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A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? --------- Correct Answer ----------- A toddler is expected to play in parallel with other children. As socialization begins, the child plays alongside other children, not with them. A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to reduce these manifestations? --------- Correct Answer ----------- The knee-chest position, which is similar to squatting, facilitates the oxygenation of the lungs. The nurse should assist the child into this position to facilitate breathing. A nurse is collecting data from a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs exed and a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? --------- Correct Answer ----------- Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence of acrocyanosis. A nurse is caring for a 3-year-old child on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child? --------- Correct Answer --------- -- Preschoolers have increasing ne motor control and imagination abilities. They enjoy toys that allow for creativity and self-expression. A nurse is caring for a child who adheres to a vegetarian diet and has sustained supercial partial-thickness burns. The nurse should recommend which of the following food choices due to the highest protein content? --------- Correct Answer ----------- Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which helps with the healing process. A nurse is reinforcing teaching about the introduction of solid foods with the parent of an infant. Which of the following instructions should the nurse provide? --------- Correct Answer ----------- The extrusion reex results in food being pushed out of the mouth instead of being swallowed. The tongue extrusion reex diminishes after 4 months of age

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of these laboratory values? --------- Correct Answer ----------- An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration A nurse is caring for a newborn who has spina bida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? --------- Correct Answer ----------- Touching and caretaking will assist the parents with bonding with the newborn. A nurse is collecting data on a toddler at a well-child visit. Which of the following observations should the nurse report to the provider as a potential manifestation of an autism spectrum disorder? --------- Correct Answer ----------- Decits in social development, communication, and behavior are core characteristics of children with an autism spectrum disorder. They often display a lack of interest in social interaction and demonstrate delays in language skills, play, and motor function. They may also display repetitive, impulsive behaviors such as rocking, hand apping, spinning, and twirling A nurse is contributing to the preoperative teaching plan for a school-aged child who is scheduled for cardiac surgery. Which of the following recommendations should the nurse make? --------- Correct Answer ----------- The nurse should recognize the school- aged child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis (JIA). Which of the following actions should the nurse include in the plan?. --------- Correct Answer ----------- The nurse should encourage the child to remain physically active to promote mobility and joint function A nurse is talking with a parent of a preschooler. The parent reports that her child becomes upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent? --------- Correct Answer ----------- Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime and allow parental-child interaction prior to bed. A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following ndings should the nurse identify as a manifestation of severe dehydration? ---- ----- Correct Answer ----------- The nurse should identify skin that is cool to the touch, acrocyanosis, and mottled skin as indications of severe dehydration. The infant might also display a delayed capillary rell of >4 seconds. A nurse is collecting the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform?. --------- Correct Answer ----------- It is best to count

the infant's respirations while the infant is calm and before being disturbed. The pulse should be taken next, followed by the temperature, which is the most disruptive assessment to an infant. A nurse is reinforcing teaching with a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods should the nurse increases the risk of choking in toddlers? (Select all that apply.) --------- Correct Answer ----------- Foods that are tubular or circular in shape such as hot dogs and grapes increase the risk of choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew such as bagels and marshmallows can block the airway if swallowed before they are adequately chewed A nurse is caring for a 1-week-old newborn whose mother wants to breastfeed. For which of the following diagnoses is breastfeeding contraindicated due to the newborn's inability to process lactose? --------- Correct Answer ----------- A baby who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected newborns. A nurse is checking the ne motor development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? --------- Correct Answer -----------. The nurse should expect a 3-year-old child to have the ne motor ability to copy a circle. A 4-year-old child should have the ability to copy a square. A school nurse is collecting data from an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following ndings should the nurse identify as the reason for this excusal? --------- Correct Answer ----------- An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, he must avoid activities that might result in trauma to the enlarged spleen. A nurse on a pediatric unit is assisting with the admission of 4 children from the emergency department. After receiving a verbal report from the nurse, for which of the following children should the nurse plan to initiate droplet precautions? --------- Correct Answer ----------- The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis (whooping cough) is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include a fever, sneezing, and a severe productive cough that generally becomes worse before getting better. A nurse is reinforcing teaching about home care with the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? --------- Correct Answer ----------- Zinc oxide can be applied as a barrier ointment to areas that are reddened or open and moist. While removing the waste material, zinc oxide should

