Exam 10 Mom Baby

A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he has a 0 on the numerical pain scale. Which nursing intervention should the nurse use as follow up when assessing this child? Tell him to let you know if he begins to feel pain. Explain to his caregiver that his pain level shows he is getting better quickly. Observe him for physiologic signs which might indicate pain. Ask him to show you his pain level using the color pain scale.

Observe him for physiologic signs which might indicate pain

The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor about assessing head circumference? Measure the head circumference routinely on children up to the age of 6 years. Place the tape measure around the head just above the eyebrows. Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. Place the tape measure around the head with the tape touching just below the eyes.

Place the tape measure around the head just above the eyebrows.

A 3-year-old client has been hospitalized for 1 week with her mother rooming-in; however, the mother has gone home to tend to other family responsibilities for a few days. After being inconsolable for the first 24 hours after the mother's departure, the nurse notes the child is now lying quietly in bed sucking her thumb. Which is the nurse's best response in this situation? "Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts." "I'm glad you're feeling better. You must be tired from all that crying." "Do you miss your mom? Your sister missed her, too, so she had to go home to visit for a few days." "Should I read a story to you or would you like to play a game?"

"Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts."

A nurse is discussing post-procedure interventions with new pediatric nurses. Which statement addresses the most immediate safety action required? "Remove all equipment related to the procedure from the child's environment." "Handle all contaminated linens in accordance with the facility policies." "Assess to ensure that the side rails are up and the bed is lowered to the floor." "Document the procedure and the response of the child as soon as the procedure is completed."

"Assess to ensure that the side rails are up and the bed is lowered to the floor."

A child is undergoing a painful procedure and is upset. Which statement by the nurse would be the best approach in dealing with the child? "If you hold still and be quiet, I will give you a Popsicle." "You were brave and good, so you get a sucker." "I know that this hurts some but you are being so strong. It is OK to cry." "Please don't bite or kick me; that would be very naughty."

"I know that this hurts some but you are being so strong. It is OK to cry."

The nurse is preparing a child for surgery and is demonstrating and evaluating the child for using a patient-controlled analgesia device after surgery. The nurse would determine which client would be most appropriate to use this device A 3-year-old who has a caregiver at the bedside at all times A 5-year-old who is able to use the call light to call the nurse when needed A 7-year-old who has told the nurse about using the control button A 10-year-old with a history of behavior issues who has been compliant with care

A 7-year-old who has told the nurse about using the control button

Which physical assessment data would the nurse find concerning and would warrant reporting to the physician? Head circumference is 2 inches less than the chest on a 5-year-old child. A school-aged child has a heart rate of 90. A blood pressure of 128/80 in a preschool-aged child An infant who has a closed posterior fontanelle at age 4 months

A blood pressure of 128/80 in a preschool-aged child

A mother observes the office nurse charting her son's height and weight on a growth chart and asks the nurse the purpose of plotting this information for her child. The nurse would reply with which explanation? The height and weight of each client is plotted on a growth chart at each visit to note how the child is growing and compare the growth to the norm to determine if the child is growing appropriately. The doctor wants to see how fast he is growing over the last year. Each child grows at a certain rate and the doctor wants to see her child's rate of growth. Boys and girls grow differently and the doctor wants to compare her son's growth to her daughter's growth at the same age.

The height and weight of each client is plotted on a growth chart at each visit to note how the child is growing and compare the growth to the norm to determine if the child is growing appropriately.

A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his mother. Which statement by the mother is most concerning and warrants further investigation after noting the father has a history of alcoholism? "I wish there was a blood test for alcoholism. I know my son is at risk." "Our next door neighbor is older than my son, and he drinks when they hang out together." "I think I know how my son feels about drinking. He has had substance abuse education in school." "Sometimes my son asks me questions about his father's low tolerance for alcohol."

"Our next door neighbor is older than my son, and he drinks when they hang out together."

The pediatric unit in the hospital is designed to make the child feel comfortable and secure. Which action will best accomplish this goal? The hallways are painted with bright colors and characters familiar to children. Procedures and treatments are done in a room other than the child's hospital room. Staff members wear clothes that are a variety of colors, designs and patterns. A playroom stocked with toys and activities for a variety of ages is readily available.

Procedures and treatments are done in a room other than the child's hospital room.

