Pediatric success- Issues Related to Pediatric Health - Chapter 3

16. Which statement by the parent of a newborn male diagnosed with galactosemia demonstrates successful teaching? 1. "This is a rare disorder that usually does not affect future children." 2. "Our newborn looks normal; he may not have galactosemia." 3. "Our newborn may need to take penicillin and other medications to prevent infection." 4. "Penicillin and other drugs that contain lactose as fillers need to be avoided."

4. Many drugs, such as penicillin, contain unlabeled lactose as filler and need to be avoided.

20. Which intervention might the nurse anticipate in a 2-day-old infant diagnosed with maple syrup urine disease? 1. High-protein, high-amino-acid diet. 2. Low-protein, limited amino-acid diet. 3. Low-protein, low-sodium diet. 4. Phenylalanine-restricted diet.

2. A child with maple syrup urine disease will be on a low-protein, limited amino-acid diet for life. Patients need a diet high in thiamine.

59. Which statement is true of abused children? 1. They will tell the truth if asked about their injuries. 2. They will repeat the same story as their parents. 3. They usually are not noted to have any changes in behavior. 4. They will have outgoing personalities and be active in school activities.

2. Abused children frequently repeat the same story as their parents.

17. Which signs and symptoms would the nurse expect to assess in a newborn with congenital hypothyroidism? 1. Preterm, diarrhea, and tachycardia. 2. Post-term, constipation, and bradycardia. 3. High-pitched cry, colicky, and jittery. 4. Lethargy, diarrhea, and tachycardia.

2. Congenital hypothyroidism clinical manifestations may include bradycar dia, constipation, poor feeding, lethargy, jaundice prolonged for more than 2 weeks, cyanosis, respira tory difficulties, hoarse cry, large anterior/posterior fontanels, post term, and birth weight greater than 4000 g.

51. Which statement most accurately describes child abuse? 1. Intentional physical abuse and neglect. 2. Intentional and unintentional physical and emotional abuse and neglect. 3. Sexual abuse of children, usually by an adult. 4. Intentional physical, emotional, and sexual abuse and neglect.

4. Child abuse is intentional physical, emotional, and/or sexual abuse and/or neglect.

45. Which would be the priority nursing intervention for a child with carbon monoxide poisoning? 1. Provide supplemental 100% oxygen. 2. Provide continuous oxygen saturation monitoring. 3. Establish intravenous access. 4. Draw blood for a STAT carbon monoxide level.

45. 1. 100% oxygen via non-rebreather mask is given as quickly as possible if carbon monoxide poisoning is suspected be cause the signs and symptoms of car bon monoxide poisoning are related to tissue hypoxia.

54. The mother of a 6-month-old states that since yesterday, the child cries when anyone touches her arm. Which would be the priority assessment after the airway, breathing, and circulation had been assessed and found stable? 1. Ask the mother if she knows what happened. 2. Assess child for other signs of potential physical abuse. 3. Prepare for radiological diagnostic studies. 4. Establish intravenous access, and draw blood for diagnostic testing.

54. 1. The health-care provider's highest priority should be to try to get history information from the parent.

2. The nurse received a report on a new admission: a 3-year-old with Kawasaki disease. Understanding the etiology and major complications of Kawasaki disease, the priority nursing intervention would be: 1. Continuous cardiovascular and oxygen saturation monitoring. 2. Vital signs every 4 hours until stable. 3. Strict intake and output monitoring hourly. 4. Begin aspirin therapy after fever has resolved.

2. 1. Cardiovascular manifestations of Kawasaki disease are the major compli cations in pediatric patients. Continuous cardiac monitoring is required to alert the nurse of any cardiovascular compli cations. Decreased oxygen saturation and respiratory changes have been shown to be early indicators of potential complications.

58. What would be the priority intervention when a 10-year-old girl comes to the nurse's office because of a headache, and the nurse notices various stages of bruising on her inner upper arms? 1. Call her mother and ask her if acetaminophen can be given for the headache. 2. Ask the girl what happened to her arms, and have her describe the headache. 3. Inquire about her headache and the bruising on her arms; file mandatory reporting forms. 4. Call her mother to pick her up from school, and complete required school nurse visit forms.

