Passpoint - Toddler

For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority?

Avoiding abdominal palpation

A 2-year-old child is brought to the emergency department with suspected croup. Which data collection finding reflects increasing respiratory distress?

Intercostal retractions

Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital?

Side rails in the halfway position

A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent:

"Does your child tug at either ear?"

A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction?

"Give the elixir with water or juice."

Which statement by the mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective?

"I've been checking the urine for protein so I'll be able to do it at home."

A 2-year-old hospitalized child is HIV positive with severe thrush. The child's anxious grandparents are at the bedside, continually calling the nurses with various concerns. The staff speak disparagingly about them because they are tired of responding to the frequent call lights. When working with the unit's staff, which response by the nurse manager would be appropriate in creating a more optimal care environment for the child?

"If we stop by the room before the light goes on, they may be less anxious."

A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching?

"We'll go to the physician if our child pulls on his ears or won't lie down."

A nurse is preparing to give an IM injection into the left leg of a 2-year-old client. Indicate the area where the nurse will administer this injection.

*** The nurse should administer this IM injection in the vastus lateralis, located in the child's thigh. To give the injection, the nurse should first divide the distance between the greater trochanter and the knee joints into quadrants and then inject in the center of the upper quadrant.

A 3-year-old is to receive 500 mL of dextrose 5% in normal saline solution over 8 hours. At what rate (in milliliters per hour) should a nurse set the infusion pump? Round your answer to a whole number.

63

A 2-year-old is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches. The nurse needs to auscultate the child's breath sounds. What is the most appropriate way for the nurse to approach the child?

Allow the child to handle the stethoscope before listening to the lungs.

When assisting in developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate?

Arm restraints while asleep

When teaching the mother of a 17-month-old child about toilet training, which instruction would initially be most appropriate?

Be sure the child is ready before starting to toilet train.

For a child with a circumferential chest burn, what is the most important factor for the nurse to monitor?

Breathing pattern

Parents bring their 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on the buttocks. Which instruction should the nurse give the parents?

Change diapers frequently and air-dry when possible.

A mother brings her 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on his buttocks. Which instruction should the nurse give the mother?

Change diapers frequently and use air-drying when possible.

An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler?

Coin rubbing

A mother says a 2-year-old child is up to date with vaccines. Which immunization should be included?

DTaP, IPV, MMR, hepatitis B, Haemophilus influenzae type b (Hib), varicella, PCV, rotavirus (Rota), and influenza

The nurse caring for an 18-month-old child just admitted to the unit, and notices that the child clings to the parents. Which is the most appropriate action by the nurse?

Document as normal behavior for an 18-month old.

A 3-year-old child is given a preliminary diagnosis of acute epiglottitis. Which nursing intervention is appropriate?

Don't attempt to visualize the epiglottis.

A 2-year-old child comes to the emergency department with inspiratory stridor and a barking cough. What is the highest priority action by the nurse?

Establish and maintain the airway.

The nurse is teaching parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?

Eustachian tubes

A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. During assessment, it is noted that the child does not enunciate words well and holds onto furniture when walking. Which assessment question regarding development is most helpful?

Is this normal behavior for your child?

A 16-month-old with a history of hydrocephalus is admitted with an infected ventriculoperitoneal shunt. Which assessment takes priority in this toddler?

Monitor for signs of increased intracranial pressure.

What should the nurse do to ensure a safe hospital environment for a toddler?

Move the equipment out of reach.

A 2-year-old who's admitted to the pediatric unit for a tonsillectomy is in foster care. The nurse assists the physician in gaining informed consent. Who can legally give informed consent for this elective procedure?

Parents or guardian

A toddler is having a tonic-clonic seizure. What should the nurse do first?

Remove objects from the child's surroundings.

Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery?

Risk for infection

A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased respiratory rate, and a decreased oxygen saturation level. Which of the following should be the nurse's first action?

Suction the tracheostomy.

Which of the following would be the best approach when trying to take a crying toddler's temperature?

Talk to the mother first and then to the toddler.

A nurse is reinforcing education with parents on providing adequate nutrition for their toddler who has cerebral palsy. Which observation by the nurse indicates that the education has been effective?

The child eats finger foods independently.