be left in place as much as possible during a diaper change. More ointment can be applied as needed. The ointment can be removed, if necessary, by applying mineral oil to the area and gently wiping. A nurse is caring for an adolescent client whose weight is in the 76th percentile on a growth chart. Which of the following recommendations should the nurse make?. --------- Correct Answer ----------- The nurse should recommend having frequent group meals in which everyone in the adolescent's household sits and eats together as an important behavioral modication to prevent obesity A nurse is providing immediate postoperative care for a child who had a tonsillectomy. Which of the following actions should the nurse take? --------- Correct Answer ----------- Straws can accidentally injure the surgical site and cause bleeding. Their use should be avoided in the immediate postoperative period. A nurse is reinforcing teaching about otic medication administration with the guardian of an 18-month-old toddler. Which of the following statements should the nurse make? ----- ---- Correct Answer ----------- The nurse should instruct the guardian to pull the pinna gently down and back to straighten the eustachian tube when administering the medication A nurse is collecting data on an infant who has coarctation of the aorta. Which of the following ndings should the nurse expect? --------- Correct Answer ----------- Coarctation of the aorta is an obstructive defect in which there is constriction of the aorta near the ductus arteriosus. This narrowing causes an increased pressure in the aorta prior to the defect, which causes the blood pressure in the arms to be higher than that of the lower extremities A nurse is reinforcing teaching with the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? --------- Correct Answer ----------- The parent should withhold the medication and notify the provider if the infant's heart rate is less than 110/min A nurse is reinforcing teaching about home safety and poisoning with the guardian of a toddler. Which of the following statements by the guardian indicates understanding? ---- ----- Correct Answer ----------- The National Poison Control Center can assist guardians in knowing how to handle accidental poisoning. They can provide information about expected effects, treatment, and seeking medical care A nurse is reinforcing teaching with a school-aged child who has just had a berglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse reinforce with the child and his parents about care during the rst 48 hours? --------- Correct Answer ----------- Immediately following the injury and for at least the rst 48 hours, the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return.

A nurse is caring for a 4-week-old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following ndings is an indication that the surgery was successful? --------- Correct Answer ----------- A bilirubin level of 0.3 mg/dL is within the expected reference range and indicates the surgery was successful. A nurse is caring for a toddler. Which of the following laboratory ndings should the nurse report to the provider? --------- Correct Answer ----------- The expected reference range for a toddler is a creatinine level of 0.3 to 0.7 mg/dL. This level is above the expected reference range and should be reported to the provider A nurse is collecting data from a 1-week-old infant at a well-baby visit. The nurse should notify the provider about which of the following assessment ndings? --------- Correct Answer ----------- This discoloration is associated with osteogenesis imperfecta, a genetic disorder which results in bone fragility. The nurse should notify the provider of this nding A nurse is collecting data from a 6-year-old child who is immediately postoperative following a tonsillectomy. Which of the following ndings should the nurse report to the provider? --------- Correct Answer ----------- The nurse should identify that frequent swallowing is a manifestation of hemorrhage. Therefore, the nurse should immediately notify the provider of this nding. A nurse is reinforcing teaching with the parent of a toddler who is hospitalized and has varicella. Which of the following points should the nurse reinforce? --------- Correct Answer ----------- Varicella requires airborne and contact precautions because the mode of transmission is by direct or indirect contact with saliva or open vesicles A nurse is collecting data from a toddler who has Down syndrome. Which of the following ndings should the nurse expect? --------- Correct Answer ----------- The nurse should expect to nd a transverse palmar crease in a toddler who has Down syndrome. Other ndings associated with Down syndrome include a attened forehead, a small nose with a depressed nasal bridge, a protruding tongue, a protruding abdomen, short stature, hyperexibility, muscle weakness, hypotonia, and a short, broad neck A nurse is collecting data from a 10-month-old infant at a well-infant checkup. Which of the following assessment ndings should the nurse report to the provider? --------- Correct Answer ----------- An infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this nding to the provider A nurse is reinforcing preoperative teaching for a 5- year-old child. Which of the following interventions should the nurse include? --------- Correct Answer ----------- Teaching for a preschooler should focus on the child's sensory experience. The teaching can also include what the child can do during the procedure A nurse on a pediatric care unit is assisting with the care of a child who has autism spectrum disorder. Which of the following actions should the nurse take? --------- Correct

