peds exam 1
The nurse is caring for several clients on the pediatric unit. When interacting with the preschool-age child, which action does the nurse predict will occur?
Takes in new information at a rapid rate and asks "why" and "how" Explanation: The preschool-aged child soaks in information and asks "why" and "how" over and over. The school-aged child has a longer attention span and can become absorbed in a craft or activity for several hours. The toddler insists he or she can do things one minute and then becomes dependent the next minute. The infant grows and develops skills more rapidly than he or she ever will again.
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply.
The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. Explanation: Most subjective data are collected through interviewing the family caregiver and the child. Subjective is the data collected from another source or data that the nurse can not assess, such as pain.
(Weight in pounds X 703) ÷ (height in inches X height in inches)
formula for bmi
The nurse is providing anticipatory guidance to a parent of an 8-year-old girl whose weight is 65 lb (29.5 kg) and height is 50.5 in (128.3 cm). Which statement by the parent demonstrates the need for further teaching?
"Based on my child's weight and height, I should be concerned my child is overweight." Explanation: An 8-year-old girl needs between 1400 and 1600 calories per day. Based on the child's weight and height, the child has a body mass index (BMI) of 17.9 (around 75th percentile). To calculate BMI use [wt in lb/{ht in inches}x{ht in inches}] x703. This child is not in the overweight or obese category (>85th percentile is classified as overweight). An 8-year-old needs 1000 mg calcium per day. Children should be encouraged to make half of their of plate fruits and vegetables, to make half of their grains whole grains, and to choose lean proteins and calcium-rich foods.
The mother of a newborn reports she does not think her baby likes his formula since he spits up after only taking a small amount. Which response by the nurse is most appropriate?
"Your baby's stomach is small and can only hold about 0.5 to 1 oz at birth." Explanation: At the time of birth, an infant's stomach can only hold 0.5 to 1 oz ounce. This will gradually increase. While it is true that the infant does not eat much, this does not meet the educational needs of the mother and is not the best response. Burping is a part of normal newborn feeding practices but is not the best response. There is no indication there is a milk intolerance from the information reported
The nurse is caring for an 18-month-old child who has had surgery. The medical record indicates the child weighs 23 pounds (10.45 kg). When monitoring his urinary output the nurse is aware that normal hourly output should be what value?
10 ml/hr Explanation: The normal urinary output for a toddler is approximately 1 ml/kg/hr. This child weighs 23 pounds. This is 10.45 kg. This is approximately 10 ml/hr.
By what age should the child know his/her own gender?
3 years Explanation: Toddlers observe differences in both male and female body parts. They question their parents about the differences. By 3 years of age, toddlers can say their name, their age and their gender. This age group begins to understand and mimic social gender differences. A 1-year-old or 2-year-old child would be too young to make this distinction because these children are just identifying their own body parts. By 4 years of age the child should be able to identify body parts. If not, there may be some delay with the child.
The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation?
A bubble behind the tympanic membrane Explanation: A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation
A hospitalized 7-year-old is recovering from a head injury. Occupational therapy has been ordered to assist the child in regaining eye/hand coordination. If the child cannot master this skill, what feelings may arise?
A feeling of inferiority Explanation: Children who are unsuccessful in completing activities during the school-age phase, whether from physical, social, or cognitive disadvantages, develop a feeling of inferiority.
The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take?
Demonstrate the appropriate technique. Explanation: A cremasteric reflex is elicited by stroking the medial aspect of the thigh in boys. With this, the testes move perceptibly upward. The presence of this reflex indicates integrity of the first and second lumbar nerves. Abdominal reflexes should be assessed in both sexes. An abdominal reflex is elicited by lightly stroking each quadrant of the abdomen. Normally, the umbilicus moves perceptibly toward the stroke. Presence of this reflex indicates integrity of the 10th thoracic nerve and the first lumbar nerve of the spinal cord.
Johnny exhibits the following growth pattern. Which interpretation of the data is accurate? Select all that apply. 3 yrs: Ht. 37 inches Wt. 32 pounds 4 yrs: Ht. 39 inches Wt. 39 pounds 5 yrs: Ht. 40 inches Wt. 46 pounds
Johnny is growing slowly in height but rapidly in weight. Johnny may be at risk for overweight or obesity. Johnny's height and weight should be plotted on a growth chart. Explanation: The preschool child's growth is fairly even. The child should grow about 2½ to 3 inches and gain around 5 pounds yearly. Johnny is not following this pattern. Plotting the child's height and weight on a growth chart would make it visually easy to follow his growth pattern and compare it to the norms.
A nurse is testing a client for strabismus and amblyopia using the cover-uncover test. Which is the likely developmental age of the client?
Preschool-age child Explanation: The cover-uncover test is reliable for assessing strabismus in children older than 2 years. One can test the corneal light reflex in children older from age 6 months to 24 months, but it is not reliable. If testing is not done until school age, a vision loss may have occurred.
A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate?
School age Explanation: Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.