2. Her safety should be ensured first, then discuss physical complaints. School nurses are mandatory reporters of any suspected child abuse.

30. What would be the best plan of care for a newborn whose mother's hepatitis B antigen status is unknown? 1. Give the infant the hepatitis B vaccine within 12 hours of birth. 2. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. Give the infant the hepatitis B vaccine within 24 hours of birth. 4. Give the infant the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth.

2. Infants born to mothers of unknown hepatitis B antigen status should be given the hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth. If the mother is positive for hepatitis B antigen, then the baby should receive the hepatitis B immune globulin as soon as possible within 12 hours of birth. Timely administration of the hepatitis B vaccine is important to prevent passive acquisition of hepatitis B from the mother. 3

60. 1. There may be absence of external signs of injury in shaken baby syndrome because the injury can cause retinal hemorrhage and subdural hematoma.61. What would be the best response if the mother of a 10-year-old boy on kidney dialysis tells the nurse he has no appetite and only eats bananas? 1. "Right now his stomach is upset, and as long as he is eating something to give him strength, it is fine." 2. "Let's talk about your son and his diet." 3. "Bananas are good to eat; they are rich in needed nutrients." 4. "Did you try asking him what else he may want to eat?"

2. It would be most therapeutic to discuss with the mother and child the best foods to eat and to avoid on a renal diet. Bananas should be limited because of their high potassium content.

13. Which teaching would be important to discuss with the family of a child born with PKU? 1. Studies have shown that children with PKU outgrow the disease. 2. Consumption of decreased amounts of protein and dairy products is advised. 3. High-protein and high-dairy products consumption must be maintained. 4. Exclusive breastfeeding is encouraged for maximal nutrition for the child.

2. Many high-protein foods such as meats and dairy products are restricted or eliminated from the diet due to the high phenylalanine content.

56. Which would be the nurse's priority intervention if a 7-year-old girl's mother tells the nurse she has noticed excessive masturbation? 1. Tell her it is normal development for children of her age. 2. Ask the mother if anyone is abusing the daughter that she knows about. 3. Talk with the child and find out why she is touching herself down there. 4. Investigate thoroughly the circumstances in which she masturbates.

2. Masturbation may indicate sexual abuse. It is imperative that the nurses do a thorough investigation if a parent is concerned about a child's masturbation.

52. What is the most likely cause of a child's illness if it is unexplained, prolonged, recurrent, extremely rare, and usually occurs when the mother is present? 1. Genetic disorder. 2. Munchausen syndrome by proxy. 3. Duchenne muscular dystrophy. 4. Syndrome of inappropriate antidiuretic hormone.

2. Munchausen syndrome by proxy may be the cause of unexplained, pro longed, rare, recurrent illnesses. It usually occurs when the caregiver is present.

21. What would be the priority nursing action on finding the varicella vaccine at room temperature on the shelf in the medication room? 1. Ensure the varicella vaccine's integrity is intact; if intact, follow the five rights of medication administration. 2. Do not administer this batch of vaccine. 3. Ensure the varicella vaccine's integrity is intact; if intact, give the vaccine after verifying proper physician orders. 4. Ask the mother if the child has had any prior reactions to varicella.

2. The varicella vaccine integrity cannot be ensured if the vaccine is at room temperature, so do not administer.

26. Which medication is most important to have available in all clinics and offices if immunizations are administered? 1. Benadryl (diphenhydramine) injection. 2. Epinephrine 1:10,000 injection. 3. Epinephrine 1:1000 injection. 4. Benadryl (diphenhydramine) liquid.

3. Epinephrine 1:1000 injection would be the drug of choice for subcutaneous injection if a severe allergic reaction occurs in an office or clinic setting.

