Block 9.0 Pediatrics

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support

a. A. Closed posterior fontanel Rationale: The infant's posterior fontanel should close by about 8 weeks of age. B. Uses thumb and index fingers in a pincer grasp Rationale:A 9-month-old infant should be able to use his thumb and index fingers in a crude pincer grasp. C. Lateral incisors Rationale:An infant should develop upper lateral incisors between 9 and 13 months of age and lower lateral incisors at 10 to 16 months of age. D. Sitting steadily without support Rationale:At 6 months of age, most infants can sit only with support. An 8-month-old infant should be able to sit without support

A nurse is caring for a 3-year-old child whose parents report that she has an intense fear of painful procedures, such as injections. Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply.) A. Have a parent stay with the child during procedures. B. Cluster invasive procedures whenever possible. C. Perform the procedure as quickly as possible. D. Allow the child to keep a toy from home with her. E. Use mummy restraints during painful procedures.

a, c, d Rationale: Have a parent stay with the child during procedures is correct. Maintaining parent-child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures.Cluster invasive procedures when possible is incorrect. Clustering creates an unnecessarily lengthy and painful period for the client, which is likely to increase her fear.Perform procedures as quickly as possible is correct. Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures.Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization.Use mummy restraints during painful procedures is incorrect. Mummy restraints help to immobilize very young children and keep them safe during procedures, but it is likely to increase fear in toddlers and preschoolers.

A nurse teaching the parents of a 10-month-old infant about home safety. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Serve food in small, non-circular pieces. B. Tie plastic bags in knots before discarding them. C. Install accordion style gates. D. Set the water heater at 65.6° C (150° F). E. Fit the mattress so that it is snug against the sides of the crib E. Fit the mattress so that it is snug against the sides of the crib.

a,b,e Rationale:Serve food in small, non-circular pieces is correct. Infants have small airways. Food items are a common cause of aspiration. The foods most associated with choking and aspiration are hot dogs, candy, nuts, and grapes.Tie plastic bags in knots before discarding them is correct. Tying the bags in knots prevents the child from placing the plastic over her head.Install accordion style gates is incorrect. This type of gate can cause the child to pinch herself or to become entangled in the openings.Set the water heater at 65.6° C (150° F) is incorrect. Water heaters should be set to a temperature of 48.9° C (120° F) or lower to prevent burns.Fit the mattress so that it is snug against the sides of the crib is correct. The mattress should be fit snugly to prevent the child from being caught between the slats of the crib and the mattress.

A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'm glad that my child's ostomy is only temporary." B. "I'm glad my child will have normal bowel movements now." C. "I want to learn how to use my child's feeding tube as soon as possible." D. "I want to learn how to empty my child's urinary catheter bag."

a. A. "I'm glad that my child's ostomy is only temporary." Rationale: Hirschsprung disease is also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest. B. "I'm glad my child will have normal bowel movements now." Rationale: The child will not have bowel movements after the initial surgery. C. "I want to learn how to use my child's feeding tube as soon as possible." Rationale: The child will not have a feeding tube after the surgery. D. "I want to learn how to empty my child's urinary catheter bag." Rationale: The child will not have a urinary catheter after the surgery

A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching? A. "Our baby will sleep in our bed because I am breastfeeding." B. "We will give my baby a pacifier during naps and at bedtime." C. "We will place my baby on her back when sleeping." D. "We will remove blankets and toys from the crib."

a. A. "Our baby will sleep in our bed because I am breastfeeding." Rationale:Allowing an infant to sleep in the same bed as an adult can lead to suffocation and falls. The parent should place the infant back in her crib or bassinet after breastfeeding. B. "We will give my baby a pacifier during naps and at bedtime." Rationale:Evidence-based practice indicates that the use of pacifiers during nap time or bed time can reduce the risk of SIDS. The parents can introduce a pacifier at 3 to 4 weeks after the infant is breastfeeding well. C. "We will place my baby on her back when sleeping." Rationale: The parents should place infant supine during naps and at bedtime because this decreases the risk of SIDS. D. "We will remove blankets and toys from the crib." Rationale: The infant should lie on a firm mattress without soft materials such as pillows, quilts, pillows, blankets, and stuffed animals that can cause suffocation.

A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother? A. "Placing your child on her back when sleeping will decrease the risk of SIDS." B. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." C. "SIDS rates have been rising over the last 10 years." D. "Sleep apnea is the main cause of SIDS."

a. A. "Placing your child on her back when sleeping will decrease the risk of SIDS." Rationale: The nurse should instruct the mother to position in the infant on her back during sleep to prevent SIDS. The incidence of SIDS has declined since the Back to Sleep campaign started in the 1990s. B. "SIDS is directly correlated with the diphtheria, tetanus, and pertussis vaccines." Rationale: There is no correlation between SIDS and diphtheria, tetanus, and pertussis vaccines. C. "SIDS rates have been rising over the last 10 years." Rationale: Mortality rates for SIDS have declined more than 50% in the U.S. since the 1990s. D. "Sleep apnea is the main cause of SIDS." Rationale:SIDS might be related to a brainstem abnormality in the neurologic regulation of cardiorespiratory control. Sleep apnea does not cause SIDS.

A nurse is speaking with the mother of a 6-year-old child. Which of the following statements by the mother should concern the nurse? A. "The teacher says my child has to squint to see the board." B. "My child has recently lost both front top teeth." C. "My child often cheats when we play board games." D. "Sometimes my child acts bossy with his friends."

a. A. "The teacher says my child has to squint to see the board." Rationale:Squinting to see the board can indicate a vision problem. It is essential to assess children for hearing and vision problems. If not caught early, they lead to frustration and decreased ability to learn. B. "My child has recently lost both front top teeth." Rationale:Children begin to lose their deciduous teeth around 6 years of age and replace them with their permanent teeth. C. "My child often cheats when we play board games." Rationale: Children who are 5 to 7 years of age often cheat to win at games because they feel winning is most important. D. "Sometimes my child acts bossy with his friends." Rationale: Children of this age are learning how to interact with peers. During this gradual process of learning to appreciate the feelings of others, they can remain somewhat egocentric.

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? A. 3 years B. 4 years C. 5 years D. 6 years

a. A. 3 years Rationale:At age 3, children can typically ascend stairs using alternating feet but still descend by placing both feet on each step. B. 4 years Rationale:By age 4, children can descend stairs using alternating feet and holding the railing. C. 5 years Rationale:By age 5, children's balance improves but they continue hold the railing when ascending and descending stairs. D. 6 years Rationale:At age 6, balance improves so that children are proficient at ascending and descending stairs.

