RN Pediatric Nursing Online Practice 2023 B

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? A. Wrist B. Great toe C. Index finger D. Heel

B. Great toe Rationale: The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse.

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? A. Hypotension B. Reports insomnia C. Difficulty concentrating D. Tachycardia

C. Difficulty concentrating Rationale: The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem.

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? A. Decreased cerebrospinal fluid pressure B. Decreased WBC count C. Increased protein concentration D. Increased glucose level

C. Increased protein concentration Rationale: The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

A school nurse is preparing to administer Atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is Atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero).

1 capsule

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should secure the car seat using lower anchors and tether instead of the seat belt." B. "I should position the car seat harness 1 inch above my baby's shoulders." C. "I will make sure that the car seat is placed at a 90-degree angle." D. "I will pad by baby's car seat with a blanket for traveling long distances."

A. "I should secure the car seat using lower anchors and tether instead of the seat belt." Rationale: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the backrest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.

A nurse is caring for a school-age child who has peripheral edema. The nurse should identify which of the following assessments should be performed to confirm peripheral edema. A. Palpate the dorsum of the child's feet. B. Weigh the child daily using the same scale. C. Assess the child's skin turgor. D. Observe the child for periorbital swelling.

A. Palpate the dorsum of the child's feet. Rationale: The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? A. Place the child in a side-lying position. B. Delay documentation until the child is fully alert. C. Give the child a high-carbohydrate snack. D. Administer an oral sedative to the child.

A. Place the child in a side-lying position. Rationale: The nurse should place the child in a side-lying position to prevent aspiration.

A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? A. Provide the child with a book about adventure. B. Arrange frequent visits from family members and peers. C. Give the child a large piece puzzle. D. Use puppets to entertain the child.

A. Provide the child with a book about adventure. Rationale: The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read.

A nurse is providing discharge teaching to the guardian of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? A. Occupational therapist B. Speech therapist C. Respiratory therapist D. Physical therapist

B. Speech therapist Rationale: The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.

A nurse is teaching a school-age child who has a new dx of type I DM. Which of the following statements by the child indicates an understanding of teaching? A. "I will puncture the pad of my finger when I am testing my BG." B. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." C. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." D. "I will decrease the amount of fluids I drink when I am sick."

C. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." Rationale: The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.

A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? A. Excoriated scrotal area B. Multiple capillary hemangiomas C. Depressed posterior fontanel D. Substernal retractions

D. Substernal retractions Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? A. Use sterile scissors to remove the dressing from the site. B. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. C. Access the site using a noncoring angled needle. D. Use a semipermeable transparent dressing to cover the site.

D. Use a semipermeable transparent dressing to cover the site. Rationale: The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.

A nurse is preparing to administer Ibu 5 mg/kg every 6 hr PRN for a temperature above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is Ibu oral suspension 100 mg/5 mL. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero).

2 mL

NGN* The nurse is providing discharge teaching to the child and their parent 36 days after admission. Select 6 statements by the parent that indicate an understanding of the discharge teaching. "I will give my child Hydroxyzine to prevent bacterial infection." "I should apply a moisturizer to the scar tissue." "I will use a measured spoon or medicine cup to give my child Hydroxyzine." "I can give my child Hydroxyzine every 6 hours as needed." "Puppet play can be helpful for my child." "I should avoid giving Hydroxyzine at bedtime." "I will avoid massaging the scar tissue." "My child is too young to be concerned about their body image." "I need to assess for any redness or open skin areas before applying my child's left arm splint." "My child will need to use a compression garment to decrease blood supply to the scarred tissue."

1. "I should apply a moisturizer to the scar tissue." Rationale: Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. 2. "I will use a measured spoon or medicine cup to give my child Hydroxyzine." Rationale: All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. 3. "I can give my child Hydroxyzine every 6 hours as needed." Rationale: Hydroxyzine is administered every 6 to 8 hr each day as needed 4. "Puppet play can be helpful for my child." Rationale: Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. 5. "I need to assess for any redness or open skin areas before applying my child's left arm splint." Rationale: It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. 6. "My child will need to use a compression garment to decrease blood supply to the scarred tissue." Rationale: Using a compression garment on the scar tissue decreases the blood supply to avoid nourishing the hypertrophic tissue. It also forces the collagen into a more normal alignment. Compression garments are worn during the healing of the burned tissue and should be worn as much as possible.

