NUR 2038 Exam 2 Practice Questions
The nurse is caring for a 1-year-old child after cleft palate repair. On completion of feeding, the nurse should plan for which appropriate nursing action? 1.Rinsing the mouth with water 2.Cleaning the mouth with diluted hydrogen peroxide 3.Using a soft lemon and glycerin swab to clean the mouth 4.Using cotton swabs saturated with half-strength povidone-iodine to clean the mouth
1.Rinsing the mouth with water
The nurse is assisting the pediatrician in performing an assessment on a newborn suspected of having imperforate anus. Which finding would be noted in this disorder? 1.Presence of an anal membrane 2.An elevated rectal temperature 3.Widening of the anal rectal canal 4.Meconium stool passing from the rectum
1.Presence of an anal membrane
The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period? 1.Prone position 2.Supine with no head elevation 3.Side-lying with the legs extended 4.Supine with the head elevated 45 degrees
1.Prone position
A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. Which assessment findings by the nurse are characteristic of this disorder? Select all that apply. 1.Red throat 2.Cracking lips 3.Conjunctival hyperemia 4.Desquamation of the skin 5.Enlargement of the cervical lymph nodes
1.Red throat 3.Conjunctival hyperemia 5.Enlargement of the cervical lymph nodes
The nurse is reviewing the laboratory test results for an infant suspected of having hypertrophic pyloric stenosis. The nurse should expect to note which value as the most likely laboratory finding in this infant? 1.Blood pH of 7.50 2.Blood pH of 7.35 3.Blood bicarbonate of 22 mEq/L (22 mmol/L) 4.Blood bicarbonate of 27 mEq/L (27 mmol/L)
1.Blood pH of 7.50
After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? 1.Turn the child to the side. 2.Administer the prescribed antiemetic. 3.Maintain NPO (nothing by mouth) status. 4.Notify the primary health care provider (PHCP).
1.Turn the child to the side.
The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1.Prone position 2.Knee-chest position 3.High-Fowler's position 4.Reverse Trendelenburg's position
2.Knee-chest position
Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? 1.Prevents blue (tet) spells 2.Maintains adequate cardiac output 3.Maintains an adequate hormonal level 4.Maintains the position of the great arteries
2.Maintains adequate cardiac output
The nurse is reviewing the laboratory results for an infant with suspected hypertrophic pyloric stenosis. What should the nurse expect to note as the most likely finding in this infant? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
2.Metabolic alkalosis
The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? 1.Bile-stained fecal emesis 2.The passage of currant jelly-like stools 3.Failure to pass meconium stool in the first 24 hours after birth 4.Sausage-shaped mass palpated in the upper right abdominal quadrant
3.Failure to pass meconium stool in the first 24 hours after birth
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? 1.Prone position 2.On the stomach 3.Left lateral position 4.Right lateral position
3.Left lateral position
The nurse is assisting a primary health care provider (PHCP) examine a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PHCP to assess? 1.Babinski's sign 2.The Moro reflex 3.Ortolani's maneuver 4.The palmar-plantar grasp
3.Ortolani's maneuver
Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition. 1.Aortic stenosis 2.Atrial septal defect 3.Patent ductus arteriosus 4.Ventricular septal defect
3.Patent ductus arteriosus
On assessment during a well-baby visit, the nurse notes that a 6-month-old infant has crossed eyes. Which interpretation would the nurse make based on this finding? 1.The condition will resolve without treatment. 2.The condition is normal up to the age of 2 years. 3.Surgical intervention may be necessary to realign weak eye muscles. 4.Once the child begins to read, eye muscles strengthen and the condition will resolve.
3.Surgical intervention may be necessary to realign weak eye muscles.
The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1.Pallor 2.Cough 3.Tachycardia 4.Slow and shallow breathing
3.Tachycardia
The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the primary health care provider? 1.Bradypnea 2.Diaphoresis 3.Decreased blood pressure 4.A weight gain of 1 lb (0.5 kg) in 1 day
4.A weight gain of 1 lb (0.5 kg) in 1 day
The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? 1.Diarrhea 2.Projectile vomiting 3.Regurgitation of feedings 4.Foul-smelling ribbon-like stools
4.Foul-smelling ribbon-like stools
A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action? 1.Tell the mother that the child must stay in the tent. 2.Place a toy in the tent to make the child feel more comfortable. 3.Call the pediatrician and obtain a prescription for a mild sedative. 4.Let the mother hold the child and direct the cool mist over the child's face.