The nurse is caring for a child with a fractured leg. The child's mother becomes concerned when she visits her son and notices him sucking his thumb, a behavior that he had previously given up. What does this behavior indicate?

The child is responding to stress.

A child's parents state that they childproofed their home for their 2-year-old boy. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which of the following situations displays misunderstanding by the parent?

Toy chest in front of a second-story, locked window

The parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment?

Using gestures to express desires

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, doing this helps the child achieve:

autonomy.

The nurse is caring for a 30-month-old client in the pediatrician's office. The client is being assessed for autism spectrum disorder. While assessing the client with the health care provider, which clinical characteristics does the nurse anticipate documenting in the medical record? Select all that apply.

avoiding eye-to-eye contact with others using repetitive behaviors throughout the session

Parents tell the nurse that they want to begin toilet training their 22-month-old child. What is the most important factor regarding toilet training that the nurse should stress to the parents?

developmental readiness of the child

A 2-year-old child has been admitted with a diagnosis of diabetes. Which cardinal sign would support this diagnosis?

frequent urination

A parent of a toddler diagnosed with atopic dermatitis is concerned about how the child acquired the disease. The nurse should explain that atopic dermatitis is caused by which condition?

hereditary disorder

A 2-year-old child is being treated with rifampin for tuberculosis. Which finding does the nurse expect to find in the client?

orange body secretions

A nurse is observing a 2½-year-old child playing with another child of the same age in the playroom on the pediatric unit. What type of play should the nurse expect the children to engage in?

parallel play

An 18-month-old child comes to the primary health care provider's office for a well-baby checkup. Which foods should the nurse recommend as providing the best sources of dietary iron for the child?

peanut butter, green vegetables, and raisins

An emergency department nurse suspects neglect in a 3-year-old child admitted for failure to thrive. What behavior in the child should the nurse look for that might indicate signs of neglect?

poor hygiene and weight loss

A nurse is obtaining data from a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?

positive Kernig's sign

The nurse is caring for a toddler admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report?

proteinuria

The nurse is caring for a 3-year-old client being treated for severe status asthmaticus. After comparing clinical manifestations with laboratory results (reported as shown), a nurse determines that this client has progressed to which condition?

respiratory acidosis

The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit:

strong food preferences.

A 1-year-old underwent hypospadias repair yesterday; he has a urethral catheter in place and an IV. Which rationale is appropriate for administering propantheline on an as-needed basis?

to prevent bladder spasms while the catheter is present

The parents of a 2-year-old scheduled for surgical repair of an inguinal hernia are fearful and their fears are affecting their child. A play therapist is consulted to help with the child's care. The nurse should explain to the parents that the play therapist will:

use puppets to gain insight into how the child feels about his hospitalization and fears.

The nurse should expect a 3-year-old child to be able to perform which action?

Ride a tricycle

The nurse is reinforcing education about injury prevention to the parents of a toddler. Which instruction is appropriate for the nurse to tell the parents?

"Place locks on cabinets containing toxic substances."

A nurse in a primary health care provider's office is reinforcing education about car seat safety with the parent of a 2-year-old. The parent asks if the child, who weighs 35 lb (15.9 kg), requires a car seat. Which response by the nurse is most appropriate?

"The child should ride in the car seat until he is 4 years old and weighs at least 40 lb."

The nurse is caring for a toddler with right lower lobe pneumonia. In order to improve gas exchange, which position should hte child be placed in?

left side-lying

The parents of a 4-year-old report that their child has been scratching the rectum recently. About which infestation or condition will the nurse reinforce education?

pinworms

When attempting to reduce the risk of impaired skin integrity related to immobility in a toddler, which action should the nurse take?

Gently massage the skin with a lubricating substance.

A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to his mother. Which data should the nurse obtain first?

Heart rate, respiratory rate, and blood pressure

During a well-child visit, the nurse is reinforcing education with the parents of a 2-year-old child. What is the best recommendation a nurse can give to the parents regarding frequent temper tantrums?

Ignore the behavior when it happens.

Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position?

Place the child on the hip.

The nurse is teaching a group of mothers about normal toddler development. When talking about toddlers' play, the nurse should include which point?

They play with similar objects nearby other children rather than with them.

A father expresses concern over his toddler's eating habits. He states the toddler eats very little and consumes only a single type of food for weeks on end. Which instruction is most helpful?