The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will be best for the nurse and specialist to assist this child in better understanding what will be happening in the treatment of the cancer? Play therapy Therapeutic play Onlooker play Cooperative play

Therapeutic play

As part of the admitting process for a child on the pediatric unit, the nurse instills a small amount of saline into the nose, aspirates, and then places solution into a sterile specimen container. What is the most likely reason this will be done? To diagnose an infection To clear the nasal passages To remove a foreign body To detect the presence of old blood

To diagnose an infection

The nurse is assigned to care for a child diagnosed with a chronic illness. The child has just been admitted but has been on the unit many times before. From the report the admitting nurse gives, the child is sicker than the last time the child was admitted. In planning the child's care, the nurse notes that the provider has ordered a nasogastric gavage feeding, but the nurse remembers that even the last time the child was on the unit, the child was unable to tolerate the nasogastric feedings. The most appropriate nursing action would be for the nurse to: begin the nasogastric gavage feeding to see if the child can tolerate it. begin an orogastric gavage in hopes the child can handle the feeding. ask the nursing supervisor to decide which type of feeding to give. talk with the care provider and request further instruction and orders.

talk with the care provider and request further instruction and orders.

The nurse is preparing discharge teaching for a child and the caregivers after a week of hospitalization. Which activity would best facilitate the discharge plan? Begin the teaching sessions just prior to the child leaving the facility. Provide written instructions which can be taken home to read and follow. Ensure the caregiver has assistance to handle the complex treatments at home. Plan a conference to review information and procedures with the family caregivers before discharge.

Plan a conference to review information and procedures with the family caregivers before discharge.

A urine specimen has been ordered for a 2-year-old girl who has not been potty trained. Which method would be the best way for the nurse to obtain this urine specimen? Clean the child's genital area thoroughly and when she has urinated, squeeze the urine from her diaper into a specimen cup. Give the child some water or juice, leave off her diaper, ask the caregiver to call you when the child needs to void, and obtain the specimen in a sterile container. Place a sterile cotton ball into the child's diaper; after the child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab. Get down on the child's level and speak to her explaining that you need her to tell you when she needs to use the bathroom and when she does, obtain the specimen.

Place a sterile cotton ball into the child's diaper; after the child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab.

A young client has a temperature of 102℉ (38.9℃). The nurse is treating the fever with nonpharmacologic methods, in addition to the scheduled antipyretic the child received, by removing the blanket that covers the child. What is the rationale for this action? The blanket adds heat to the child. Removing excess coverings allows for evaporation, which aids in cooling the child. The blanket soaks up the sweat, making the child warmer. Covering the child with a blanket leads to shivering, which will only generate more heat.

Removing excess coverings allows for evaporation, which aids in cooling the child.

Tess is a 5-year-old client who must receive an IV infusion of antibiotics. She is anxious, resistant, and wiggly. To keep her safe during the time the IV is in place, the nurse would choose which method to restrain her? Restrain her with a mummy restraint and loosen and rewrap it every 3 hours. Restrain her on a papoose board and release her as soon as the IV is in place. Use a clove-hitch restraint to keep her arm still and loosen it every 2 hours. Allow her caregiver to hold her during the time the IV is in place.

Use a clove-hitch restraint to keep her arm still and loosen it every 2 hours.

The nurse is interviewing the mother of a child who is at the local clinic. When asked why she brought her toddler in today, she replies that he has been running a fever and coughing a lot since last weekend. This information would be noted in the chart as what data? Heath history Present health concern Chief complaint Biographical history

Chief complaint

The nurse working in the pediatric unit of the hospital is always monitoring for safety issues on the unit. The nurse determines the biggest concern related to safety of the hospitalized child is related to which situation? The child is out of the home environment he or she is used to, without safety locks on doors and cabinets and things being placed in safe storage. The caregivers are in a high-stress situation and are unable to concentrate and pay attention to what the child is doing at all times. Taking a child in and out of bed, doing frequent checks and procedures, and caregivers sitting at the side of the bed leaves opportunity for the side rails to be left down. A variety of nursing staff and other hospital staff are in and out of the child's room during hospitalization, and close observation of the child by the staff is difficult.

Taking a child in and out of bed, doing frequent checks and procedures, and caregivers sitting at the side of the bed leaves opportunity for the side rails to be left down.