To be able to cooperate in toilet training, the child's anal and urethral sphincter muscles must have developed to the stage where the child can control them. Control of the anal sphincter usually develops first. The child also must be able to postpone the urge to defecate or urinate until reaching the toilet or potty and must be able to signal the need before the event. In addition, before toilet training can occur, the child must have a desire to please the caregiver by holding feces and urine rather than satisfying his/her own immediate need for gratification. This level of maturation seldom takes place before the age of 18 to 24 months.
The mother of a 15-month-old son is returning to work and wants to place her son in the day care close to work; however, they will only accept potty-trained children. Which response from the nurse will best address this situation in answering the mother's questions of how best to potty train her son? You Selected: "Wait a few more months until your son has more muscle control and shows signs that he's ready to be potty trained."
The father of a 15-year-old daughter is concerned she is not getting adequate nutrition to play high school basketball. Her games are on Friday nights. Which suggestion should the nurse point out will best suit the needs of this adolescent?
Three daily meals that include choices from each of the food groups; Friday's lunch eaten around 2 p.m. with a small amount of fat and a somewhat larger than usual portion of complex carbohydrates. Explanation: A meal that is low in fat and high in complex carbohydrates, eaten 3 to 4 hours before an event, is appropriate for the teen athlete. Carbohydrate-loading, which some practice during the week before an athletic event, increases the muscle glycogen level to 2 to 3 times normal and may hinder heart function. The other suggested menus would not provide the additional muscle glycogen needed for optimal functioning.
The nurse is assessing a 6-year-old child. The nurse instructs the child, "Let me see all of your pretty white teeth." Which cranial nerve is the nurse assessing?
VII Explanation: The nurse is testing if cranial nerve VII was intact. The cranial nerve VII is the facial nerve and can be assessed by asking to see a child's teeth, having them smile, or lift an eyebrow. In infants facial symmetry would be assessed. Cranial nerve II is assessed by testing visual fields and visual acuity. Cranial nerve IV is tested by having the child move eyes downward and inward. Cranial nerve VI is assessed by checking for the ability of the eyes to move laterally.
A nursing instructor is teaching students how to assess a newborn and emphasizes the importance of taking femoral pulses. Doing so will help to rule out which condition?
coarctation of the aorta Explanation: When performing an assessment on a newborn, it is important to assess the femoral pulse to rule out coarctation of the aorta. The narrowing, or coarctation, of the aorta causes blood to flow to the upper part of the body but not the lower part. The upper half of the body is warm and perfused while the lower is cool and pale. This diagnosis can also be ascertained by B/P readings. If the reading is lower in the leg than the arm then coarctation should be considered. Hypotension would be determined by B/P measurement, not palpating a pulse. Peripheral disease can be arterial or venous in nature. These would be assessed either from the popliteal or dorsal pulses. Pulmonary hypertension is high B/P in the arteries of the lungs. It could not be determined by palpating a peripheral pulse
The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action?
heart rate of 120 beats per minute Explanation: The normal range for heart rate for a preschooler is between 65 and 110 beats per minute. The normal range for respiratory rate for a preschooler is between 20 and 25 breaths per minute.
A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe?
redness of the cheeks and lips Explanation: Plethora is used to describe redness of the skin, especially the cheeks and lips. Cyanosis refers to the bluish discoloration of the skin and mucous membranes. Macules are round flat lesions. Ecchymoses are large, diffuse areas of black and blue color.
The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark?
salmon nevus Explanation: A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.
School age Explanation: Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.
testicular enlargement Explanation: The first sign of pubertal changes in boys is testicular enlargement in response to testosterone secretion, usually occurring in Tanner stage 2. As testosterone levels increase, the penis and scrotum enlarge, hair distribution increases, and scrotal skin texture changes.
The nurse is caring for a 4-year-old girl following an appendectomy. The girl becomes fearful and starts to cry as soon as the nurse walks into the room. When the nurse asks about the crying, the girl says, "Nurses who wear shirts with flowers give shots." The nurse understands that this statement is an example of:
transduction. Explanation: The nurse identifies transduction. Because the 4-year-old recently received an injection from a nurse in a flowered uniform, the girl believes that all nurses who wear flowered uniforms give shots. Transduction is reasoning by viewing one situation as the basis for another situation even though the two may or may not be causally linked. Magical thinking involves believing that one's thoughts are all-powerful. Animism is attributing life-like characteristics to inanimate objects. Empathy is the understanding of others' feelings.
The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately?
visible peristaltic waves Explanation: Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age.
If the child is gaining weight at an expected rate, a child who weighs 36 lb (16.3 kg) at 3 years of age would weigh what amount at age 5?
44 to 46 lb (20 to 21 kg) Explanation: The preschool age child gains about 4 to 5 lb (1.8 to 2.3 kg) each year and grows about 2.5 to 3 in (6.3 to 7.6 cm). So a 36 lb (16.3 kg) child at 3 years gaining 4 to 5 lb (1.8 to 2.3 kg) per year would be 44 to 46 lb (36 lb + 8 lb = 44 lb; 36 lb + 10 lb = 46 lb).
The nurse is about to see a 9-year-old girl for a well-child checkup. Knowing that the child is in Piaget's period of concrete operational thought, which characteristic should the child display?