4.Let the mother hold the child and direct the cool mist over the child's face.
After hydrostatic reduction for intussusception, the nurse should expect to observe which client response? 1.Abdominal distension 2.Currant jelly-like stools 3.Severe, colicky-type pain with vomiting 4.Passage of barium or water-soluble contrast with stools
4.Passage of barium or water-soluble contrast with stools
A child is diagnosed with Hirschsprung's disease. The nurse is teaching the parents about the cause of the disease. Which statement, if made by the parent, supports that teaching was successful? 1."Special cells are not present in the rectum, which caused the disease." 2."The protein part of wheat, barley, rye, and oats is not being digested fully." 3."The disease occurs from increased bowel motility that leads to spasm and pain." 4."The disease occurs because of inability to tolerate sugar found in dairy products."
1."Special cells are not present in the rectum, which caused the disease." (ganglion cells are not present)
The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1.The child exhibits nasal flaring and bradycardia. 2.The child is leaning forward, with the chin thrust out. 3.The child has a low-grade fever and complains of a sore throat. 4.The child is leaning backward, supporting herself or himself with the hands and arms.
2.The child is leaning forward, with the chin thrust out.
The nurse is developing a plan of care for a 10-year-old girl with an exacerbation of eczema. Which problem should be addressed in the care for this child? 1.The client is at risk for infection related to viral lesions. 2.The client is at risk for infection related to scratching of pruritic lesions. 3.The client may have poor nutritional intake related to throat edema and mouth ulcers. 4.The client may have a negative body image related to the presence of thick, white crusty plaques over the elbows and knees.
2.The client is at risk for infection related to scratching of pruritic lesions.
A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1.During sleep 2.When changing the infant's diapers 3.When the mother is holding the infant 4.When drawing blood for electrolyte level testing
4.When drawing blood for electrolyte level testing
A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1.Anxiety 2.A temper tantrum 3.A hypercyanotic episode 4.The need for immediate primary health care provider notification
3.A hypercyanotic episode
A school-age child with Down's syndrome is brought to the ambulatory care center by the mother. The child has bruising all over the body. To work most effectively with this child, the nurse first addresses which complication associated with Down's syndrome? 1.Children with Down's syndrome are more likely to develop acute leukemia than the average child. 2.Children with Down's syndrome fall down easily as a result of hyperflexibility and muscle weakness. 3.Children with Down's syndrome are at risk for physical abuse because of their low intellectual functioning. 4.Children with Down's syndrome scratch themselves a lot because of dry, cracked, and frequently fissuring skin.
1.Children with Down's syndrome are more likely to develop acute leukemia than the average child.
The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1.Elevated C-reactive protein 2.Elevated antistreptolysin O titer 3.Presence of Reed-Sternberg cells 4.Presence of group A beta-hemolytic strep 5.Decreased erythrocyte sedimentation rate
1.Elevated C-reactive protein 2.Elevated antistreptolysin O titer 4.Presence of group A beta-hemolytic strep
A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1.Elevated antistreptolysin O titer 2.Decreased erythrocyte sedimentation rate 3.Negative result on antinuclear antibody assay 4.Negative result on C-reactive protein determination
1.Elevated antistreptolysin O titer
The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1.Fine grayish red lines 2.Purple-colored lesions 3.Thick, honey-colored crusts 4.Clusters of fluid-filled vesicles
1.Fine grayish red lines
The nurse is developing a plan of care for a 5-week-old infant being admitted with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. In the preoperative period, the nurse should place the infant in which best position? 1.In an infant seat placed in the crib 2.Prone with the head of the bed elevated 3.Supine with the head at a 90-degree angle 4.Supine with the head of the bed at a 15-degree angle
1.In an infant seat placed in the crib
A child with cerebral palsy is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action? 1.Placing the child on a wheeled scooter board 2.Removing ankle-foot orthoses and braces once the child arrives at school 3.Keeping the child in a special education classroom with other children with similar disabilities 4.Placing the child in the supine position with a 30-degree elevation of the head of the bed to facilitate feeding
1.Placing the child on a wheeled scooter board
A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition? 1.Tender, distended abdomen 2.Presence of fecal incontinence 3.Incomplete development of the anus 4.Infrequent and difficult passage of dry stools
1.Tender, distended abdomen
The clinic nurse is reviewing the primary health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? 1.The child is 18 months old. 2.The child is being bottle-fed. 3.A sibling is using lindane for the treatment of scabies. 4.The child has a history of frequent respiratory infections.
