Pediatric Nursing NCLEX
The nurse knows that the most common characteristic associated with nephrotic syndrome is: a. Generalized edema b. Frank bright red blood in the urine c. Increased urinary output d. Hypertension
a. Generalized edema
Which behavior should the nurse expect a 3- year-old child to be capable of doing? a. Going up the stairs on alternate feet b. Pedaling a bicycle c. Dressing without supervision d. Tying shoelaces
a. Going up the stairs on alternate feet
On the day of surgery, Santino will most likely be fearful of: a. Intrusive procedure b. Perceived abandonment c. Premature death d. Unfamiliar caregivers
a. Intrusive procedure
The nurse prepares to take the child's temperature and avoids which method of measurement? a. Tympanic b. Axillary c. Rectal d. Electronic
c. Rectal
The nurse is assessing the child for dehydration. The nurse determines that the child is moderately dehydrated if which symptom is noted on assessment? a. Flat fontanels b. Moist mucous membranes c. Pale skin color d. Oliguria
d. Oliguria
At 7 months of age, an infant exhibits the following skills. The nurse should know that the most recently acquired skill is the ability to: a. Roll over b. Sit up c. Bear some weight on legs d. Pick up objects with palmar grasp
?b. Sit up
The nurse understands that isotonic dehydration: A. Occurs when water and electrolytes are lost in about the same proportions as they exist in the body B. Occurs when the loss of electrolytes is greater than the loss of water C. Occurs when the loss of water is greater than the loss of electrolytes D. Causes the serum sodium level to rise above 150 mEq/L
A. Occurs when water and electrolytes are lost in about the same proportions as they exist in the body
In planning a roommate for the child, Nurse Melai should realize that a child of this developmental level will: A. Prefer another girl her own age B. Most likely seek out opportunities to socialize with teenagers C. Enjoy being with either a girl or boy, as long as they are the same age D. Feel helpful if given the opportunity to look after a slightly younger child
A. Prefer another girl her own age
What type of room assignment should the nurse make? A. A room near the nurse's station so that he can be checked frequently and heard if he vomits B. A single room with a sink nears the doorway for isolation use C. A double room with another toddler who also has vomiting and diarrhea D. A bed in the pediatric intensive care unit, in case dehydration develops
B. A single room with a sink nears the doorway for isolation use
Nurse Melai reviews the results of the CSF analysis and determines that which of the following results would confirm bacterial meningitis? A. Cloudy CSF, ↓ protein, and ↓ glucose B. Cloudy CSF, ↑ protein, and ↓ glucose C. Clear CSF, ↑ protein, and ↓ glucose D. Clear CSF, ↓ pressure, and ↑ protein
B. Cloudy CSF, ↑ protein, and ↓ glucose
As the child recovers from meningitis, for which long-term complication should Nurse Melai watch carefully? A. Encephalitis B. Hydrocephalus C. Learning D. Mental retardation
B. Hydrocephalus
In performing the lumbar puncture, which safety measure would Nurse Melai implement while CSF specimen is obtained? A. Place the child in a sitting position with the head extended B. Place the child in a side-lying position with the back closest to the edge of the bed C. Do not wear gloves because the physician is collecting the specimen D. Place one arm behind the child's neck and the other behind the knees
B. Place the child in a side-lying position with the back closest to the edge of the bed
Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started B. Maintain enteric precautions C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics D. Maintain neutropenic precautions
C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
Which priority nursing intervention should be included when caring for a client diagnosed with gastroenteritis? A. Encouraging optimal nutritional intake B. Alleviating abdominal pain and cramping C. Administering an oral anti-emetic every 2 hours D. Monitoring intake and output, and electrolyte levels
D. Monitoring intake and output, and electrolyte levels
On admission, the nurse prepares to ask the mother which question to elicit assessment information specific to the development of rheumatic fever? a. "Did the child have a sore throat or an unexplained fever within the last 2 months?" b. "Has the child had any nausea or vomiting?" c. "Has the child complained of headaches?" d. "Has the child complained of back pain?"
a. "Did the child have a sore throat or an unexplained fever within the last 2 months?"