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen

a. A. At the end Rationale: When examining a toddler, the nurse should follow a modified head-to-toe approach, starting at the head but deferring anything that the toddler is likely to view as invasive and traumatic to the very end. The toddler is likely to resist not only having the ears examined, but also anything that follows. B. At the beginning Rationale: The nurse should not examine the tympanic membranes first because the toddler is likely to view examination of the ear canal as invasive and traumatic. The toddler is likely to resist not only having the ears examined, but also anything that follows. C. Before examining the head and neck Rationale: The nurse should examine the head and neck before examining the tympanic membrane. D. Before auscultating the chest and abdomen Rationale: The nurse should auscultate the chest and abdomen before examining the tympanic membrane.

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. Body weight B. Skin integrity C. Blood pressure D. Respiratory rate

a. A. Body weight Rationale:Body weight is the most reliable indicator of fluid loss for infants and young children. B. Skin integrity Rationale:Impaired skin integrity can indicate dehydration but is not the best indicator of fluid loss. C. Blood pressure Rationale: Change in a child's blood pressure can indicate dehydration but is not the best indicator of fluid loss. D. Respiratory rate Rationale: Change in a child's respiratory rate can indicate dehydration but is not the best indicator of fluid loss.

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson? A. Encourage the client to complete school work. B. Vary the child's schedule each day. C. Discourage visits from the client's friends. D. Provide a daily session with a play therapist.

a. A. Encourage the client to complete school work. Rationale:Erikson's stage of psychosocial development for a 10-year-old child is industry vs. inferiority. By providing school-age children the opportunity to keep up with their school work, they can continue to develop skills and knowledge and maintain a sense of accomplishment. B. Vary the child's schedule each day. Rationale: Maintaining a consistent daily schedule can help make the child feel more secure, decrease stress, and feel less isolated from their peers. C. Discourage visits from the client's friends. Rationale:Encouraging visits from friends can help the school-age child adjust emotionally to the stress of prolonged hospitalization. D. Provide a daily session with a play therapist. Rationale: The school-age child needs to play, and a daily therapeutic session with the play therapist will help the child adjust to the stress of prolonged hospitalization. However, this action does not address the child's psychosocial development according to Erikson.

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Encourage the parents to rock the infant. B. Offer the infant a pacifier. C. Administer ibuprofen as needed for pain. D. Position the infant on her abdomen.

a. A. Encourage the parents to rock the infant. Rationale:A rocking motion will calm and soothe the infant. Additionally, involving the parents in the infant's care can reduce feelings of helplessness. B. Offer the infant a pacifier. Rationale:Sucking on a pacifier can cause pressure on the incision line, which can result in inflammation and trauma to the surgical site. C. Administer ibuprofen as needed for pain. Rationale:It is a contraindication for an infant who is younger than 6 months of age to receive ibuprofen. D. Position the infant on her abdomen. Rationale:Placing the infant on her abdomen allows the infant to rub the suture line on the bedding, which can result in inflammation and trauma to the surgical site.

A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? A. Inability to raise head when in prone position B. Inability to sit without support C. Inability to pick up an object with her fingers D. Inability to bring an object to her mouth

a. A. Inability to raise head when in prone position Rationale:A 3-month-old infant should be able to raise her head and shoulders from prone position;therefore, the nurse should report this finding to the provider. B. Inability to sit without support Rationale:An 8-month-old infant should be able to sit without support. C. Inability to pick up an object with her fingers Rationale:A 6-month-old infant should be able to grasp objects with her fingers. D. Inability to bring an object to her mouth Rationale:A 4-month-old infant should be able to bring objects to her mouth.

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book

a. A. Large building blocks Rationale:Large building blocks are age-appropriate toys for a 12-month-old toddler. B. Hanging crib toys Rationale:A crib gym is not an age-appropriate toy for a 12-month-old toddler. The ability to stand places the toddler at risk of strangling from the strings of the toys. C. Modeling clay Rationale: Modeling clay is not an age-appropriate toy for a 12-month-old toddler due to the risk of the child ingesting it. D. Crayons and a coloring book Rationale: Crayons and a coloring book are not age-appropriate toys for a 12-month-old client.

A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book

a. A. Large building blocks Rationale:Large building blocks are age-appropriate toys for a 12-month-old toddler. B. Hanging crib toys Rationale:A crib gym is not an age-appropriate toy for a 12-month-old toddler. The ability to stand places the toddler at risk of strangling from the strings of the toys. C. Modeling clay Rationale:Modeling clay is not an age-appropriate toy for a 12-month-old toddler due to the risk of the child ingesting it. D. Crayons and a coloring book Rationale: Crayons and a coloring book are not age-appropriate toys for a 12-month-old client.

A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant? A. Oral electrolyte solution B. Half-strength infant formula C. Half-strength orange juice D. Sterile water

a. A. Oral electrolyte solution Rationale:After gastrointestinal surgery, infants should receive clear liquids that contain glucose and electrolytes, such as an oral electrolyte or rehydration solution. They should then advance to formula or breast milk as they demonstrate tolerance. B. Half-strength infant formula Rationale: Half-strength formula is not a clear liquid. C. Half-strength orange juice Rationale: Half-strength orange juice is not a clear liquid. D. Sterile water Rationale:Sterile water does not contain nutrients and is not appropriate to include in a clear liquid diet for an infant who is postoperative

A nurse is teaching about safety recommendations for car seats with the parents of a 24-month-old toddler who is in the 50th percentile for height and weight. Which of the following instructions should the nurse include in the teaching? A. Position the toddler rear-facing in the middle of the back seat. B. Position a booster seat forward-facing in the middle of the back seat. C. Position a convertible seat rear-facing in the front passenger side. D. Position a convertible seat forward-facing in the front passenger side and inactivate the airbag.

