Download Hesi Rn Peds Exam 2026 / 2025 With Rationale / Hesi Pediatric Evolve Peds Practice and more Exams Nursing in PDF only on Docsity!
Hesi Rn Peds Exam 2024 / 2025
With Rationale / Hesi Pediatric
Evolve Peds Practice Questions
A 12-month-old is admitted w/ a respiratory infection and possible pneumonia. He is placed in a tent w/ oxygen. Which nursing intervention has the greatest priority for this infant? - ✔✔✔ANSWER-a. C- a patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making having a bulb syringe the highest priority A 14 yr old female client tells the nurse that she is concerned about the acne she has recently developed/ Which recommendation should the nurse provide? - ✔✔✔ANSWER-a. C- wash the hair and skin frequently w/ soap and hot water
a.i. Washing the hair & skin w/ soap & hot water removes oil debris fr. the skin and helps prevent & treat acne. Oily skin especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne is contraindicated. Cosmetics "medicated" or not should be used sparingly to avoid further blocking sebaceous gland ducts. Might be indicated at a later time, if healthcare recommendations are not successful. A 15 yr old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide? - ✔✔✔ANSWER-a. C- explain that menarche varies and occurs between the ages of 12-18 years A 16 y old is brought to the ER with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received 8 ys ago. What action should the nurse take? - ✔✔✔ANSWER-a. C- administer the tetanus toxoid booster. a.i. After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult if every 10 years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds fr. missiles, burns or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered A 17 yr old male student reports to the school clinic one morning ofr a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assess his VS: temp 100, pulse, 80, RR 20, and BP is 122/82. What is the best action for the nurse to take? - ✔✔✔ANSWER-a. A- tell the student to proceed directly to his regulary scheduled class. a.i. The student has just completed football practice, and increased muscle activity increases body heat production. A temp of 100F is NORMAL for this student @ this time. The student should attend class A 2 yr old child w/ Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated w/ Down syndrome? - ✔✔✔ANSWER-a. A- congenital heart disease a.i. Is the most common assoc w/ defect in children w/ Down Syndrome A 2 yr old child w/ gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parent's teaching plan? - ✔✔✔ANSWER-a. D- a 2- year old child is comforted by consistency
A 4- year- old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated w/ the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? - ✔✔✔ANSWER-a. A- children need to retian a sense of initiative w/o impinging on the rights and privileges others a.i. Children aged 3-6 are in Erickson's initiative vs. guilt stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative w/o impinging on the rights of others A 4- yr old boy was admitted to the emergency room w/ fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? - ✔✔✔ANSWER-a. A- call the healthcare provider immediately if his nailbeds appear blue. a.i. A- Cyanosis indicates impaired circulation to fingers and should be reported immediately. Although the actions described may be indicated, they are implemented rather excessively & might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days. A 5 month old is admitted to the hospital w/ vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline w/ 2 mEq KCL/100 ml to be infused @ 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? - ✔✔✔ANSWER-a. B - Serum BUN & Creatinine levels a.i. Reguardless of a client's age, adequate renal function must be present before adding potassium ot IV fluids, is important in determining the need for fluid replacement A 6 month old boy and his mother are at healthcare provider's office for a well-baby check up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today? - ✔✔✔ANSWER-a. B- all the immunizations w/ the influenza vaccine given at a separate site fr. any other injection a.i. At 6 months of age, the routine immunizations should HEP B, DTaP, Hib, PCV (pneumococcal) , IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site fr. any other injection. A 6 month old returns fr. surgery w/ elbow restraints in place. What nursing care should be included when caring for any restrained child? - ✔✔✔ANSWER-a. B- remove restraitnts one at a time and provide range of motion exercises a.i. Removing restraints one at a time (B) is safer than removing all of them at once. The child needs to exercise and should not be kept in restraints at all times