53. Which statement would be most therapeutic to a child the nurse suspects has been abused? 1. "Who did this to you? This is not right." 2. "This is wrong that your mother did not protect you." 3. "This is not your fault; you are not to blame for this." 4. "I will not tell anyone."

3. When communicating with a child you think may have been abused, it is the most therapeutic to tell the child it is not the child's fault.

35. An adolescent male comes in for his yearly physical. Which would be the most appropriate injury prevention/safety teaching for him? 1. Inquire which are his favorite sports and discuss his knowledge and application of appropriate safety principles. 2. Tell him to be careful performing sports activities because every sport has the potential for injury. 3. Tell him not to let his friends encourage him to drink or smoke or take any drugs. 4. Ask his mother what sports he plays and if he wears a helmet with contact sports.

35. 1. Adolescence is a time of need for independence and learning to make appropriate decisions. Safety is always a concern, and tying a safety discussion to the teen's interest in sports will help keep him safe. The nurse needs to inquire and build on the teen's interests and knowledge.

4. The mother of an 18-month-old is discharged from the hospital after the child has a febrile seizure secondary to exanthem subitum (roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which teaching about the transmis sion of roseola would be most accurate? 1. The child should be isolated in the home until the vesicles have dried. 2. The child does not need to be isolated from the older siblings. 3. Administer acetaminophen to the older siblings to prevent seizures. 4. Monitor older children for seizure development.

4. 1. The rash is pink and maculopapular, not vesicular. The period of communicabil ity is unknown, and the incubation pe riod is 5 to 15 days and more commonly seen in children 6 months to 3 years of age. Isolating the siblings is not necessary.

47. Which would be the best response to a 10-year-old girl who asks if she can take acetaminophen daily if she gets aches and pains? 1. Tell her it is better not to take medication if she gets aches and pains; she should check with her mother before taking any medication. 2. Teach her that nonprescription drugs like acetaminophen can be a poisoning hazard if too many are taken; it is best for her to check with her mother. 3. Encourage her to keep a log of when she takes acetaminophen to try to establish what is causing her aches and pains. 4. Sometimes it is okay to take acetaminophen daily, but it depends on why she has aches and pains.

4. If she needs pain medication daily, a cause needs to be determined.

27. Which is the nurse's best response when the mother of a 2-month-old who is going to get the IPV tells the nurse the older brother is immunocompromised? 1. "Your baby should not be immunized because your immunocompromised son could develop polio." 2. "Your baby should receive the oral poliovirus vaccine instead so your immunocompromised son does not get sick." 3. "You should separate your 2-month-old child from the immunocompromised son for 7 to 14 days after the IPV." 4. "Your baby can be immunized with the IPV; he will not be contagious."

4. The infant sibling can and should be immunized as recommended. The infant will not shed the poliovirus.

25. What would be the nurse's best response if the foster mother of a 15-month-old with an unknown immunization history comes to the clinic requesting immunizations? 1. "Your foster child will not receive any immunizations today." 2. "Your foster child will receive the measles, mumps, rubella (MMR); and Hib; IPV; and hepatitis B vaccines." 3. "Your foster child could have harmful effects if we revaccinate with prior vaccines." 4. "Your foster child will receive only the Hib and DTaP vaccines today."

4. Vaccines routinely due at 15 months include Hib and DTaP. To catch up missed immunizations the nurse would need the child's immunization record to verify what he has received.

7. Which of the following would be the priority teaching to the parent of a child diagnosed with chickenpox (varicella) who was prescribed diphenhydramine (Benadryl) for itching? 1. Give a warm bath with mild soap before lotion application. 2. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). 3. Apply Caladryl lotion generously to decrease itching. 4. Give a cool shower with mild soap to decrease itching.

2. Caladryl lotion contains diphenhy dramine (Benadryl), and the child would be at risk for toxicity if the Caladryl is applied to open lesions.

57. Which statement by the mother would lead the nurse to suspect sexual abuse in a 4- year-old girl? 1. Masturbation. 2. Increased temper tantrums. 3. She is not grateful. 4. She does not demonstrate loyalty.