A nurse is planning an educational program to teach caregivers about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? A. "Allow your child to play outside during the hours between 10:00 am and 2:00 pm." B. "Choose a waterproof sunscreen with a minimum SPF of 15." C. "Dress your child in loose weave polyester fabric prior to sun exposure." D. "Reapply sunscreen every 4 hours."

B. "Choose a waterproof sunscreen with a minimum SPF of 15." Rationale: The nurse should instruct caregivers to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parent should apply sunscreen prior to sun exposure to reduce the risk of sunburn.

A nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect? A. Hyperactive bowel sounds B. Abdominal distention C. Bradycardia D. Bloody stool

B. Abdominal distention Rationale: The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering Acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? A. Apply a cooling blanket to the toddler. B. Dress the toddler in minimal clothing. C. Give the toddler a tepid bath. D. Administer Diphenhydramine to the toddler.

B. Dress the toddler in minimal clothing. Rationale: The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.

A nurse is caring for a school-age child who is receiving Cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? A. Prednisone B. Epinephrine C. Diphenhydramine D. Albuterol

B. Epinephrine Rationale: This child is most likely experiencing an anaphylactic reaction to Cefazolin. According to evidence-based practice, the nurse should first administer Epi to treat anaphylaxis. Epi is a beta-adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? A. Laryngeal edema B. Flank pain C. Distended neck veins D. Muscular weakness

B. Flank pain Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.

NGN* A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). The nurse should identify which of the following findings require immediate follow-up. Select the 3 findings that require immediate follow-up. A. Child is awake and crying B. Partial, and full-thickness burns to the left upper anterior chest and anterior neck C. Non-productive cough D. SaO2 89% on room air E. Heart rate 150/min F. Temperature 37.7 C (99.9 F) G. Blood pressure 100/52 mmHg

B. Partial, and full-thickness burns to the left upper anterior chest and anterior neck Rationale: Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate f/u due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. D. SaO2 89% on room air Rationale: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately f/u on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. E. Heart rate 150/min Rationale: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately f/u on the child's increased HR. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock d/t fluid loss.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? A. BP 90/30 mmHg B. RR 45/min C. Weight 14.5 kg (32 lb) D. HR 110/min

B. RR 45/min Rationale: The nurse should identify that a RR of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include? A. "You should give your child their Salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." B. "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." C. "Pulmonary function tests will be performed every 12 to 14 months to evaluate how your child is responding to therapy." D. "When using the peak expiratory flow meter, record your child's average of three readings."

C. "Pulmonary function tests will be performed every 12 to 14 months to evaluate how your child is responding to therapy." Rationale: The nurse should inform the parent that their child will need PFTs every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly.

A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? A. "When your child no longer has an increased temperature." B. "Three days after you first noticed the rash appear on your child." C. "When your child's lesions are crusted, usually 6 days after they appear." D. "Two to three weeks, when your child's lesions completely disappear."

C. "When your child's lesions are crusted, usually 6 days after they appear." Rationale: The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make? A. "Place a beaded teething necklace around your baby's neck." B. "Rub your baby's gums with an aspirin to decrease discomfort." C. "Your baby might pull at their ears when they are teething." D. "Your baby's upper middle teeth will erupt first."

C. "Your baby might pull at their ears when they are teething." Rationale: The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness.

A nurse is receiving a change of shift report for four children. Which of the following children should the nurse assess first? A. An adolescent who was placed in halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 B. An adolescent who has infective endocarditis and reports having a HA C. A toddler who has a concussion and is experiencing an episode of forceful vomiting D. A school-age child who has acute glomerulonephritis and brown-colored urine

C. A toddler who has a concussion and is experiencing an episode of forceful vomiting Rationale: When using the urgent vs non-urgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

NGN* The nurse is continuing to care for the child. After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. Change the morphine route to family-controlled analgesia via a PCA pump. Obtain a wound culture. Place the child on a pressure-reduction mattress. Limit daily protein intake.

Change the morphine route to family-controlled analgesia via a PCA pump is anticipated. Rationale: A pain rating of 8 indicates severe pain. the use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is anticipated. Rationale: The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an abx should be administered. Place the child on a pressure-reduction mattress is anticipated. Rationale: The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Limit daily protein intake is contraindicated. Rationale: Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.

A nurse is teaching the parent of an infant about ways to prevent sudden unexplained infant death (SUID). Which of the following instructions should the nurse include? A. "Place the infant in a prone position to sleep." B. "Allow the infant to sleep on a large pillow." C. "Use a soft mattress in the infant's crib." D. "Give the infant a pacifier at bedtime."