a. A. Position the toddler rear-facing in the middle of the back seat. Rationale:A child should remain in a rear-facing car seat until the child outgrows the height or weight limits of a rear-facing seat. Car seat manufacturers provide specifics regarding use. B. Position a booster seat forward-facing in the middle of the back seat. Rationale: Children should remain in a toddler seat with harness until they outgrow the harness. Booster seats are designed for children who are less than 145 cm (4 ft, 9 in) tall and weigh between 15.9 and 36.3 kg (35 to 60 lb). C. Position a convertible seat rear-facing in the front passenger side. Rationale: Children who are properly restrained in the center of the back seat have a lower risk of injury. D. Position a convertible seat forward-facing in the front passenger side and inactivate the airbag. Rationale:Infants and children who are properly restrained in the center of the back seat have a lower risk of injury. Unless a rear seat is not available,

A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs? A. "Can I listen to your lungs?" B. "I am going to listen to your heart." C. "I am going to take your blood pressure now." D. "Can you stand very still while I feel how warm you are?"

b. A. "Can I listen to your lungs?" Rationale: The nurse should not ask yes/no questions. Negativism is exhibited by toddlers as a way of asserting self-control and gaining independence. Therefore, toddlers tend to answer questions with a negative response and are likely to initially resist attempts to measure their vital signs. If the nurse asks the question, the toddler responds "no," and the nurse proceeds anyway, it creates an environment of mistrust between the toddler and the nurse. B. "I am going to listen to your heart." Rationale: The nurse should inform the toddler of the procedure prior to taking vital signs. C. "I am going to take your blood pressure now." Rationale: The nurse should avoid using the word "take" when measuring vital signs. The toddler might interpret the words literally and think his blood pressure will be taken away from him. D. "Can you stand very still while I feel how warm you are?" Rationale: The nurse should not ask yes/no questions. Negativism is exhibited by toddlers as a way of asserting self-control and gaining independence. Therefore, toddlers tend to answer questions with a negative response and are likely to initially resist attempts to measure their vital signs. If the nurse asks the question, the toddler responds "no," and the nurse proceeds anyway, it creates an environment of mistrust between the toddler and the nurse.

A nurse is teaching new parents the proper way to use an infant safety seat. Which of the following should indicate to the nurse a need for further teaching? A. "I will dress my baby in a one piece outfit so I can use the harness to secure her in the car seat." B. "My baby will be able to watch me drive while sitting in the back seat." C. "I will place the infant safety seat in the middle of the back seat, away from the windows." D. "We will need to go by the weight and height of the child when deciding to change to a booster seat."

b. A. "I will dress my baby in a one piece outfit so I can use the harness to secure her in the car seat." Rationale: Dressing the infant in clothing with legs and arms allows the parents to close the harness in such a way that that the infant is secure in the car seat. B. "My baby will be able to watch me drive while sitting in the back seat." Rationale: The safest area for a car seat is in the back seat. Infants should travel in a rear-facing position for the best protection from airbags and neck and head injury. While in a rear-facing position, the back of the car seat supports the infant's weak neck muscles, soft fontanels, and spine in the event of a frontal motor vehicle crash. C. "I will place the infant safety seat in the middle of the back seat, away from the windows." Rationale: The safest place for infants is in the back seat, preferably in the middle away from airbags and side impact airbags. D. "We will need to go by the weight and height of the child when deciding to change to a booster seat." Rationale:Parents should keep their children in car seat until they reach the maximum weight that the manufacturer recommends. Then the parents can switch the child to a booster seat. Children should remain in booster seats until approximately 7 or 8 years of age or until the c

The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make? A. "Let your child sleep in your bed with you." B. "Keep a night light on in your child's room." C. "Tell your child that monsters are not real." D. "Stay with your child until the child is asleep."

b. A. "Let your child sleep in your bed with you." Rationale: Co-sleeping can develop into a habit that can be difficult to break. B. "Keep a night light on in your child's room." Rationale: Fears of the dark and "monsters" are common in preschool-age children who are imaginative thinkers and have difficulty distinguishing between real and make-believe. After the parent reassures the child that there are no monsters, the night light provides enough illumination for the child to see that there is nothing hiding in the closet. C. "Tell your child that monsters are not real." Rationale: This is not an appropriate suggestion for a preschool-age child who has difficulty distinguishing between real and make-believe. D. "Stay with your child until the child is asleep." Rationale: This behavior can develop into a habit that can be difficult to break.

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? A. Carotid artery B. Apex of the heart C. Brachial artery D. Radial artery

b. A. Carotid artery Rationale: The carotid artery is difficult to palpate on an infant. B. Apex of the heart Rationale: The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart. C. Brachial artery Rationale: The brachial artery is used to assess for a pulse in cardiopulmonary resuscitation. The nurse should not use this site for a routine assessment of a pulse. D. Radial artery Rationale: The radial artery is generally not used to assess pulse rate until the age of 2.

A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? A. Feed the infant with a spoon for 48 hr. B. Apply and release elbow restraints every hour. C. Keep the infant supine. D. Suction the mouth with an oral suction tube.

b. A. Feed the infant with a spoon for 48 hr. Rationale: The nurse should avoid feeding the infant with a spoon to prevent trauma to the surgical site. B. Apply and release elbow restraints every hour. Rationale:It is essential to apply elbow restraints after surgery to keep the infant from placing her hands in and around her mouth. The nurse should remove them periodically to inspect the skin and allow the infant to exercise her arms. C. Keep the infant supine. Rationale:Keeping the infant upright in an infant seat helps with drainage of secretions. D. Suction the mouth with an oral suction tube. Rationale: The nurse should suction the infant's nose and mouth with a bulb syringe as needed to maintain a patent airway, but should not place hard objects, such as an oral suction tube, in the infant's mouth to avoid trauma.

A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take? A. Notify the provider. B. Continue to monitor the client. C. Provide oral rehydration fluids. D. Perform a bladder scan at the bedside

b. A. Notify the provider. Rationale: The child's urine output should be greater than 1 mL/kg/hr. There is no need to notify the provider. This urine output is within the expected reference range for a toddler. The client weighs 33 lb / 2.2 kg = 15 kg. 15 kg x 8 hr = 120 mL. This client's output indicates an adequate amount of urinary output during the 8 hr. B. Continue to monitor the client. Rationale: This urine output is within the expected reference range for a toddler. The child's urine output should be greater than 1 mL/kg/hr. The client weighs 33 lb, which converts to 15 kg. 15 kg x 8 hr = 120 mL. This client's output indicates an adequate amount of urinary output during 8 hr. Other signs of adequate fluid volume are moist mucous membranes, capillary refill of 2 seconds or less, brisk skin turgor, balanced fluid intake and output, and electrolytes within expected range. C. Provide oral rehydration fluids. Rationale: This urine output is within the expected reference range for a toddler. The client would require oral rehydration fluids if signs of dehydration were present. These signs include dry mucous membranes, voiding less than 1 mL/kg/hr, poor skin turgor, or imbalanced fluid intake and output. D. Perform a bladder scan at the bedside. Rationale: This urine output is within the expected reference range for a toddler. The client would require a bladder scan if there was an indication of urinary retention. The bladder scan would screen for postvoid residual volumes and determine the need for intermittent catheterization. There is no indication that the client is experiencing increased postvoid residuals.