a 6- year old admitted to the pediatric unit after falling of a bicycle. Which intervention should the nurse implement to assist the child's adjustments to hospitalization? - ✔✔✔ANSWER-a.Explain hospital schedules to the child, such as mealtimes. Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety. A 6-month-old infant w/ congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention? - ✔✔✔ANSWER-a. A- Apical heart rate of 60 a.i. A heart rate of 60 is much lower than normal for a 6-month old and warrants immediate intervention. The normal heart rate for a 6 month old is 80-150 when awake, and a rate of 70 while sleeping is considered w/in normal limits. A burned child is brought to the ER. In estimating the percentage of the body burned, the nurse uses a modified "rule of nines" Which part of a child's body is calculated as a larger percentage of total body surface than an adult's? - ✔✔✔ANSWER-a. A-Head & Neck a.i. A child's head & neck are proportionately larger to their body than and adult's. The standard "Rule of nines" is inaccurate for determining burned body surface areas w/ children, and must be modified for use with children. Specially designed charts for children and are commonly used to determine body surface are involvement A child falls on the playground and is brought to the school nurse w/ a small lacreration on the forearm. Which action should the nurse implement first? - ✔✔✔ANSWER-a. C-Wash the wound gently w/ mild soap and water a.i. A small, superficial laceration to the skin should be washed gently w/ mild soap and water for several minutes, followed by thorough rinsing. a child with hemophilia A - ✔✔✔ANSWER-apply pressure and ice for bleeding while elevating and resting the extremity. Hemophilia, a blood disorder, causes joint bleeding which is treated with rest, ice, compression adn elevation (RICE). A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan? - ✔✔✔ANSWER-a. A- Use sunscreen when lying by the pool
A three month old boy weighing 10 lbs 15 oz an axillary temp of 98.8. The nurse determines the daily caloric need for this child is approximately - ✔✔✔ANSWER-a.600 calories per day. C- 10lbs 15oz = 10.9. Convert lbs by dividing 2.2; 10.9/2.2=4.59kg, rounded to 5kg. An infant requires 108 calories/kg/day ( x 5=540 calories/day.) However this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 and 540 + 54= 594. This infant will require approx 600 calories/day. All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20 month old child? - ✔✔✔ANSWER-a. B-assessing fontanels a.i. All of these interventions evaluate fluid status in infants (weight diapers, checking skin turgor, oserving mucous membranes for moisture checking for fluid status) An 18 month old is admitted to the hospital w/ possible Hirschsprung's disease. When obtaining a nursing hx the nurse asks about bowel habits. What description of the disease? - ✔✔✔ANSWER-a. D- Ribbon-like and brown a.i. Hirschsprung's disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results fr. failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constripation and smaller diameter, brown colored stools An infant is born w/ a ventricular septa defect (VSD) and surgery is planned to correct the defect. The nurse regcognizes that surgical correction is designed to achieve which outcome? - ✔✔✔ANSWER-a. prevents the return of oxygenated blood to the lungs Closure of VSDs stops oxygenated blood fr. being shunted fr. the left ventricle to the right ventricle. VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation is common w/ tetrology of Fallot, which is a cyanotic defec As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? - ✔✔✔ANSWER-a. A- a 6 moth old w/ failure to thrive that has a closed anterior fontanel a.i. @ 6 months of age the anterior fontanel should be open, and it should not be closed until approx 18 months at 8am the unlicensed assistive personnel (UAP) informed the charge nurse that a female adolescent client w/ acute glomerulonephritis has a BP of 210/110. The 4am BP reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should
the nurse take first? - ✔✔✔ANSWER-a. - Administer PRN prescription of nifedipine (Procardia) sublingually a.i. Sublingual procardia lowers blood pressure very quickly, and this should be done first Children with chronic otitis media are at risk for developing what problem? - ✔✔✔ANSWER-Hearing loss Descbrine the s/s of a child with meningitis. - ✔✔✔ANSWER-Fever, irritability, vomiting, neck stiffness, opisthotonos, positve Kernig's sign, positive Brudzinski sign; infant may not show classic signs even though very ill Descrbine the mechanism of inheritence of Duchenne muscular dystrophy. - ✔✔✔ANSWER-Duchenne muscular dystrophy is inherited as an X-linked recessive trait. Describe developmental factors that would impact the school-age child with diabetes - ✔✔✔ANSWER- need to be like peers; assuming responsibility for own carel modification of diet; snacks and exercise in school Describe feeding techniques for a child with cleft lip or palate - ✔✔✔ANSWER-Use lamb's nipple or prosthesis. Feed child upright, with frequent bubbling Describe nursing interventions to reduce the workload of the heart - ✔✔✔ANSWER-Give small frequent feedings or gavage feedings. Plan frequent rest periods. Maintain a neutra thermal enviroment. Organize activites to disturb child only as indicated Describe scissoring? - ✔✔✔ANSWER-A common characteristic of spastic cerbral palsy in infants; legs are extended and crossed over each other, feet are plantarflexed Describe the care of a child in a mist tent? - ✔✔✔ANSWER-Monitor child's temperature; keep tent edges tucked in clothing dry; assess respiratorty status; look at child inside tent Describe the function of an osmotic diuretic - ✔✔✔ANSWER-Osmotic diuertics remove water from the CNS to reduce cerebral edema