Answer ----------- Children with autism spectrum disorders have difculty adjusting to new situations. The staff should keep interactions with the child as brief as possible. A nurse is observing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? - --------- Correct Answer ----------- month-old infant should be able to turn completely over, sit momentarily without support, and reach to be picked up. A nurse is reinforcing teaching about post-seizure care with the parent of a school-aged child who has a seizure disorder. Which of the following should the nurse include? ------- -- Correct Answer ----------- During a tonic-clonic seizure, the child may inadvertently bite the tongue, cheeks, and lips. The parents and caregivers should check for these types of injury after the seizure has stopped. A nurse is collecting developmental data on a 4- year-old child. Which of the following ndings should the nurse expect? --------- Correct Answer ----------- The nurse should expect a 4-year-old child to have the gross motor ability to hop on 1 foot. A nurse is planning to perform chest physiotherapy (CPT) for an infant who has cystic brosis. Which of the following techniques should the nurse plan to include? --------- Correct Answer ----------- Percussion involves striking a cupped or curved palm against the infant's chest to produce an audible thumping noise. This technique loosens the mucus in the airway for expectoration and should not produce discomfort A nurse is reinforcing teaching with the guardian of an adolescent. The guardian reports that the adolescent sleeps for about 10 hours on weekend nights. Which of the following responses should the nurse make? --------- Correct Answer ----------- The nurse should identify that sleeping for 10 hours on weekend nights is an expected nding because adolescents need more sleep time than other age groups. Common reasons for the increased need for sleep include stress; busy schedules, including extracurricular activities; and rapid physical growth A nurse is assisting with an informational session about otitis media for a group of parents. Which of the following should the nurse identify as a risk factor for this illness? --------- Correct Answer ----------- The nurse should identify passive smoking as a risk factor for otitis media. Exposure to secondhand smoke promotes attachment of pathogens to the middle ear, extends the inammatory response, and impairs drainage through the eustachian tube. Each of these effects increases the risk of developing otitis media A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago, and he is currently experiencing the despair stage of separation anxiety. Which of the following ndings should the nurse expect? --------- Correct Answer ----------- This child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.

A nurse is reinforcing teaching with a 13-year-old client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of diabetes mellitus management? --------- Correct Answer ----------- Blood glucose levels should be checked every 3 hours during illness for a client who has type 1 diabetes mellitus, even if the client consumes fewer calories than usual. Hyperglycemia often occurs with an infection, requiring additional doses of insulin A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? --------- Correct Answer ----- ------ The nurse should check the bag for stool every 4 hours or less to prevent the bag from overlling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin. A nurse is preparing to administer an intramuscular injection to a 2-week-old infant. Which of the following interventions should the nurse plan to perform?. --------- Correct Answer ----------- The vastus lateralis muscle is a large, easily accessible muscle in infants and children. A nurse is reviewing the laboratory values for a 6- month-old infant who has acute renal failure. Which of the following ndings should the nurse expect? --------- Correct Answer - ---------- The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEq/L is below the expected reference range for an infant A nurse is reinforcing teaching with the parent of a school-aged child who has muscular dystrophy. Which of the following instructions should the nurse reinforce? --------- Correct Answer ----------- The nurse should reinforce with the parent that children who have muscular dystrophy can benet from a diet that is low in calories and high in protein. This low-calorie diet helps prevent excessive weight gain, which can aggravate mobility issues A nurse is collecting data from an adolescent who takes insulin for the treatment of type 1 diabetes mellitus. The nurse should identify which of the following findings indicates effective management of the client's diabetes mellitus? --------- Correct Answer ----------- The nurse should identify that a blood glucose value of 140 mg/dL at bedtime is within the expected reference range for an adolescent. This finding indicates the effectiveness of the client's insulin treatment and management of diabetes mellitus A nurse is reinforcing teaching about baclofen with the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? --------- Correct Answer ----------- Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? -----

---- Correct Answer ----------- The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator A nurse is assisting with the care of a school-aged child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? --------- Correct Answer ----------- Placing the child on a pressure-reduction mattress will reduce the pressure on bony prominences, which decreases the risk of skin breakdown. A nurse is reinforcing teaching about exercise with an adolescent client who has type 1 diabetes mellitus. Which of the following points should the nurse reinforce? --------- Correct Answer ----------- Eating additional carbohydrates or decreasing the regular insulin injection according to an established protocol before exercise is sometimes necessary to prevent hypoglycemia. A nurse is reinforcing teaching with the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicate an understanding of the teaching?(Select all that apply.) --------- Correct Answer ----------- A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. Clients with this condition receive high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. The temperature of a child with Kawasaki disease should be recorded until she has been afebrile for several days A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer? --------- Correct Answer ----------- A child who has acute otitis media should take an antibiotic to help alleviate the infection. A nurse is collecting data from a toddler who has AIDS. The nurse should identify which of the following ndings as an indication of an opportunistic infection? --------- Correct Answer ----------- Candidiasis (oral thrush) results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS A nurse is reinforcing teaching with a 12-year-old child who is recovering from an acute bleeding episode of hemophilia A. Which of the following statements should the nurse make? --------- Correct Answer ----------- Although the child still needs to be seen by a health care provider, applying pressure and ice to the site of the bleeding can help control the bleeding and prevent the need for hospitalization. A hospice nurse is assisting with a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse reinforce in the teaching? --------- Correct Answer ----------- The nurse should identify that toddlers

