PEDS HESI ULTIMA

During the admission procedure of a 6-year-old, the child states, "I'm going to have an operation." Which response is best for the nurse to provide to this child? • "We're going to do everything we can to take very good care of you." • "Tell me what an operation is." • "Are you scared?" • "I'm glad your mother told you why you were coming to the hospital."

"Tell me what an operation is."

An adolescent who is taking antiretroviral therapy for HIV infection arrives at the clinic for a follow up visit. Which information is most important for the nurse to obtain? - Missed medication doses - A 24-hour dietary recall - Barrier contraceptive use - Ingestion of illicit drugs

- Missed medication doses

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? - Reduce peripheral tissue hypoxia and nailbed clubbing. - Stop the flow unoxygenated blood into systemic circulation. - Increase the flow of unoxygenated blood to the lungs. - Prevent the return of oxygenated blood the lungs.

- Prevent the return of oxygenated blood the lungs.

The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer?

0.3

The healthcare provider prescribed Amoxicillin 500 mg PO every 8 hours for a child who weighs 77 pounds. The available suspension is labeled, 250 mg/5mL. The recommended max dose is 50 mg/kg/24 hour. How many mL should the nurse administer in a single dose based on the child's weight? Round to the nearest whole number?

10

The nurse adds 20 units of oxytocin to 1 L of LR's which should infuse over 8 hours for a client who delivered 2 hours ago. How many mL/hr should the nurse add to the infusion pump?

125

A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only)

13

A 32-week primigravida client who is in preterm labor (PTL) receives a prescription for an infusion of D5W 500 mL with magnesium sulfate 20 g at 1g/hr. How many mL/hr should the nurse program the infusion pump?

25

A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only)

75

The charge nurse working on a postpartum unit is making assignments for a staff consisting of a nurse (RN), a practical nurse (PN), and two unlicensed assistive personnel (UAP). Which client should the charge nurse assign to the practical nurse? A primigravida who delivered a 10lb infant 8 hours ago via c-section and is now complaining of pain A multigravida who had an epidural for a vaginal delivery one hour ago and now needs assistance to the bathroom A multigravida who delivered via c-section 20 mins ago and needs her vital signs taken A primigravida who delivered an infant 6 hours ago via vaginal delivery and is now complaining of seeing spots

A multigravida who delivered via c-section 20 mins ago and needs her vital signs taken

The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant?

A sore throat last week

The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How can our son have this disease? We are wondering if we should have any more children." What information should the nurse provide to parents? A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family. B. The striated muscle groups of males can be impacted by a lack of protein dystrophin in their mothers. C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred. D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles.

A. This is an inherited X-linked recessive disorder, which primarily affects male children

When planning care for a laboring client , the nurse identifies the need to withhold solid foods while the client is in labor . What is the most important reason for this nursing intervention ? A. Gastric emptying time decreases during labor B. Nausea occurs from analgesic used during labor C. An increased risk for aspiration can occur if general analgesic is needed D. Autonomic nervous system stimulation during labor decreases peristalsis

An increased risk for aspiration can occur if general analgesic is needed

A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 beast| minute. What action should the nurse implement? • Determined the pulse déficit • Calculate the safe dose range • Administer the scheduled dose • Review the serum digoxin level

Administer the scheduled dose

Vaginal examination reveals that a laboring client's cervix is dilated to 2 cm, 70% effaced, with the presenting part at -2 station. The client tells the nurse "I need my epidural now! This hurts!" The nurse's response to the client should be based on which information? Administering an epidural at this point would slow the labor process The client should be dilated to at least 8 cm before receiving an epidural The baby needs to be at 0 station before an epidural can be administered

Administering an epidural at this point would slow the labor process

During a prenatal visit, a client at 30-weeks gestation reports persistent heartburn during the past two weeks. The nurse notes the client has 3+ bilateral, pitting, pedal edema. Which action should the nurse implement?

Ask if blurred vision and headache have occurred.

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the care plan? a. Allow liberal family visitation b. Monitor blood pressure, pulse, and respirations q4h c. Assess temp q1h d. Keep an airway at the bedside

Assess temp q1h

The nurse notes that a newborn at 24 hours of age has a large cephalhematoma. Which intervention has the highest priority?

Assess the infant for jaundice every 8 hours

A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her respiratory rate and heart rate have increased during the last hour. Which intervention should the nurse implement? A. Notify the healthcare provider of these findings. B. Administer a PRN analgesic prescription. C. Record the findings in the child's record. D. Wrap the infant tightly and rock in rocking chair.