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take? A. Obtain a throat culture. B. Place the child in an upright position. C. Transport the child to radiology for a throat x-ray. D. Visualize the epiglottis with a tongue depressor

b. A. Obtain a throat culture. Rationale: Obtaining a throat culture from a child who has suspected epiglottitis can precipitate an obstruction of the airway and should be avoided. B. Place the child in an upright position. Rationale:Placing the child in an upright position will assist in maintaining a patent airway. C. Transport the child to radiology for a throat x-ray. Rationale: The airway of a child who has suspected epiglottitis can become obstructed easily; therefore, transferring the child to radiology for a throat x-ray is not an appropriate action for the nurse to take. D. Visualize the epiglottis with a tongue depressor. Rationale:Visualizing the epiglottis of a child who has suspected epiglottitis using a tongue depressor can precipitate an obstruction of the airway and should be avoided.

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? A. Restrain the child physically. B. Ignore the temper tantrums. C. Tell the child that temper tantrums are not acceptable. D. Distract the child by offering to play a game.

b. A. Restrain the child physically. Rationale: Restraints can cause the behavior to intensify. B. Ignore the temper tantrums. Rationale:Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly. C. Tell the child that temper tantrums are not acceptable. Rationale: This action is not developmentally appropriate. Temper tantrums occur due to an age-appropriate lack of self-control, which is gradually gained as the child matures. D. Distract the child by offering to play a game. Rationale: Offering the child an opportunity to play a game provides positive reinforcement for an unacceptable behavior.

A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler. Which of the following statements by the parents indicates an understanding of the teaching? A. "I should expect him to have an increased appetite." B. "His average daily intake should be about 3,000 calories." C. "The quality of food I provide him is more important than the quantity." D. "Because he is such a picky eater, I will give him one of my vitamins each day."

c. A. "I should expect him to have an increased appetite." Rationale: Toddlers have a decrease in appetite and calorie requirements. At approximately 18 months of age, most toddlers experience a decrease in appetite, a phenomenon known as physiologic anorexia. B. "His average daily intake should be about 3,000 calories." Rationale: During the period from 12 to 18 months of age, the growth rate slows, decreasing the child's need for calories, protein, and fluid. However, the protein (13 g/day) and energy requirements are still high to meet demands for muscle tissue growth and high activity level. Estimated energy requirements for toddlers vary by age, gender, and feeding method. Average intake is about 1,800 calories per day. C. "The quality of food I provide him is more important than the quantity." Rationale: Toddlers are very picky eaters and usually eat only one or two meals each day. Therefore, it is essential that the meals are balanced with essential nutrients. The nutritious quality of the food is much more important than the quantity. Toddlers generally prefer finger foods because of increasing autonomy. D. "Because he is such a picky eater, I will give him one of my vitamins each day." Rationale: Toddlers are picky eaters. However, children should not be given adult doses of vitamins because a child's needs for vitamins are different from the needs of adults.

.A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? A. "Share piercing needles only with close friends you trust." B. "Limit your caloric intake to avoid becoming overweight." C. "Your need for sleep will increase during periods of growth." D. "Tanning beds are much safer then lying in the sun."

c. A. "Share piercing needles only with close friends you trust." Rationale:According to Erickson, the developmental goal of adolescence is the need to establish an identity. Some choose methods of body modification, such as piercing and tattooing. The goal for the nurse is not to prevent these practices, but to educate the adolescent and care givers about engaging in safe practices if they choose these activities. B. "Limit your caloric intake to avoid becoming overweight." Rationale:Adolescents have more independence and often make nutrition decisions on their own. Caloric intake should be based on the level of activity and the nurse should educate the adolescent regarding dietary guidelines for all nutrients. C. "Your need for sleep will increase during periods of growth." Rationale: The nurse should inform the adolescent that sleep needs increase during growth spurts. Adequate sleep and rest during the adolescent period is important for optimal health. D. "Tanning beds are much safer then lying in the sun." Rationale: Tanning beds pose serious long-term risks. The long-term effects of tanning beds include premature aging of the skin as well as an increased risk of skin cancer.

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler? A. Explains the difference between right and wrong B. Prints letters and numbers C. Separates easily from primary care giver for short periods of time D. Cooperates in doing simple chores

c. A. Explains the difference between right and wrong Rationale:Appropriate psychosocial development for a school-age child includes the ability to understand the difference between right and wrong. B. Prints letters and numbers Rationale:By 5 years of age, a preschooler's motor development should include the ability to print letters and numbers. C. Separates easily from primary care giver for short periods of time Rationale:By 3 years of age, a toddler's psychosocial development should include the ability to accept separating from a primary care giver for short periods of time. A toddler should also be able to express likes and dislikes and begin to play with children and others outside the family D. Cooperates in doing simple chores Rationale:By 5 years of age, a preschooler's psychosocial development should include performing simple chores around the house, such as putting toys away and assisting with setting the table for meals.

A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Offer fluids through a straw. B. Apply bilateral wrist restraints. C. Administer opioids for pain. D. Implement a soft diet.

c. A. Offer fluids through a straw. Rationale: To avoid trauma to the surgical site, objects such as tongue depressors, thermometers, syringes, spoons, or straws should not be placed in the mouth of the infant who is 24 hr postoperative following a cleft palate repair. B. Apply bilateral wrist restraints. Rationale: The nurse should apply bilateral elbow restraints to prevent the toddler from placing his hands in and around his mouth, which can result in trauma. C. Administer opioids for pain. Rationale:Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN. D. Implement a soft diet. Rationale: The toddler should receive clear liquids for 24 hr following surgery, after which the nurse should implement a liquid diet for 2 weeks, followed by a soft diet for 6 weeks following the repair.