2. Increased temper tantrums, increased sleep disorders, and depression may indicate sexual abuse

40. Which would be the best response to the mother of a 13-year-old boy who continues to ask to ride his 16-year-old cousin's all-terrain vehicle? 1. Emphasize that if he wears safety apparel and has adult supervision, it is fine. 2. Explain to the mother that he is developing increased physical skills and, if he wears safety apparel and shows maturity, it should be fine. 3. Discuss that all-terrain vehicles are not recommended for those younger than 16 years of age. 4. Discuss with the mother that this is a stage where the child is seeking independence and should be allowed to participate in new physical activities.

3. He may be at the developmental stage of seeking independence, but adolescents do not yet have the emotional or physical development to operate allterrain vehicles. The American Academy of Pediatrics states that those younger than 16 years should not operate all-terrain vehicles.

10. After airway, breathing, and circulation have been assessed and stabilized, which intervention should the nurse implement for a child diagnosed with encephalitis? 1. Assist with a lumbar puncture, and give reassurance. 2. Obtain a throat culture, then begin antibiotics. 3. Perform initial and serial neurological assessments. 4. Administer antibiotics and antipyretics.

3. In a child with a neurological problem, initial and serial neurological assess ments would be a priority nursing intervention to monitor for changes in neurological status.

9. The parents of a 12-month-old male with HIV are concerned about his receiving routine immunizations. What will the nurse tell them about immunizations? 1. "Your child will not receive routine immunizations today." 2. "Your child will receive the recommended vaccines today; regular immunizations help prevent childhood illnesses." 3. "Your child is not severely immunocompromised, but I would still be concerned about his receiving them. Let's not give them today." 4. "Your child may develop infections if he gets his routine immunizations. Your child will not be immunized today."

9. 1. It is the nurses' function to acknowl edge a client's fears and then discuss concerns to clarify any misconceptions. Immunizations and influenza vaccine are recommended to prevent infection. Immunocompromised HIV-infected children should not receive the varicella and MMR live vaccines.

11. Expected nursing assessments of a newborn with suspected cystic fibrosis would include: 1. Observe frequency and nature of stools. 2. Provide chest physical therapy. 3. Observe for weight gain. 4. Assess parent's compliance with fluid restrictions.

11. 1. Cystic fibrosis is inherited as an autosomal-recessive trait, causing exocrine gland dysfunction. About 7% to 10% of newborns with cystic fibrosis present with meconium ileus, so assessing stool frequency and con sistency is important.

15. Which intervention should the nurse implement for a newborn diagnosed with galactosemia? 1. Eliminate all milk and lactose-containing foods. 2. Encourage breastfeeding as long as possible. 3. Encourage lactose-containing formulas. 4. Avoid feeding soy-protein formula to the newborn.

15. 1. Galactosemia is a rare autosomal recessive disorder involving an inborn error of carbohydrate metabolism. The hepatic enzyme galactose-1-phosphate uridyl transferase is absent, causing the failure of galactose to be converted into glucose. Glucose builds up in the bloodstream, which can result in liver failure, cataracts, and renal tubular problems. Treatment of galactosemia involves eliminating all milk and lactose-containing foods, including breast milk.

48. What would be the nurse's best advice to a mother who says her 3-year-old son ingested his father's Visine eye solution? 1. "Initiate vomiting immediately." 2. "Call the Poison Control Center." 3. "Call the pediatrician right away." 4. "Dilute with milk 1:1 volume of suspected ingestion."

2. Calling Poison Control is the first step for ingestion of any known or un known substance. Visine (topical sym pathomimetic) can cause serious or fatal consequences if even a little is ingested.

49. What would be the best response if a mother tells the nurse that the only way she can get her 2-year-old daughter to take medicine is to call it candy? 1. Tell her that is fine as long as the child takes all of the medicine. 2. Discuss the importance of not calling medicine candy to prevent accidental drug ingestion. 3. Discuss with the mother that the child does not have to take the medicine if she does not want it. 4. Tell the mother her child will have to go to "time out" if she does not take her medicine.

