ATI Nursing Care of Children Practice B
A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler. Which of the following should the nurse include in the teaching?
"An appropriate serving size is 1 tablespoon of food per year of age." The nurse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age.
A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective?
"I should give my child 4 ounces of orange juice followed by cheese and crackers." The parent should treat mild hypoglycemia with 10 to 15 g of a simple carbohydrate, such as 4 oz of orange juice, and follow it with a starch-protein snack.
A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching?
"I will allow my baby to have a pacifier while sleeping." The nurse should reinforce with the parent that allowing the infant to fall asleep with a pacifier in his mouth decreases the risk for SIDS.
A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make?
"Tell me more about what you are feeling." The nurse should use open-ended statements that will allow the parent to share his feelings and emotions. During times of grief, the parent needs to express his emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.
A nurse is reinforcing teaching with an adolescent who has an inflamed, nonperforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching?
"You will sit in your chair at least twice a day after surgery." The nurse should instruct the client that she will sit in a bedside chair at least twice a day and will be encouraged to ambulate as soon as possible following surgery. This activity will enhance lung function and help prevent postoperative complications.
A nurse is reinforcing dietary teaching with an adolescent who is a lacto-vegetarian and has iron deficiency anemia. The nurse should recommend which of the following as the best source of iron?
1 cup (8 oz) shredded wheat cereal The nurse should determine that shredded wheat cereal is an iron-fortified food. Therefore, it is the best option to recommend because it contains 1 g of iron per serving.
A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose?
6.25 mL
A nurse is caring for a toddler who has otitis media and a temperature of 39.1 C (102.4 F). Which of the following actions should the nurse take first?
Administer an antipyretic When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature.
A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate?
Apical The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.
A nurse is caring for a 3-year-old female child who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take when performing this procedure?
Apply 2% lidocaine lubricant into the urethral meatus. The nurse should apply 2% lidocaine lubricant into the urethral meatus to assist in decreasing the discomfort the child might experience during catheterization.
A nurse is reinforcing teaching with the guardians of a school-age child who has frequent nosebleeds. Which of the following instructions should the nurse include?
Apply pressure to the child's nose. The nurse should instruct the guardians to apply pressure to the child's nose for at least 10 min to decrease bleeding. The nurse should also instruct the guardians to tilt the child's head forward, because this position prevents aspiration of the blood.
A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler?
Ask the guardian to verify the child's name. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier.
A nurse is caring for a toddler following a tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider?
Continuous swallowing When using the urgent vs. nonurgent approach to client care, the nurse should identify that continuous swallowing is a manifestation of hemorrhage. Therefore, this is the priority finding for the nurse to report to the provider.
A nurse is reinforcing anticipatory guidance to the parents of an adolescent. Which of the following recommendations should the nurse include?
Be open to the adolescent's point of view. During this stage of development, adolescents are developing autonomy and self-identity. The nurse should recommend that the parents actively listen and be open to the adolescent's point of view, even if the parents disagree with his viewpoint.
A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further?
Blood pressure 120/80 mm Hg A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse.
A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is having a hemolytic reaction?
Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.
A nurse is reinforcing teaching with the parent of a 4-month-old infant who has a new prescription for nystatin to treat oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching?
Continue nystatin for 2 weeks after the symptoms disappear. To prevent relapse, nystatin therapy should continue for at least 2 weeks after the lesions disappear.
A nurse is caring for a 1-month-old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take?
Position the head of the crib at a 30° angle between feedings. The nurse should place the infant with the head of the crib elevated 30° to 45° to prevent aspiration.
During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?
Provide the toddler with a favorite toy at bedtime. The nurse should recommend to the parent that providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep.
A nurse is reinforcing teaching with the parents of a 2-year-old toddler at a well-child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler?
Putting together a large-piece puzzle The nurse should recommend putting together a large-piece puzzle as an age-appropriate activity for a 2-year-old toddler. Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons.
A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor?
