Peds Exam 3 Review

The nurse is collecting data for a child diagnosed with nonorganic failure to thrive, and notes that the child voluntarily vomits after eating. This is referred to as: A. encopresis. B. rumination. C. tolerance. D. self-inflicted starvation.

B. rumination. Rationale: A common characteristic noted in the child with nonorganic failure to thrive is rumination (voluntary regurgitation), perhaps as a means of self-satisfaction when the desired response is not received from the caregiver.

The nurse is caring for an 8-month-old infant with a suspected congenital heart defect. The nurse examines the child and documents which expected finding? A. steady weight gain since birth B. softening of the nail beds C. appropriate mastery of developmental milestones D. intact rooting reflex

B. softening of the nail beds Rationale: Softening of nail beds is the first sign of clubbing due to chronic hypoxia. Rounding of the fingernails is followed by shininess and thickness of nail ends.

The nurse cares for an infant with myelomeningocele before surgical intervention. What action will the nurse take? A. Keep the mass uncovered and dry. B. Prevent cold stress using an isolette and blankets. C. Cover the sac with a saline-moistened dressing. D. Change position from side to side hourly.

C. Cover the sac with a saline-moistened dressing. Rationale: Protection of exposed neural tissue is of high priority. Keeping the cystic mass moist prevents damage to neural elements from drying. Blankets may cause trauma to the sac. An isolette can be used for warmth, but much attention will have to be directed toward keeping the sac moist.

To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority? A. Cerebral edema B. Renal failure C. Left-sided heart failure D. Cardiogenic shock

A. Cerebral edema Rationale: The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload.

During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? A. Dramatic increase in head circumference B. Pupil of one eye dilated and reactive C. Vertical nystagmus D. Posterior fontanel (fontanelle) is closed

A. Dramatic increase in head circumference Rationale: A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain. Only one pupil that is dilated and reactive is a sign of an intracranial mass. Vertical nystagmus indicates brain stem dysfunction. A closed posterior fontanel (fontanelle) would be frequently seen by this age.

The nurse is caring for a child with a fractured femur in traction. Which action will the nurse complete while caring for this client? A. Ensure traction weights are hanging freely, not touching the bed or floor. B. Remove traction weights once per shift for 30 minutes and then replace them. C. Plan to add additional weights as the fracture heals, usually once per day. D. Have the unlicensed assistive personnel remove the weights daily and encourage the child to move around in bed.

A. Ensure traction weights are hanging freely, not touching the bed or floor. Rationale:

A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? A. Peeling hands and feet; fever B. Decreased heart rate and impalpable pulse C. Irritability and dry mucous membranes D. Low blood pressure and decreased heart rate

A. Peeling hands and feet; fever Rationale: Kawasaki disease is an acute systemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region. The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue.

The nurse is conducting an assessment of a 7-year-old client. During the assessment, the nurse notes that the child does not maintain eye contact or speak. The nurse suspects an autism spectrum disorder. Which additional finding supports the nurse's suspicion? A. The child constantly opens and closes the hands. B. The child is highly active and inattentive. C. The child has a slight decrease in head circumference. D. The child has difficulty reading.

A. The child constantly opens and closes the hands. Rationale: Repetitive motor mannerisms such as constantly opening and closing the hands are a typical behavior pattern for autism spectrum disorder. A high level of activity and inattentiveness are typical symptoms of intellectual disability. Decrease in head circumference suggests malnutrition or decelerating brain growth. Difficulty reading can indicate dyslexia, a common learning disability.

The nurse is caring for a girl with anorexia who has been hospitalized with unstable vital signs and food refusal. The girl requires enteral nutrition. The nurse is alert for which complications that signal refeeding syndrome? A. cardiac arrhythmias, confusion, seizures B. orthostatic hypotension and hypothermia C. hypothermia and irregular pulse D. bradycardia with ectopy and seizures

A. cardiac arrhythmias, confusion, seizures Rationale: The nurse should be aware that rapid nutritional replacement in the severely malnourished can lead to refeeding syndrome. Refeeding syndrome is characterized by cardiovascular, hematologic, and neurologic complications such as cardiac arrhythmias, confusion, and seizures. Orthostatic hypotension, hypertension, and irregular and decreased pulses are complications of anorexia but do not characterize refeeding syndrome.

The nurse is caring for a 2-year-old boy with cerebral palsy (CP). The medical record indicates "hypertonicity and permanent contractures affecting both extremities on one side." Based on these findings, the nurse identifies this type of CP as: A. spastic. B. athetoid or dyskinetic. C. ataxic. D. mixed.

A. spastic. Rationale: Spastic involves hypertonicity and permanent contractures on both extremities on one side. Athetoid (dyskinetic) involves abnormal involuntary movements affecting all four extremities and sometimes the face, neck, and tongue. Ataxic affects balance and depth perception. Spastic affects the lower extremities. Mixed is a combination of spastic, athetoid and ataxic.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? A. Take vital signs every 4 hours B. Monitor temperature every 4 hours C. Decrease environmental stimulation D. Encourage the parents to hold the child

C. Decrease environmental stimulation Rationale: A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours.

The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? A. Sudden, momentary loss of muscle tone, with a brief loss of consciousness B. Muscle tone maintained and child frozen in position C. Brief, sudden contracture of a muscle or muscle group D. Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention

D. Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Rationale: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.