This is normal toddler behavior.

The nurse is preparing to administer chloramphenicol to a 2-year-old client with an infection of the external auditory canal. The order reads, "2 drops in the right ear three times per day." Which steps should the nurse take to administer this medication? Select all that apply.

Wash hands and arrange supplies at the bedside. Warm the medication to body temperature. Examine the ear canal for drainage.

The nurse is trying to weigh a 3-year-old child who's irritable and refuses to stand on the scale. What's the best way to obtain an accurate weight?

Weigh the parent and child and subtract the parent's weight from the combined weight.

A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:

a barking cough.

The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to:

allow the toddler to bathe as much of himself as he can with supervision.

The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position?

lying on one side, with the back curved

A nurse is obtaining data on a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?

positive Kernig's sign

A 2-year-old is being treated for pneumonia. After reviewing the respiratory section of the client care flow sheet (shown), the nurse concludes that which position is most beneficial to maximize oxygenation?

right-side lying

The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which of the following activities would the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply.

using a spoon for eating washing and drying hands removing his or her jacket

The primary health care provider prescribes penicillin G, 300,000 units IM, for a child who is 18 months old. Which site does the nurse select to administer this injection?

vastus lateralis muscle

The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which activity does the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply.

washing and drying hands using a spoon for eating removing his or her jacket

A 2-year-old child has been diagnosed with asthma. The parents ask about the most common asthma triggers. What is the nurse's response?

weather

The nurse is reinforcing education for the parents of a toddler with congenital heart disease. Which information should the nurse include when reinforcing education regarding care?

"Try to maintain your child's usual lifestyle to promote normal development."

When reinforcing teaching the parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?

"Try to maintain your child's usual lifestyle to promote normal development."

When teaching the parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?

"Try to maintain your child's usual lifestyle to promote normal development."

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal the infant's hematocrit is 24%. Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

"What's the infant's usual daily diet?"

A toddler is ordered 350 mg of amoxicillin and clavulanate by mouth four times per day. The pharmacy sends a bottle with a concentration of 250 mg/5 ml. How many milliliters should the nurse administer per dose? Record your answer using a whole number.

7

A health care provider prescribes 150 mg of ibuprofen for a toddler whose temperature didn't lower after receiving acetaminophen. The oral suspension available contains 100 mg per 5 ml. How many milliliters of suspension should the nurse administer? Record your answer using one decimal place.

7.5

An 18-month-old toddler comes into the emergency department after being found face down in the bathtub by his mother. She was able to administer cardiopulmonary resuscitation as instructed by the emergency telephone dispatcher. The toddler fully recovers and is ready for discharge. Which instruction should the nurse include during discharge teaching?

"Don't leave your child unattended in the bathtub even for a few minutes."

An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the parent would indicate to the nurse that additional education is needed?

"I always keep phenobarbital with me in case of a fever."

The charge nurse overhears a nurse complaining that she has been assigned to a toddler diagnosed with tetralogy of Fallot for the past 3 days and the mother is very demanding. Which response by the charge nurse is best?

"It's important for the child to have someone assigned to him who's familiar with his care."

A 15-month-old has just received routine immunizations, including DTaP, IPV, and MMR. What information should the nurse give to the parents before they leave the office? Select all that apply.

"Minor symptoms can be treated with acetaminophen." "Call the office if the toddler develops a fever above 103°F (39.4°C), seizures, or difficulty breathing." "Soreness at the immunization site and mild fever are common."

A 2-year-old child's parent informs the nurse of a concern that the child may have attention deficit hyperactivity disorder (ADHD) because "my child has so much energy, doesn't pay attention for long, and is always getting into things." Which response by the nurse would be best?

"This behavior is normal. The child is exploring and learning about the world."

A parent expresses concern over a toddler's eating habits, stating the toddler eats very little and consumes only a single type of food for weeks on end. Which instruction is most appropriate?

"This is normal toddler behavior."

A mother brings her toddler to the clinic for a wellness checkup. When the nurse asks the mother if she has questions or concerns, the mother tells the nurse she is frustrated because it's so difficult to get her child to bed at night. Which response by the nurse is best?

"Toddlers need a consistent bedtime routine, such as having a set bedtime, eating a light snack before going to bed, or reading a book."