2. Medications should never be called candy so as to prevent accidental inges tion of medication by children thinking it is candy.

34. A child with a newly applied left leg cast initially feels fine, then starts to cry and tells his mother his leg hurts. Which assessment would be the nurse's first priority? 1. Cast integrity. 2. Neurovascular integrity. 3. Musculoskeletal integrity. 4. Soft-tissue integrity.

2. Neurovascular integrity should be as sessed first and frequently because neurovascular compromise may cause serious consequences. Neurovascular integrity should be assessed for pain: increased Pain out of proportion with injury, Pallor of extremity, Paresthesia, Pulselessness at distal part of extrem ity, and Paralysis post cast application (5 Ps). Cast integrity would be assessed, but neurovascular integrity is the highest priority.

36. Which assessment is most important after any injury in a child? 1. History of loss of consciousness and length of time unconscious. 2. Serial assessments of level of consciousness. 3. Initial neurological assessment. 4. Initial vital signs and oxygen saturation level.

2. Serial assessments of level of con sciousness are the most important observations of a child after any injury. That information tells you if the child's condition is changing.

19. Which statement from parents of a newborn male diagnosed with Tay-Sachs disease indicates successful understanding of his long-term prognosis? 1. "If we give our baby a proper diet, early intervention, and physical therapy, he can live to adulthood." 2. "He will have normal development for about 6 months before progressive developmental delays develop." 3. "With intense physical therapy and early intervention, we can prevent developmental delays." 4. "If we give our baby a lactose-free diet for life, we can minimize developmental delays and learning disabilities."

2. Tay-Sachs disease is a genetic disorder in which the infant has normal devel opment for the first 6 months. After 6 months, developmental delays and neurological worsening occur. Dietary restriction or providing physical ther apy does not change the outcome.

37. Which would be the most appropriate nursing intervention when caring for a child newly admitted with a mild head concussion and no cervical spine injury? 1. Keep head of bed flat, side rails up, and safety measures in place. 2. Elevate head of bed, side rails up, and safety measures in place. 3. Observe for drainage from any orifice and notify physician immediately. 4. Continually stimulate the child to keep awake to check neurological status.

2. The head of the bed should be elevated to decrease intracranial pressure. Side rails should be up to help ensure the child stays in bed, and age-appropriate safety measures should be instituted.

42. Which intervention would be most appropriate for a 3-year-old boy who had just ingested dish detergent? 1. Discuss childproofing measures in the home in a nonthreatening manner. 2. Inquire about the circumstances of the ingestion. 3. Discuss having ipecac and the Poison Control phone number in the home. 4. Tell the mother you will be giving the boy medicine to make him throw up.

2. The most therapeutic approach is to inquire about the circumstances of the ingestion in a nonjudgmental manner.

39. What would be the most appropriate advice to give to the parent of a boy with sligh visual blurring after being hit in the face with a basketball? 1. "Apply ice, observe for any further eye complaints, and bring him back if he has increased pain." 2. "Take him to the emergency department to ensure that he does not have any internal eye damage." 3. "Call your pediatrician if he starts vomiting, is hard to wake up, or has worsening of eye blurring." 4. "Observe for any further eye complaints, headaches, dizziness, or vomiting, and i worsening occurs, take him to your pediatrician."

2. This type of eye injury is considered blunt force trauma to the eyes, and the child should be evaluated medically for assessment and prevention of eye damage. Slight blurring could indicate eye injuries, such as detached retina and hyphema, which need immediate medical intervention.

6. Which of the following would be the priority intervention the nurse should initiate for a child suspected of having varicella (chickenpox)? 1. Contact precautions. 2. Contact and droplet respiratory precautions. 3. Droplet respiratory precautions. 4. Universal precautions and standard precautions.

2. Varicella (chickenpox) is highly conta gious. Contact and droplet respiratory precautions should be started immedi ately because the primary source of transmission is secretions of the respiratory tract (droplet) and also by contaminated objects.