D. "Give the infant a pacifier at bedtime." Rationale: The nurse should inform the parent that protective factors against SUID include breastfeeding and the use of a pacifier when the infant is sleeping.

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? A. "It is important that you provide emotional support for your family at this time." B. "You have to do what you feel is best. Everything will turn out fine." C. "I know how you feel. This is an extremely stressful time for your family." D. "Let's talk about some of the ways you have handled previous stressors in your life."

D. "Let's talk about some of the ways you have handled previous stressors in your life." Rationale: This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? A. Increased anterior convexity of the lumbar spine. B. Increased curvature of the thoracic spine. C. Lateral flexion of the neck. D. A unilateral rib lump.

D. A unilateral rib lump. Rationale: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

NGN* The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first? Complete the following sentence by using the lists of options. Dropdown 1: Temperature Saturated dressing Urine output BP Respiratory status Dropdown 2: Pain Sensorium Nutrition Drainage on dressing Fluid status

Dropdown 1: Temperature Rationale: When using the urgent vs nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. Dropdown 2: Pain Rationale: When using the urgent vs nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing.

NGN* A nurse is caring for a toddler. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential condition: CF Rationale: The toddler is most likely experiencing CF, as evidenced by reports of recurring respiratory infections, wheezing, coughing, tachypnea, tachycardia, labored RR, decreased oxygen saturation, nasal congestion, inability to gain weight, loose fatty stool, salty-tasting sweat, and hyponatremia. Action 1: Educate the guardian about sweat chloride testing. Action 2: Prepare toddler for chest physiotherapy. Parameter to monitor 1: Oxygen saturation level Parameter to monitor 2: Stools Rationale: These are parameters that indicate if the toddler is further experiencing respiratory distress, inadequate intake, and dehydration, which can lead to further complications, including pneumothorax, respiratory failure, and failure to thrive.

A nurse on a pediatric unit is caring for a school-age child. After reviewing the information in the child's medical record, which of the following findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider. ABGs Cardiovascular assessment WBC count Hgb Oxygen saturation level Respiratory assessment

ABGs WBC count Oxygen saturation level Respiratory assessment

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as a 7 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Instill a 500 mL tap water enema. B. Give morphine 0.05 mg/kg IV. C. Administer polyethylene glycol 1 g/kg PO. D. Apply a heating pad to the child's abdomen.

B. Give morphine 0.05 mg/kg IV. Rationale: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.

NGN* A nurse on a pediatric unit is admitting a preschooler. After reviewing the information in the medical record the nurse should identify that the child is at risk for developing which of the following conditions? Dropdown 1: Splenomegaly Acute post-streptococcal glomerulonephritis (APSGN) Dysrhythmias Dropdown 2: Positive mononucleosis rapid test Urinary output Cardiovascular assessment

1. Splenomegaly Rationale: The child's positive mononucleosis rapid test result indicates the presence of infectious mono, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mono. 2. Positive mono rapid test Rationale: The child's positive mononucleosis rapid test result indicates the presence of infectious mono, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mono.

A nurse in a provider's office is caring for a preschooler. Which of the following statements by a guardian indicate that the discharge teaching was effective? SATA A. "We should apply a skin emollient immediately after bathing our child." B. "We should keep our child's fingernails trimmed short." C. "We should rub the sores vigorously to remove the scabs." D. ."We should allow our child to take a bubble bath prior to going to bed." E. "We should use a mild detergent for our laundry." F. "We should apply a large amount of the ointment to the sores."

A. "We should apply a skin emollient immediately after bathing our child." Rationale: An emollient is an oil that moisturizes the skin and should be applied immediately after bathing, while the skin is damp, to prevent drying. B. "We should keep our child's fingernails trimmed short." Rationale: The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. E. "We should use a mild detergent for our laundry." Rationale: The use of mild detergents for laundry helps prevent allergens and itching.

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? A. Deep respirations of 32/min B. Shallow respirations of 10/min C. Paradoxic respirations of 26/min D. Periods of apnea lasting for 20 seconds

A. Deep respirations of 32/min Rationale: The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control? A. Have a designated stethoscope in the infant's room. B. Place the infant in a room equipped with negative airflow. C. Administer Palivizumab as prescribed for the infant. D. Remove gloves after leaving the infant's room.

A. Have a designated stethoscope in the infant's room. Rationale: The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as blood pressure cuff and stethoscope, should be placed in the infant's room.