The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care? Clean the outside of the collection device. Check for leakage around the stoma. Leave the ileostomy open to the air. Apply a sterile dressing around the stoma.

Check for leakage around the stoma.

The nurse is assessing a 5-month-old infant at a well-child visit. In measuring and weighing the child, which action is most important to the child's safety? Wipe the scale with an alcohol-based cleanser. Cover the scale with a clean piece of paper or paper towel. Straighten the child's legs and hold the knees flat. Hold one hand within 1 inch (2.54 cm) of the child.

Hold one hand within 1 inch (2.54 cm) of the child.

After the provider has written a prescription for the use of heat therapy, the nurse will apply heat using a K-pad or heating pad as ordered. Which of the following is most accurate regarding the use of heat therapy? Heat is a vasoconstrictor and decreases circulation. Heat may be used to prevent swelling. Heat should be used 1 hour at a time and then removed. Heat causes muscle relaxation and decreases pain.

Heat causes muscle relaxation and decreases pain

The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor related to taking a temperature? "A rectal temperature is usually 0.5° to 1.0° lower than the oral measurement." "Tympanic temperatures should not be taken on a child who is sleeping." "An axillary temperature usually measures 0.5° to 1.0° higher than the oral measurement." "Rectal temperatures should not be taken on a child with diarrhea."

"Rectal temperatures should not be taken on a child with diarrhea."

A few days after discharge, the parent of an 8-year-old calls the pediatric clinic, expressing concern about the child's behavior now that she is home. The child has been treating her siblings badly and using inappropriate language. Which suggestion is the nurse's best response to this caregiver as an appropriate way to handle this situation? "Coming home is a difficult adjustment. Warn your daughter that you expect her to begin to behave better over the next few weeks." "Respond to her behavior in a firm, loving, consistent way." "Children often feel guilty for the attention they've taken away from their siblings and act out as a way of earning the attention." "Tell her you don't like her behavior and have her stay in her room until she can be nicer to her siblings."

"Respond to her behavior in a firm, loving, consistent way."

The nurse is meeting with a group of families to assist them in dealing with the hospitalization of their child. Which comment by a family member should alert the nurse that the family may need assistance with coping with the situation? "We have really good insurance—it covered everything the last time she was in the hospital." "When my sister was in the hospital before, the nurse let me get up on her bed while she read me a story." "Sometimes I wonder if the reason she is sick is because I have so many responsibilities at work and at home." "My husband was so relieved when he heard that after the next surgery our son will probably not need to have any more, and will be fine."

"Sometimes I wonder if the reason she is sick is because I have so many responsibilities at work and at home."

The nurse is presenting a post-conference seminar to a group of nursing students on the topic of nasal/oral suctioning of a child. Which statement made by a student demonstrates a need for further instruction on the procedure? "The purpose of this form of suctioning is to removes secretions from the nose and mouth." "Sterile normal saline drops are used to loosen the dried secretions prior to nasal suctioning." "Such suctioning is only done with a bulb syringe." "If possible, the child should be asked to cough before suctioning."

"Such suctioning is only done with a bulb syringe."

The nurse is caring for a child in the emergency department who is on a cardiac monitor. Which nursing action has the highest priority? Clean the skin with alcohol before placing the electrodes. Confirm the alarms are set with maximum and minimum settings. Check the site and skin condition daily Check to be sure that the electrodes are secure when the alarm sounds.

Confirm the alarms are set with maximum and minimum settings.

The caregiver of an infant keeps removing the pulse oximetry sensor claiming it is too tight and hurting her baby. Which is the nurse's best response in addressing this situation? Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin. Place the probe of the oximeter on the child's chest and secure it with tape. Ensure the oximeter probe site is checked every 8 hours for possible reactions. Explain that pulse oximetry is done to detect respiratory retractions.

Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin.

The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process? Interviewing the child's caregiver Weighing and measuring the child Reinforcing teaching with the child's caregivers Taking the child's vital signs

Interviewing the child's caregiver

What actions can a pediatric hospital staff take to lessen the stress of hospitalization for a child? Select all that apply. Have the parents stay with the client at all times. Allow children to wear their own clothing. Perform any treatments in the procedure room. You Answered Select age-appropriate foods for the child. Involve Child Life in teaching about upcoming surgeries.

Involve Child Life in teaching about upcoming surgeries. Perform any treatments in the procedure room. Allow children to wear their own clothing.