Uint 4

A 10-year-old child in remission from leukemia is upset over the appearance of cushingoid characteristics from long-term use of corticosteroids that are currently being administered every other day. Which therapeutic statements should the nurse make to the child about the cushingoid appearance? Select all that apply.

"Which manifestations of this condition do you find most troublesome?" "The signs/symptoms are lessened by taking the prednisone every other day instead of daily." "The cushingoid appearance will gradually disappear once the steroids are tapered and discontinued."

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions should the nurse anticipate to be prescribed? Select all that apply.

Initiate an intravenous line. Maintain nothing-by-mouth status. Administer intravenous antibiotics. Administer preoperative medications.

A child is diagnosed with intussusception. The nurse collects data on the child, knowing that which is a characteristic of this disorder?

Invagination of a section of the intestine into the distal bowel

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation?

It is negative.

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and should avoid which action?

Keeping the child uncovered to assist in reducing the fever

The nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which information in the conference?

PKU results in central nervous system (CNS) damage.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply.

Provide adequate nutrition. Restrict fluids, as prescribed. Institute measures to prevent infection. Administer blood products to treat severe anemia. Anticipate the child will have central nervous system involvement.

The nurse is caring for a 1-year-old child following a cleft palate repair. Which solution should the nurse use after feedings to cleanse the child's mouth?

Sterile water

The nurse is reinforcing the teaching to parents of a diabetic child about the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse include when reinforcing the teaching? Select all that apply.

Sweating Dizziness Trembling

A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which nursing intervention would be most appropriate to alleviate the child's fears and the mother's anxiety?

Ask the mother if she would like to stay overnight with the child.

The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications should the nurse plan to administer? Select all that apply.

Atenolol Propranolol Methimazole

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

Rectal

The nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests which position for the infant?

Side-lying position

The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need forfurther teaching?

"I'll let him decide when to return to his play activities."

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?

Avoid tub baths until the stent has been removed.

The nurse is caring for a child who is scheduled for an appendectomy. When the nurse reviews the primary health care provider's preoperative prescriptions, which should be questioned?

Administer a Fleet enema.

An adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse should instruct the adolescent to take which action?

Eat six graham crackers or drink a cup of orange juice before practice or game time.

The nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? Select all that apply.

Fever Constipation Abdominal distention Explosive, watery diarrhea

The nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux (GER). To assist in reducing the episodes of emesis, which instruction should the nurse provide the mother

Thicken the feedings by adding rice cereal to the formula.

The nurse is reinforcing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand these measures if they make which statement?

"We will provide comfort measures to reduce any crying periods by our child."

The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching?

"I will insert a glycerin suppository before the dilation."

The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy?

"It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall."

A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. Which statement is the appropriate nursing response?

"It is the inability to tolerate sugar found in dairy products."

A urinalysis has been prescribed for an infant and the nurse plans to collect the specimen. The nurse implements which appropriate method to collect the specimen?

Attaches a urinary collection device to the infant's perineum

The nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and should expect to note which finding?

An elevated thyroid-stimulating hormone (TSH) level

The nurse is assisting in developing a plan of care for a child diagnosed with acute glomerulonephritis. The nurse should include which intervention in the plan of care?

Encourage limited activity and provide safety measures.

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? Select all that apply.

Fever Increased heart rate Change in the level of consciousness

The nurse has reinforced discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further teaching?

"I should carry my child by straddling the child on my hip."

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement?

"In most cases, medication and diet will control fluid retention."

The nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which statement should the nurse make to the mother?

"The fluid retention should be controlled by medication and diet."

The nurse caring for a child with nephrotic syndrome reviews the medication record. The nurse notes that prazosin hydrochloride is prescribed for the child. The nurse determines that this medication has been prescribed to achieve which result?

Control hypertension.

A 2-year-old child is admitted to the hospital with a diagnosis of nephrotic syndrome. In planning care for this child, which nursing intervention should be of highest priority?

Dipstick the urine for protein every 4 hours.