Depression Clients taking isotretinoin can experience mental status changes, such as suicidal thoughts, aggression, emotional lability, and depression. The nurse should monitor the adolescent's mental status while taking isotretinoin.
A nurse is assisting with the care of a 4-year-old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? (Select all that apply.)
Discuss the benefits of the procedure. The nurse should discuss the benefits of the procedure with the child, because this action is an age-appropriate activity that will decrease the child's anxiety about the procedure. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Give the child needleless IV supplies to play with. The nurse should allow the child to see, hold, and collect the supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Allow the child to perform the procedure with a doll. The nurse should allow the child to mimic the procedure with a doll to alleviate anxiety. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.
A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate?
Droplet precautions The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets.
A nurse is reinforcing teaching with the parent of a child who is being treated with diphenhydramine for allergic rhinitis. The nurse should tell the parent to monitor the child for which of the following?
Drowsiness Diphenhydramine can cause drowsiness due to CNS depression. The nurse should reinforce with the parent to administer the medication at bedtime to avoid daytime sedation.
A nurse is collecting data from a 12-month-old infant during a well-child visit. At birth, the infant's weight was 3.6 kg (8 lb) and his length was 50.8 cm (20 in). Based on this data, which of the following findings should the nurse expect?
The infant is 76.2 cm (30 in) long The nurse should expect a length of 76.2 cm (30 in), because the infant's length should increase by about 50% by 12 months of age.
A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE).
Gloves Goggles Gown Mask The infant is on droplet and contact precautions due to the RSV. First, the nurse should remove his gloves, because these are the most contaminated. Second, the nurse should remove goggles, so they do not interfere with removing the other PPE. The nurse should then remove the gown, and finally the mask, to decrease exposure to the disease.
A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months?
Glycosylated hemoglobin Glycosylated hemoglobin provides an accurate average of the client's blood glucose level over the past 120 days. This test can be used to determine the effectiveness of, or compliance with, a treatment plan. It can also be used to diagnose diabetes mellitus.
A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take?
Have the client stand during the procedure. To obtain the peak expiratory flow rate, the nurse should have the client stand during the procedure, which will allow the nurse to get an accurate reading.
A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect?
Hgb 9.0 g/dL The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 9.5 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range.
A nurse is administering an injection of epinephrine to a child who is experiencing manifestations of anaphylaxis. The nurse should monitor for which of the following adverse effects?
Increased systolic blood pressure Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased systolic blood pressure following administration of epinephrine.
A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetaminde. Which of the following instructions should the nurse include?
Instill medication immediately after cleansing the eye. The nurse should instruct the guardian to place the medication in the eye immediately after cleansing.
A nurse is preparing to administer levabuterol via nebulizer to a child with asthma. Which of the following data should the nurse collect prior to administering the medication?
Lung sounds Levalbuterol is a bronchodilator used to increase air exchange. The nurse should evaluate lung sounds prior to and after the administration of the medication to determine changes in respiratory status.
A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan?
Maintain the leg in an extended position. The nurse should have the child maintain her affected leg in an extended position while in Buck's traction. This position decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms.
A nurse is preparing to assist a provider with a lumbar puncture for a school-aged child. Which of the following actions is the nurse's priority?
Maintaining the child's position The greatest risk to the child is injury to the spinal nerves or the major vessels. Therefore, the priority action is for the nurse to maintain the child's position to prevent trauma.
A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?
Mummy restraint The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.
A nurse is contributing to the plan of care for a 10-month-old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care?
Place the infant in side-lying position. The nurse should place the infant in side-lying position to promote healing and prevent injury to the surgical site.
A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching?
Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt. The nurse should instruct the parents to secure both the child and the booster seat with the shoulder-lap seat belt inside the motor vehicle, because booster seats do not have built-in straps.
A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider?
Sits with support by leaning on hands The nurse should identify that sitting with support can indicate a developmental delay, because an infant should be able to sit unsupported by 8 months of age. Therefore, the nurse should report this finding to the provider.
A nurse is collecting data from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse?
The child was born at 30 weeks of gestation. The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy.