A maternity nurse is providing instructions to a new mother regarding the psychosocial development theory, the nurse would instruct the mother to: a. Allow the newborn infant to signal a need b. Anticipate all of the needs of the newborn infant c. Avoid the newborn infant during the first 10 minutes of crying d. Attend to the newborn infant immediately when crying
a. Allow the newborn infant to signal a need
When the corrective surgery for hypertrophic pyloric stenosis is completed, the infant was returned in stable condition to the pediatric unit with an intravenous infusion and a nasogastric tube in place. The priority nursing action should be to: a. Apply adequate restraints b. Administer a mild sedative c. Assess the IV site for infiltration d. Attach the nasogastric tube to wall suction
a. Apply adequate restraints
A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse would expect the physician to order: a. Barium enema b. Suprapubic aspiration c. NG Tube Insertion d. Indwelling urinary catheter insertion
a. Barium enema
Which among the following is the most appropriate location to assess the pulse of an infant under 1 year of age? a. Brachial b. Carotid c. Popliteal d. Radial
a. Brachial
Which of the following activities should a 2-year-old child be able to do? a. Build a tower of 8 cubes b. Point out a picture c. Wash and dry his hands d. Remove a garment
a. Build a tower of 8 cubes
At a previous visit, the parents of an infant with cystic fibrosis received instruction in administration of pancrelipase (Pancrease). At a follow up visit, which finding in the infant suggests that the parents are not administering the pancreatic enzymes as instructed? a. Fatty stools b. Bloody urine c. Bloody stools d. Glucose in urine
a. Fatty stools
Which of the following actions would be least effective in maintaining a neutral environment for the newborn? a. Placing an infant under a radiant warmer after bathing? b. Covering the scale with a warmed blanket prior to weighing c. Placing crib close to the nursery window for family viewing d. Covering the Infant's head with a stockinette
a. Placing an infant under a radiant warmer after bathing?
A nurse is reviewing the laboratory results of Santino. The nurse determines that which of the following laboratory values is most significant to review? a. Prothrombin time b. Sedimentation rate c. Blood urea nitrogen d. Creatinine
a. Prothrombin time
The foul-smelling, frothy characteristics stool in cystic results from the presence of large amounts of: a. Undigested fat b. Sodium and chloride c. Semidigested carbohydrates d. Lipase, trypsin and amylase
a. Undigested fat
The mother asks the nurse if the child will ever look thin again. The nurse most appropriately responds by telling the mother: a. "Wearing loose-fitting clothing should help conceal the extra weight." b. "In most cases, medication and diet will control fluid retention." c. "Do you feel guilty because you didn't notice the weight gain?" d. "When children are little, it's expected they'll look a little chubby."
b. "In most cases, medication and diet will control fluid retention."