The nurse is assigned to assist in caring for a newborn with a colostomy that was created during surgical intervention for imperforate anus. When the newborn returns from surgery, the nurse checks the stoma and notes that it is red and edematous. Which is the appropriate nursing intervention?

Document the findings.

The nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume based on which knowledge?

Each gram of diaper weight is equivalent to 1 mL of urine.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

The nurse is assisting with preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child?

Encourage the child to eat in the playroom.

The nurse is admitting a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to note?

Frothy stools

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing level of consciousness

The nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse would expect which medication to be prescribed?

Furosemide

A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which information?

It is a congenital aganglionosis or megacolon.

The nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which acid-base disorder would the nurse expect to note in the infant?

Metabolic alkalosis

The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child?

Prevent tension on the suture.

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record?

Projectile vomiting

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet?

Rice

The nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which immediate problem as the priority for the infant?

Skin disruption

The nurse is checking the status of jaundice in a child with hepatitis. Which location should the nurse check to ascertain if the child is jaundiced?

The mucous membranes

The nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse should tell the parents that the infant should be maintained in which position?

A 60-degree angle when supine

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?

Calcium and vitamin D

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likelymanifestation of this condition in the medical record?

Choking with feedings

The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body?

Computed tomography scan

A parent with a 6-year-old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching?

"I take away privileges such as TV time when the bed is wet in the morning."

The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit information about the cause of this disease?

"Did your child recently complain of a sore throat?"

The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will mostspecifically elicit information regarding this disorder?

"Does your infant have foul-smelling, ribbon-like stools?"

A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting with care for the child checks the intravenous (IV) and medication supply area for what?

0.9% normal saline IV infusion

An infant, weighing 12 kg, is receiving diuretic therapy, and the nurse is closely monitoring the intake and output. Which is the amount of hourly urine output should the nurse expect as adequate?

12 to 24 mL/hour

The nurse is planning care for a hospitalized child with syndrome of inappropriate antidiuretic hormone (SIADH). The primary health care provider has prescribed that the 24-hour fluid maintenance for the child weighing 12 kg be at ¾ of the maintenance. Using the formula shown (refer to figure), which volume of fluid should the nurse plan as the 24-hour maintenance for this child?

825 mL

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?

A side-lying position

The nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which food item should the nurse mix with the medication?

Applesauce

A nursing student is asked to administer a tepid bath to a child with a fever. The student should avoid which action when performing this procedure?

Applies alcohol-soaked cloths over the child's body

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply.

Ascites Anorexia Proteinuria Periorbital and facial edema

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?

Bacteriuria

The nurse is reviewing the record of a child scheduled for a primary health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which factor when collecting data?

Bladder function

The nurse is planning care for a child with type 1 diabetes. Which items should the nurse plan to use to treat an early mild hypoglycemic episode? Select all that apply.

Candy Orange juice Glucose tablets

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?

Drink a half a cup of orange juice before soccer practice.

A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. Which should be the nurse's initialaction?

Obtain a complete history of the child's feeding habits.

The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms should be noted in determining this finding? Select all that apply.

Oliguria Slightly sunken fontanels Very dry, mucous membranes

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time?

On his or her left side

The nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which intervention is the priority for the child?

Promoting bed rest

The nurse is assigned to care for a child with hypertrophic pyloric stenosis scheduled for a pyloromyotomy. In which position should the nurse place the child during the preoperative period?

Prone with the head of the bed elevated

The nurse is reviewing the record of a child admitted to the hospital with nephrotic syndrome. Which finding should the nurse expect to note documented in the record?

Proteinuria

The nurse has just administered ibuprofen to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?

Remove excess clothing and blankets from the child.

A male child who had surgery to correct hypospadias is seen in a primary health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias?

Renal anomalies

A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder?

The infrequent and difficult passage of dry stools

The nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. Which assessment finding is unassociated with this diagnosis?

The passage of currant jelly-like stool

The nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?

Urinary output is increased.

The nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the priority in the plan of care?

Wound care

The nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. Which supplement should the nurse give the child to treat the reaction?

½ cup of fruit juice

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as which level of dehydration?