B. Administer a PRN analgesic prescription.

During a follow-up clinical visit a mother tells the nurse that her 5-month-old son who had surgical correction for Tetralogy of Fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement? A. Stimulate the infant to cry to produce cyanosis. B. Auscultate heart and lungs while infant is held. C. Evaluate infant for failure to thrive. D. Obtain a 12-lead electrocardiogram.

B. Auscultate heart and lungs while infant is held.

A child with Grave's disease who is taking propranolol (Inderal) is seen in the clinic. The nurse should monitor the child for which therapeutic response? A. Increased weight gain B. Decreased heart rate C. Reduce headaches D. Diminished fatigue

B. Decreased heart rat

36. When assessing a 5-year-old, which ability should the nurse expect the child to be developing at this age? A. Learning to ride a tricycle B. Tying shoelaces C. Buttoning clothes D. Cutting with scissors

B. Tying shoelaces

A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform?

Babinski's reflex.

The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?

Betamethasone (Celestone) 12 mg deep IM.

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?

Blood pressure 149/90.

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this finding?

Both the lower uterine segment and the fundus must be massaged.

4.A three-hour-old newborn of a gestational diabetic mother who is asymptomatic and successful breastfed shortly after birth, heel stick glucose level is 36 mg/dL. Which intervention should the nurse do first? A. Give IV 10% dextrose in water B. Initiate formula feeding C. Assist the mother to breastfeed the infant D. Provide 1.125 oz (34 mL) of oral glucose

C. Assist the mother to breastfeed the infant

A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse to review before reporting to the healthcare provider?

Calcium.

A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet?

Chicken.

The healthcare provider prescribes 10 units/L of oxytocin via IV drip to augment a clients labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?

Contraction duration of 100 seconds

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

Contraction pattern.

15.A toddler is hospitalized with Kawasaki's disease. Pharmacological management includes aspirin therapy. What is this primary benefit of this aspirin?

Control high fever

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Cries vigorously when stimulated.

A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain? A. Understanding of quality control process used to troubleshoot the pump B. Interpretation of fingerstick glucose levels that influence diet selections C. Knowledge of her glycosylated hemoglobin A1c levels for past year D. Ability to perform the pump for basal insulin with mealtime boluses

D. Ability to perform the pump for basal insulin with mealtime boluses

A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care? A. Obtain vital signs at onset of fluid overload B. Change IV site dressing q3 days and PRN C. Monitor for signs of facial swelling or urticartia D. Assess for abdominal pain and vomiting

D. Assess for abdominal pain and vomiting

The mother of a breastfeeding 24 hr old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is "doing it right." She tells the nurse, "I just know my daughter is not getting enough to eat." What response would be best for the nurse to make?

D. if your baby's urine is straw-colored, she is getting enough milk*

A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first?

Determine current cervical dilation.

The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity?

Early ambulation after surgery will be encouraged to reduce complications and promote healing.

At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

A female of child - bearing age receives a rubella vaccination. She has two children at home, ages 13 months and 3 years. Which instruction is most important for the nurse to provide to this client? • Tell the mother to isolate the children for 3 days • Inquire if anyone in the family is allergic to eggs • Encourage the client to immunize the children • Assess family history for incidence of rubella

Encourage the client to immunize the children

A young Astanazi Jewish woman is planning to become pregnant and asks the nurse if she should be tested for any genetic disorders. What action should the nurse implement?

Explain the risk for carrying genes for Tay-Sachs disease

The nurse is assisting the mother of child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? • High fat foods • Foods sweetened with aspartame • Wheat products • High calorie foods

Foods sweetened with aspartame

Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority?

Have a meconium aspirator available at delivery.

The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Heart rate and blood pressure

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's...

Heat loss

A 32 week multipara with a history of preeclampsia arrives at the clinic for her routine appointment. The nurse observes the client has an elevated blood pressure of 155/90 resting. Which action should the nurse take?

Inquire about a history if migraines

While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Inspect the posterior oropharynx.

A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide?

Maternal blood pressure.

Which instruction should the nurse include in the discharge teaching plan of a 7-year- old girl with a history of frequent urinary tract infections?

Monitor for changes in urinary odor.

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

Offer information about ultrasonography and genotyping to determine sex assignment.

The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal lab assessment, prescribed at 28-weeks, should the nurse includes One-hour glucose screen Multiple marker screening Direct coombs' test Repeat HIV test

One-hour glucose screen

The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan?

Oral contraceptive use for at least one year.

