Prep-U chapter 31
During the health history of a 2-week-old neonate, the nurse discovers the child has not yet had a hearing screening. Which of the following should the nurse schedule?
Auditory brain stem response test
The nurse has just finished administering the DTaP vaccine to a 2-month-old and is educating the parent about immunization. Which of the following statements is accurate?
"Bring her back for the second dose when she is 4 months old."
What is the most important way to increase immunization awareness?
Education of parents and families
What will the nurse ask the school-age patient when a vibrating tuning fork is placed at the middle of the top of the child's head?
"Do you hear the sound in one or both ears?"
The nurse is discussing measles, mumps, and rubella vaccination with a mother who is concerned about using the combined vaccine for her 12-month-old. Which of the following statements by the nurse will be most helpful to the mother in accepting the vaccine?
"The vaccine is shown to be effective and safe and will reduce the number of injections your child will need."
Which question by the nurse is the best one to elicit complete information about a young boy's immunization status?
"When and where did your child receive his last immunization?"
A mother tells the nurse that she is newly pregnant and asks about her 15-month-old's need for the chicken pox immunization because her two older children did "fine" when they had the disease. What is the nurse's best response?
"When your child avoids chicken pox, it protects other children from being exposed to the disease. Some cannot be immunized because of their health conditions."
During a health maintenance visit, the nurse determines that a 12-year-old boy is overweight for his age and height. Which of the following approaches for promoting healthy weight will help the boy maintain his self-esteem?
Emphasizing how activity and a nutritious diet promote health
Julie calls the doctor's office to let them know that her son Jacob has had a fever and a runny nose. Julie wants to know if she should still bring him for his 15-month immunizations. What is the appropriate response from the nurse?
"Yes, bring him in, he can still have his shots."
Children in what age range are screened by nurses using the Denver II Screening Test?
0 to 6 years
A dental home (like a medical home) establishes a continuing comprehensive relationship of care with the child and family. The American Academy of Pediatric Dentistry (AAPD) recommends this dental home be established by the time the child is age:
1 year
The nurse will use the Denver Articulation Screening Exam -DASE- for children in what age range?
2 1/2 to 6 years
The nurse realizes that the newborn is at high risk for a hearing deficit when the infant's 1-minute Apgar score falls below what number?
4. The newborn with an Apgar score of 4 or less at 1 minute or of 6 or less at 5 minutes is at high risk for a hearing deficit. Careful, continuing follow-up is important
The nurse will expect that which hearing test will be performed before the newborn is discharged home?
Auditory brainstem response
What is the reason why only injected polio vaccine is used in the United States.
Because of the ease of administration, oral polio vaccine containing a live virus continues to be used in underdeveloped countries. Vulnerable individuals are at risk for infection from live viruses excreted in the stool.
Parents report that their 4-year-old is difficult to understand. Which screening tool will the nurse use?
Denver Articulation Screening Exam -DASE
The 4-year-old due for the DTaP, IVP, MMR, and varicella vaccines has a runny nose, slight cough, and temperature of 99°F (37.2°C). What should be the response of the nurse?
Do the well-child exam and give the immunizations due.
Place in proper order the vision screening procedures used by the nurse to assess children from neonate to school age.
Fixate on an object at 10 to 12 inches Follow object to midline Follow object past midline Respond to E chart Use Snellen test for visual acuity
Infants born to mothers who are HbsAg-positive need to receive the hepatitis B immunoglobulin (HBIG) within how many hours?
HBIG needs to be given in 12 hours and complete all doses. Otherwise, the infant is at 90% risk of contracting hepatitis B or liver cancer in his or her 30s and 40s.
Using the recommended immunization schedule for infants, the nurse administers vaccines in what order from first to last?
Hepatitis B (HepB) Rotavirus (RV) Influenza Measles, mumps, rubella (MMR)
A pediatric nurse will state that the priority reason to have a thorough grasp of the growth and development of children is to:
Identify developmental risks or delays promptly.
By which route is the diphtheria, tetanus, and pertussis (TDaP) vaccine administered to infants?
Intramuscularly
During the health surveillance of a 13-year-old girl, the nurse recorded the following information: blood pressure 108/48, pulse 70, respirations 18; dieting, dislikes meat; eats yogurt, drinks two glasses low-fat milk daily; gymnastics team member; fairly regular, normal menstrual periods. What risk would the nurse identify?
Iron-deficiency anemia
The nurse is doing a health history for a 14-year-old pregnant girl during a health supervision visit. For which of the following conditions should she be screened?
Iron-deficiency anemia
The nurse is performing a vision screening for a 2-month-old. Which of the following techniques should the nurse use?
Move a card with a black-and-white checkerboard pattern in a 180-degree arc past the infant.
Which action should the nurse take when it is discovered that the refrigerator containing vaccines has been unplugged and is warmer than the proper storage temperature?
Not use any of the vaccines and alert others to do likewise
While enrolled in a geography course, a student nurse learns that diarrheal illness is deadly for large numbers of infants in Third World countries. What vaccine will this nursing student identify as part of the solution to this problem?