Consider an action and its consequences. Explanation: The child will be able to consider an action and its consequences in Piaget's period of concrete operational thought. However, she is now able to empathize with others. She is more adept at classifying and dividing things into sets. Defining lying as bad because she gets punished for it is a Kohlberg characteristic
The nurse finds the diet of a 30-month-old girl to be low in calcium. What suggestion can significantly increase this toddler's calcium intake?
Give her slices of cheddar cheese as a snack. Explanation: Two and one-half ounces of cheddar cheese provides the toddler's daily requirement of 500 mg of calcium. Chocolate milk provides calcium but the sugar it contains should not be a regular part of a toddler diet. Applesauce provides fiber, not calcium. Spinach and dark greens do contain calcium, but that calcium has limited bioavailability.
The nurse is assessing the vital signs of several toddlers in the pediatric medical unit. Which findings are of most concern to the nurse?
Heart rate 60 beats per minute; respiratory rate 14 breaths per minute Explanation: The normal heart rate for a toddler ranges between 90 and 140 beats per minute and the respiratory rate ranges between 20 to 37 respirations per minute. A heart rate 60 beats per minute and respiratory rate 14 breaths per minute are both below the normal range for toddler.
The infant measures 21.5 in (54.6 cm) at birth. If the infant is following a normal pattern of growth, what would be an expected height for the infant at the age of 6 months?
Infants gain about 0.5 to 1 in (1.25 to 2.5 cm) in length for each of the first 6 months of life. Therefore, a 21.5-in (54.6-cm) infant adding 6 in (15 cm) of growth would be 27.5 in (70 cm). Infants grow the fastest during the first 6 months of life and slow down the second 6 months. By 12 months of age, the infant's length has increased by 50%, making this infant 32 in (81 cm) at 1 year old.
Which gross motor skill would the 4-year-old child have most recently attained?
The child can hop on one foot. Explanation: Gross and fine motor skills continue to develop rapidly in the preschool-aged child. Gross motor skills have to do with the development of large muscles. Balance improves around the age of 4, thus the child can hop on one foot and stand on one foot for 5 seconds. A 3-year-old child does not have the ability to accomplish these tasks. A 5-year-old child can button his/her own clothes, tie shoes, and cut his/her food.
The nurse is performing an assessment on a teen's clavicle strength. The teen is asked to shrug and raise the shoulders while the nurse applies gentle pressure to them. When documenting the findings, this should be identified as an assessment of which cranial nerve?
cranial nerve XI Explanation: Test shoulder strength and the function of cranial nerve XI in the older child by requesting that the child shrug the shoulders while you apply downward pressure. Cranial nerve VII is responsible for the tongue and facial movements. Cranial nerve IX is responsible for swallowing and salivation. Cranial nerve X is responsible for speech and swallowing.
A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction?
down and back Explanation: The nurse should pull the pinna of the ear down and back for a child younger than age 3 years to help straighten the ear canal. For a child older than age 3 years, the pinna is pulled up and back.
The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?
Between the sternum and the left nipple Explanation: When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum. The other locations will not assist with localizing over the apex of the heart.
The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse?
It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally." Explanation: Light pink macule typically found on the eyelids, nasal bridge, or back of neck are called salmon nevi (or, more commonly, "stork bites"). They usually fade over time, but may never go away completely. An infantile (strawberry) hemangioma is a raised reddish papule made of blood vessels. They recede over time, usually by age 9 years. A nevus flammeus is a dark purple-red flat patch and grows with the child. It is more commonly known as a port-wine stain. Ecchymosis is a purplish discoloration that is more commonly known as a bruise.
During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition?
meningeal irritation Explanation: A positive Kernig and Brudzinski sign are indicative a meningeal irritation and are not associated with auditory or visual problems or heart murmurs.
The nurse is conducting a well-child assessment of a 4-year-old. Which assessment finding warrants further investigation?
presence of 10 deciduous teeth Explanation: The presence of only 10 deciduous teeth would warrant further investigation. The preschooler should have 20 deciduous teeth present. The absence of dental caries or presence of 19 teeth does not warrant further investigation.
The nurse is assessing an infant at the 6-month well-baby check-up. The nurse notes that at birth the baby weighed 8 lb (3600 g) and was 20 in (50.8 cm) in length. Which finding is consistent with the normal infant growth and development?
weight of 16 lb (7300 g) and length of 26 in (66.0 cm) Explanation: The average newborn weighs 7.5 lb (3400 kg) at birth. Most infants double their birth weight at 4 to 5 months and will triple by the time they are 1 year old. If this infant was 8 lb (3600 kg) at birth, then it is most likely now 16 lb (7300 g). The average newborn is 20 in (50 cm) long at birth. They grow more quickly in length over the first 6 months, than during the second 6 months. By 12 months of age, the infant's length has increase by 50%. At 1 year, this infant will most likely be 30 in (76.2 cm) in length; however, since most of the growth occurs in the first 6 months, it is possible for the infant to grow an additional 6 in (15 cm) during that time.