Which of the following statements best describes the relationship school-age children have with their families? a.Children desire to spend equal time with family and peers. b.Children are prepared to reject parental controls. c.Children need and want restrictions placed on their behavior by the family. d.The peer group replaces the family as the primary influence in setting standards of behavior and rules.

c. School-age children need and want restrictions placed on their behavior, and they are not prepared to cope with all the problems of their expanding environment. They feel more secure knowing that an authority figure can implement controls and restrictions. In the middle school years, children prefer peer group activities to family activities and want to spend more time in the company of peers. Although increased independence is the goal of middle childhood, children are not ready to abandon parental control. Family values usually take precedence over peer value systems.

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." B. "Newborns do not expand their lungs fully with each respiration." C. "Activity will increase the respiratory rate." D. "The rate and rhythm of breath are irregular in newborns."

d. A. "Newborns are abdominal breathers." Rationale: Newborns are abdominal breathers. However, this fact has no impact on obtaining a respiratory rate. B. "Newborns do not expand their lungs fully with each respiration." Rationale: The labor of breathing in a newborn varies. However, this fact has no impact on obtaining a respiratory rate. C. "Activity will increase the respiratory rate." Rationale:Activity will increase the respiratory rate. However, this fact has no impact on obtaining a respiratory rate. D. "The rate and rhythm of breath are irregular in newborns." Rationale: Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.

A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority? A. Insert an IV catheter. B. Obtain blood culture specimens. C. Administer an antipyretic. D. Prepare for nasotracheal intubation.

d. A. Insert an IV catheter. Rationale: The client will require IV access to administer fluids, but this is not the priority action. B. Obtain blood culture specimens. Rationale: The client will require culture and sensitivity testing, but this is not the priority action. C. Administer an antipyretic. Rationale: The client will require antipyretics, but this is not the priority action. D. Prepare for nasotracheal intubation. Rationale: The client's manifestations suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the priority action is to prepare for intubation to maintain airway patency.

A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which of the following findings should the nurse expect? A. Skips and hops on one foot B. Has a vocabulary of 1,500 words C. Walks backwards heel to toe D. Stands on one foot for a few seconds

d. A. Skips and hops on one foot Rationale: The nurse should expect a 4 year-old-child to be able to skip and hop on one foot. B. Has a vocabulary of 1,500 words Rationale:The nurse should expect a 3 year-old-child to have a vocabulary of about 900 words. The nurse should expect a 4 year-old-child to have a vocabulary of 1,500 words. C. Walks backwards heel to toe Rationale: The nurse should expect a 5 year-old-child to be able to walk backwards heel to toe. D. Stands on one foot for a few seconds Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off of the bottom step

A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings? A. Tracheoesophageal fistula B. Inguinal hernia C. Hypertrophic pyloric stenosis D. Intussusception

d. A. Tracheoesophageal fistula Rationale: Findings associated with a tracheoesophageal fistula include excessive salivation, drooling, abdominal distension, and respiratory distress after feeding. B. Inguinal hernia Rationale: Findings associated with an inguinal hernia include a palpable, and often visible, mass in the scrotum. C. Hypertrophic pyloric stenosis Rationale: Findings associated with hypertrophic pyloric stenosis include a distended upper abdomen, chronic hunger, weight loss, projectile vomiting, and a palpable olive-shaped shaped tumor in the epigastrium. D. Intussusception Rationale: These findings are associated with a diagnosis of intussusception. Other associated findings include vomiting, lethargy, periods of screaming and drawing the knees to the chest followed by periods of normal behavior, and eventual fever and signs of peritonitis.

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? A. Uses a unidextrous grasp B. Has a fear of strangers C. Shows preferences towards foods D. Babbles one-syllable sounds

d. A. Uses a unidextrous grasp Rationale:A 7-month-old infant should exhibit a unidextrous approach and grasp; therefore, this does not indicate the need for further evaluation. B. Has a fear of strangers Rationale:A 7-month-old infant should exhibit a fear of strangers; therefore, this does not indicate the need for further evaluation. C. Shows preferences towards foods Rationale:A 7-month-old infant should exhibit a preference toward food likes and dislikes; therefore, this does not indicate the need for further evaluation. D. Babbles one-syllable sounds Rationale:A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.

Erikson Pyschosocial stages of Development: What age: Identity vs. Role confusion

Adolescence

What is the biggest concern when using Prostaglandin medication?

-Apnea (also makes them feel "yucky")

Transposition of Great Arteries: -What are 3 nursing interventions to include with this Congenital Heart Defect?

-Make sure Prostaglandins are running -O2 Sat >75% -Cardiac assessment

What do Prostaglandins do in congenital heart defects?

-Open the ductus arteriosis to allow dexoygenated blood to pool into pulmonary artery to get oxygenated

What 2 congenital heart defects are prostaglandins used?

-Transposition of Great Arteries -Coarctation of Aorta

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? a. Body weight b. Skin intergrity c. Blood Pressure d. Respiratory Rate

A. A. Body weight Rationale:Body weight is the most reliable indicator of fluid loss for infants and young children. B. Skin integrity Rationale:Impaired skin integrity can indicate dehydration but is not the best indicator of fluid loss. C. Blood pressure Rationale: Change in a child's blood pressure can indicate dehydration but is not the best indicator of fluid loss. D. Respiratory rate Rationale: Change in a child's respiratory rate can indicate dehydration but is not the best indicator of fluid loss.

Erikson Pyschosocial stages of Development: -Toddler

Autonomy vs. Shame/Doubt

Piaget Cognitive Development: -Phase: 7-11 years

Concrete Operational

What disease has a fever lasting >5 days, red eyes, strawberry tongue and peeling skin?

Kawasaki Disease

Erikson Pyschosocial stages of Development: What age: Initiative vs. Guilt

Preschool

Erikson Pyschosocial stages of Development: What age: Industry vs. Inferiority

School age

Piaget Cognitive Development: -Phase: Birth-2 years

Sensorimotor

Erikson Pyschosocial stages of Development: What age: Autonomy vs. Shame/Doubt

Toddler

.A nurse is providing health promotion teaching to the parents of a toddler. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Management of tantrums B. How to establish trust C. How to encourage cooperative play D. Dental care E. Need for increased caloric intake

a, d Rationale: Management of tantrums is correct. It is expected for toddlers to have temper tantrums.How to establish trust is incorrect. According to Erickson, establishing trust is the developmental goal associated with infancy.How to encourage cooperative play is incorrect. Toddlers engage in parallel play. Preschool-age children engage in cooperative play.Dental care is correct. Toddlers should be receiving dental care.Need for increased caloric intake is incorrect. The growth rate during the toddler years slows, which decreases the child's need for calories, protein, and fluid.