a.i. The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified ©. After the transfusion is discontinused, IV access should be maintained. (A) w/ fluids that do not introduce any more cellular products. (B & D) place the child @ risk for further blood reactions During discharge teaching of a child w/ juvenile rheumatoid arthritis, the nurse should stree to the parents the importance of obtaining which diagnostic testing? - ✔✔✔ANSWER-a. B- eye exams a.i. Visual changes leading to blindness an occur in children w/ JRA/ Regular eye exams can help to prevent this complication 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. What action should the nurse take next? - ✔✔✔ANSWER-a. B- Ask the child if he/she has had cold, runny nose, or any ear pain lately. a.i. More information is needed to interpret these finding, the tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of hx and related s/s is indicated for accurate interpretation of the finding. Explain why hydration is a priority in treating sickle cell disease - ✔✔✔ANSWER-Hydration promots hemodilution and circulation of the red cells through the blood vessels How can the nurse best evaluate the adequacy of fluid replacement in children? - ✔✔✔ANSWER-By monitoring the urine output How is a child usually positioned after brain tumor surgery? - ✔✔✔ANSWER-Flat or on either side How is congenital hypothyroidism diagnosed? - ✔✔✔ANSWER-Newborn screening revealing a low T and a high TSH How is skeletal tracion applied? - ✔✔✔ANSWER-Skeletal traction is maintained by pins or wires applied to the distal fragment of the fracture.
How should a parent be instructed to childproof a house? - ✔✔✔ANSWER-By being taught to lock all cabinents, to safely store all toxic household items in locked cabinents, and to examine the house from the child's point of view How should burns in chilren be assessed? - ✔✔✔ANSWER-By using the Lund-Browder chart, which takes into account the changing proportions of the child's body How would the nurse conduct a scoliosis screening? - ✔✔✔ANSWER-Ask the child to bend forward from the hips, with arms hanging free. Examine the child for a curve in the spin, a rib hump, and hip asymmetry Identify food sources of vitamin A - ✔✔✔ANSWER-Liver, sweet potatoes, carrots, spinach, peaches, and apricots In developing a teaching plan for a 5 year old child w/ diabetes, which component of diabetic management should the nurse plan for the child to manage first? - ✔✔✔ANSWER-a. C-process of glucose testing a.i. Developmentally a 5 yr old has the cognitive and psychomotor skills to use a glucometer and to read the number (it is especially helpful if the nurse presents this activity as a game List dietary sources of iron - ✔✔✔ANSWER-Meat, green leafy veggies, fish, liver, whole grains, legumes List five risks in cardiac catherization. - ✔✔✔ANSWER-Arrhythmia, bleeding, perforation, phlebitis, and obstruction of the arterial entry site. List food high in phenylalanine content - ✔✔✔ANSWER-Meat, milk, dairy products, and eggs List normal findings in nerovascular assessment - ✔✔✔ANSWER-Warm extremity, brisk capillary refill, free movement, normal sensation of the affected extremity, and equal pulses List seven signs of respiratory distress in a pediatric client - ✔✔✔ANSWER-Restlessness, tachycardia, tachypnea, diaphoresis, flaring nostrils, retractions, and grunting
State the three main goals in providing nursing care for a child experiencing a seizure? - ✔✔✔ANSWER- Maintain patent airway, protect from injury, and observe carefully Surgery is being delayed for an infant with undescended testes. In collaboration w/ the health care provider and the family, which prescription should the nurse anticipapte? - ✔✔✔ANSWER-trial of human chorionic gonadotrophic hormone a.i A trial of HCG may aid in testicular descent, but does not replace surgical repair for true undescended testes. (cryptorchidism: may be found in the inguinal canal due to exaggerated creamasteric reflex The clinic nurse is taking the hx for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? - ✔✔✔ANSWER-a. Type of reaction to loud noises a.i. Ototoxicity diminishes hear acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing the infant's reation to loud noises (A) helps to determine an infant's risk for hearing deficit r/t to a hx of the mother taking ototoxic drug, such as aspirin, while pregnancy (B,C,D are not assoc w/ the exposure to aspirin in utero The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? - ✔✔✔ANSWER-a. Walk away from him and ignore the behavior a.i. The best approach for a toddler is to ignor the attention-seeking behavior. The parents should be somewhat nearby, w/in view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's hospitalizations. Which is the best response that the nurse should offer? - ✔✔✔ANSWER- a. Encourage the mother to have the children visit the hospitalized sibling. a.i. Needs of a sibling will be better met with facture information and contact w/ the ill child, so siblings visitation should be encouraged (D). Parents are experts on their children and should determine when their children are old enough to visit. (A) in the hospital/ Separation fr. a family & home (B) may intensify fear & anxiety (suggest that the child visit a grandmother until the sibling returns home. Children may have difficulty expressing questions (C) ask the mother if the child asks when the sibling will be discharged, so the support of parents & other caregivers are needed to help alleviate their fears.