A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?

Place the infant on the abdomen to protect the sac.

The nurse is using the Stage Questionnaire (b) to assess a 24 - month-old child. What is the best intervention for the nurse to initiate after the assessment is completed? • Assess for changes in the vital signs • Review the child's birth history • Provide the parents with a list of stimulating activities • Meet with a social worker to review the results

Provide the parents with a list of stimulating activities

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum? Soft, spongy fundus Saturating two perineal pads per hour Pulse rate of 56 bpm Unilateral lower leg pain

Pulse rate of 56 bpm

A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first?

Push the call light for help

A client in the third trimester of pregnancy complains of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5cm during the pregnancy. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement? a. Ask a nurse with more experience to validate the costal angle finding b. Ask the healthcare provider to evaluate the client's respiratory status c. Record the respiratory finding in the client's record as normal d. Examine the client for signs of tissue anoxia, such as pallor

Record the respiratory finding in the client's record as normal

The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?

Reduce cerebral edema and lower intracranial pressure.

A 7-year-old male is referred to the school clinic because he fainted on the playground. His height is 3 feet, 7 inches (107.5 cm), he weighs 55 pounds ( 25 kg), and his body mass index (BMI) IS 20.9. Which assessment finding is most important for the nurse to address? • He consumed two bottles of water 30 minutes prior to fainting • Since age 3 he has experienced exercise induced asthma • Reports drinking 3 to 4 high calorie, carbonated beverages day • The child's father has a history of fainting when exercising

Reports drinking 3 to 4 high calorie, carbonated beverages day

The school nurse is presenting a seminar to parents about child safety that focuses on prevention of spinal cord injuries. What information is most important for the nurse include in the teaching plan? • Trampoline activities of school-aged children should be supervised by adults • Protective gear to prevent neck flexion should be worn during contact sports • Seat belt and car seat laws for use in motor vehicles should be reinforced • Monkey bars should be removed from school playgrounds to reduce falls

Seat belt and car seat laws for use in motor vehicles should be reinforced

A father brings his 3-year-old daughter, who has a history of asthma, to the ED because her wheezing increased over the past 2 days. The father has been giving the child's medication using a metered-dose inhaler (MDI). Which information is most important for the nurse to obtain?

Spacer

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

Stimulate the infant to cry.

A 4-month-old boy has an inguinal hernia that is visible when he cries, but it does not cause him discomfort. His parents ask if the hernia should be repaired now. The nurse's response should be based on what information? • An inguinal hernia is treated as a surgical emergency • Surgical repair is planned after successful toilet training • An inguinal hernia is surgically repaired if persistent diarrhea occurs • Surgical correction is indicated if the hernia is incarcerated

Surgical repair is planned after successful toilet training

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents?

The chorea or movements are temporary and will eventually disappear.

An infant is admitted to the newborn nursery and is believed to have Down syndrome. Which physical finding might the nurse expect to see?

Transverse palmar crease

A new mother asks the nurse why her infant son has a needle mark on his leg. Which response is best for the nurse to provide the mother? Vitamin K was administered subcutaneously in the thigh to act as a blood coagulant Your baby was given an injection of vitamin K to prevent bleeding We usually use the thigh when administering injections to infants Your baby had blood drawn to determine his hemoglobin and hematocrit levels The nurse receives a newborn within the first minutes

Your baby was given an injection of vitamin K to prevent bleeding

33. The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

a. Ibuprofen should be used prophylactically to prevent febrile seizures

The nurse is caring for a toddler with chronic active hepatitis. Which pathological process places the client at greatest risk for hemorrhage? a. Portal hypertension b. Ascites c. Jaundice d. Elevated LFT

a. Portal hypertension

A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform?

encourage the client to empty her bladder *

The client will need to be catheterized before the epidural can be administered A client who is HIV+ is receiving zidovudine during labor. Which information should the nurse provide to the client? a. This treatment helps prevent transmission of the virus to the fetus b. The drug treats fungal infections associated with HIV c. The medication is given for treatment of chorioamnionitis d. This intervention helps to prevent HIV complications in the mother

a. This treatment helps prevent transmission of the virus to the fetus

33. A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge.

a.Continue prenatal vitamins with B12 while breast feeding

The nurse is evaluating an adolescent with growth hormone deficiency who has been treated with growth hormone therapy for the last 12 months. Which outcome should the nurse expect for successful treatment? a. Fussing the epiphyseal growth plates b. A 4-inch (10cm) increase in height without complications in the first year c. Bone age greater than 14 years d. Linear height above the 97th percentile on standard growth charts