have very little understanding of death. Their reaction is related to changes in routine and parents' emotions. A nurse in a provider's ofce is collecting data from a client. The nurse determines the client's body mass index (BMI) is 21.2. This nding is classied as which of the following? --------- Correct Answer ----------- Body mass index is a measure of an individual's weight relative to height. A BMI from 18.5 to 24.9 is in the healthy range. Therefore, this client's weight is considered healthy. A nurse is assisting the provider with a preschooler's annual exam. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make? --------- Correct Answer ----------- The preschooler should gain about 2 to 3 kg (4.4 to 6.6 lb) each year. Therefore, the nurse should reassure the parent that this child's weight gain is an expected nding for the age group A school nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? --------- Correct Answer ----------- Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint. A nurse is reinforcing teaching with an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? --------- Correct Answer ----------- The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18-month-old infant who has Pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors? - - ------- Correct Answer ----------- Transmission of HIV from a woman to her infant can occur during pregnancy, delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants. A nurse is reinforcing teaching about home care with the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide? - -------- Correct Answer ----------- The nurse should instruct the guardian that the adolescent should be allowed to participate in noncontact sports such as walking, bowling, and golf. Contact sports may be allowed if the adolescent wears protective gear and receives routine recombinant factor VIII infusions. A nurse is reinforcing teaching about injury prevention with the parent of an infant. Which of the following statements by the parent indicates an understanding of the teaching? --------- Correct Answer ----------- The nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration

A nurse is reinforcing discharge teaching with the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider? --------- Correct Answer ----------- manifestation of hemorrhage following a tonsillectomy is the constant clearing of blood that is draining in the back of the throat. Therefore, the provider should be notied if the adolescent begins constantly clearing her throat following a tonsillectomy A nurse is collecting data from a 4-year-old preschooler about his gross motor skills. The nurse should expect the preschooler to perform which of the following activities? --- ------ Correct Answer ----------- The nurse should expect to nd that a 4-year-old preschooler is able to hop on 1 foot A nurse is reinforcing teaching with the parents of a 1-year-old infant regarding appropriate play activities for this age group. Which of the following activities should the nurse include? --------- Correct Answer ----------- This is an appropriate toy for a 12- month-old infant. Beads that are too large to pass through a toilet paper tube do not present a choking hazard. This toy would provide visual and tactile stimulation for a 1- year-old infant A nurse in a pediatric clinic is collecting data from a preschooler during a well-child visit. Which of the following ndings should the nurse report to the provider? --------- Correct Answer ----------- The nurse should identify that this blood pressure measurement indicates signicant hypertension, which requires further assessment to conrm. Therefore, the nurse should report this nding to the provider immediately A nurse is reinforcing teaching with the guardian of a schoolaged child who has diabetes mellitus about how to recognize diabetic ketoacidosis (DKA). Which of the following ndings should the nurse describe as a manifestation of this complication?.. --- ------ Correct Answer ----------- The nurse should identify that deep and rapid respirations are Kussmaul respirations, which is a manifestation of DKA. This respiratory pattern results from the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. The child's breath can be sweet-smelling due to the body's attempt to eliminate ketones through the respiratory system A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? --------- Correct Answer ----------- The nurse should recognize that celiac disease causes chronic diarrhea due to malabsorption. Other malabsorption conditions include short-bowel syndrome, lactose intolerance, and congenital enzyme deciency A nurse in a pediatric clinic is preparing to assist with a sweat chloride test for a toddler who is suspected to have cystic brosis. Which of the following actions should the nurse plan to take? --------- Correct Answer ----------- The nurse should ensure that the examination room is warm. A warm environment promotes the toddler's ability to

produce sweat for the sweat chloride test. To further promote sweating, the nurse should apply blankets to maintain the toddler's body heat during the test. A nurse is collecting data during a well-child assessment of a 7- year-old child who takes great pride in bringing school papers home. This behavior demonstrates which of the following of Erikson's stages of psychosocial development? B. --------- Correct Answer ----------- The developmental task of industry vs. inferiority is reected by a child's level of motivation in relation to personal achievements that build good character during the school-aged years (6 to 12 years) During a well-child visit, the guardian of a toddler expresses a concern that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? --------- Correct Answer ----------- Providing the toddler with a favorite toy at bedtime can help the toddler to feel more secure and facilitate sleep A nurse on a pediatric unit is assisting with the plan of care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan due to which of the following benets? --------- Correct Answer ----------- A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse will help decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people A nurse is reinforcing teaching with a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching?. --------- Correct Answer ----------- Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided. A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9°C (102°F). The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer per dose?(Fill in the blank with the numeric value only. Round the answer to the nearest tenth. Use a leading zero if applicable but do not use a trailing zero.) Show Explanation 78% of exam takers gotthis question correct. Correct Answer: To solve using the ratio and proportion method: STEP 1: What is the unit of measurement to calculate? mL STEP 2: What is the dose needed? 240 mg STEP 3: What is the dose available? 160 mg STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the quantity of the dose available? 5 mL STEP 6: Set up an equation and solve for X. Have/Quantity =