The mother of a 6 month old asks the nurse when her baby will get the first MMR vaccine. Based on the recommended childhood immunization schedule published by the CDC, which response is accurate? - ✔✔✔ANSWER-a. (b) the MMR vaccine should be given no sooner than 12 months of age, and ideally between 12 & 15 months of age. (a) 3-6 months should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered @ 18-24, but others like dTaP and Hep B may be given at that time. The mother of a preschool aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he has a "tummy ache" After reminding the mother to check the label of all OTC drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?
- ✔✔✔ANSWER-a. Do not give if the child has chickenpox, the flu, or any other viral illness a.i. Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (a) is a common effect of peptobismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D) complication of antacids containing calcium The nurse assigning care for 5 yr old child w/ otitis media is concerned about the child's inceasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? - ✔✔✔ANSWER-a. B- tympanic and oral temps are equally accurate a.i. A tympanic membrane sensor approximates core temps because the hypothalamus and eardrum are perfused by the same circulation. Typmpanic readings obtained using proper technique correlated moderately to strongly w/ oral temperatures in recent research studies The nurse is assessing a 13 yr old girl w/ susptected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? - ✔✔✔ANSWER-a. B-are you experiencing any type of nervousness? a.i. Assessing the client's physiological state upon admission is priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism, but assessing loss (even w/ a hearty appetite) (A) occurs in those w/ hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid The nurse is assessing a 2 year old. What behavior indicates that the child's language development is within normal limits? - ✔✔✔ANSWER-a. D- half of a child's speech is understandable a.i. Between approximately 15 & 24 months of age, a child's speech is only ½ understandable
The nurse is giving preoperative instruction to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? - ✔✔✔ANSWER-a. I understand that I will be in a body cast and I will show you how you taught me to turn a.i. Outcome of learning is best demonstrated when the client not only verbalizes an understand, but can also provide a return demonstration The nurse is having difficulty communicating w/ a hospitalized 6 yr old child. Which approach by the nurse is most helpful in establishing communication? - ✔✔✔ANSWER-a. A- engage the child through drawing pictures a.i. Drawing pictures is a valuable fr. non verbal communication. As the nurse & child look at the drawings, a verbal story can be told that projects the child's thinking The nurse is planning care for school-aged children @ a community care center. Which activity is best fo the children? - ✔✔✔ANSWER-a. B- playing follow the leader a.i. School aged children strive for independence and productivity (ericksons industry vs. inferiority) & enjoy individual & group activites r/t real life situation, such as playing follow the leader The nurse is planning the care of a 2 year old w/ severe eczema on the face, next, and scalp fr. scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the purities? - ✔✔✔ANSWER-a. C- place elbow restraints on the child's arms. a.i. Elbow restraints prevent arm flexion and scratching of involved area, but do not inhibit use of the nads for play activities. Others can be removed easily The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction? - ✔✔✔ANSWER-a. B- store all toxic agents and medicines in locked cabinets. a.i. The only reliable way to prevent poisoning in young children is to make them inaccessible The nurse is teaching a 12 yr old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated w/ growth hormone therapy, should the nurse plan to describe to the child and his family? - ✔✔✔ANSWER-a. A- polyuria/polydipsia a.i. s/s of diabetes or hyperglycemia need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance
