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A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome?
A. Presence of a systolic murmur
B. New onset of patchy alopecia
C. Complaints of long bone pain
D. Recent projectile vomiting - CORRECT ANSWER - A. Presence of a systolic murmur
Rationale:
Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly.
A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period?
A. Place the infant upright in an infant seat position.
B. Provide mittens with the use of elbow restraints.
C. Use soft rubber catheters for nasal suctioning. - CORRECT ANSWER - A. Place the infant upright in an infant seat position.
Rationale:
The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need?
a 400 calories/day
b 500 calories/day
c 600 calories/day
d 700 calories/day - CORRECT ANSWER - c 600 calories/day
A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate?
A. Vertex delivery
Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs. Mistrust" occurs from birth to 1 year of age.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care?
A. Keep restraints on at all times to prevent unplanned extubation.
B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities.
D. Document the reason for application of the restraints every 72 hours. - CORRECT ANSWER - B. Remove restraints one at a time and provide range-of-motion
Rationale:
Removing restraints one at a time is safer than option C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of- motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first?
A. Obtain a scale to weigh the infant's diapers.
B. Instruct the mother to offer Pedialyte regularly.
C. Insert an intravenous (IV) line and begin IV fluids.
D. Obtain a stool specimen for analysis. - CORRECT ANSWER - C. Insert an intravenous (IV) line and begin IV fluids.
Rationale:
An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids to rehydrate the infant.
A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse?
A. "My son often chokes while I am feeding him."
B. "Is it normal for my child's legs to cross each other?"
C. "He gets stiff when I pull him up to a sitting position."
D. "My 4-year-old son is jealous of his little brother." - CORRECT ANSWER - A. "My son often chokes while I am feeding him."
Rationale:
Airway obstruction is always a priority when caring for any client. Options B and C are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures.
The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client.
A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take?
A. Send the child home with the parents to see the health care provider before returning to school
B. Send the child home with the parents and report this to the health department.
C. Cover the lesion with a dry gauze dressing and send the child back to class.
D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class. - CORRECT ANSWER - A. Send the child home with the parents to see the health care
Rationale:
Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition.
A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit?
A. Bone pain, pallor
B. Weakness, tremors
C. Nystagmus, anorexia
D. Fever, abdominal distention - CORRECT ANSWER - A. Bone pain, pallor
Rationale:
Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor. Options B and C could be associated with central nervous system disorders. Option D commonly occurs in children but is not specific for leukemia.
A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child?
A. Cover the tracheostomy site with clothing so that other children will not notice.
B. Apply suction for 30 seconds when inserting a catheter into the stoma.
C. Discourage the child from coughing deeply to remove mucous secretions.
D. Place suctioning supplies on the back of the wheelchair when transporting. - CORRECT ANSWER
- D. Place suctioning supplies on the back of the wheelchair when transporting.
Rationale:
Suctioning supplies should always be readily available for use with any client who has a tracheostomy.
D. Bring the child to the clinic today for an examination related to the cough. - CORRECT ANSWER
- D. Bring the child to the clinic today for an examination related to the cough.
Rationale:
The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production
A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit?
A. Shortness of breath
B. Joint pain
C. Persistent cold
D. Organomegaly - CORRECT ANSWER - C. Persistent cold
Rationale:
Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection.
A nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take?
A. Communicate the result to the oncoming nurse and document.
B. Tell the oncoming nurse that the level is dangerously high.
C. Ask the laboratory to redo the test because the result is faulty.
D. Hold the next dose of theophylline based on this finding. - CORRECT ANSWER - A. Communicate the result to the oncoming nurse and document.
Rationale:
The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report.
A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman?
A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully."
B. "The fear of losing another child to SIDS is very realistic. Have you thought
about what support you may need?"
C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need."
C. Restrain the child's lower extremities for a minimum of 4 hours.
D. Place the child in a prone position to apply pressure to the site. - CORRECT ANSWER - B. Show the parents how to hold the child with the extremity extended.
Rationale:
The extremity should be extended to prevent trauma to the femoral catheterization site
An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement?
A. Call for a portable chest radiograph.
B. Obtain a therapeutic drug level.
C. Reassess the heart rate in 30 minutes.
D. Administer digoxin immune Fab stat. - CORRECT ANSWER - B. Obtain a therapeutic drug level.
Rationale:
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority
At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions?
A. Inspiration
B. Coughing
C. Apneic episodes
D. Expiration - CORRECT ANSWER - A. Inspiration
Rationale:
Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take?
A. No action is required because this is an expected finding for a school-aged child.
B. Ask if the child has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising parents to have the child evaluated by a health care provider.
D. Call the parents and have them take the child home from school for the rest of the day. - CORRECT ANSWER - B. Ask if the child has had a cold, runny nose, or any ear pain lately.
Rationale:
More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is
D. Straining during defecation - CORRECT ANSWER - B. Presence of an inguinal bulge after gentle palpation
Rationale:
The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect?
A. Irregular respiration and heart rate
B. Gagging
C. Blue feet and hands
D. Diminished femoral pulses - CORRECT ANSWER - D. Diminished femoral pulses
Rationale:
Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity).
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence?
A. Adjustment of orthodontic appliances or braces
B. Loss of deciduous teeth (baby teeth)
C. Urinary catheterization
D. Insect bites - CORRECT ANSWER - C. Urinary catheterization
Rationale:
Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure
The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor - What is the most safety precaution for child?
A. maintain NPO status
B. Limit visitors to the immediate family
C. Place a do not palpate abdomen sign on head of bed
D. Encourage ambulation in the pre-operative period - CORRECT ANSWER - C. Place a do not palpate abdomen sign on head of bed
Rationale:
Rationale:
Two-year-old children are egocentric and unable to share with other children.
The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse?
A. "Tell me what you know about birth control."
B. "Do you know how to apply a condom?"
C. "Teen pregnancy should not be taken lightly."
D. "You need to visit with your guidance counselor." - CORRECT ANSWER - A. "Tell me what you know about birth control."
Rationale:
Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception. It would be best for the nurse to ask a more general question, such as option A
The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first?
A. Evacuate the bowel of impacted feces
B. Administer magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color - CORRECT ANSWER - C. Place the child on a clear liquid diet
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation.
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement?
A. Assess the child's mucous membranes and skin turgor.
B. Contact food services about needed menu restrictions.
C. Determine the child's food likes and dislikes.
D. Ask the parents about the child's recent dietary intake. - CORRECT ANSWER - A. Assess the child's mucous membranes and skin turgor.
Rationale:
An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit.
