Pediatric Test 3
19. Which pediatric client diagnoses necessitate close monitoring for respiratory acidosis? (Select all that apply) 1. Aspiration 2. Epiglottis 3. Sepsis 4. Meningitis 5. Cystic Fibrosis
1,2,5
At delivery, it was discovered that the newborn had a bilateral cleft lip. The parents are distressed about the appearance of their infant. Nursing behaviors that can help the parents bond to the infant include: Standard Text: Select all that apply. 1. Calling the infant by name when referring to the infant. 2. Keeping the infant's lower face covered with the blanket. 3. Smiling at the infant and talking to the infant in the parents' presence. 4. Showing the parents before and after pictures of other children with cleft lips. 5. Discussing positive features of their baby.
1,3,4,5
The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newborn indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction. The nurse will monitor the infant for signs of neonatal abstinence syndrome, including: Standard Text: Select all that apply. 1. Poor feeding. 2. Difficult to arouse. 3. Constipation. 4. Seizures. 5. Yawning.
1,4,5
1. A four-year-old child is admitted to the hospital secondary to dehydration. Lab tests indicate a high hemoglobin and hematocrit, and the serum sodium is below normal levels. This fluid loss is indicative of which condition? 1. Hypernatremia 2. Metabolic acidosis 3. Hypotonic dehydration 4. Isotonic dehydration
.Rationale 3: This occurs when fluid loss is characterized by a proportionately greater loss of sodium than water. Serum sodium is below normal levels. Hemoglobin and hematocrit will be high due to the loss of serum water.
In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to: Standard Text: Select all that apply. 1. Expect the child to have normal intelligence. 2. Use latex precautions. 3. Allow the child to do her own self-catheterization. 4. Ensure that the child has a low-fiber diet. 5. Encourage the child to shift positions hourly when in her wheelchair.
1,2,3,5
15. A nine-month-old infant is hospitalized with vomiting and diarrhea. The mother questions why her child needed hospitalization since her school-age nephew had the same symptoms and was treated at home. The nurse would explain that an infant is more at risk for dehydration than a school-age child because: Standard Text: Select all that apply. 1. Infants have a lower proportion of their body weight as water. 2. The percentage of extra-cellular fluid is higher in the infant than the school-age child. 3. School-age children have a larger body surface area. 4. The school-age child's kidneys are more mature and better able to conserve water. 5. The metabolic rate of the school-age child is higher.
2, 4
Following diagnosis of Crohn's disease, the nurse is explaining dietary modifications to the teenagers. The nurse would recommend: Standard Text: Select all that apply. 1. Increased fiber in the diet to promote solid stools. 2. Small, frequent feedings are preferred over three meals a day. 3. Identify foods that cause distress and eliminate them from the diet. 4. High-calorie dietary supplement shakes can help meet nutritional requirements. 5. Socialization is important at mealtime no matter the dynamics.
2,3,4
17. Which rationale will the seasoned nurse share with the novice nurse regarding why the specific gravity for infants is lower than for older children? 1. The infant has a greater body surface area. 2. The infant has a higher metabolic rate 3. The has a greater percentage of body weight that is water 4. The infants kidneys are less able to concentrate urine
4
The mother brings her five-month-old infant to the clinic for a well-child visit. The mother tells the nurse that the baby's father had febrile seizures when he was an infant. The mother says she is concerned her baby will have a febrile seizure and wants to know what she should do to prevent it. The nurse explains: Standard Text: Select all that apply. 1. That the baby has no more risk of febrile seizures than any other baby. 2. When the infant has a fever, the mother should give the baby dose-appropriate aspirin. 3. That the baby should be sponged with cold water. 4. The mother should increase the child's fluid intake. 5. That after the tepid bath, the child should be patted dry.
4,5
13. The nurse is completing the intake and output record for a child admitted for fluid volume deficit. The child has had the following intake and output during shift: Intake 4 oz pedialyte One half an 8 oz cup of clear orange hello Two graham crackers Blah
440 mL
10. The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid should the nurse anticipate the doctor to order initially to replace fluids? 1. 0.9% normal saline (NS) 2. D5 0.2% (¼) normal saline 3. D5W 4. Albumin
Rationale 1: 0.9% normal saline (NS) is an isotonic fluid and maintains Na and chloride at present levels.