23. Which nursing intervention should take place prior to all vaccination administrations? 1. Document the vaccination to be administered on the immunization record and medical record. 2. Provide the vaccine information statement handout, and answer all questions. 3. Administer the most painful vaccination first, and then alternate injection sites. 4. Refer to the vaccination as "baby shots" so the parent understands the baby will be receiving an injection.

2. Written information about the vaccine should always be given prior to any immunization administered as well as allowing time for questions.

24. Which would be the nurse's best response if a mother asks if her baby still needs the Hib vaccine because he already had Hib? 1. "Yes, it is recommended that the baby still get the Hib vaccine." 2. "No, if he has had Hib, he will not need to receive the vaccine." 3. "Let me take a nasal swab first; if it is negative, he will receive the Hib vaccine." 4. "The physician will order a blood test, and depending on results, your child may need the vaccine."

24. 1. The infant needs the Hib vaccine to ensure protection against many serious infections caused by Hib, such as bac terial meningitis, bacterial pneumonia, epiglottitis, septic arthritis, and sepsis.

43. Which would be the most appropriate intervention for a 4 year-old boy brought to the emergency department after ingesting a small watch battery? 1. No treatment would be needed; assess and monitor airway, breathing, circulation, and abdominal pain. 2. Ask the mother the time of the ingestion; if it was more than 2 hours ago, it will probably pass in his bowel movement. 3. Assess and monitor airway, breathing, circulation, and abdominal pain; anticipate admission and prepare for surgical intervention. 4. Discuss childproofing measures needed in the home with a 4-year-old child; provide anticipatory guidance concerning other possible poisonous ingestions.

3. Batteries are considered corrosives; the child will be admitted, and surgery may be necessary for removal.

1. The mother of a 21-day-old male tells the nurse she is residing in a homeless shelter and is concerned about his mild cough, poor appetite, low-grade fever, weight loss, and irritability over the last 2 weeks. Which nursing intervention would be the nurse's highest priority? 1. Weigh the baby to have an accurate weight using standard precautions. 2. Reassure the mother that the baby may only have a cold, which can last a few weeks. 3. Immediately initiate droplet face-mask precautions, and isolate the infant. 4. Take a rectal temperature while completing the assessment using standard precautions.

3. Children with tuberculosis may have a history of living in a crowded home or could be homeless. Other symptoms may include a cough, cold symptoms, low-grade fever, irritability, poor appetite, and exposure to a person with tuberculosis. Initiation of droplet precautions and isolation of the infant would be warranted in this situation.

33. Which would be the most appropriate discharge instructions for a child with a right wrist sprain 3 hours ago? 1. "You should rest, elevate the wrist above the heart, apply heat wrapped in a towel, and use the sling when walking." 2. "You can use the wrist, but stop if it hurts; elevate the wrist when not in use, and use the sling when walking." 3. "You should rest, apply ice wrapped in a towel, elevate the wrist above the heart, and use the sling when walking." 4. "You do not have to take any special precautions; do not use any movements that cause pain, and apply alternate heat and ice, each wrapped in a towel.

3. For the first 24 hours, rest, ice, compression, and elevation are recommended for acute injury. This is best remembered by the acronym RICE (rest, ice, compression, and elevation).

50. Which nursing plan would be most successful if the nurse has to administer activated charcoal to a 5-year-old boy? 1. Have his parents tell him he has to drink it while providing a movie to distract him. 2. Tell him it is candy, it tastes good, do not let him look at it, and tell him he will get a toy after he takes it all down. 3. Mix it with a sweetening flavoring, provide a straw, give in an opaque cup with a cover. 4. Have his mother take some first to show the boy it does not taste too bad, and then administer it to him quickly.

3. Mixing charcoal with a sweetening agent may help the child ingest it. Children usually like sweeter drinks. Hiding the black color in an opaque container with a lid may also make it more palatable.

12. Which treatment would the nurse anticipate for a 2-week-old boy diagnosed with PKU? 1. There is no treatment or special diet. 2. A high phenylalanine diet. 3. A low phenylalanine diet. 4. The mother would be advised not to breastfeed the infant.