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? A. Hgb 8.5 g/dL B. WBC count 9,500/mm3 C. Prealbumin 18 mg/dL D. Platelets 300,000/mm3

A. Hgb 8.5 g/dL Rationale: A child receiving chemotherapy is at risk for anemia due to the chemotherapy's effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Loud, harsh murmur B. Dysrhythmias C. Weak femoral pulses D. High blood pressure

A. Loud, harsh murmur Rationale: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? A. Nasal flaring B. WBC count of 11,300/mm3 C. Diarrhea D. Abdominal distention

A. Nasal flaring Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provide is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress.

A nurse is caring for an infant who is receiving IV fluids for the treatment of tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? A. Place the infant in a knee-chest position. B. Administer a dose of Meperidine IV. C. Discontinue administration of IV fluids. D. Apply oxygen at 2L/min via nasal cannula.

A. Place the infant in a knee-chest position. Rationale: The nurse should place the infant in the knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

NGN* A nurse is caring for a toddler. Click to highlight the findings that require f/u. To deselect a finding, click on the finding again. A. Toddler appears lethargic B. Toddler is uninterested in eating C. Ribbon-like, foul-smelling stools D. Respirations are symmetric and unlabored, breath sounds clear. E. Hypoactive bowel sounds F. Abdomen distended G. Palpable fecal mass H. Temperature 37.3 C (99.2 F) axillary I. Heart rate 138/min J. Blood pressure 110/70

A. Toddler appears lethargic B. Toddler is uninterested in eating. C.Ribbon-like, foul-smelling stools. E. Hypoactive bowel sounds F. Abdomen distended G. Palpable fecal mass J. Blood pressure 110/70 Rationale: These findings indicate the toddler's constipation has worsened and the toddler needs further evaluation for suspected Hirschsprung's disease.

NGN* A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential provider's prescription is anticipated or contraindicated for the child. Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas. Insert indwelling urinary catheter. Provide 100% oxygen via face mask. Weight the child.

Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Rationale: Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Insert indwelling urinary catheter is anticipated. Rationale: Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. Provide 100% oxygen via face mask is anticipated. Rationale: Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range their RR is increased. Weigh the child is anticipated. Rationale: The nurse should recognize the need to weigh the child as an essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? A. Reports HA as 6 on a scale of 0 to 10 B. Petechiae on the lower extremities C. Nuchal rigidity D. Positive Kernig's sign

B. Petechiae on the lower extremities Rationale: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

NGN* The nurse is caring for the child 14 days after admission. The child has returned to the unit following the procedure. Which of the following actions should the nurse take? SATA A. Monitor SaO2 every 2 hr. B. Provide 100% oxygen via face mask. C. Check anterior neck and chest dressing for bleeding. D. Replace the dressing on the left thigh. E. Place a warm blanket on the child. F. Keep the child's head in a neutral position.

B. Provide 100% oxygen via face mask. Rationale: The nurse should provide 100% oxygen via a face mask to the child because of their SaO2 and RR. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemental oxygen should be initiated. C. Check anterior neck and chest dressing for bleeding. Rationale: Upon return from the procedure, all surgical dressings should be assessed for drainage and to ensure the dressing is intact. E. Place a warm blanket on the child. Rationale: The child is exhibiting hypothermia. It is important for the child to have a stable body temperature because vasoconstriction can diminish blood flow to the surgical sites and impair healing. F. Keep the child's head in a neutral position. Rationale: The child's head should be kept in a neutral alignment to prevent hyperextension or hyperflexion and to prevent graft loss.

A nurse is providing discharge teaching the guardians of a toddler with a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider? A. Capillary refill time < 2 seconds. B. Restricted ability to move the toes. C. Swelling of the casted foot when the leg is dependent. D. Pedal pulse +3 bilateral.

B. Restricted ability to move the toes. Rationale: The nurse should inform the guardians that the restricted ability of the toddler to move their toes is an indication of neuromuscular compromise and requires immediate notification to the provider. Permanent muscle and tissue damage can occur in just a few hours.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify which of the following laboratory values indicates the effectiveness of the current treatment. A. Potassium 2.9 mEq/L B. Sodium 140 mEq/L C. Urine specific gravity 1.035 D. BUN 25 mg/dL

B. Sodium 140 mEq/L Rationale: The nurse should identify that a sodium level of 140 mEq/L is within the expected range of 134 to 150 mEq/L and indicate the current treatment regimen the infant is receiving for dehydration is effective.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? A. Place the child in a prone position for the immunization. B. Request that the child's caregiver leave the room during the immunization. C. Administer the immunization using a 24-gauge needle. D. Inject the immunization slowly after aspirating for 3 seconds.