The nurse is teaching a mother to give 4ml of a liquid antibiotic to a 10 month old infant. Which statement by the parent indicates a need for further teaching? - ✔✔✔ANSWER-a. B- using a teaspoon will help me measure this correctly a.i. The prescribed medication is 4ml dosage and is measured w/ the most accuracy using a syringe, so if the parent uses teaspoon which is equiavelnt to 5ml, further teaching is indicated The nurse is teaching the parents of a 5 yr old w. cystic fibrosis about respiratory treatment. Which statement indicates to the nruse that the parents understand? - ✔✔✔ANSWER-a. C- administer aerosol therapy followed by a postural drainage before meals. a.i. Postrural drainage for a child w/ cystic fibrosis is most effective when performed after nebulization and before meals or at least 1 hour after eating to prevent nausea & vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (which open airways).. Pulmonary toileting or respiratory treatment should be given 3-4 times daily, not esisodically The nurse observes a 4 yr old boy in a daycare setting. Which behavior would the nurse consider normal for this child? - ✔✔✔ANSWER-a. C- demonstrates aggressiveness by boasting when telling a story a.i. C- 4yr old children are aggressive in their behavior and enjoy "tale telling" The nurse received a lab report stating a child w/ asthma has theophyline level of 15 mcg/dl. What action will the nurse take? - ✔✔✔ANSWER-Pass the information on in the report. a.i. Therapeutic levels of theophylline is 10-20 mcg/dl, so the child's level is w/in the therapeutic rage. this information evaluates the prescribed therapy and should be communicated in the nurse's report. The parents of a 3 week old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? - ✔✔✔ANSWER-a. A- description of vomiting episodes in past 24 hrs a.i. A description of the vomiting episodes will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant/ The signs of hyperglycemia? - ✔✔✔ANSWER-Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, and syncope
What are common signs of digoxin toxicity? - ✔✔✔ANSWER-Diarrhea, fatigue, weakness, nausea, and vomiting; the nurse should check for bradycardia prior to administration What are the metabolic effects of PKU? - ✔✔✔ANSWER-CNS damage, mental retardation, and decreased melanin What are the outcomes of untreated congenital hypothyroidism? - ✔✔✔ANSWER-Mental retardation and growth failure What are the physical assessment findings for a child with asthma? - ✔✔✔ANSWER-Expiratory wheezing, rales, tight-cough, and signs of altered blood gases What are the physical features of a child with down syndrome? - ✔✔✔ANSWER-Simian creases in palms, hypotonia, protruding tongue, and upward-outward slant of eyes What are the priorites for a child undergoing abdominal surgery? - ✔✔✔ANSWER-Maintain fluid balance (I&O, nasogastric suction, monitor electrolytes); monitor VS; care for rains, if present; assess bowel function; prevent infection of incisional area and other postop complications, and support child and family with teaching What are the s/s of compartment syndrome - ✔✔✔ANSWER-Abnormal neurovascular assessmentl cold extremity, severe pain, inability to move the extremity, and poor capillary refill What are the s/s of congenital dislocated hip in infants? - ✔✔✔ANSWER-Unequal skin folds of the buttocks. Ortolani sign, limited abduction of the affected hip, and unequal leg lengths What are the side effects of Dilantin? - ✔✔✔ANSWER-Gingival, hyperplasia, dermatitis, ataxia, GI distress What are the signs of anorectal malformation? - ✔✔✔ANSWER-A newborn who does not pass meconium within 24 hrs; meconium appearing through a fistula or in the urine; an unusual-appearing anal dimple
What are the symptoms of congenital hypothyroidism in early infancy? - ✔✔✔ANSWER-Larg, protruding tongue, coarse hair, lethargy, sleepiness, and constipation What are the three classic signs of diabetes? - ✔✔✔ANSWER-Polydipsia, polyphagia, and polyuria What are the two objectives in treating congestive heart failure? - ✔✔✔ANSWER-Reuce the workload of the heart, and increase cardiac output What are two nursing priorities for a newborn with myelomeningocele? - ✔✔✔ANSWER-Prevention of infection of the sac and monitoring for hydrocephalus (measure head circumference; check fontanel; assess neurologic functioning). What cardiac complications are associated with rhematic fever? - ✔✔✔ANSWER-Aortic valve stenosis and mitral valve stenosis What care is indicated for a child with juvenile rheumatoid arthritis? - ✔✔✔ANSWER-Prescribed exercise to maintain mobility; splinting of affected joints; and tea ching about medication management and side effects of drugs What care is needed for a child with a temporary colostomy? - ✔✔✔ANSWER-Family needs education about skin care and appliances. Referral to an enterostomal therapist is appropriate. What discharge instructions should be included concerning a child with a spica cast? - ✔✔✔ANSWER- Check child's circulation. Keep cast dry. Do not place anything under cast. Prevent cast soilage during toileting or diapering. What disease occurs with vitamin C defiency? - ✔✔✔ANSWER-Scurvy What early signs should the nurse assess for if lead poisoning is suspected? - ✔✔✔ANSWER-Anemia, acute cramping, abdnominal pain, vomiting, constipation, anorexia, lethargy, hyperactivity, aggression, impulsiveness, decreased interest to play, irritability, short attention span.