b. A 4-inch (10cm) increase in height without complications in the first year

An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm hg, respiratory rate is 18 breaths/minute, heart rate is 74 bpm, and temperature is 96.6F (37C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first? a. Obtain a STAT Hg and HCT b. Notify the healthcare provider of the assessment findings c. Determine if the client received anesthesia during delivery d. Assign a practical nurse (PN) to reassess the client's vital signs

b. Notify the healthcare provider of the assessment findings

A newborn's head circumference is 12 inches (30.5cm), and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and was a breech presentation delivered by c-section. What action should the nurse take based on these data? a. Notify the pediatrician immediately. These findings support the possibility of hydrocephalus b. Record the findings on the chart. They are within normal limits c. No action needs to be taken. It is normal for an infant born by c-section to have a small head circumference d. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal

b. Record the findings on the chart. They are within normal limits

The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child? a. Uses 1 to 2 word sentences b. Speaks in simple sentences with four or more words c. Recognizes most letters and numbers d. Uses 1 word sentences

b. Speaks in simple sentences with four or more words

Which action should the nurse take if an infant, who was born yesterday weighing 7.5lbs (3,317grams) weights 7 lbs. (3,175grams) today. A. Monitor the stool and urine output of the neonate for the last 24 hours b.Inform and assure the mother that this is a normal weight loss c.Encourages the mother to increase the frequency of breastfeeding. d.After verifying the accuracy of the weight, notify the healthcare provider

b.Inform and assure the mother that this is a normal weight loss

When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP? a. +1 pedal edema b. 130/70 blood pressure c. 101.2 F oral temp * d. +1 proteinuria

c. 101.2 F oral temp *

The nurse is developing a plan of care for a school-aged child who underwent a below-the-knee amputation due to osteosarcoma of the fibula and tibia. Which action should the nurse include in the plan of care to help the child adjust to the temporary prosthesis? a. Weekly sessions with a psychologist b. Follow up with the orthopedic surgeon c. Ambulation with the physical therapist d. Recreational therapy with the occupational therapist

c. Ambulation with the physical therapist

43. The nurse is caring for a child scheduled to undergo a cystoscopy. The nurse is teaching the parents about pre-procedure care and what to expect during the procedure. Which assessment by the parents indicates to the nurse a need for further teaching? a. Antibiotics will be prescribed before and after the procedure b. Anesthesia is administered during the procedure c. Oral liquids can be taken up until 6 hours before the procedure d. Daily medications should be given with breakfast the morning of the procedure

c. Oral liquids can be taken up until 6 hours before the procedure

A child admitted to the hospital for acute glomerulonephritis receives a prescription for labetalol from the healthcare provider. Which action should the nurse implement prior to administering the medication? a. Test bilateral extremity reflex responses b. Determine the time of the last meal consumed c. Compare arm strength and range of motion d. Assess skin turgor and oral mucous membranes

d. Assess skin turgor and oral mucous membranes

The parents of a child who is diagnosed with Wilms tumor asks the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide? a. Surgery is necessary to stage the tumor and determine metastasis to other sites b. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread c. Metal clips are surgically applied at the tumor site for exact marking for radiation d. The surgery provides a visualization of other pathology and dysfunction of the kidney

d. The surgery provides a visualization of other pathology and dysfunction of the kidney

The nurse is assessing a child with acute glomerulonephritis who presents within the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider? a. Maculopapular rash over trunk of body b. Positive rapid strep test of oropharynx c. BP 88/50 mmHg d. Weight loss

d. Weight loss

The nurse should instruct the parent of an 8-year-old child who has sickle anemia to alert for which complaint from the child? • "I'm shorter than everyone else" • "I'm really hot and thirsty" • "I don't want to eat any vegetables" • "I have to urinate every few hours"

• "I'm really hot and thirsty"

The nurse is performing a routine examination of a 6-month-old infant at community health clinic. Records indicate that the child weighed 3 kg at birth. The clinic uses lbs to describe weight. When assessing this child, approximately what weight, in lbs, should the nurse consider to be within normal range for this child? • 15 to 18 lb • 12 to 15 lb • 9 to 11.5 lb • 6 to 7.5 lb

• 12 to 15 lb

The nurse is assessing a 3-year-old boy who attends a daycare center. Following an upper respiratory tract infection, he developed acute otitis media. Which factor places this child at greatest risk for developing acute otitis media? • A child's Eustachian tube is shorter and straighter than an adult's Eustachian tube. • Attending a daycare center causes frequent exposure to other children with upper respiratory infections. • A child's inner ear is more narrow than an adult's and does not protect him from infection. • The immunity he received at birth from his mother is no longer effective.