Moderate dehydration

The nurse determines that an adolescent client with diabetes mellitus needs further teachingabout A1c levels and their purpose if the client made which statement when told that a level will be drawn?

"I already had a complete blood cell count drawn an hour ago, so this test is not necessary."

The nurse is reinforcing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further teaching?

"I am so pleased that I won't have to eliminate oatmeal from my child's diet."

The nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further teaching?

"I need to use a nipple with a small hole to prevent choking."

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions?

"I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."

The clinic nurse is reinforcing instructions to an adolescent with type 1 diabetes about administration of insulin. Which statements by the adolescent indicate the need for further teaching? Select all that apply.

"I should give my injections only in my thighs."v "I should place any unopened insulin vials in the freezer."

The nurse is reinforcing the teaching of parents of a diabetic child on the differences between type 1 and type 2 diabetes mellitus. Which statements by the parents indicate understanding of the teaching? Select all that apply.

"The onset of diabetes is sudden with type 1." "Type 2 diabetes can often be managed with diet only." "Three symptoms of type 1 diabetes are polyuria, polydipsia and polyphagia."

The nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year-old consumes approximately which amount?

175 mL per feeding

A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder?

A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which finding is noted?

A decrease in urine output to 0.5 mL/kg/hr

An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse assisting in caring for the infant should ensure that which action is done to the gastrostomy tube?

Elevated

A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion?

Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV).

A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?

Gastric contents regurgitate back into the esophagus.

The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome?

Generalized edema

An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. Which initial nursing intervention is appropriate?

Give the child 6 oz of a regular cola drink.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Normal saline infusion

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.

Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply.

Headache Red-brown urine Periorbital edema

The nurse has reinforced dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the dietary instructions if she indicates eliminating which products? Select all that apply.

Oatmeal Rye crackers Wheat bread

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which prioritycare measure?

Preventing infection at the surgical site

The nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation should the nurse expect to note documented in the health record?

Profuse watery diarrhea and vomiting

The nurse reviews the record of a 1-year-old child seen in the clinic and notes that the primary health care provider has documented a diagnosis of celiac crisis. Which symptom should the nurse expect to note in this condition?

Profuse, watery diarrhea

A primary health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child should check which highest priority item before administration of the potassium?

Urine output

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dL. Which is the appropriate intervention?

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn, and the results indicate a glucose level of 60 mg/dL. Which is the appropriate intervention?

The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?

Obtain a blood glucose reading.

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?

"I need to provide a well-balanced, high-fat diet to my child."

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching?

"PKU primarily affects the gastrointestinal system."

The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?

Hiccupping and spitting up after a meal

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents?

Pain

The nurse is assisting a primary health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the primary health care provider palpates the child at McBurney's point. What response does the nurse expect the child to have during the examination?

Pain in the lower right side between the umbilicus and the iliac crest

Which interventions should the nurse include when preparing a plan of care for a child with hepatitis? Select all that apply.

Providing a low-fat, well-balanced diet\ Teaching the child effective hand-washing techniques Instructing the parents about the risks associated with taking medications

A nurse caring for a 2-month-old febrile infant is asked to collect a urine specimen for a culture and sensitivity. The nurse collects the specimen by performing which action?

Catheterizing the infant using the smallest available straight catheter

The nurse is assisting a school-age client with type 1 diabetes to follow an appropriate diet. Which recommendations should the nurse make for this client? Select all that apply.

Limit concentrated sweets. Consume snacks between meals and at bedtime. Plan to eat a larger snack during active times of the day.

A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by performing which action?

Covering the bladder with a nonadhering plastic wrap

A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account?

Fears of separation and mutilation are present.

A child is seen in the clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The mother asks the nurse about the diagnosis. Which should the nurse relay to the mother about primary nocturnal enuresis?

Primary nocturnal enuresis is common, and most children will outgrow bed-wetting without therapeutic intervention.

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which sign as evidence of this disorder?

Evidence of soiled clothing

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Take temperature measurements rectally. Start clear liquid diet after 8 hours postoperative.

An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion? Refer to chart.

Glucose level at 2 am of 65 mg/dL