A mother asks when to take her 2-year-old to the dentist. For dental prophylaxis, the nurse encourages her to take the child: a. Before starting school b. Between 2 and 3 years of age c. When the child begins to lose deciduous teeth d. The next time another family member goes to the dentist
b. Between 2 and 3 years of age
During a nap, a 3-year-old hospitalized boy wets the bed. The best approach by the nurse would be to: a. Tell him to help with remaking the bed b. Change his clothes and make no issue of it c. Change his bed putting a rubber sheet on it d. Explain that big boys should try to call the nurse
b. Change his clothes and make no issue of it
In assessing the development of a 5-year-old, the nurse would not expect the child to be able to: a. Name primary colors b. Count to 100 c. Know the days of the week d Give telephone number and address
b. Count to 100
The nurse observes a 2-year-old child at play and notes at this age a toddler: a. Builds houses with blocks b. Is extremely possessive of toys c. Attempts to stay within the lines when coloring d. Amuses self with a picture book for 15 minutes
b. Is extremely possessive of toys
Nursing care for Agua after the surgical repair of a cleft lip should include: a. Keeping the baby NPO b. Keeping the infant from crying c. Placing the infant in a semi-sitting position d. Spoon-feeding for the first 2 days after surgery
b. Keeping the infant from crying
The most critical factor in the immediate care of an infant after repair of cleft lip would be the: a. Prevention of vomiting b. Maintenance of a patent airway c. Administration if parenteral fluids d. Administration of drugs to reduce oral secretions
b. Maintenance of a patent airway
Agua has just returned to the nursing unit following a surgical repair of a cleft lip located on the right side of the lip. The nurse places the infant in which most appropriate position? a. On the right side b. On the left side c. Prone d. Supine
b. On the left side
Medications that will probably be used in the therapeutic regimen for a child with cystic fibrosis include: a. Asteroid and an antimetabolite b. Pancreatic enzymes and antibiotics c. Aerosol mists, decongestants, and fat-soluble vitamins d. Antibiotics, a multivitamin preparation, and cough drops
b. Pancreatic enzymes and antibiotics
To reduce vomiting, the nurse should teach the mother that immediately after the feeding the infant, she should: a. Rock the baby for 20 minutes b. Place the baby in an infant seat. c. Place the baby flat on the right side d. Keep the baby awake with sensory stimulation
b. Place the baby in an infant seat.
A nurse planning care for Santino knows that which of the following would present the highest risk of aspiration during surgery? a. Difficulty swallowing b. The presence of loose teeth c. Bleeding during surgery d.Exudate in the throat area
b. The presence of loose teeth
The mother of an 8-year-chid tells the nurse that she is concerned about the child that she is concerned about the child because the child seems to be more attentive to friends than anything else. The most appropriate nursing response would be which of the following? a. "You need to be concerned." b. You need to monitor the child's behavior closely." c. "At this age, the child is developing his own personality." d. "You need to provide more praise to the child to stop this behavior."
c. "At this age, the child is developing his own personality."
The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. The most appropriate response by the nurse is which of the following? a. "The child is very young to begin this behavior and should be brought to the clinic." b. "This is not normal behavior, and the child should be seen by the physician" c. "This is a normal behavior at this age." d. "Children usually begin this behavior at 8 years."
c. "This is a normal behavior at this age."
A nurse is performing CPR on an infant. When performing chest compressions, the nurse understands that the compression rate is at least: a. 60 times per minute b. 80 times per minute c. 100 times per minute d. 160 times per minute
c. 100 times per minute
A 9-year-old child has a fractured tibia, and a full leg cast has been applied. Nurse Jean should immediately notify the physician if assessment demonstrates: a. A pedal pulse of 90 b. An increased urinary output c. An Inability to move the toes d. A plaster cast that is still damp after 4 hours
c. An Inability to move the toes
When palpating the infant's abdomen, the nurse would expect to find: a. An impacted and distended colon b. Marked tenderness around the umbilicus c. An olive-sized mass in the right upper quadrant d. Rhythmic peristaltic waves in the lower abdomen
c. An olive-sized mass in the right upper quadrant