1.The child is 18 months old.
Cerebral palsy (CP) is suspected in a child, and the parents ask the nurse about the potential warning signs of CP. The nurse should provide which information? Select all that apply. 1.The infant's arms or legs are stiff or rigid. 2.A high risk factor for CP is very low birth weight. 3.By 8 months of age, the infant can sit without support. 4.The infant has strong head control but a limp body posture. 5.The infant has feeding difficulties, such as poor sucking and swallowing. 6.If the infant is able to crawl, only one side is used to propel himself or herself.
1.The infant's arms or legs are stiff or rigid. 2.A high risk factor for CP is very low birth weight. 5.The infant has feeding difficulties, such as poor sucking and swallowing. 6.If the infant is able to crawl, only one side is used to propel himself or herself.
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1.Weighing the diapers 2.Inserting a urinary catheter 3.Comparing intake with output 4.Measuring the amount of water added to formula
1.Weighing the diapers
The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1."A balance of rest and activity is important." 2."I can apply lotion or powder to the incision if it is itchy." 3."Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4."Large crowds of people need to be avoided for at least 2 weeks after surgery."
2."I can apply lotion or powder to the incision if it is itchy."
The nurse in the hospital is giving at-home feeding instructions to a family whose child is being discharged after being born with a cleft lip. Which statement by the mother would indicate that further teaching is indicated? 1."I am so glad that I am able to breast-feed my baby." 2."I must always feed my baby with a syringe and not use a nipple." 3."I will feed my baby while sitting in a chair and holding her more upright." 4."I will burp my baby very frequently so that she does not swallow a lot of air."
2."I must always feed my baby with a syringe and not use a nipple."
The nurse provides home care instructions to the mother of a child who had a cleft palate repair 4 days ago. Which statement by the mother indicates the need for further instruction? 1."I will use a short nipple on the bottle." 2."I need to buy some straws for drinking." 3."I can give my child the pacifier in 2 weeks." 4."I may give my baby food mixed with water."
2."I need to buy some straws for drinking."
The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother? 1."You should use a plastic spoon to feed the child." 2."You need to use an orthodontic nipple on the child's bottle." 3."You can allow the child to use a pacifier but only for 30 minutes at a time." 4."You need to monitor the child's temperature for signs of infection using an oral thermometer."
2."You need to use an orthodontic nipple on the child's bottle."
The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF? 1.Transmitted as an autosomal dominant trait 2.A chronic multisystem disorder affecting the exocrine glands 3.A disease that causes the formation of multiple cysts in the lungs 4.A disease that causes dilation of the passageways of many organs
2.A chronic multisystem disorder affecting the exocrine glands
The nurse is reviewing the plan of care for a child with a diagnosis of suspected appendicitis. The nurse would question which intervention if noted in the plan of care? 1.Taking the child's temperature with an oral thermometer 2.Applying a heating pad to abdomen to promote pain relief 3.Palpating between the right anterior superior iliac crest and umbilicus 4.Obtaining blood for complete blood count while starting an intravenous line
2.Applying a heating pad to abdomen to promote pain relief
The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? 1.The child has difficulty hearing. 2.The child consistently tilts the head to see. 3.The child does not respond when spoken to. 4.The child consistently turns the head to hear.
2.The child consistently tilts the head to see.
An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take their child home? 1.Leave the diapers off to allow the site to heal. 2.Avoid tub baths until the stent has been removed. 3.Encourage toilet training to ensure that flow of urine is normal. 4.Restrict fluid intake to reduce urinary output for the first few days.
2.Avoid tub baths until the stent has been removed.
An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on this finding, which action should the nurse take? 1.Elevate the buttocks. 2.Document the findings. 3.Apply ice immediately. 4.Call the primary health care provider.