Desired/X 7.5 Back Next Check Answer 160 mg/5 mL = 240 mg/X mL X = 7.5 mL STEP 7: Round if necessar --------- Correct Answer ----------- A nurse is caring for a child who has an exacerbation of cystic brosis. Which of the following laboratory ndings should the nurse report to the provider immediately? --------- Correct Answer ----------- The nurse should apply the ABC prioritysetting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efciently carrying oxygen to them. Therefore, the nurse should report this nding to the provider immediately Oxygen saturation 85% Back Next A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L immediately. A nurse is caring for a 4-month-old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take? --------- Correct Answer ----------- The nurse should identify that a hypercyanotic spell occurs when a vascular spasm reduces pulmonary blood ow and forces blood to shunt from the right ventricle to the left ventricle through the ventricular septal defect. The nurse should place the infant in a knee-chest position to increase systemic vascular resistance, which will help force more blood through the pulmonary artery. A nurse in a pediatric clinic is reinforcing teaching with the parent of a school-aged child who has type 1 diabetes mellitus and an upper respiratory infection. Which of the following statements by the parent indicates an understanding of the instructions? ------- -- Correct Answer -----------. The nurse should identify that a child who has type 1 diabetes mellitus has an increased risk of diabetic ketoacidosis during an illness. Therefore, the nurse should instruct the parent to monitor the child's blood glucose level every 3 hours. A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? --------- Correct Answer ----------- Alcohol consumption is a maternal risk factor for the development of congenital heart disease. A nurse is assisting with the immediate postoperative care of an 8-month-old infant who had a cleft palate repair. Which of the following actions should the nurse perform? ------- -- Correct Answer ----------- Following a cleft palate repair, infants should be positioned side-lying to allow the drainage of blood and secretions and to minimize the risk of aspiration.

A nurse is caring for an infant receiving phototherapy for hyperbilirubinemia. Which of the following should the nurse recognize as an indication of increased bilirubin excretion? --------- Correct Answer ----------- Phototherapy promotes bilirubin excretion by changing the structure of bilirubin into a form which can be excreted through the bowel. The presence of loose green stools indicates accelerated bilirubin excretion. A nurse is collecting data for a school-aged child who has cystic brosis. Which of the following manifestations should the nurse expect? --------- Correct Answer ----------- Steatorrhea (large, bulky, greasy bowel movements) is a manifestation of cystic brosis. It is the result of an absence of pancreatic enzymes in the duodenum, which causes an inability to digest protein, fat, and some sugars. The resulting increase in intestinal ora and fat leads to bulk and a foul odor. A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take? --------- Correct Answer -----------. When caring for a toddler who is postoperative following a cleft palate repair, the nurse should apply elbow restraints (unless prescribed otherwise) to prevent the toddler from rubbing or disrupting the sutured area. A nurse is preparing to administer an oral liquid medication to a 6-month-old infant. Which of the following interventions should the nurse plan to perform? --------- Correct Answer ----------- The nurse should plan to administer small amounts of the medication into the side of the infant's mouth and allow swallowing before administering additional medication. A nurse is collecting data about the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? --------- Correct Answer ----------- The nurse should allow each child to wear his or her glasses during a screening for visual acuity A nurse is reinforcing dietary teaching with the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend?. --------- Correct Answer -----------. The nurse should instruct the parent to offer the toddler foods that are low in protein such as cooked carrots and fruits. A nurse is assisting with the care of a school-aged child who had a tonsillectomy. Which of the following interventions should the nurse take? --------- Correct Answer ----------- Straws should be avoided because they can accidently damage the surgical site and cause excessive bleeding A nurse is caring for a 3-year-old toddler who has Haemophilus inuenzae type b meningitis. Which of the following actions should the nurse take? --------- Correct Answer ----------- Using a pillow when in a supine position will cause exion of the neck, which increases discomfort in most children due to nuchal rigidity.