The nurse is caring for a child with a suspected head injury. The nurse observes for what response to the child's eye reflex examination that would indicate potential increased intracranial pressure (ICP)? A. While turning the child's head to the left, the eyes turn to the right. B. While stimulating the child's foot, the big toe points upward and other toes fan outward. C. While calling the child's name, the child stares straight ahead and does not turn to the sound. D. While assessing the child's pupils, there is no change in diameter in response to a light

D. While assessing the child's pupils, there is no change in diameter in response to a light Rationale: Lack of pupillary light reflex can indicate increased intracranial pressure (ICP).

The nurse is conducting a physical examination of a 9-month-old infant with a suspected neuromuscular disorder. Which finding would warrant further evaluation? A. presence of symmetrical spontaneous movement B. absence of Moro reflex C. absence of tonic neck reflex D. presence of Moro reflex

D. presence of Moro reflex Rationale: The persistence of a primitive reflex in a 9-month-old would warrant further evaluation. Symmetrical spontaneous movement and absence of the Moro and tonic neck reflexes are expected in a normally developing 9-month-old child.

What finding would suggest that a 5-year-old boy might have a developmental disorder? A. The child is not able to follow directions. B. The child must be supervised when brushing his teeth. C. The child knows what a dog and a cat sound like. D. The child has trouble with R, L, and Y sounds.

A. The child is not able to follow directions. Rationale: A 5-year-old child should be able to follow simple directions. If he is unable to do this, he has not yet achieved a developmental milestone. Brushing his teeth with supervision and knowing cat and dog sounds are normal for this age. Having trouble with R, L, and Y sounds is not unusual and may continue until age 7.

When reviewing the record of a child with tetralogy of Fallot, what would the nurse expect to discover? A. Leukopenia B. Polycythemia C. Increased platelet level D. Anemia

B. Polycythemia Rationale: Tetralogy of Fallot is a congenital heart defect causing decreased pulmonary blood flow. This causes mild to severe oxygen desaturation. To compensate for the low blood oxygenation the kidneys produce erythropoietin to stimulate the bone marrow to make more red blood cells (RBCs). The increased amount of RBCs is known as polycythemia. This increased blood volume causes more workload on the heart. It also does not increase the amount of blood reaching the lungs so the child remains desaturated.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority? A. Place the child in a knee-to-chest position. B. Use a calm, comforting approach. C. Provide supplemental oxygen. D. Administer morphine as prescribed.

A. Place the child in a knee-to-chest position.

The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority? A. Place the child in a knee-to-chest position. B. Use a calm, comforting approach. C. Provide supplemental oxygen. D. Administer morphine as prescribed.

A. Place the child in a knee-to-chest position. Rationale: The priority nursing action is to place the child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as prescribed. A calm, comforting approach should be used but is not the priority action.

A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges? A. Positive Kernig sign B. Negative Brudzinski sign C. Positive Chadwick sign D. Negative Kernig sign

A. Positive Kernig sign Rationale: A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition.

What is an example of impaired adaptive functioning in an 8-year-old girl with a developmental disorder? A. The child cannot correctly copy a phone number. B. The child cannot properly dress herself. C. The child's vision is fine but she is a poor reader. D. The child cannot correctly copy a sentence.

B. The child cannot properly dress herself. Rationale: A child with impaired adaptive functioning would not be able to dress herself properly, if at all. The inability to copy a phone number or sentence, or to read well, reflects learning disorders.

The nurse is caring for a child admitted with focal onset motor seizures (simple partial motor seizures). Which clinical manifestation would likely have been noted in the child with this diagnosis? A. The child had jerking movements in the legs and facial muscles. B. The child had shaking movements on one side of the body. C. The child was rubbing the hands and smacking the lips. D. The child was dizzy and had decreased coordination.

B. The child had shaking movements on one side of the body. Rationale: A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part. A focal onset sensory seizure may include sensory symptoms called an aura, which signals an impending attack.

The nurse is examining a child with fetal alcohol spectrum disorder. Which assessment finding should the nurse expect? A. macrocephaly B. low nasal bridge with short upturned nose C. clubbing of fingers D. short philtrum with thick upper lip

B. low nasal bridge with short upturned nose Rationale: Typical facial features in an infant with fetal alcohol spectrum disorder include a low nasal bridge with short upturned nose, flattened midface, and a long philtrum with narrow upper lip. Microcephaly rather than macrocephaly is associated with fetal alcohol spectrum disorder. Clubbing of fingers is associated with chronic hypoxia.

The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status? A. "She always cries when the person holding her has on glasses...I guess glasses scare her." B. "She typically breastfeeds, but lately we have had to supplement with some oat cereal." C. "She has been irritable for the last hour....seems like she is just upset for some reason." D. "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper."

C. "She has been irritable for the last hour....seems like she is just upset for some reason." Rationale: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.

The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure? A. "The child will be held by the mother on her lap with his back toward the health care provider." B. "When positioning the child, the nurse needs to assist the child to a side-lying position and keep his back as flat as much as possible." C. "The child will be placed in the prone position with the nurse holding the child still." D. "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back."

D. "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." Rationale: Correct positioning for a lumbar puncture is to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.

The nurse is caring for a child diagnosed with Duchenne muscular dystrophy and notes the presence of a Gower sign on the assessment form. What action by the child would support this assessment? A. the presence of a waddling gait and difficulty climbing stairs B. a short heel cord caused by walking on the toes C. meeting motor milestones such as sitting, walking, and standing but at a later age than the average child D. when on the floor, rising to the knees and pressing the hands against the ankles, knees, and thighs to stand

D. when on the floor, rising to the knees and pressing the hands against the ankles, knees, and thighs to stand Rationale: A Gower sign is when children "walk up their front." When on the floor, the only way they can stand is to roll on their stomach and push themselves up to their knees. They then press their hands against their ankles, knees, and thighs.