7. A nurse is planning care for a child with hyponatremia. The nurse, delegating care of this child to a licensed vocational nurse (LVN), cautions the LVN to watch for which clinical manifestation? 1. Seizures 2. Respiratory distress 3. Hyperthermia 4. Bradycardia
Rationale 1: A child with hyponatremia is at risk for seizures.
5. In the morning, a nurse receives a report on four pediatric clients, each of whom has some form of fluid-volume excess. Which of the children should the nurse see first? 1. The child with tachypnea and pulmonary congestion 2. The child with hepatomegaly and normal respiratory rate 3. The child with dependent and sacral edema and regular pulse 4. The child with periorbital edema and normal respiratory rate
Rationale 1: A child with respiratory distress should be the first client the nurse checks after receiving a report.
16. As a result of opioid administration, a child's respirations are slow and shallow. The nurse would expect that lab changes that might be noted in response to the changes in the child's uncompensated respiratory pattern would include: 1. Increased PCO2 and respiratory acidosis. 2. Decreased PCO2 and respiratory alkalosis. 3. Low pH and low PCO2. 4. High pH and high PCO2.
Rationale 1: Due to inadequate respirations, the child retains CO2 and develops respiratory acidosis.
12. A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give? 1. Furosemide (Lasix) 2. Hydrochlorothiazide (Aquazide) 3. Spironolactone (Aldactone) 4. Mannitol (Osmitrol)
Rationale 1: Furosemide (Lasix) is the diuretic used to aid in excretion of calcium.
A nine-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? 1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia
Rationale 1: Hypotonia in infancy and muscle instability are seen in ataxic cerebral palsy.
The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis? 1. Impaired gas exchange 2. Infection, risk for 3. Anxiety (parental) 4. Acute pain
Rationale 1: Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange.
A woman pregnant at term arrives at the small rural hospital in active labor. She has received no prenatal care. At delivery, it is discovered that the newborn has a gastroschisis defect. Immediate transfer to a pediatric hospital is planned. Nursing care to prepare the infant for discharge would include: 1. Covering the exposed intestines with sterile moist gauze. 2. Wrapping the infant warmly in two or three blankets. 3. Providing a sterile water feeding to maintain hydration during transport. 4. Preventing the parents from seeing the infant prior to transfer to reduce their anxiety.
Rationale 1: It is important to keep the intestine from drying during transport.
An infant born with an omphalocele defect is being admitted to the intensive care nursery. Which of the following should the nurse in charge instruct the nursing technician to prepare? 1. Radiant warmer 2. Crib 3. Bilirubin light 4. Formula for feeding
Rationale 1: Omphalocele is a congenital malformation in which intra-abdominal contents herniate through the umbilical cord. The infant loses heat through the viscera; a warmer is indicated to prevent hypothermia.
A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for: 1. Periorbital ecchymosis. 2. Subdural hematoma. 3. Protruding bone. 4. Epidural hematoma.
Rationale 1: Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture.
11. A six-year-old child is hypokalemic. The nurse is helping the child complete the menu. The nurse would encourage this child to select which menu items? 1. Pizza with a fruit plate 2. Chicken strips with chips 3. Fajita with rice 4. A hamburger with French fries
Rationale 1: Pizza with a fruit plate should be encouraged because fruit (bananas, apricots, cantaloupe, cherries, peaches, and strawberries) have high amounts of potassium, and a child is likely to eat this combination.
The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician's order would the nurse question? 1. Passive range-of-motion exercises 2. Oxygen at 2L nasal cannula to keep saturation above 95% 3. Hourly vital signs and neuro checks 4. Elevate head of bed 30 degrees
Rationale 1: Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible.
6. The nurse is caring for a child on bed rest who has severe edema in a left lower leg due to blocked lymphatic drainage. Which nursing diagnosis would take priority? 1. Risk for impaired skin integrity 2. Risk for altered body image 3. Risk for imbalanced nutrition: less than body requirements 4. Risk for activity intolerance
Rationale 1: The highest-priority problem is skin integrity.
The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal? 1. The posterior fontanel is open. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft.
Rationale 1: The posterior fontanel closes between two and three months of age.
Following an outbreak of chicken pox in the school, the school nurse is concerned that children are at risk for Reye syndrome. The nurse sends home letters reminding the parents not to administer aspirin and describes the initial symptoms of Reye syndrome which are: 1. Nausea, vomiting, and confusion. 2. Headache, vomiting, and seizures. 3. Sore throat, moist respirations, and cough. 4. Fever, rash, and photophobia.