2.Document the findings.
The nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, which is the priority problem? 1.Choking 2.Infection 3.Inability to tolerate stimulation 4.Delayed growth and development
2.Infection
A mother brings her 2-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation? 1.It is positive. 2.It is negative. 3.It is inconclusive. 4.It requires rescreening at age 6 weeks.
2.It is negative.
The nurse is caring for a child who was brought to the clinic complaining of severe abdominal pain and is suspected of having acute appendicitis. The child is lying on the examining table with the knees pulled up toward the chest. What is the priority nursing action? 1.Collect urine sample for urinalysis. 2.Perform a pain assessment using the FACES scale. 3.Prepare the child for magnetic resonance imaging. 4.Notify primary health care provider of white blood cell count above 10,000 mm3 (10 × 109/L).
2.Perform a pain assessment using the FACES scale.
The primary health care provider prescribes patching for a child with strabismus of the right eye, and the nurse instructs the mother regarding this procedure. What should the nurse include in the instructions? 1.Place the patch on both eyes. 2.Place the patch on the left eye. 3.Place the patch on the right eye. 4.Alternate the patch from the right to the left eye hourly.
2.Place the patch on the left eye.
The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? 1.Possible trauma 2.Possible sexual abuse 3.Presence of an allergy 4.Presence of a respiratory infection
2.Possible sexual abuse
The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? 1.Watery diarrhea 2.Projectile vomiting 3.Increased urine output 4.Vomiting large amounts of bile
2.Projectile vomiting
The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make? 1."The child may be allergic to antibiotics." 2."The child is too young to receive antibiotics." 3."Antibiotics are not indicated unless a bacterial infection is present." 4."The child still has the maternal antibodies from birth and does not need antibiotics."
3."Antibiotics are not indicated unless a bacterial infection is present."
A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition? 1."Are the stools ribbon-like, and is the infant eating poorly?" 2."Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?" 3."Does the vomit contain sour, undigested food without bile, and is the infant constipated?" 4."Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?"
3."Does the vomit contain sour, undigested food without bile, and is the infant constipated?"
The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment? 1."Has your child had difficulty urinating?" 2."Has your child been exposed to anyone with chickenpox?" 3."Has any family member had a sore throat within the past few weeks?" 4."Has any family member had a gastrointestinal disorder in the past few weeks?"
3."Has any family member had a sore throat within the past few weeks?"
The nurse reinforces instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further teaching? 1."I need to purchase the medication from the pharmacy." 2."After rinsing out the medication, I need to avoid washing my child's hair for 24 hours." 3."I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours." 4."I need to shampoo my child's hair, apply the medication, and leave it on for 10 minutes and then rinse it out."
3."I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours."
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine if this child is experiencing a long-term effect of cleft palate, which question should the nurse ask? 1."Was the child recently treated for pneumonia?" 2."Does the child play with an imaginary friend?" 3."Is the child unresponsive when given directions?" 4."Has the child had any difficulty swallowing food?"
3."Is the child unresponsive when given directions?"
The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? 1."I need to wash my hands frequently." 2."I need to clean the eye as prescribed." 3."It is okay to share towels and washcloths." 4."I need to give the eye drops as prescribed."
3."It is okay to share towels and washcloths."
The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? 1."It is extremely contagious." 2."It is most common in humid weather." 3."Lesions most often are located on the arms and chest." 4."It might show up in an area of broken skin, such as an insect bite."
3."Lesions most often are located on the arms and chest."
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process? 1.An infectious disease of the central nervous system 2.An inflammation of the brain as a result of a viral illness 3.A chronic disability characterized by impaired muscle movement and posture 4.A congenital condition that results in moderate to severe intellectual disabilities
3.A chronic disability characterized by impaired muscle movement and posture
The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1.Pallor 2.Hyperactivity 3.Activity intolerance 4.Gastrointestinal disturbances
3.Activity intolerance
The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding? 1.Extreme fatigue 2.The presence of pain 3.An airway obstruction 4.The presence of dehydration
3.An airway obstruction
The nurse is creating a plan of care for a newborn infant with spina bifida (myelomeningocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure. Which assessment technique should be performed that will best detect the presence of an increase in intracranial pressure? 1.Check urine for specific gravity. 2.Monitor for signs of dehydration. 3.Assess anterior fontanel for bulging. 4.Assess blood pressure for signs of hypotension.
