caring for a child admitted with a neurologic disorder. The nurse is using the Glasgow coma scale to monitor the child. Which of the following is the most accurate related to the Glasgow coma scale? a) The scale is used to compare the child's results with other children of the same age. b) The scale measures the verbal and motor responses of the child. c) The scale is used one or two times a day to note changes in the neurologic status. d) The scale monitors the child's vision by using a bright flashlight.
The scale measures the verbal and motor responses of the child.
A nurse encourages a school-age child to draw a picture after a painful procedure. The best rationale for this intervention is that the nurse is: a) encouraging quiet play. b) attempting to re-establish rapport. c) providing a way for the child to express his feelings. d) distracting the child from thinking about the pain.
providing a way for the child to express his feelings.
The nurse is taking health history for a toddler in the emergency department. The child's mother informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection 6 weeks ago. What would the nurse recognize as is the patient's chief concern/complaint? a) pneumonia b) vomiting c) asthma d) UTI
vomiting
Which of the following are situations that might warrant a restraint of a pediatric patient? (Select all that apply.) a) to ensure the child's safety b) to protect the child from injury during a procedure or examination c) to teach a child how to be cooperative d) to keep an active child confined to bed
• to protect the child from injury during a procedure or examination • to ensure the child's safety
The nurse is measuring the head circumference of a newborn during a well-child visit. The mother asks the nurse, "How long will you need to measure this?" The nurse responds to the mother, stating that this measurement will be made until the child reaches which age? a) 18 months b) 12 months c) 24 months d) 6 months
24 months
The nurse is caring for a 10-year-old boy who had an appendectomy 2 days ago. Prior to surgery he had expressed that he was worried that after the procedure he would hurt and have lots of pain. The nurse asks the child what his pain level is on a scale of 0 to 10, with 10 being the worst pain. He tells the nurse he has no pain. The most appropriate action by the nurse would be to a) Ask him to show you his pain level using the color pain scale. b) Explain to his caregiver that his pain level shows he is getting better quickly. c) Observe him for physical signs which might indicate pain. d) Tell him to let you know if he begins to feel pain.
Observe him for physical signs which might indicate pain.
The nurse is caring for a client needing oxygen. Many forms of oxygen delivery can be used. Which of the following is the most difficult to manage the oxygen concentration? a) Oxygen tent b) Oxygen hood c) Nasal prongs d) Mask
Oxygen tent
The nurse has been assigned to care for a child who is on transmission-based precautions. This nurse has not cared for this child before. Which of the following actions would be the best way to help the child feel comfortable with the nurse? a) Ask the previous nurse to introduce the new nurse. b) Let the child see his or her face before the mask is put on. c) Remind the child that her caregivers will be in to visit soon. d) Read to the child for a few minutes before starting care.
Let the child see his or her face before the mask is put on.