A mother of a 5-year-old child tells the nurse that the child scolds the floor or a table if the child hurts herself on the object. According to Piaget's theory of cognitive development, this behavior is identified as: a. Object permanence b. Egocentric speech c. Animism d. Global organization
c. Animism
At 2 years of age, a child is readmitted to the hospital for additional surgery. The most important factor in preparing the child for this experience is: a. Gratification of the child's wishes b. The child's previous hospital visits c. Assurance of affection and security d. Avoiding leaving the child with strangers
c. Assurance of affection and security
A 5-year-old child has lactose intolerance. The nurse tells the mother that it is necessary to provide which dietary supplement in the child's diet? a. Zinc b. Protein c. Calcium d. Fats
c. Calcium
The child experiences the following signs or symptoms of rheumatic fever. The nurse should plan any interventions based on the knowledge that the only one that may result in permanent damage is: a. Sydenham's chorea b. Migratory polyarthritis c. Carditis d. Erythema marginatum
c. Carditis
Which findings will the nurse observe in this patient? a. Macular rash that is pruritic b. Decreased antistreptolysin O titer c. Elevated C-reactive protein levels d. Decreased erythrocyte sedimentation rate
c. Elevated C-reactive protein levels
The nurse monitors the infant with suspected diagnosis of imperforate anus, knowing that which of the following is a clinical manifestation associated with this disorder? a. Sausage-shaped mass palpated in the upper right abdominal quadrant b. Bile-stained fecal emesis c. Failure to pass meconium stool in the first 24 hours after birth d. The passage of currant jelly-like stools
c. Failure to pass meconium stool in the first 24 hours after birth
The nurse documents that the infant with GERD should be maintained in which position following feeding and at night in order to manage reflux? a. 30-degree angle when supine b. 60-degree angle when supine c. Head-elevated prone position d. 20-degree angle when supine
c. Head-elevated prone position
The nurse, when planning care, recalls that chest percussion and postural drainage for a toddler with cystic fibrosis are best done: a. After suctioning b. Before aerosol therapy c. One hour before meals d. Immediately after meals
c. One hour before meals
In young children with cystic fibrosis, frequent stool and tenacious mucus often produce: a. Anal fissures b. Intussusception c. Rectal prolapse d. Meconium ileus
c. Rectal prolapse
After the corrective surgery, the nurse caring for an infant, who had been formula-fed, notices that the post-operative orders are similar to those for the other infants having undergone such surgery and include: a. Thickened formula 24 hours after surgery b. Withholding all feedings for the first 24 hours c. Regular formula feeding 24 hours after the surgery d. Additional glucose feeding as desired after the first 24 hours
c. Regular formula feeding 24 hours after the surgery
A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. The nurse most appropriately tells the mother to: a. Punish the child every time the child says "no", to change the behavior b. Allow the behavior because this is normal at this age period c. Set limits on the child's behavior d. Ignore the child when this behavior occurs
c. Set limits on the child's behavior
After a tonsillectomy, the nurse documents on the plan of care to place Santino in which most appropriate position? a. Supine b. Trendelenburg's c. Side-lying d. High fowler's
c. Side-lying
The nurse should carefully observe the infant for: a. Quality of cry b. Character of stool c. Signs of dehydration d. Coughing after feeding
c. Signs of dehydration
A nurse providing care to a newborn would use knowledge of which of the following concepts underlying adaptation of the newborn's immune system? a. Iron stores from the mother are sufficient to carry the newborn through the 5th month of extrauterine life b. Unconjugated bilirubin can leave the vascular system and permeate the other extravascular tissues c. The newborn is unable to limit invading organisms at their point of entry d. Most newborns void in the first 24 hours after birth and 5 to 20 times thereafter
c. The newborn is unable to limit invading organisms at their point of entry
Which of the following would the nurse identify as goal of newborn care in the initial postpartum period? a. To facilitate development of a close parent-newborn relationship b. To assist parents in developing healthy attitudes about childbearing practices potential problems c. To identify actual or requiring immediate or emergency attention d. To provide the parents of the newborn with Information about well-baby programs
c. To identify actual or requiring immediate or emergency attention