3.Assess anterior fontanel for bulging.
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? 1.Hematuria 2.Glucosuria 3.Bacteriuria 4.Proteinuria
3.Bacteriuria
The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1.Incessant crying 2.Coughing at nighttime 3.Choking with feedings 4.Severe projectile vomiting
3.Choking with feedings
The parents of a newborn with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond? 1.Cleft lip cannot be repaired. 2.Cleft-lip repair is usually performed by 6 months of age. 3.Cleft-lip repair is usually performed during the first months of life. 4.Cleft-lip repair is usually performed between 6 months and 2 years.
3.Cleft-lip repair is usually performed during the first months of life.
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1.Cracked lips 2.Normal appearance 3.Conjunctival hyperemia 4.Desquamation of the skin
3.Conjunctival hyperemia
The nurse is reviewing the primary health care provider's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the primary health care provider has documented which manifestation? 1.Scleral jaundice 2.Projectile vomiting 3.Currant jelly-like stools 4.Pale-colored and hard stools
3.Currant jelly-like stools
A 12-year-old girl is admitted to the hospital with suspected appendicitis. What nursing interventions should be implemented preoperatively? 1.Applying a heating pad for 5-minute intervals as prescribed 2.Administering acetaminophen as needed for pain, as prescribed 3.Placing the adolescent in a fetal position, side-lying with legs drawn up to chest 4.Inserting a nasogastric tube and attaching it to low intermittent suction; measuring drainage as prescribed
3.Placing the adolescent in a fetal position, side-lying with legs drawn up to chest
A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. Which statement should the nurse educator include in the session? 1."Treatment includes dietary restriction of tyramine." 2."Phenylketonuria is an autosomal dominant disorder." 3."Phenylketonuria primarily affects the gastrointestinal system." 4."All 50 states require routine screening of all newborn infants for phenylketonuria."
4."All 50 states require routine screening of all newborn infants for phenylketonuria."
An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder? 1."Does the child have any food allergies?" 2."What do the bowel movements look like?" 3."Has the child eaten any food in the last 24 hours?" 4."Can you describe the type of pain that the child is experiencing?"
4."Can you describe the type of pain that the child is experiencing?"
The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1."Caution should be used when straddling the infant on a hip." 2."Vital signs should be taken daily to check for bladder infection." 3."Catheterization will be necessary when the infant does not void." 4."Circumcision has been delayed to save tissue for surgical repair."
4."Circumcision has been delayed to save tissue for surgical repair."
The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder? 1."Does your infant have diarrhea?" 2."Is your infant constantly vomiting?" 3."Does your infant constantly spit up feedings?" 4."Does your infant have foul-smelling, ribbon-like stools?"
4."Does your infant have foul-smelling, ribbon-like stools?"
A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1.Absence of C-reactive protein 2.Presence of Reed-Sternberg cells 3.Decreased antistreptolysin O titer 4.Elevated erythrocyte sedimentation rate
4.Elevated erythrocyte sedimentation rate
The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1.Immunoglobulin 2.Red blood cell count 3.White blood cell count 4.Anti-streptolysin O titer
4.Anti-streptolysin O titer
The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1."I will not mix the medication with food." 2."If more than 1 dose is missed, I will call the pediatrician." 3."I will take my child's pulse before administering the medication." 4."If my child vomits after medication administration, I will repeat the dose."
4."If my child vomits after medication administration, I will repeat the dose."
A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder? 1."It is an acute bowel obstruction." 2."It is a condition that causes an acute inflammatory process in the bowel." 3."It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel." 4."It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel."
4."It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel."
The nurse is providing home care instructions to the mother of a 9-year-old child diagnosed with bacterial conjunctivitis. Topical antimicrobial therapy is prescribed for the child. Which statement by the mother indicates the teaching has been effective? 1."My child cannot return to school until seen by the pediatrician in 1 month." 2."My child can return to school immediately because my child is not contagious." 3."My child needs to stay at home from school for at least 3 weeks to complete the entire prescription of eyedrops." 4."My child will need to stay home from school until my child has received the eye medication for at least 24 to 48 hours."