Rotavirus (RV) Rotavirus is a very common cause of gastroenteritis among young children that spreads readily via the fecal-oral route. The disease is most severe in children between 4 and 23 months, causing severe, watery diarrhea that results in dehydration
The mother of a 4-month-old refuses for her baby to be "stuck" when immunized. What immunization will the nurse administer under these restrictions?
Rotavirus. Rotavirus is the only vaccine given orally. All the others are injected.
Before administering an immunization to their child, the nurse asks parents to take which priority action?
Sign a consent form
A single mother has brought her 9-month-old recently adopted Chinese daughter for a health supervision visit. Although there are screening documents from China and the child seems healthy, the nurse plans to screen for infectious diseases. Which of the following explains the nurse's caution?
Testing by the child's home country is unreliable.
A nurse asking questions during an infant's health surveillance visit has the mother tell her: "My baby was premature and weighed 3 pounds at birth." The medical record provides an Apgar score of 5 at 5 minutes and indicates the child received gentamicin in the neonatal intensive care unit (NICU). What should the nurse consider as the greatest risk for this child?
The greatest risk is for a hearing deficit. All factors point in that direction: low birth weight, Apgar less than 6 at 5 minutes, and having received an ototoxic medication. This child should have had a hearing evaluation prior to discharge from the NICU and now should be screened periodically at well-child visits.
Shelley, a mother, is new to the community, and the family is in a low-income bracket with limited transportation options. How could the pediatric nurse help Shelley get her new baby to her well-child visits to promote healthy growth and development?
The nurse could link Shelley with the community child clinic.
Which of the following is an example of anticipatory guidance of healthcare by the community nurse?
The nurse teaches hand washing at an elementary school.
The nurse has just taken the blood pressure on a 13-year-old, and the percentile rank is 88%. Why would the nurse categorize the child as prehypertensive?
The teenager's blood pressure was 122/83.
A family of five seeks care for their preschooler with an upper respiratory infection. The facility has no medical record for the family. Why does the nurse encourage this family to establish a medical home?
To establish a continuing relationship with a physician or nurse practitioner
Which nursing intervention is likely to be most effective in keeping the immunization status of children of all ages at its highest possible level?
Use every contact to potentially immunize
Anticipatory guidance is primary prevention. The nurse should take a proactive role in discussing anticipatory guidance issues with children and families. The nurse should be an educator to promote a healthy lifestyle,
and any encounters with children and families should be an opportunity to educate.
The nurse practitioner inspects a toddler's teeth. The nurse practitioner encourages the family to establish a dental home in order to achieve optimal dental health for the various family members because: Select all that apply.
• Comprehensive healthcare is possible only if oral health is part of the equation. • Dental care is the most unmet health need of children in the United States. see next
A nurse is working to provide health promotion services throughout the community. What institutions or organizations best serve as important avenues for disseminating health promotion information? Select all that apply.
• Day care centers • Churches, synagogues, and mosques • Schools (public and private)
The nurse will record what information about each vaccine after immunizing a child? Select all that apply.
• Lot number and expiration date of vaccine • Site and route of vaccine administration • Manufacturer of vaccine
What developmental categories will the nurse assess when screening with the Denver II Developmental Screening Test? Select all that apply.
• Personal-social • Fine motor--adaptive • Gross motor skills • Language
The nurse working with children and families knows there are certain universal screening tests all children should receive. These include tests for: Select all that apply.
• Phenylketonuria • Auditory brain stem response
• Certain dental interventions including fluoride treatments could reduce the cost of oral care for children significantly.
• Poor oral healthcare for children can result in systemic health problems.
Which children will the nurse avoid immunizing with a live-virus vaccine? Select all that apply.
• Preschooler receiving radiation therapy • Pregnant teen
The nurse will administer which recommended immunizations to an 11- or 12-year-old patient during a wellness visit? Select all that apply.
• Tetanus, diphtheria, pertussis (Tdap) • Human papillomavirus (HPV) • Meningococcal vaccine (MCV)
A nursing student is asked to provide reasons it is important for the physician or nurse practitioner to have knowledge of the community in which the families and children seen in the practice live. The student replies: Select all that apply.
• The community can be a contributor to child-family health or a cause of illness. • Knowing the community is necessary in developing appropriate health surveillance programs. • Awareness of agencies serving children results from knowing the community. • Understanding the community promotes improved working relationships between families and physicians or nurse practitioners.
During the health history of a 3-month-old, the nurse identified a risk factor for developmental delay and is preparing to assess the child's development. Which of the following risk factors did the nurse find? Select all that apply.
• The mother did not complete high school. • The infant's mother is a single parent.
Choose the options below that will assist nurses in overcoming some of the barriers to having children fully immunized. Select all that apply.
• Using combination vaccines to reduce the number of injections children receive • Using every health contact with the child (hospital, urgent care, emergency, and well-child visits) to check status/administer vaccines • Checking the immunization status of siblings who accompany the child who has the healthcare appointment