A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching? --------- Correct Answer -----------. Weight loss and diet modications improve the body's insulin use and normalize hormone levels. A reduced-carbohydrate diet and exercise increase the cells' sensitivity to insulin and helps normalize testosterone secretions, ultimately reducing PCOS manifestations. A nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching? --------- Correct Answer ----------- The nurse should instruct the parent to weigh the child 2 to 3 times per week to monitor for weight loss, which is an adverse effect of methylphenidate. The parent should report weight loss to the provider A nurse is reinforcing teaching about prevention with the parents of a 3-year-old child who has persistent otitis media. Which of the following statements by the parents indicates an understanding of the teaching? --------- Correct Answer ----------- Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inammation of the respiratory tract. A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take rst? --------- Correct Answer -----------. When using the urgent vs. nonurgent approach to client care, the nurse should rst administer an antipyretic to decrease the toddler's body temperature A nurse is reinforcing teaching with the guardian of a toddler about preventing burn injuries. Which of the following pieces of information should the nurse include? --------- Correct Answer ----------- The nurse should instruct the guardian to use a cool-mist vaporizer rather than a steam vaporizer in the home because the steam from a steam vaporizer can cause scalding. A nurse is reinforcing care instructions with the parent of a child who has a newly placed gastrostomy tube. Which of the following statements demonstrates an understanding of the instructions? --------- Correct Answer ----------- When administering multiple medications at the same time through the gastrostomy tube, the tube should be ushed with clear water in between each medication. A nurse is caring for a preschool-aged child who presents with manifestations of epiglottitis. Which of the following actions is the nurse's priority to perform? --------- Correct Answer -----------. When using the airway, breathing, and circulation (ABC) approach to client care, the nurse's priority is to place resuscitation equipment and suction equipment at the bedside. Children with epiglottitis may develop sudden respiratory obstruction. A nurse is caring for a preschooler who has a vesicular, honeycolored, crusty region around the nose and mouth and has been diagnosed with impetigo contagiosa. Which

of the following instructions should the nurse plan to reinforce with the parents? --------- Correct Answer -----------. Impetigo contagiosa is a bacterial infection of the skin. Therefore, the nurse should plan on reinforcing teaching about applying an antibacterial ointment, washing the child's bed linens daily in hot water, and washing hands before and after contact with the affected area to decrease the risk of reinfection or transmission to others. A nurse is reinforcing teaching with the guardian of a toddler who has fth disease. Which of the following statements should the nurse include in the teaching? --------- Correct Answer ----------- The toddler is no longer contagious once a red rash appears on his cheeks. Initial manifestations of fth disease can last for 7 to 10 days and include a fever, a headache, and malaise. Following the rash on the cheeks, a maculopapular rash can appear on the arms, thighs, and buttocks. Treatment for fth disease is primarily symptomatic to promote comfort. A nurse is caring for a 2-year-old child who has a history of frequent urinary tract infections. When reinforcing teaching with the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include? --------- Correct Answer ----------- The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra. A nurse is assisting with the care of a child who has paralytic poliomyelitis. Which of the following actions should the nurse take?. --------- Correct Answer ----------- Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause discomfort. A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use?.. --------- Correct Answer ----------- The FACES pain rating scale presents the client with various images of faces that represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels A nurse working on a maternal-newborn unit is assisting with planning an in-service training session for staff about assisting new mothers with breastfeeding. Which of the following infant conditions should the nurse recommend including in the teaching as a contraindication for breastfeeding? --------- Correct Answer ----------- An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes. A nurse is reviewing laboratory ndings of an adolescent who has acute renal failure. Which of the following ndings should the nurse expect? --------- Correct Answer -----------

. Metabolic acidosis is an expected nding for clients who have acute renal failure

A nurse is inspecting the eyes of a 5-day-old infant. Which of the following is the correct technique for the nurse to use? --------- Correct Answer ----------- To inspect the eyes of an infant, the nurse should lay the infant in a supine position and lift the head. This maneuver usually causes the infant to open the eyes. A nurse is reinforcing teaching with a 10-year-old child who requires crutches for a 2- point gait. Which of the following instructions should the nurse reinforce? --------- Correct Answer ----------- Using the crutch opposite the foot provides a wider base of support than using the crutch next to the foot. This is the correct way to use the 2-point gait with crutches. A nurse is assisting with the care of an infant who has pertussis. Which of the following actions should the nurse take?. --------- Correct Answer ----------- Infants with pertussis typically present with apnea in response to coughing spasms and mucus plugs. Humidied oxygen and suction equipment should be used as needed A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse,"My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take? --------- Correct Answer ----------- The nurse should prepare to assist with the administration of intravenous uids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to nish a bottle of formula. Also, uids will help loosen congestion, which typically occurs with RSV A nurse is reinforcing discharge teaching with the parent of a newborn who has been prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? --------- Correct Answer ----------- The parent should lightly massage the skin under the harness daily to promote circulation. A nurse is reinforcing teaching about home safety with the parent of a 2-month-old infant. Which of the following information should the nurse include?. --------- Correct Answer ----------- The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation. A nurse is applying EMLA cream to a child's hand prior to the insertion of an intravenous catheter. Which of the following interventions should the nurse perform? ---- ----- Correct Answer ----------- A. EMLA cream is a topical anesthetic that should be applied at least 60 minutes prior to a procedure. Procedures requiring deeper penetration such as a bone marrow aspiration may require application 2 to 3 hours prior to the scheduled procedure A nurse is caring for a child who has electrical burns on her lower arms and hands. Which of the following ndings indicates the child is experiencing a complication of the injury? --------- Correct Answer ----------- Dark urine can be an indication of

myoglobinuria. It results from elimination of waste products from muscle damage and can cause renal failure. A nurse is caring for a child who has electrical burns on her lower arms and hands. Which of the following ndings indicates the child is experiencing a complication of the injury? --------- Correct Answer ----------- Dark urine can be an indication of myoglobinuria. It results from elimination of waste products from muscle damage and can cause renal failure. A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? --------- Correct Answer ----------- The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The rst 3 doses are administered between 2 months and 18 months of age. A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? --------- Correct Answer ----------