Rationale 1: These are the early symptoms of Reye syndrome.
The woman has a normal pregnancy except for polyhydramnios. The delivery goes well and the baby is born and receives APGAR scores of seven and nine. Upon admission to the newborn nursery, the nurse is unsuccessful in inserting a nasogastric tube. The infant is suspected of having an esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, the nurse should: 1. Position the infant in semi-Fowler position. 2. Allow the infant to be taken to the mother's room for bonding. 3. Offer the infant formula feeding instead of breastfeeding. 4. Wrap the infant in blankets and place in a crib by the viewing window.
Rationale 1: This will reduce stomach juices from being aspirated into the lungs.
When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? 1. The mother leaves the filled mop bucket on the floor while in another room. 2. The mother turns all pan handles to the back of the stove. 3. The mother fills the bath tub before bringing the baby into the bathroom. 4. When riding in a car, the child is in a car seat in the middle of the back seat.
Rationale 1: Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in head first. Because of mobility limitations, the child may not be able to get out of the bucket without help.
An adolescent complains of recurrent abdominal pain with diarrhea and bloody stools. The nurse should recognize these as symptoms of which inflammatory bowel disease? 1. Necrotizing enterocolitis 2. Ulcerative colitis 3. Crohn's disease 4. Appendicitis
Rationale 2: Diarrhea and bloody stools are typical symptoms of UC.
Which statement indicates that parents have understood the nurse's teaching with regard to colostomy stoma care for their toddler? 1. "We will change the colostomy bag with each wet diaper." 2. "We will expect a moderate amount of bleeding after cleansing the area around the stoma." 3. "We will watch for skin irritation around the stoma." 4. "We will use adhesive enhancers when we change the bag."
Rationale 3: Skin irritation around the stoma should be assessed; it could indicate leakage.
14. A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg and is estimated to have lost 7% of his normal body weight. The nurse is double-checking the IV rate the physician has ordered. The formula the physician used was for maintenance fluids: 1,000 mL for 10 kg of body weight plus 50 cc for every kg over 10 for 24 hours. Replacement fluid is the percentage of lost bodyweight × 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, what should this child's hourly IV rate for 24 hours be? 1. 88 2. 86 3. 81 4. 83
Rationale 2: Maintenance need for 13 kg is 1,000 + (50 [×] 3), or 1,150 mL/24 hours. Add to this the replacement fluid loss = 7 (% of total body weight lost) × 10 = 70 mL/kg/24 hours (70 × 13 = 910). 1,150 + 910 = 2,060 for 24 hours. 2,060/24 = 86 cc per hour.
4. The nurse is assessing an infant brought to the clinic because of diarrhea. The infant is alert but has dry mucous membranes. Which other sign indicates the infant is still in the early to moderate stage of dehydration? 1. Bradycardia 2. Tachycardia 3. Increased blood pressure 4. Normal fontanels
Rationale 2: Tachycardia is a sign that indicates moderate dehydration.
A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: 1. A sign that this child has a spinal cord injury. 2. A sign of increased intracranial pressure. 3. Typical for a sleeping child at this age. 4. A sign that the child's condition is improving.
Rationale 2: These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure.
The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child has been put on valproic acid (Depakote) for control of seizures. The nurse knows that the mother does not understand the effects of valproic acid when she states: 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician office for regular blood work to check bleeding times."
Rationale 2: Valproic acid (Depakote) should be given with foods to decrease GI irritation.
A nasogastric tube to suction is ordered for a child newly diagnosed with a diaphragmatic hernia. The nurse notes that the surgeon has not ordered fluid replacement for the NG drainage. What might occur if large amounts of gastric drainage are noted without replacement? 1. The infant may lose weight due to loss of nutrition. 2. The infant will develop metabolic alkalosis. 3. The infant will become dehydrated. 4. The infant will develop hyperbilirubinemia.
Rationale 2: When large quantities of gastric juice is removed, acid is lost and metabolic alkalosis follows.
3. The nurse has just finished a parent teaching session on preventing heat-related illnesses for children who exercise. Which statement by a parent indicates understanding of preventive techniques taught? 1. Wearing dark clothing during exercise is recommended 2. Water is the drink of choice to replenish fluids. 3. During activity, stop for fluids every 15 to 20 minutes. 4. Hydration should occur at the end of an exercise session.