3. PKU is inherited as an autosomalrecessive trait. The enzyme phenylalanine hydroxylase controlling the conversion of phenylalanine to tyrosine is missing. A low-phenylalanine diet is the treatment to prevent brain damage.

55. Which assessment of a 2-year-old with burns on his feet would cause suspicion of child abuse? 1. Splash marks on his right lower leg. 2. Burns noted on right arm. 3. Symmetrical burns on both feet. 4. Burns mainly noted on right foot.

3. Physical abuse has certain characteris tics. Symmetrical burns on both feet indicate abuse.

31. When discharging a newborn, which injury prevention instruction would be of highest priority to tell the parents? 1. "Place safety locks on all medicine cabinets and household cleaning supplies." 2. "Transport the infant in the front seat when driving alone so you can see the baby." 3. "Never leave the baby unattended on a raised, unguarded area." 4. "Place safety guards in front of any heating appliance, stove, fireplace, or radiator."

3. The highest priority in newborn injury prevention is to never leave the baby unattended on a raised, unguarded sur face. Involuntary reflexes may cause the infant to move and fall.

28. Which of the following would be the priority intervention for the newborn of a mother positive for hepatitis antigen? 1. The newborn should be given the first dose of hepatitis B vaccine by 2 months of age. 2. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. 3. The newborn should receive the hepatitis B vaccine and hepatitis B immune globulin within 24 hours of birth. 4. The newborn should receive hepatitis B immune globulin only within 12 hours of birth.

3. The newborn should receive both hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth to prevent hepatitis B infection.

29. Which instruction would be of highest priority for the mother of an infant receiving his first oral rotavirus vaccine? 1. "Call the physician if he develops fever or cough." 2. "Call the physician if he develops fever, redness, or swelling at the injection site." 3. "Call the physician if he develops a bloody stool or diarrhea." 4. "Call the physician if he develops constipation and irritability."

3. There is a very small incidence of in fants developing intussusception-bloody stool or diarrhea after receiving oral rotavirus vaccine.

32. A 10-month-old female is carried into the emergency department by her parents after she fell down 15 stairs in her walker. Which would be your highest priority nursing intervention? 1. Assess airway while simultaneously maintaining cervical spine precautions. 2. Assess airway, breathing, and circulation simultaneously. 3. Prepare for diagnostic radiological testing to check for any injuries. 4. Obtain venous access and draw blood for testing.

32. 1. Priority nursing intervention with pediatric trauma patients is airway assessment while maintaining cervical spine precautions. If the airway is com promised, immediate corrective action should be taken prior to assessment of breathing.

3. The nurse is assessing a 3-week-old with suspected bacterial meningitis. Isolation and respiratory precautions have already been initiated. Which clinical assessment by the nurse would warrant immediate intervention? 1. The neonate is irritable. 2. The neonate has a rectal temperature of 100.6° F (38.1°C). 3. The neonate is quieter than usual. 4. The neonate's respiratory rate is 24 breaths per minute.

4. A normal neonate's respiratory rate is 30 to 60 breaths per minute. Neonates' respiratory systems are immature, and the rate may initially double in response to illness. If no immediate interventions are begun when there is respiratory dis tress, a neonate's respiratory rate will slow down, develop worsening respira tory distress and, eventually, respiratory arrest. Neonates with slower or faster respiratory rates are true emergencies cases; they require identification of cause of distress.

38. Which would be the most appropriate teaching to the parents of a female child in the emergency department who is awake, alert, and has no respiratory distress after a near-drowning experience? 1. "She will most likely be discharged, and you should watch for any cough or trouble breathing." 2. "She will need to have a preventive tube for breathing and ventilation to ensure her lungs are clear." 3. "She will be fine but sometimes antibiotics are started as a preventive." 4. "She will most likely be admitted for at least 24 hours and observed for respiratory distress or any swelling of the brain."