• When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should determine that the priority item to have in the child's room is suction equipment. If the child experiences a tonicclonic seizure, the child is at risk for aspiration and airway occlusion due to secretions, food, or uids. The nurse should have suction equipment available to maintain a patent airway for effective respiration, administration of oxygen, and use of a bag valve mask if needed. A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse,"My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take? --------- Correct Answer ----------- The nurse should prepare to assist with the administration of intravenous uids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to nish a bottle of formula. Also, uids will help loosen congestion, which typically occurs with RSV. A newly licensed nurse in an urgent care center is caring for a child who has bruises that raise suspicion for child abuse. Which of the following actions should the nurse take? --------- Correct Answer ----------- The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement. A nurse in an acute pediatric unit is caring for a 2- year-old child who has separation anxiety when her parents leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? --------- Correct Answer - ---------- Separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse prepare to administer? --------- Correct Answer ----------- The nurse should prepare to administer albuterol to a child who is experiencing an acute exacerbation of asthma and requires a rescue medication. Albuterol is a betaadrenergic agonist that promotes bronchodilation and suppresses histamine release in the lungs. A nurse is contributing to the plan of care for a preschool-aged child who has Wilms tumor. Which of the following items should the nurse include in the plan of care prior to surgery? --------- Correct Answer ----------- Wilms tumor is an encapsulated tumor typically involving only 1 of the child's kidneys. Palpation or pressure on the abdomen could cause the cancerous cells to spread to other parts of the body. The nurse should use extreme care when bathing and handling the child pre-operatively. A nurse is collecting data from an infant who is experiencing respiratory distress, absence of breath sounds on a side, and deviation of the trachea away from the affected side. The nurse should identify that the infant is experiencing which of the following conditions? --------- Correct Answer ----------- These manifestations indicate the infant is developing a tension pneumothorax. The infant might also become cyanotic and show asymmetry of the thorax. A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurse's priority to collect? --------- Correct Answer - ---------- The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent ndings to be the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which nding is the most critical. Daily weights are the most sensitive indicator of uid balance in clients of all ages. Daily weights are especially critical for infants and children because uid accounts for a greater portion of body weight. A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso- occlusive crisis. Which of the following actions should the nurse take? --------- Correct Answer ----------- The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic A nurse on a pediatric mental health unit is caring for a school-aged child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation? --------- Correct Answer ----------- The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication. A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy? --------- Correct Answer --------

--- Correct Answer: B. The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction. A nurse is contributing to the plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse recommend for the child? --------- Correct Answer ----------- The nurse should recommend putting together a puzzle with large pieces for a hospitalized preschooler. Other recommended activities for preschoolers on airborne precautions include playing pretend and dress up, painting, and looking at illustrated books A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following ndings should the nurse identify as a manifestation of hypoglycemia?. --------- Correct Answer ----------- A rapid heart rate is a manifestation of hypoglycemia. Other manifestations the nurse should expect the child to exhibit include tremors, difculty concentrating, dizziness, hunger, and irritability A nurse is collecting data from an infant who has diabetes insipidus (DI). Which of the following ndings should the nurse expect? --------- Correct Answer ----------- Diabetes insipidus is characterized by a decreased secretion of ADH, which results in an increased production of urine. A nurse is contributing to the plan of care for a 6- month-old infant who has respiratory syncytial virus (RSV). Which of the following interventions should the nurse plan to include? --------- Correct Answer ----------- Respiratory syncytial virus is a highly contagious virus that is spread through contact with respiratory secretions and via large droplets. Therefore, both forms of isolation are indicated for a client with this infection. The nurse is reinforcing teaching for the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching? --- ------ Correct Answer ----------- Explanation: Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged. A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take rst? --------- Correct Answer ----------- The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should gently ease the child onto the oor to decrease the chance of injury and turn the child on her left side to prevent aspiration. A nurse in an urgent care clinic is collecting data from an infant who recently started taking digoxin for a supraventricular arrhythmia. Which of the following ndings should the nurse identify as a possible indication of digoxin toxicity? --------- Correct Answer ---- ------- Vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider immediately