C. Administer the immunization using a 24-gauge needle. Rationale: The nurse should administer an immunization for a 4-year-old child using a 22 to 25-gauge needle to minimize the amount of pain the child experiences.

A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Check the child for a head injury. B. Observe for oral bleeding. C. Check the child's respiratory rate. D. Observe for extremity weakness.

C. Check the child's respiratory rate. Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to asses the child's RR. If the child is not breathing the nurse should administer rescue breaths.

A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? A. Insert a nasogastric tube. B. Initiate prophylactic abx therapy. C. Cleanse the affected area with mild soap and water. D. Apply a topical corticosteroid to the affected area.

C. Cleanse the affected area with mild soap and water. Rationale: The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? A. Expresses a reluctance to leave home B. Provides a detailed description of how the burns occurred C. Denies discomfort during assessment of injuries D. describes strong relationships with peers

C. Denies discomfort during assessment of injuries Rationale: The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? A. Obtain a sputum specimen. B. Perform an Allen test. C. Perform a finger stick. D. Obtain a stool specimen

C. Perform a finger stick Rationale: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.

A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? A. "I will plan to increase the amount of homework I assign to students who have ADHD." B. "I will give students who have ADHD the same amount of time as other students to complete tests." C. "I will allow students who have ADHD one rest breast throughout the day." D. "I will teach challenging academic subjects to students who have ADHD in the morning."

D. "I will teach challenging academic subjects to students who have ADHD in the morning." Rationale: Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? A. Until the adolescent is afebrile B. For 7 days following admission to the facility C. Until the adolescent has a negative blood culture D. For 24 hr following initiation of antimicrobial therapy

D. For 24 hr following initiation of antimicrobial therapy Rationale: The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic abxs might be prescribed to individuals who were in close contact with the adolescent.

A nurse is planning care to address the nutritional needs of a preschooler who has CF. Which of the following interventions should the nurse include in the plan? A. Administer pancreatic enzymes 2 hr after meals. B. Discontinue the use of pancreatic enzymes if steatorrhea develops. C. Limit fluid intake 750 mL per day. D. Increase fat content in the child's diet to 40% of total calories.

D. Increase fat content in the child's diet to 40% of total calories. Rationale: A child who has CF is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? A. Administer Ibu to the child for a temperature greater than 38 C (100.4 F). B. Assess the child's BP every 8 hr. C. Weigh the child weekly at various times of the day. D. Initiate seizure precautions for the child.

D. Initiate seizure precautions for the child. Rationale: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? A. Apple juice B. Peanut butter C. Chicken broth D. Oral rehydration solution

D. Oral rehydration solution Rationale: A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.

A nurse is caring for a preschooler who has CHF. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? A. Furosemide B. Captopril C. Regular insulin D. Potassium chloride

D. Potassium chloride Rationale: The nurse should identify that a child who has CHF can develop electrolyte imbalances such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride which can increase the severity of hyperkalemia.

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child. A. Wheat crackers B. Rye bread C. Barley soup D. White rice

D. White rice Rationale: The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and that sometimes lactose deficiency can be secondary to this disease.

NGN* A nurse is caring for a preschool-age child. For each assessment finding, click to specify if the finding is consistent with nightmares, sleep terrors, or insomnia. Each finding may support more than 1 disease process.

When analyzing cues, the nurse should recognize that manifestations of nightmares include awakening during the night after a scary dream. Nightmares are sleep disturbances that cause distress after the dream is over. The child might be crying, fearful of returning to sleep, and believe the dream is real. Sleep disturbances can cause interruptions in the sleep-wake cycle and can cause impaired concentration, daytime fatigue, and impulsive behaviors. When analyzing cues, the nurse should recognize that manifestations of sleep terrors include partial awakening during a deep sleep. Sleep terrors are sleep disturbances that cause a child to exhibit behaviors such as thrashing, screaming, moaning, and diaphoresis that disappear once the child awakens. The child does not remember the episode and is not comforted by others during the disturbance. The child usually falls asleep easily afterward. Sleep terrors cause interruptions in the sleep-wake cycle and can cause impaired concentration, daytime fatigue, and impulsive behaviors. When analyzing cues, the nurse should recognize that manifestations of insomnia include difficulty falling or staying asleep and feeling tired when waking up. Insomnia is a sleep disorder that causes an inability to sleep, causing an imbalance in the sleep-wake cycle, leading to impaired concentration and daytime fatigue. Insomnia occurs in older children.