4. Any child who has had a near-drowning experience should be admitted for observation. Even if a child does not appear to have any injury from the event, complications can occur within 24 hours after the event. Respiratory compromise and cerebral edema can be delayed complications.

14. Which teaching is most important for a child with PKU during a well-child visit? 1. The child is able to eat a quarter-pound hamburger and drink a milkshake daily. 2. If the child wants soda, diet soda is preferred over milk or dairy products. 3. The child may have ice cream in an unlimited quantity once a week. 4. Diet soda or anything with the sweetener aspartame should be avoided.

4. Artificial sweeteners such as aspartame are converted to phenylalanine in the body and should be avoided.

44. Which nursing intervention would be of highest priority for a 2-year-old suspected of ingestion of his grandmother's digoxin? 1. Provide supplemental oxygen. 2. Establish intravenous access. 3. Draw blood for a STAT digoxin level. 4. Provide continuous cardiac monitoring.

4. Bradycardia and cardiac dysrhythmias are common signs of digoxin toxicity in children. Continuous cardiac monitor ing is the highest priority to detect dys rhythmias before they became lethal.

18. Which of the following families would be appropriate to refer for genetic counseling? 1. Parents with macrosomic infant. 2. Parents with neonatal abstinence syndrome infant. 3. Couple with a history of planned abortions. 4. Couple with a history of multiple miscarriages.

4. Couples with a history of multiple miscarriages, stillbirths, or infertility should be referred for genetic counsel ing to try to determine the cause of their problems with maintaining a pregnancy.

5. A child is diagnosed with erythema infectiosum (fifth disease). You observe the mother crying, and she says, "I am afraid. Will my unborn baby die? I have a planned cesarian section next week." Which statement would be the most therapeutic response? 1. "Let me get the physician to come and talk with you." 2. "I understand. I would be afraid, too." 3. "Would you like me to call your obstetrician to have you seen as soon as possible?" 4. "I understand you are afraid. Can we can talk about your concerns?"

4. There is less risk of fetal death in the second half of the pregnancy. It is mor therapeutic to acknowledge a client's fears. After acknowledging her fears, the appropriate response would be to discuss concerns and clarify any misconceptions.

22. What would the most therapeutic response if the mother of a 6-month-old female tells the nurse she does not want her infant to have the DTaP vaccine because the infant had localized redness the last time she received the vaccine? 1. "I will let the physician know, and we will not administer the DTaP vaccination today." 2. "Every child has that allergic reaction, and your child will still get the DTaP today." 3. "I will let the physician know that you refuse further immunizations for your daughter." 4. "Would you mind if we discussed your concerns?"

4. This is the therapeutic response, dis cussing the mother's concerns about the immunizations and local reactions.

41. Which response about safety measures is the most appropriate advice to the 2-year old girl's mother who had her older home remodeled to reduce the lead level? 1. "Wash and dry the child's hands and face before eating." 2. "Remodeling the home to remove the lead is all you need to do." 3. "It is best to use hot water to prepare the child's food to decrease the lead." 4. "Diet does not matter in reducing lead levels in the child."

41. 1. Washing and drying hands and face, especially before eating, decrease lead ingestion.

46. Which of the following would be appropriate anticipatory guidance for a well-care visit of a 17-year-old? 1. Discuss alcohol use and potential for alcohol poisoning. 2. Discuss secondary sex characteristics that will develop. 3. Teach about anger management and safe sex. 4. Teach about peer pressure and desire for independence.

46. 1. Age- and developmentally appropriate anticipatory guidance teachings for a 17-year-old are to discuss alcohol use and potential for alcohol poisoning.

8. Which signs and symptoms would the nurse expect to assess in a child with rheumatic fever? 1. Joint pain in ankles and knees. 2. Negative group A beta streptococcal culture. 3. Large red "bulls eye"-appearing rash. 4. Stiff neck with photophobia.

8. 1. Joint pain or arthritis is the most com mon symptom of acute rheumatic fever (60% to 80% of first attacks). The joint pain usually occurs in two or more large joints (ankle, knee, wrist, or elbow).