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? A. "Bring your baby in to the clinic today." B. "Burp your baby more frequently during feedings." C. "Give your infant an oral rehydration solution." D. "Try switching to a different formula."

a. A. "Bring your baby in to the clinic today." Rationale:Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible. B. "Burp your baby more frequently during feedings." Rationale: Burping the infant does not address the cause of the projectile vomiting. C. "Give your infant an oral rehydration solution." Rationale:Administering an oral rehydration solution does not address the cause of the projectile vomiting. D. "Try switching to a different formula." Rationale:Switching to a different formula does not address the cause of the projectile vomiting.

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever

a. A. Sudden decrease in abdominal pain Rationale:A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen. B. Absent Rovsing's sign Rationale: Rovsing's sign is a manifestation of appendicitis. The sign is positive when tenderness occurs in the right lower quadrant regardless of which of the quadrants is being palpated. C. Flaccid abdomen Rationale: The abdomen becomes progressively distended with a perforated appendix. D. Low-grade fever Rationale:Low-grade fever is a manifestation of appendicitis, but following perforation the temperature will elevate to 38.8° C to 39.4° C (102° to 103° F).

A first-time parent is discussing developmental milestones with the nurse. The nurse tells the client that she can reasonably expect her child to achieve which of the following by the time the child is 1 year old? (Select all that apply) a. Walking b. Rolling from tummy to side c. Transferring toys from hand to hand d. Beginning to respond selectively to words e. Vocalizing sounds (coos)

b, c, d, e a. Incorrect: The parent should not become concerned unless the child cannot walk at 18 months. b. Correct: Rolling from tummy to side is a developmental milestone that the client can expect the child to reach by age 1. c. Correct: Transferring toys from hand to hand is a developmental milestone that the client can expect the child to reach by age 1. d. Correct: Beginning to respond selectively to words is a developmental milestone that the client can expect the child to reach by age 1. e. Correct: Vocalizing sounds (coos) is a developmental milestone that the client can expect the child to reach by age 1.

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.) A. The preschooler stutters when speaking. B. The preschooler mispronounces words. C. The preschooler speaks in three word sentences. D. The preschooler talks to himself when reading. E. The preschooler speaks in a nasally tone.

b, e Rationale: The preschooler stutters when speaking is incorrect. Stuttering is expected in the preschooler. Stuttering or stammering is common for a preschool-age child who is learning to form new words into sentences.The preschooler mispronounces words is correct. Language begins to increase with toddlers as development progresses towards two to three word phrases. Mispronounced vowels and consonants occur between ages 24 and 36 months. The nurse should expect a toddler to mispronounce words.The preschooler speaks in three word sentences is incorrect. Three to four word sentences (telegraphic speech) is expected for preschoolers. Preschoolers ask many questions and often continue talking when no-one is listening. The preschooler talks to himself when reading is incorrect. During preschool development, the child experiences a vivid imagination that is expressed through imitative and dramatic play. In discovering books, the child becomes engaged in the story and might talk to himself. Speaking in a nasally tone is correct. A child who speaks with a nasally tone might have a neurogenic speech disorder that is caused by weakened muscles of the tongue, soft palate, and face. A speech therapist can evaluate the child and determine exercises to improve the articulation, voice, pitch quality, and volume.

A nurse is teaching a parent of a 2-year-old child about safe food choices. Which of the following foods should the nurse recommend? A. Grapes B. Bananas C. Celery D. Raw carrots

b. A. Grapes Rationale: Children are at increased risk of choking until about the age of 4. A 2-year-old child can have difficulty chewing and swallowing grapes. B. Bananas Rationale:Bananas are a safe choice for a 2-year-old child because they are easy to chew and swallow. C. Celery Rationale: Children are at increased risk of choking until about the age of 4. A 2-year-old child can have difficulty chewing and swallowing celery. D. Raw carrots Rationale: Children are at increased risk of choking until about the age of 4. A 2-year-old child can have difficulty chewing and swallowing raw carrots.

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot stand upright without support. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob.

b. A. The toddler cannot build a tower of six to seven cubes. Rationale: The nurse should expect a 24-month-old toddler to be able to build a tower of six to seven cubes. B. The toddler cannot stand upright without support. Rationale: The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay. C. The toddler cannot jump with both feet. Rationale: The nurse should expect a 30-month-old toddler to be able to jump with both feet. D. The toddler cannot turn a doorknob. Rationale: The nurse should expect a 24-month-old toddler to be able to turn a doorknob.

According to Erikson, which psychosocial task is developing in adolescence? a. Intimacy b. Identity c. Initiative d. Independence

b. Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood. Independence is not one of Erikson's developmental stages. ANSWER is b.

A nurse is assessing a preschool-age child and notes the child exhibits magical thinking. According to Piaget, which describes magical thinking? a. Events have cause and effect. b. God is like an imaginary friend. c. Thoughts are all-powerful. d. If the skin is broken, the child's insides will come out.

c Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are all-powerful. Cause-and-effect implies logical thought, not magical thinking. Thinking God is like an imaginary friend is an example of concrete thinking in a preschooler's spiritual development. Thinking that if the skin is broken, the child's insides will come out is an example of concrete thinking in development of body image. •Correct answer is C

A nurse is obtaining the length and weight of a 6-month-old infant. Which of the following actions should the nurse take? (Select all that apply.) A. Weigh the infant in a diaper. B. Use a stadiometer to measure the infant. C. Place a disposable covering on the scale. D. Measure the infant from crown of the head to the heels of feet. E. Balance the scale to 0 prior to use.

c,d,e Rationale: Weigh the infant in a diaper is incorrect. To obtain an accurate weight, the nurse should weigh a child who is 36 months of age or younger without a diaper or clothing.Use a stadiometer to measure the infant is incorrect. The nurse should place the infant in a recumbent position and use a length board to obtain the infant's length. The nurse should use a stadiometer, a wall-mounted unit, for measuring the height of individuals who can stand independently.Place a disposable covering on the scale is correct. The nurse should use a thin disposable cover to promote safety and minimize transmission of pathogens.Measure the infant from crown of the head to the heels of feet is correct. The nurse should place the infant in a recumbent position, keeping the head against the top of the board and the heels against the footboard. The nurse can also help extend the infant's body by gently holding the infant's legs down against the board.Balance the scale to 0 prior to use is correct. The nurse should balance the scale to 0 prior to weighing the infant to ensure an accurate measurement.