• A child's Eustachian tube is shorter and straighter than an adult's Eustachian tube.

The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacked cast. Which assessment finding indicates to the nurse the client is developing cast syndrome? • Diminished pulses in the foot. • Musty, unpleasant odor to cast. • "Hot spot" felt on cast. • Abdominal distention.

• Abdominal distention.

The nurse is planning care for a newborn infant scheduled for a cardiac catheterization. Which occurrence poses the greatest risk for this child? • Loss of pulse proximal to the entry side of the catheter • Allergic response to the plastics in the catheter used for catheterization • Acute hemorrhage from the entry site of the catheter after the procedure • Fever associated with nausea and vomiting after the procedure

• Acute hemorrhage from the entry site of the catheter after the procedure

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and been walking without assistance for one month. Which technique should the nurse select for administration? • Administer the injection into the middle of the lateral aspect of the thigh. • Use a needle length of 1⁄2 inch (1.25cm) to avoid deep tissue damage. • Divide the gluteal area into quarters and give IM into the upper outer quadrant. • Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.

• Administer the injection into the middle of the lateral aspect of the thigh.

The clinic nurse is assessing a 3-year -old child with sudden onset of irritability, thick muffled voice, and barking on inspiration. The child is febrile and leaning forward to breathe with tongue protruding, is drooling, and has suprasternal retractions. Which intervention should the nurse implement first? • Alert the emergency response team • Examine the child's throat for edema • Collect a sputum specimen • Prepare the child for X-ray

• Alert the emergency response team

A one - month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days. The infant is afebrile, dehydrated, and pyloric stenosis is suspected. What other finding should the nurse identify that are consistent with pyloric stenosis? • Perianal diaper rash from persistent diarrhea • Rooting, hunger, and irritability • Bite-stained emesis • An olive-shaped mass in the abdominal area

• An olive-shaped mass in the abdominal area

32. A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. What action should the nurse implement first? • Initiate an IV site and begin infusing normal saline • Type and cross for possible transfusion • Monitor the child's vital signs frequently • Apply ice pack and compression dressing to knee

• Apply ice pack and compression dressing to knee

A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to the mother? • Apply padding on the sharp corners of the furniture • Prevent the child from running inside the house • Give an 81 mg tablet of aspirin for pain relief • Use a soft toothbrush for frequent cleaning

• Apply padding on the sharp corners of the furniture

A mother brings her 2-month-old son to the clinic for a well-baby exam. During the assessment the nurse finds that the right testicle is not descended into the scrotum but the left is palpable. Which action should the nurse take? • Address possible concerns about the child's future fertility. • Ask if the right testis has been seen in the scrotum before. • Schedule an IV pyelogram to validate presence of testicle. • Prepare to obtain a catheterized urine specimen for culture.

• Ask if the right testis has been seen in the scrotum before.

A 10-year-old boy has been seen frequently by the nurse over the past three weeks after school begins in the fall. He reports headaches, stomach, and difficulty sleeping. What intervention should the nurse implement? • Conduct a complete neurological assessment • Ask the boy to describe a typical day at school • Counsel the parents to play more attention to the child • Compare the child's vital signs over the past three weeks

• Ask the boy to describe a typical day at school

The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take? • Document the finding. • Auscultate bowel sounds. • Palpate scrotum for testicular descent. • Assess for bladder distention.

• Document the finding.

A 12-year-old obese male comes to the clinic with his mother and a note from the school nurse for follow-up of Acanthosis Nigricans, a thickening and darkening of the skin. The child is concerned and anxious that he has a serious condition. How should the nurse respond? • Refer the child immediately to an endocrinologist for treatment • Ask the child and his mother what he was told about this condition • Encourage the child to modify his diet and begin an exercise • Assess the presence of type 2 diabetes mellitus in the family

• Ask the child and his mother what he was told about this condition

A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child's oral temperature is 101.2 F (38 C). Which intervention should the nurse implement? • Provide parent education to prevent recurrence • Clearance purulent exudate from the affected ear canal • Apply a topical antibiotic to the preauricular area • Ask the mother if the child has had a runny nose

• Ask the mother if the child has had a runny nose

An adolescent boy is hospitalized with full-thickness (third degreed) burns to both hands following a house fire. Three days after his admission to the burned unit, the nurse notes that teenager's hands are becoming more edematous. Which intervention is most important for the nurse to include in this client's plan care? • Record accurate intake and output • Ensure patient intravenous access • Assess radial pulses every 2 hours • Ensure that antibiotics are administered on time

• Assess radial pulses every 2 hours

A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response? • Recommend that the mother bring the child in for immediate. • Assure the mother that she is using the medication correctly. • Advise the mother that over-use of the drug may cause chronic. • Confirm that the medication helps to reduce airway inflammation.