4."My child will need to stay home from school until my child has received the eye medication for at least 24 to 48 hours."
An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? 1."I should obtain new contact lenses." 2."I should not wear my contact lenses." 3."My old contact lenses should be discarded." 4."My contact lenses can be worn if they are cleaned as directed."
4."My contact lenses can be worn if they are cleaned as directed."
The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1."The child may return to school in 1 week." 2."The child will not be able to return to school during this academic year." 3."The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4."The child may return to school in 3 weeks but needs to go half-days for the first few days."
4."The child may return to school in 3 weeks but needs to go half-days for the first few days."
The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1."The immunization schedule will need to be altered." 2."The child should not receive any hepatitis vaccines." 3."The child will receive all of the immunizations except for the polio series." 4."The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
4."The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
The mother arrives at a well-baby clinic with her 1-month-old infant. She expresses concern because one of the infant's eyes appears to be crossed. What is the nurse's best response? 1."The infant will probably need surgery." 2."This condition is probably permanent." 3."It requires monitoring because the other eye may do the same thing." 4."This is normal in the young infant but should not be present after the age of about 4 months."
4."This is normal in the young infant but should not be present after the age of about 4 months."
The nurse is counseling the young mother of a small child recently diagnosed with impetigo. The nurse should make which statement that provides the best information about impetigo? 1."The main treatment while your daughter has impetigo will be to force fluids." 2."Your daughter probably caught the impetigo because you don't wash her hands enough." 3."There is no risk of passing impetigo to the other children once you begin the prescribed antibiotics." 4."You will need to prevent any of the fluid from the blisters from coming into contact with your other children."
4."You will need to prevent any of the fluid from the blisters from coming into contact with your other children."
An infant is brought to the child care clinic for a follow-up visit. The nurse notes that the infant is wearing this apparatus. The nurse documents that the infant is wearing which device? Refer to figure. 1.A back brace for the treatment of scoliosis 2.Bilateral foot braces for the treatment of clubfoot 3.A shoulder brace for the treatment of shoulder dystocia 4.A Pavlik harness for the treatment of congenital hip dislocation
4.A Pavlik harness for the treatment of congenital hip dislocation
The nurse is assisting a primary health care provider (PHCP) during the examination of an infant with developmental hip dysplasia. The PHCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted? 1.A shrill cry from the infant 2.Asymmetry of the affected hip 3.Reduced range of motion in the right and left hip 4.A palpable click during abduction of the affected hip
4.A palpable click during abduction of the affected hip
A topical corticosteroid is prescribed by the primary health care provider for a child with contact dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1.Apply the cream over the entire body. 2.Apply a thick layer of cream to affected areas only. 3.Avoid cleansing the area before application of the cream. 4.Apply a thin layer of cream and rub it into the area thoroughly.
4.Apply a thin layer of cream and rub it into the area thoroughly.
A school-age child is seen in the primary health care provider's office for complaints of intense itching mostly at night. The primary health care provider makes a diagnosis of scabies and prescribes permethrin for treatment of the skin condition. Which at-home instruction should the nurse provide to the mother? 1.Retreatment is recommended the next day. 2.The child's bedding and clothing should be washed in cold water. 3.Leave the lotion on throughout the day and rinse off within 6 hours. 4.Apply the lotion liberally to the body and head, avoiding the eyes and mouth.
4.Apply the lotion liberally to the body and head, avoiding the eyes and mouth.
Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? 1.Apply the lotion to areas of the rash only. 2.Apply the lotion and leave it on for 6 hours. 3.Avoid putting clothes on the child over the lotion. 4.Apply the lotion to cool, dry skin at least 30 minutes after bathing.
4.Apply the lotion to cool, dry skin at least 30 minutes after bathing.
A child arrives at the emergency department with a nosebleed. On assessment, the nurse is told by the mother that the nosebleed began suddenly and for no apparent reason. What is the initial nursing action? 1.Insert nasal packing. 2.Prepare a nasal balloon for insertion. 3.Place the child in a semi-Fowler's position, and apply ice packs to the nose. 4.Ask the child to sit down and lean forward, and apply pressure to the nose.
4.Ask the child to sit down and lean forward, and apply pressure to the nose.