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A. Broth B. Water C. Diluted apple juice D. Oral rehydration solution

d. A. Broth Rationale:Broth provides fluid and sodium but does not replace other vital elements lost in diarrhea. B. Water Rationale: Water provides fluid but does not replace other vital elements lost in diarrhea. C. Diluted apple juice Rationale: Diluted apple juice provides fluid and sugar but does not replace other vital elements lost in diarrhea. D. Oral rehydration solution Rationale: Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea.

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? A. Uses a unidextrous grasp B. Has a fear of strangers C. Shows preferences towards foods D. Babbles one-syllable sounds

d. A. Uses a unidextrous grasp Rationale:A 7-month-old infant should exhibit a unidextrous approach and grasp; therefore, this does not indicate the need for further evaluation. B. Has a fear of strangers Rationale:A 7-month-old infant should exhibit a fear of strangers; therefore, this does not indicate the need for further evaluation. C. Shows preferences towards foods Rationale:A 7-month-old infant should exhibit a preference toward food likes and dislikes; therefore, this does not indicate the need for further evaluation. D. Babbles one-syllable sounds Rationale:A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.

Tetralogy of Fallot: -If O2 Sat is <75%, what are the nursing interventions?

1. Give Oxygen 2. Knees to chest 3. Morphine

Piaget Cognitive Development: -Phase: 2-6 years

Preoperational

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Inspection B. Superficial palpation C. Deep palpation D. Auscultation

a, d, b, c Rationale: When performing an abdominal assessment on a child, the nurse should first inspect the abdomen without touching and observe for anything that could indicate a medical concern. Because palpation prior to auscultation can alter the bowel sounds, the nurse should auscultate the abdomen for bowel sounds next. Then, the nurse should palpate the abdomen superficially so the child won't tense her abdominal muscles. Finally, the nurse should perform a deep palpation of the abdomen, making sure to palpate any painful areas last.

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Inspection B. Superficial palpation C. Deep palpation D. Auscultation

a, d, b, c When performing an abdominal assessment on a child, the nurse should first inspect the abdomen without touching and observe for anything that could indicate a medical concern. Because palpation prior to auscultation can alter the bowel sounds, the nurse should auscultate the abdomen for bowel sounds next. Then, the nurse should palpate the abdomen superficially so the child won't tense her abdominal muscles. Finally, the nurse should perform a deep palpation of the abdomen, making sure to palpate any painful areas last.

A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? A. Irritability B. Slow, bounding pulse C. Decreased temperature D. Tetany

a. A. Irritability Rationale:An infant who is dehydrated will exhibit irritability. B. Slow, bounding pulse Rationale:An infant who is dehydrated will exhibit tachycardia, rather than a slow, bounding pulse. C. Decreased temperature Rationale:An infant who is dehydrated will exhibit an increased, rather than a decreased, temperature. D. Tetany Rationale: Tetany is a manifestation of hypoglycemia

A nurse is caring for a 6-month-old infant. Which of the following findings indicates to the nurse that the infant may be experiencing pain? A. Dry palms and feet B. Decreased muscle tone C. Furrowed brow D. Eyes wide open

c. A. Dry palms and feet Rationale:Pain indicators for an infant include palmar sweating and diaphoresis. B. Decreased muscle tone Rationale:Pain indicators for an infant include an increase in muscle tone. C. Furrowed brow Rationale:A furrowed brow may indicate that the infant is in pain or distress. Pain indicators for an infant include a change in facial expressions, such as a furrowed brow and grimacing. The nurse should assess the infant for pain using an age-appropriate scale and provide appropriate pain relief as prescribed. D. Eyes wide open Rationale:Pain indicators for an infant include eyes that are tightly closed and an open mouth.c

A nurse is planning care for 2-month-old infant following a surgical procedure. Which of the following pain rating scales should the nurse plan to use to determine the infant's level of pain? A. FACES scale B. OUCHER scale C. FLACC scale D. PANAD scale

c. A. FACES scale Rationale: The FACES pain rating scale is for children ages 3 years and older. B. OUCHER scale Rationale: The OUCHER pain rating scale is for children ages 3 to 13 years. C. FLACC scale Rationale: The FLACC scale is used for children 2 months to 7 years. It uses facial expressions, leg movement, activity, cry, and consolability to assess the client's level of pain. D. PANAD scale Rationale: The PANAD scale is used for older adult clients who have advanced dementia. It uses breathing, vocalization, facial expression, body language, and consolability to assess the client's level of pain.

A nurse in a pediatric clinic is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching? A. Have the child remain at the table after meals to increase food intake. B. Add fruit juice to the child's diet to increase vitamin intake. C. Emphasize the quantity, rather than the quality, of food consumed. D. Expect that food consumption might not decrease significantly.

d. A. Have the child remain at the table after meals to increase food intake. Rationale:Parents should avoid prolonging the time a child remain at the table as this promotes overeating and poor nutrition habits. B. Add fruit juice to the child's diet to increase vitamin intake. Rationale: Fruit juice consumption should be limited as it is associated with dental caries and gastrointestinal upset. C. Emphasize the quantity, rather than the quality, of food consumed. Rationale: The quality of food the child eats is more important than the quantity consumed D. Expect that food consumption might not decrease significantly. Rationale: Food consumption varies and most preschool-age children consume an adequate quantity of food despite their fads and preferences.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply.) A. Coughing B. Apnea C. Sunken abdomen D. Cyanosis E. Frothy saliva

a,b,d,e Coughing is correct.Coughing is a finding associated with a tracheoesophageal fistula.Apnea is correct. Apnea is a finding associated with a tracheoesophageal fistula.Sunken abdomen is incorrect. Abdominal distension, rather than a sunken abdomen, is a finding associated with a tracheoesophageal fistula.Cyanosis is correct. Cyanosis is a finding associated with a tracheoesophageal fistula.Frothy saliva is correct. Frothy saliva is a finding associated with a tracheoesophageal fistula.