• Assure the mother that she is using the medication correctly

When assessing a newborn, the nurse includes assessment for early signs of congenital hip dysplasia. Which finding is an indication of this condition? • Depressed dance reflex. • Limited adduction of the affected leg. • Asymmetry of the gluteal folds. • Shortening of the leg on the unaffected side.

• Asymmetry of the gluteal folds.

A 12-year-old boy with leukemia is being discharged from the hospital with a white blood cell (WBC) count of 4,000/mm. He is scheduled to receive antineoplastic chemotherapy as an outpatient. What instruction should the nurse include in this child's discharge plan? • Avoid eating at buffets, smorgasbords, and salad bars • Spend time resting with family pets, bur only cats and dogs • Have all visitors wear protective masks when coming to the home • Swim weekly at the neighborhood pool for neuromuscular integrity

• Avoid eating at buffets, smorgasbords, and salad bars

During her sports physical examination, 15-year -old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. What action should the nurse take? • Explain that she needs parental approval to receive contraceptives • Encourage the client to discuss her need for contraceptives with her parents • Counsel the client about the risks and benefits of using oral contraceptives • Tell the client how to receive a variety of oral contraceptives from the clinic

• Counsel the client about the risks and benefits of using oral contraceptives

A male infant is admitted to the pediatric unit with pertussis and is exhibiting a "whooping-like cough." The mother brings the infant to the nurse's station to seek assistance. Which intervention should the nurse implement first? • Explain the need to maintain droplet precautions to prevent spread to others on the unit. • Ask the mother if the cool mist humidifier at the bedside is functioning and releasing mist. • Give the infant an oral dose of a prescribed antitussive and analgesic/antipyretic. • Cover the infant's mouth and assist the mother to take the infant back to the room.

• Cover the infant's mouth and assist the mother to take the infant back to the room.

A 12-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is schedule. Which information should the nurse provide concerning to this procedure? • Explain that fluids cannot be taken for 8 hours before the procedure and 4 hours after the procedure • Tell the child to expend loud clicking during the procedure that may be annoying • Describe the side-lying, knee to the chest position that must be assumed during the procedure • Reassure the child that there will be no restrictions on activity after the procedure is completed

• Describe the side-lying, knee to the chest position that must be assumed during the procedure

In developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first? • Provide the child with positive feedback. • Encourage other children on the unit to describe the token system. • Determine what activities, foods, and toys the child enjoys. • Evaluate the child's previous reactions to punishment.

• Determine what activities, foods, and toys the child enjoys.

An adolescent with non-Hodgkin's lymphoma (NHL) is complaining of sore mouth two days after begging chemotherapy. What activity should the nurse implement? • Encourage large meals during steroid and chemotherapy • Provide lemon glycerin swabs and dilute peroxide oral rises • Recommended fluids using citrus and drinking with a straw • Frequent use of saline oral rinses and soft sponge toothbrush

• Frequent use of saline oral rinses and soft sponge toothbrush

A male toddler is brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin). What prescription should the nursed implement first? • Obtain a 12-lead electrocardiogram. • Give IV digoxin immune fab (Digibind) • Prepare for gastric lavage. • Administer activated charcoal orally.

• Give IV digoxin immune fab (Digibind)

The mother of an 11 -year-old boy who has juvenile arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting". Which information is most important for the nurse to provide this mother? • The nurse use of hot baths can be used as an alternative for pain medication • The child should be encouraged to rest when he experiences pain • Encourage quiet activities such as watching television as a pain distracter • Giving pain medication around the clock helps control the pain

• Giving pain medication around the clock helps control the pain

A 10-year-old girl is diagnosed with inflammatory bowel disease (IBD). Her mother is concerned that she will experience developmental delays as the result of this disorder. How should the nurse respond? • She is at high risk for a number of different problems, including developmental delays • Scheduling a private tutor can help to prevent developmental delays • She will only experience developmental delays if weight loss cannot be controlled • Growth failure is a concern, but developmental delays are not likely to occur

• Growth failure is a concern, but developmental delays are not likely to occur

The nurse is evaluating a young child with atopic dermatitis. Which question should the nurse ask the parent while obtaining the child's history? • Does the child have any nausea or vomiting? • Has the child displayed any symptoms of asthma or hay fever? • Can any particular stress be associated with onset of the rash? • What time of day does the rash appear on the body?