A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the following is the priority goal for this child?
The child will maintain an effective breathing pattern. Manifestations of cystic fibrosis, such as chronic cough, pulmonary infection, and bronchiolar obstruction lead to severely impaired ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when utilizing the airway, breathing, circulation approach to client care, maintaining an effective breathing pattern is the priority goal for the child who has cystic fibrosis.
A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program?
The leading cause of death in adolescents is physical injury. The nurse should recommend including this information, because injuries from motor-vehicle crashes are the leading cause of death in the adolescent population.
A nurse is collecting data from an 18-month-old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider?
The toddler is unable to recognize familiar objects by name. The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age.
A nurse is preparing to administer an IM injection to an 11-month-old infant. In which of the following areas should the nurse administer the injection?
Vastus lateralis The nurse should administer an IM injection in the vastus lateralis muscle of an 11-month-old infant. The vastus lateralis is a well-developed muscle that is safe to use for infants and small children.
A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the parent to include in the child's diet?
Vitamin D Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose.
A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include?
Wait 1 week before giving the infant a tub bath. The nurse should instruct the guardians to keep the infant's penis as dry as possible until the stent or catheter is removed. The parent should provide sponge-baths to the child until the stent or catheter is removed.
A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend?
Yellow corn A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet.
A nurse is collecting data from a school-aged child. The nurse should identify that which of the following findings is a manifestation of physical abuse?
Bruises at various stages of healing The nurse should recognize that bruises at various stages of healing are a clinical manifestation of physical abuse.
A nurse is assisting with the care for a 7-month-old infant who has a cleft palate. Which of the following actions should the nurse take to decrease the infant's risk for aspiration?
Burp the infant frequently during feedings. Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infant frequently, following every ounce of fluid consumed, dissipates swallowed air and helps to prevent aspiration.
A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor?
The child's abdomen. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. The child who is dehydrated will have a prolonged period of tenting.
A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching?
"I should bring my child in for immunizations on schedule." Immunizations provide protection from communicable diseases and should be administered on schedule.
A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will give this medication to my child with a straw." The nurse should reinforce with the guardian to administer this medication with a straw to prevent staining the child's teeth.
A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching?
"I will perform daily stretching exercises to my toddler's affected muscles." The nurse should reinforce that performing stretching exercises of the toddler's affected muscles will prevent muscle contractures.
A nurse in a pediatric clinic is talking on the telephone with the parent of a 6-month-old infant who has a UTI and started taking an oral antibiotic the day before. Listen to the (audio clip) and determine which of the following responses the nurse should make?
"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item.
A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statement by the parent indicates the desired therapeutic effect of the medication?
"My baby is breathing easier than she used to." The nurse should identify that the desired effect of digoxin is to increase cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands.
A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make?
"Six days after lesions appear if they are crusted." The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.
A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6-month-old infant during a well-baby visit. Which of the following statements by the parent indicates an understanding of the teaching?
"My baby will receive his third DTaP vaccine today." The nurse should reinforce with the parent that the infant should receive his third diphtheria, tetanus, and pertussis (DTaP) immunization at 6 months of age.
A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse?
"My child has refused to drink any fluids for the past 8 hours." An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse.
A nurse is reinforcing teaching with the guardian of a child who has a new prescription for levalbuterol solution for use in a nebulizer. Which of the following statements by the guardian indicates an understanding of the teaching?
"My child might experience palpitations after taking this medication." Palpitations are an adverse effect of levalbuterol. If this occurs, the guardian should discontinue the medication and notify the provider.
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching?
"My child might have a period of irregular movement of the extremities." The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Chorea is a temporary lack of coordination and the presence of sudden, irregular movements or periods of clumsiness.
A nurse is reinforcing teaching about vital signs with the guardian of a 1-year-old toddler. Which of the following statements by the guardian indicates an understanding of the teaching?
"My child's pulse could increase to 150 beats a minute with activity." A pulse rate of 150/min is within the expected reference range for a toddler during physical activity.