A nurse is preparing to attempt to relieve an airway obstruction on a 3-year-old conscious child. The nurse performs this maneuver by placing the hands between the: a. Umbilicus and the groin b. Groin and the abdomen c. Umbilicus and the xiphoid process d. Lower abdomen and the chest
c. Umbilicus and the xiphoid process
When preparing to administer the vitamin K to a neonate, the nurse would select which of the following sites as appropriate for the injection? a. Deltoid muscle b. Anterior femoris muscle c. Vastus lateralis muscle d. Gluteus maximus muscle
c. Vastus lateralis muscle
The best way to detect fluid retention would be to: a. Have the child urinate in a bedpan b. Measure the child's abdominal girth daily c. Weigh the child at the same time every day d. Test the child's urine for hematuria and proteinuria
c. Weigh the child at the same time every day
A 10-year-old child begins to choke and cough on a piece of candy. Which priority nursing action should the nurse implement? a. Provide abdominal thrusts b. Give 5 back slaps, followed by S abdominal thrusts c. Look in the mouth and perform a blind finger sweep d. Allow a child to expel the candy by himself or herself
d. Allow a child to expel the candy by himself or herself
The best roommate for a 9-year-old girl with rheumatic fever would be: a. An 8-year-old girl with -impetigo b. A 9-year-old girl with a tonsillectomy c. A 10-year-old girl with a concussion d. An 11 year-old girl with a fractured elbow in skeletal traction
d. An 11 year-old girl with a fractured elbow in skeletal traction
27. Which laboratory study would assist in confirming the diagnosis of rheumatic fever? a. White blood cell count b. Red blood cell count c. Immunoglobulin d. Antistreptolysin O titer
d. Antistreptolysin O titer
The best way to perform a DDST on a 9-month-old is to: a. Take the infant from the mother and ask her to wait in the child's room b. Take the infant from the mother and ask her to come with them to the testing area c. Briefly talk first with the mother, then take the infant to the testing area alone d. Ask the infant's mother to carry the child to testing area
d. Ask the infant's mother to carry the child to testing area
The first period of reactivity in the newborn begins at birth. The following are characteristics of this period EXCEPT: a. This lasts for 30 minutes b. Respirations are increased to 80/minute c. Flaring of nares and grunting are common d. Bowel sounds are present
d. Bowel sounds are present
The nurse performs cardiopulmonary resuscitation (CPR) for 1 minute on an infant without calling for assistance. In reassessing the infant after 1 minute of CPR, the nurse finds he still isn't breathing and has no pulse. The nurse should then: a. Resume CPR beginning with breaths b. Declare her efforts futile c. Resume CPR beginning with chest compressions d. Call for assistance
d. Call for assistance
The preschooler is started on prednisone. If the prednisone is having the expected therapeutic effect, the nurse should expect that this child will: a. Experience mood swings b. Have sugar in the urine c. Gain weight d. Feel better
d. Feel better
A nurse reviews the record of 3-week-old Infant and notes that the physician has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment finding documented in the record, knowing that which symptorn most likely led the mother to seek healthcare for the infant? a. Diarrhea b. Projectile vomiting c. Regurgitation of feedings d. Foul-smelling ribbon-like stools
d. Foul-smelling ribbon-like stools
A cleft lip predisposes an infant to infections primarily because of: a. Poor nutrition from disturbed feedling b. Poor circulation to the defective area c. Waste products that accumulate along the defect d. Mouth breathing, which dries the oropharyngeal mucous membranes
d. Mouth breathing, which dries the oropharyngeal mucous membranes
A clinic nurse is preparing to discuss the concepts of moral development with a mother. The nurse understands that according to Kohlberg's theory of moral development. In the pre-conventional level, moral development is thought to be motivated by which of the following? a. The parents' behavior b. Peer pressure c. Social pressures d. Punishment and reward
d. Punishment and reward
The child is already in remission. What type of diet would the nurse plan to feed this child? a. High protein, low calorie b. High calorie, low protein c. Low sodium, low fat d. Regular diet, no added salt
d. Regular diet, no added salt
After a tonsillectomy, the nurse suspects hemorrhage postoperatively when the child: a. Snores noisily b. Becomes pale c. Complains of thirst d. Swallows frequently
d. Swallows frequently
Feeding for Agua will probably be: a. Limited to IV fluids b. With a cross-cut nipple c. Too difficult because of breathing problems d. With a rubber-tipped syringe or medicine dropper
d. With a rubber-tipped syringe or medicine dropper