• Has the child displayed any symptoms of asthma or hay fever?

The nurse is caring for a one-year-old boy who has type 1 diabetes mellitus (DM). His mother asks how will she recognize hypoglycemia in her infant who cannot tell her how he feels. Which information should the nurse provide? • The baby's breath smell swells sweet when the sugar and blood ketone levels are high • Hypoglycemia in infants causes changes in behavior and cold clammy skin • Weight loss and a good appetite often occur when a baby's glucose levels change • Excess urination and dry skin are common indicators of hypoglycemia

• Hypoglycemia in infants causes changes in behavior and cold clammy skin

The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain? • Vigorous feeding and satiation • Hemiplegia • Fever • Hypotension and tachycardia

• Hypotension and tachycardia

36. The nurse is assessing an 8-month-old who has a cough, axillary temperature of 100 F, and rhinorrhea. What information is most important for the nurse to obtain from this child's mother? • Alcohol and drug intake of the mother • Labor and delivery history of the infant • Immunization status of the infant • Living conditions

• Immunization status of the infant

A male infant with bronchiolitis is brought to the clinic by his mother. The infant is congested and febrile with a capillary refill time of 2 seconds. What information should the nurse discuss with the mother? • Lay infant flat on back for naps. • Keep infant isolated from others. • Limit the amount of oral intake. • Encourage the infant to play.

• Keep infant isolated from others.

An infant who has been diagnosed with a tracheoesophageal fistula (TEF). Which nursing intervention is indicated for this infant prior to surgical repair? • Provide frequent sips of liquid • Give isotonic enemas as prescribed • Maintain nothing by mouth status • Prepare the infant for a barium enema

• Maintain nothing by mouth status

In developing a plan of care for a child with bacterial meningitis, which intervention should the nurse plan to implement? • Maintain strict insolation after identification of the causative agent. • Maintain Trendelenburg's position to decrease intracranial pressure. • Administer large volumes of intravenous fluids to minimize nephrotoxic effects of antibiotics. • Administer antibiotic therapy until the cerebrospinal fluid finding are negative.

• Maintain strict insolation after identification of the causative agent.

Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care? • A Consult with healthcare provider about use of insulin detemir (Levemir Flex Pen). • Determine the child's compliance schedule for subcutaneous NPH insulin (Humulin N). • Monitor serum glucose for adjustment in infusion rate of Regular insulin (Novolin R). • Demonstrate to parents how to program an insulin pen for daily glucose regulation.

• Monitor serum glucose for adjustment in infusion rate of Regular insulin (Novolin R).

A breast feeding mother returns to work when her infant is 5 months old. She is having difficulty pumping enough milk to meet her infant's dietary requirements. Which suggestion should the nurse provide to this mother? • Mix infant formula with breast milk • Supplement with an iron-rich formula • Introduce baby food for one meal daily • Offer a follow-up transitional formula

• Offer a follow-up transitional formula

When caring for a child sickle cell disease, the nurse knows that the child will most likely exhibit which sign when experiencing a sickle cell crisis? • Decreased hemoglobin • Pain • Infection • Dehydration

• Pain

An 8 year-old child is admitted to the Emergency Department because of lower right quadrant pain, nausea, and vomiting. Which assessment of the abdomen should the nurse conduct after all other assessments are complete? • Percussion • Palpation • Inspection • Auscultation

• Palpation

The teacher notifies the school nurse that a child's nose is bleeding for no apparent reason. What action should the nurse implement first? • Tip the child's head back to avoid swallowing blood • Pinch the nose using thumb and finger for 10 minutes • Insert a sterile cotton ball in the nares that is bleeding • Apply an ice compress to the child's nose right away

• Pinch the nose using thumb and finger for 10 minutes

When development a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the to eat a source of sugar if which symptom occurs? • Excessive thirst • Racing pulse • Profuse perspiration • Seeing spots

• Profuse perspiration

The healthcare provider prescribes antipyrine and benzocaine (Auralgan Otic), and anesthetic ear drop, for a two-year-old child with otitis media in the right ear. After positioning the child with the affect ear up, what action should the nurse take? • Cleanse the ear canal with saline • Put upward traction on the ear lobe • Pull pinna of the ear down and back • Gently massage in front of the ear

• Pull pinna of the ear down and back

31. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? • Repair should be done by one month to prevent bladder infection. • To form a proper urethra repair, it should be done after sexual maturity. • Repairs typically should be done before the child is potty trained. • Delaying the repair until school age reduces castration fears.