Rationale 3: During activity, stopping for fluids every 15 to 20 minutes is recommended.
The nurse is teaching the kindergarten teacher about a five-year-old with cerebral palsy who will be starting school. The child has a continuous baclofen pump. The nurse informs the teacher of possible side effects of this drug, including: 1. Diarrhea. 2. Hypertonia. 3. Hypotonia. 4. Restlessness.
Rationale 3: Hypotonia is possible if the child is getting too much baclofen.
9. A child with croup has an increased pCO2, a decreased pH, and a normal HCO3 blood gas value. The nurse interprets this as uncompensated: 1. Metabolic alkalosis. 2. Metabolic acidosis. 3. Respiratory acidosis. 4. Respiratory alkalosis.
Rationale 3: If the pH is decreased and the pCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Also, croup can be a disease process that causes respiratory acidosis.
Following hospital discharge for treatment of gastroesophageal reflux, the home health nurse visits the family. Which finding made by the nurse during the visit requires the nurse to intervene? 1. The infant's formula has rice cereal added. 2. The mother hold the infant is a high Fowler's position while feeding. 3. After feeding, the infant is placed in an infant seat. 4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.
Rationale 3: Infant seats are not recommended as they put pressure on the abdomen and may contribute to regurgitation.
The nurse is planning postoperative care for an infant after a cleft lip repair. Which intervention should the nurse include in this infant's plan of care? 1. Suctioning with a tonsil tip (Yankauer) device 2. Using a pacifier to reduce straining the suture line with crying 3. Supine positioning 4. Frequent breast or bottle feeding
Rationale 3: Integrity of the suture line is essential for postoperative care of cleft lip repair. The infant should be placed in a supine position to avoid rubbing the suture line on the bedding.
A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which nursing intervention would the nurse omit from the plan of care for this child? 1. NPO status until bowel sounds return 2. Frequent assessment of the surgical site 3. Avoiding narcotics to prevent depression of the respiratory system 4. Allow parents at the bedside as soon as possible.
Rationale 3: Pain management is essential and narcotic medications will be used. The nurse will monitor the respiratory status, but it is inappropriate to withhold pain management.
A toddler is admitted to the surgical unit for planned closure of the temporary colostomy. The nurse completes the admission assessment and reviews the medical orders. Which order should the nurse question? 1. Clear liquids today. NPO tomorrow 2. Type and cross-match for one unit of packed red blood cells. 3. Rectal temperatures every four hours 4. Start an intravenous line with D5NS at 20 ml per hour.
Rationale 3: Rectal temperatures are avoided due to the fragile state of the rectum.
The nurse who works in the newborn nursery must be alert for infants with congenital gastrointestinal defects. Defects that might be diagnosed in the newborn nursery would include: Standard Text: Select all that apply. 1. Pyloric stenosis. 2. Biliary atresia. 3. Hirschsprung's disease. 4. Umbilical hernia. 5. Diaphragmatic hernia.
Rationale 3: Symptoms of Hirschsprung's disease may be observable in the newborn nursery. Rationale 5: Diaphragmatic hernia will show symptoms immediately after birth due to compression of the lung.
The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question? 1. Vital signs and neuro checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference
Rationale 3: The nine-month-old should be placed in a flat position so that CSF drainage is not too rapid.
A three-year-old child is suspected of having Hirschsprung's disease. Which assessment factors would support such a medical diagnosis? 1. Clay-colored stools and dark urine 2. History of early passage of meconium in the newborn period 3. History of chronic, progressive constipation and failure to gain weight 4. Continual bouts of foul-smelling diarrhea
Rationale 3: These are symptoms of Hirschsprung's disease in an older infant or child.
8. A nurse is planning care for a child with hyperkalemia. The nurse explains to the parents that an adverse outcome of hyperkalemia is: 1. Hyperthermia 2. Respiratory distress 3. Seizures 4. Cardiac arrhythmias
Rationale 4: A child with hyperkalemia is at risk for cardiac problems that can be life-threatening, such as arrhythmias.
A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse prepare for use? 1. Appropriate bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Equipment for intubation
Rationale 4: A diaphragmatic hernia (protrusion of abdominal contents into the chest cavity through a defect in the diaphragm) is a life-threatening condition. Intubation is required immediately so that the newborn's respiratory status can be stabilized.