The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary health care provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period? 1.Monitor the temperature. 2.Monitor the blood pressure. 3.Reposition the infant frequently. 4.Aspirate the NG tube every 5 to 10 minutes.
4.Aspirate the NG tube every 5 to 10 minutes.
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition? 1.Full range of motion in the affected hip 2.An apparent short femur on the unaffected side 3.Asymmetrical adduction of the affected hip when placed supine, with the knees and hips flexed 4.Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
4.Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1.Watery diarrhea 2.Ribbon-like stools 3.Profuse projectile vomiting 4.Bright red blood and mucus in the stools
4.Bright red blood and mucus in the stools
The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which instruction should the nurse provide to the mother? 1.Increase stimuli in the home environment. 2.Avoid daytime naps so that the child will sleep at night. 3.Give the child frequent small meals, if vomiting occurs. 4.Check the skin and eyes every day for a yellow discoloration.
4.Check the skin and eyes every day for a yellow discoloration.
The nurse is preparing an infant for surgery to treat Hirschsprung's disease. Which assessment finding is priority to identify and treat? 1.Vomiting and irritability 2.Malnourishment and lethargy 3.Abdominal distension and tenderness 4.Decreased blood pressure and tachycardia
4.Decreased blood pressure and tachycardia
The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which action to maintain the infant's safety? 1.Covering the back dressing with a binder 2.Placing the infant in a head-down position 3.Strapping the infant in a baby seat sitting up 4.Elevating the head with the infant in the prone position
4.Elevating the head with the infant in the prone position
The nurse is caring for a child diagnosed with Down's syndrome. Which explanation of this syndrome should the nurse provide the parents? 1.Subaverage intellectual functioning with a congenial nature 2.Above-average intellectual functioning with deficits in adaptive behavior 3.Average intellectual functioning and the absence of deficits in adaptive behavior 4.Moderate to severe intellectual disability and linkage to an extra chromosome 21, group G
4.Moderate to severe intellectual disability and linkage to an extra chromosome 21, group G
An infant is seen in the primary health care provider's office for complaints of projectile vomiting after feeding. Findings indicate that the child is fussy and is gaining weight but seems never to get enough to eat. Pyloric stenosis is suspected. Which prescription would the nurse anticipate having the highest priority in the care of this child? 1.Monitor intake and output. 2.Administer predigested formula. 3.Administer omeprazole before feeding. 4.Prepare the family for surgery for the child.
4.Prepare the family for surgery for the child.
Nursing care of the infant with eczema should focus on which action as a priority nursing intervention? 1.Keeping the infant content 2.Maintaining adequate nutrition 3.Applying antibiotic ointment to lesions 4.Preventing secondary infection of the lesions
4.Preventing secondary infection of the lesions
A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan? 1.Assessing hearing loss 2.Monitoring urine output 3.Changing body position every 2 hours 4.Providing a quiet atmosphere with dimmed lighting
4.Providing a quiet atmosphere with dimmed lighting
The nurse is preparing to care for a newborn infant following creation of a colostomy for the treatment of imperforate anus. In the immediate postoperative period, the nurse plans to inspect the stoma and expects to note which finding in the colostomy? 1.Bleeding 2.Gray in color 3.Dark blue in color 4.Red and edematous
4.Red and edematous
The parents of a child with a cleft palate are concerned and ask the nurse when the palate will be repaired. The nurse should plan to base the response on which information about cleft palate repair? 1.A cleft palate cannot be repaired in children. 2.Repair usually is performed by age 8 weeks. 3.Repair usually is performed by 2 months of age. 4.Repair usually is performed between 6 months and 2 years.
4.Repair usually is performed between 6 months and 2 years.
The school nurse is performing pediculosis capitis (head lice) assessments. Which assessment finding indicates that a child has a "positive" head check for lice? 1.Maculopapular lesions behind the ears 2.Lesions in the scalp that extend to the hairline or neck 3.White flaky particles throughout the entire scalp region 4.White sacs attached to the hair shafts in the occipital area
4.White sacs attached to the hair shafts in the occipital area
The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child? 1.Iced tea 2. A glass of milk 3.Cool cherry Kool-Aid 4.Yellow non-citrus Jell-O
4.Yellow non-citrus Jell-O