• Repairs typically should be done before the child is potty trained.

After receiving a single fluid bolus of 20 mg / kg of normal saline, a child's heart rate is 140 beats/ minute, blood pressure is 70/50, and capillary refill is 6 seconds. The child is anxious and crying. Which intervention should the nurse implement first • Encourage the caregiver to remain at bedside • Repeat the normal saline bolus as prescribed • Allow the child to assist with caregiving • Recommend age appropriate activities

• Repeat the normal saline bolus as prescribed

A 3-year -old girl who has been blind since birth is hospitalized because of a compound fracture of the femur and is now in traction. Which intervention is best for the nurse to implement to address this child's blindness? • Play a game where the child must identify unfamiliar sounds in the environment • Use a touch tour to allow the child to familiarize herself with the room layout • Request parents bring familiar objects as a stuffed animal from home • Perform the child's self-care activities until the child is no longer in traction

• Request parents bring familiar objects as a stuffed animal from home

A child with acute laryngotracheobronchitis (croup) received epinephrine 2 hours ago in the emergency room, and is now being prepared for discharge to the home. The nurse should instruct the parents to take which action if the child's uncontrolled coughing reoccurs? • Sit with the child in the bathroom with hot steam • Call for emergency transportation to hospital • Administer a dose of the prescribed cough medicine • Increase the fluid intake to liquefy the secretions

• Sit with the child in the bathroom with hot steam

How should the nurse respond to the concerned parent of a 15-month-old who is not yet able to self-feed with a spoon? • Tell parent to guide the child's hand using a spoon • Suggest using foods that can be eaten with fingers • Discuss possible causes for delay with self-feeding • Encourage longer mealtimes to practice eating with a spoon

• Suggest using foods that can be eaten with fingers

The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? • Tachycardia. • Bradycardia. • Dry mucous membrane. • Increased skin turgor.

• Tachycardia.

During a routine clinic visit, the nurse determines that 5-year-old girl's systolic blood pressure is greater than the 90th percentile. What action should the nurse implement next? • Take the blood pressure two more time during the visit and determine the average of the three readings • Measure the child's blood pressure three times during the visit and determine the highest of the readings • Conduct a head-to-toe assessment and omit repeat blood pressure during the examination • Refer child to the healthcare provider and schedule evaluation of blood pressure in two weeks

• Take the blood pressure two more time during the visit and determine the average of the three readings

A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family? • The infant's formula has been changed twice. • The diapers area shows severe skin breakdown. • The mother state the baby is irritable during feedings. • The mother is a single parent and lives with her parents.

• The diapers area shows severe skin breakdown.

The nurse has provided discharge teaching to the mother of a premature infant. Which statement by the mother would indicated that the understands the importance of making sure that her baby gets the monthly palivizumab (Synagis) injection? • Palivizumab will help with neurological and physical development • The medication will protect my baby from respiratory syncytial virus • Palivizumab will prevent the development retinopathy of premature • The monthly injections will baby's lung mature

• The medication will protect my baby from respiratory syncytial virus

The nurse is administering an oral medication to a reluctant preschool-age boy. Which intervention should the nurse implement? • Advise the parents that they will need to give the medication • Use straightforward approach with the child • Mix the medication in with the child's favorite breakfast cereal • Offer to bring the medicine back later in the day

• Use straightforward approach with the child

The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider? • Audible heart murmur • Poor oral intake and suckling effort • Heart rate of 162 beasts/minute • Weight gain of 2.2 lbs (1kg) in las 48 hours

• Weight gain of 2.2 lbs (1kg) in las 48 hours

A 4-years-old boy was recently diagnosed with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during the initial teaching? •Muscular strength can be regained with physical exercise and therapy •Growth and development have been abnormal since birth •Respiratory dysfunction and aspiration are prime concerns at this stage of the disease •Lower legs become progressively weaker, causing a wedding, unsteady gait

•Lower legs become progressively weaker, causing a wedding, unsteady gait

In caring for an client with acute epiglottitis, which nursing action takes priority? •Obtain a STAT CBC •Prepare for endotracheal intubation •Auscultate breath sounds •Apply ice packs to the neck

•Prepare for endotracheal intubation