The nurse is preparing to ambulate an 11-year-old child who has had an appendectomy. In addition to pharmacological pain management, which of the following nonpharmacologic, independent nursing pain management strategies would be appropriate for this child? 1. A warm, moist pack 2. EMLA cream to the incision site 3. An ice pack 4. A splint pillow against the abdomen when moving or coughing
Rationale 4: A splint pillow placed on the abdomen is a nonpharmacologic strategy to decrease discomfort after an appendectomy.
The teacher is speaking to the school nurse about one of the girls in the fifth grade. The girl has always been a good student but lately seems to be daydreaming a lot. The teacher says, "Sometimes when I ask her a question, she will just stare at me for 15 seconds, then blink and ask me to repeat the question. What do you think is going on with her?" Based on this data, the nurse will suspect: 1. The girl has a crush on a boy in the class. 2. The girl has increased intracranial pressure. 3. The child may have had a head injury. 4. The girl is experiencing absence seizures.
Rationale 4: Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher.
A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse's initial action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurological assessment. 4. Maintain patent airway.
Rationale 4: Airway is always the priority of care.
The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth. 1. Below the umbilicus 2. Just below the sternum 3. Just above the pubic bone 4. Just above the umbilicus, around the largest circumference of the abdomen
Rationale 4: An abdominal girth should be taken around the largest circumference of the abdomen, just above the umbilicus.
18. The nurse is evaluating an infant for dehydration. Which assessment provides the most accurate information on dehydration? 1. Urine output 2. Urine specific gravity 3. The infant's vital signs 4. Weight loss
Rationale 4: Daily weights on an infant provide the most accurate assessment of fluid balance.
A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show: 1. Decreased protein count. 2. Clear, straw-colored fluid. 3. Positive for RBCs. 4. Decreased glucose level.
Rationale 4: Glucose levels are low in CSF when a child has bacterial meningitis.
A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include: 1. Appendicitis. 2. Bowel obstruction. 3. Urinary tract infection. 4. Kidney stones.
Rationale 4: Kidney stones are seen in 5% of children on a ketogenic diet.
A child with inflammatory bowel disease is taking prednisone daily. The family should be taught to administer the prednisone at what time? 1. Between meals 2. At bedtime 3. One hour before meals 4. With meals
Rationale 4: Prednisone, a corticosteroid, can cause gastric irritation. It should be administered with meals to reduce the gastric irritation.
A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes: 1. Applying a diaper to prevent contamination of sac. 2. Positioning the newborn in a side-lying position. 3. Encouraging the mother to hold the newborn, because she will not be able to pick him up after surgery. 4. Positioning the newborn in a prone position.
Rationale 4: The newborn should be placed in a prone position to keep pressure off the sac.
2. A nurse is taking care of four different pediatric clients. Which of the following children is at greatest risk for dehydration? 1. Seven-year-old child with migraine headaches 2. Four-year-old child with a broken arm 3. Two-year-old child with cellulitis of the left leg 4. 18-month-old child with tachypnea
Rationale 4: The pediatric client with the greatest risk is under two years of age and with a condition that increases insensible fluid loss.
An infant has been born with an esophageal atresia and tracheoesophageal fistula. What is a priority preoperative nursing diagnosis? 1. Ineffective tissue perfusion: gastrointestinal, related to decreased circulation 2. Ineffective infant feeding pattern related to uncoordinated suck and swallow 3. Acute pain related to esophageal defect 4. Aspiration, risk for related to regurgitation
Rationale 4: This is the most common type of esophageal atresia and tracheoesophageal fistula, where the upper segment of the esophagus ends in a blind pouch and a fistula connects the lower segment to the trachea. Preoperatively, there is a risk of aspiration of gastric secretions from the stomach into the trachea because of the fistula that connects the lower segment of the esophagus to the trachea.
17. The nurse notes that the specific gravity of urine is lower in infants than in older children. The nurse recognizes that the rationale for this difference is related to: 1. The infant having a greater body surface area. 2. The infant having a higher basal metabolic rate. 3. The infant having a greater percentage of body weight that is water. 4. The infant's kidneys being less able to concentrate urine.
Rationale 4: This statement is accurate and explains why the specific gravity of the infant's urine is closer to water than an older child's urine specific gravity.