Piaget Cognitive Development: -Phase: 12 - Adulthood

Formal Operational

Erikson Pyschosocial stages of Development: -Adolescence

Identity vs. Role confusion

Erikson Pyschosocial stages of Development: -School age

Industry vs. Inferiority

Erikson Pyschosocial stages of Development: What age: Trust vs. Mistrust

Infant

Erikson Pyschosocial stages of Development: -Preschool

Initiative vs. Guilt

Erikson Pyschosocial stages of Development: -Infant

Trust vs. Mistrust

A nurse is teaching a parent of a 6-month-old infant about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "Our car seat is an infant model and is anchored in the car." B. "Our car seat is front-facing in the back seat." C. "I can fit my hand between the baby and the car seat harness." D. "The car seat is rear-facing in the front passenger seat."

a. A. "Our car seat is an infant model and is anchored in the car." Rationale:This statement by the parent indicates correct use of the infant care seat. B. "Our car seat is front-facing in the back seat." Rationale: The car seat should be rear-facing in the back seat of the car. C. "I can fit my hand between the baby and the car seat harness." Rationale: The parent should not be able to fit more than 2 fingers between the baby's chest and the car seat harness. D. "The car seat is rear-facing in the front passenger seat." Rationale: The car seat should be rear-facing in the back seat of the car.

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support

a. A. Closed posterior fontanel Rationale: The infant's posterior fontanel should close by about 8 weeks of age. B. Uses thumb and index fingers in a pincer grasp Rationale:A 9-month-old infant should be able to use his thumb and index fingers in a crude pincer grasp. C. Lateral incisors Rationale:An infant should develop upper lateral incisors between 9 and 13 months of age and lower lateral incisors at 10 to 16 months of age. D. Sitting steadily without support Rationale:At 6 months of age, most infants can sit only with support. An 8-month-old infant should be able to sit without support.

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? A. Restrain the child physically. B. Ignore the temper tantrums. C. Tell the child that temper tantrums are not acceptable. D. Distract the child by offering to play a game.

b. A. Restrain the child physically. Rationale: Restraints can cause the behavior to intensify. B. Ignore the temper tantrums. Rationale:Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly. C. Tell the child that temper tantrums are not acceptable. Rationale: This action is not developmentally appropriate. Temper tantrums occur due to an age-appropriate lack of self-control, which is gradually gained as the child matures. D. Distract the child by offering to play a game. Rationale: Offering the child an opportunity to play a game provides positive reinforcement for an unacceptable behavior.

A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant is unable to imitate animal sounds. B. The infant does not sit steadily without support. C. The infant cannot turn pages in a book. D. The infant cannot build a tower of three or four cubes.

b. A. The infant is unable to imitate animal sounds. Rationale:A 10-month-old infant should be able to verbalize "Dada," "Mama," and to comprehend the meaning of "Bye-bye." A 12-month-old infant should be able to imitate animal sounds. B. The infant does not sit steadily without support. Rationale:An 8-month-old infant should be able to sit steadily without support. A 10-month-old infant should be able to change from a prone to sitting position, stand while holding onto furniture, and lift one foot while standing. C. The infant cannot turn pages in a book. Rationale:A 12-month-old infant should be able to look at and follow pictures in a book. D. The infant cannot build a tower of three or four cubes. Rationale:An 18-month old toddler should be able to build a tower of three or four cubes.

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six to seven cubes. B. The toddler cannot stand upright without support. C. The toddler cannot jump with both feet. D. The toddler cannot turn a doorknob.

b. A. The toddler cannot build a tower of six to seven cubes. Rationale: The nurse should expect a 24-month-old toddler to be able to build a tower of six to seven cubes. B. The toddler cannot stand upright without support. Rationale: The nurse should expect a 15-month-old toddler to be able to stand upright without support. The nurse should report this finding to the provider as this can indicate a developmental delay. C. The toddler cannot jump with both feet. Rationale: The nurse should expect a 30-month-old toddler to be able to jump with both feet. D. The toddler cannot turn a doorknob. Rationale: The nurse should expect a 24-month-old toddler to be able to turn a doorknob.

A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is included in which statement? a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention.

a. Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and the use of the word "no." Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18-month-old. Having a rapid mood swing is an expected behavior for a toddler. Correct Answer is A

A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months

b. A. 3 months Rationale:Birth weight does not usually increase rapidly enough to double by 3 months of age. B. 6 months Rationale:Birth weight typically doubles by 6 months of age. C. 9 months Rationale:Birth usually doubles before 9 months of age. If birth weight has not doubled by this age, further investigation is warranted. D. 12 months Rationale:Birth weight typically triples by 12 months of age.

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manifestation of which of the following disorders? A. Encopresis B. Enterocolitis C. Pyloric stenosis D. Hirschsprung's disease

d. A. Encopresis Rationale:Encopresis is constipation with fecal soiling. B. Enterocolitis Rationale:Enterocolitis is diarrhea involving the colon and intestines. C. Pyloric stenosis Rationale:Pyloric stenosis is a thickening of the pyloric channel resulting in an outlet obstruction. D. Hirschsprung's disease Rationale: Hirschsprung's disease is an inadequate motility of part of the intestine resulting in a mechanical obstruction.

A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? A. Imaginary playmates B. Erikson's stage of initiative versus guilt C. Demonstrations of sexual curiosity D. Negative behaviors characterized by the need for autonomy

d. A. Imaginary playmates Rationale:At 4 to 5 years of age, children have imaginary playmates. B. Erikson's stage of initiative versus guilt Rationale: The stage of initiative versus guilt is typical of the preschool-age child. C. Demonstrations of sexual curiosity Rationale:Sexual curiosity is typical of the preschool-age child. D. Negative behaviors characterized by the need for autonomy Rationale:Assertion of autonomy is seen in toddlers as they begin their language and social development.

A nurse is providing health promotion teaching to the parents of an infant. Which of the following conditions should the nurse identify as the leading cause of death among this age group? A. Congenital anomalies B. Respiratory distress C. Low birth weight D. Sudden infant death syndrome

a. A. Congenital anomalies Rationale: Congenital anomalies are the leading cause of infant mortality in the U.S. B. Respiratory distress Rationale: Respiratory distress is the eighth leading cause of infant mortality in the U.S. C. Low birth weight Rationale:Low birth weight is the second leading cause of infant mortality in the U.S. D. Sudden infant death syndrome Rationale:Sudden infant death syndrome is the third leading cause of infant mortality in the U.S.