A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? --------- Correct Answer ----------- The infant can receive the rst dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age. A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? --------- Correct Answer ----------- A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands. A nurse is caring for a school-aged child who has epilepsy and is experiencing a tonic- clonic seizure. Which of the following actions should the nurse take?. --------- Correct Answer ----------- The nurse should loosen any clothing that is conning (e.g. around the child's neck) to reduce the risk of injury during a seizure. A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? --------- Correct Answer ----------- Age-appropriate playtime objects for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, nger paints, modeling clay, and musical toys. These toys allow manipulation and exploration and meet the child's developmental and diversional activity needs. A nurse is caring for an infant who has neonatal abstinence syndrome (NAS). Which of the following interventions should the nurse perform? --------- Correct Answer ----------- Infants with NAS should be snugly swaddled with their arms in a exed position to place the hands near the mouth. This position allows self-soothing behaviors and decreases irritability A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse include? --------- Correct Answer ----------- The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection A nurse is caring for a 4-month-old child who is hospitalized. Which of the following playtime objects should the nurse provide for the child? --------- Correct Answer ----------- The 4-month-old infant can recognize himself/herself and will also try to play with "the baby in the mirror." A mirror is a bright object that provides appropriate visual stimulation for this age group. For the infant's safety, however, the mirror must be unbreakable. A school nurse is assisting a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following ndings should the nurse expect if the child develops anaphylaxis?(Select all that apply. --------- Correct Answer ----------- Nausea and hives are common responses to excessive histamine release. A serious, lifethreatening response to excessive histamine release is airway narrowing, which presents with dyspnea and stridor

A nurse is collecting data from a 3-year-old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? ---- ----- Correct Answer ----------- The nurse should expect a 3-year-old preschooler to have the ne motor ability to stack 10 blocks. A nurse is reinforcing discharge teaching with the parents of a school-aged child who has nephrotic syndrome and a prescription for corticosteroid therapy. Which of the following home-care instructions should the nurse include? --------- Correct Answer ------ ----- The nurse should instruct the parents to keep the child away from others who have or might have an infection. Children who have nephrotic syndrome are prescribed corticosteroids, which impair the immune system. Therefore, the child is at an increased risk of contracting an infection. A nurse is caring for an 8-year-old child in the acute care setting. Which of the following actions should the nurse take? --------- Correct Answer ----------- School-aged children are in Erikson's stage of Industry versus Inferiority. They are willing to accept and thrive when assigned the responsibility to perform simple tasks. A nurse on a pediatric unit is assisting with the admission of 4 children. For which of the following children should the nurse initiate droplet precautions?. --------- Correct Answer ----------- The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to other children on the unit. Pertussis is a bacterial infection that is transmitted via direct contact with or exposure to respiratory secretions from an infected child. Manifestations include a fever, sneezing, and a severe cough. A nurse is assisting with the care of a child who has epilepsy and just experienced a tonic-clonic seizure. Which of the following actions should the nurse take rst?. --------- Correct Answer ----------- When using the airway, breathing, and circulation (ABC) approach to client care, the rst action the nurse should take after a tonic-clonic seizure is to turn and maintain the child in a side-lying position. During tonic-clonic seizures, the tongue is hypotonic, the swallowing reex is diminished or lost, and the amount of saliva increases. These ndings exacerbate the child's risk of aspiration and occlusion of the airway. Therefore, placing the child in a side-lying position is the nurse's priority because it promotes drainage of the increased saliva and retains a patent airway. A nurse is reinforcing teaching with the parent of a toddler who is undergoing the insertion of tympanostomy tubes. Which of the following statements should the nurse include? --------- Correct Answer -----------. Tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own within 6 to 12 months after insertion. A nurse is collecting data for an adolescent who presents with manifestations of appendicitis. Which of the following manifestations should the nurse expect? --------- Correct Answer -----------. A rigid abdomen is an expected manifestation of appendicitis.

A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? --------- Correct Answer ----------- Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference can help determine any increase A nurse is assisting with the plan of care for a child who has hyperthermia. Which of the following actions should the nurse take? --------- Correct Answer ----------- A cooling blanket will lower the temperature of the blood circulating at the skin's surface. This cool blood will circulate to the viscera and lower the temperature of the organs and tissues. Heat from the internal organs will be circulated to the skin and dispensed to the cooler outside surface. A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following ndings should alert the nurse to a complication related to the casting? --------- Correct Answer ----------- The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome. A nurse is caring for an infant in an acute care setting who has a tracheostomy. Which of the following interventions should the nurse perform when suctioning?. --------- Correct Answer ----------- The nurse should wait for 30 to 60 seconds between passages of the suction catheter to allow the infant's oxygen saturation level to return to baseline A nurse is reinforcing teaching with an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the nonpharmacological strategy of thought-stopping? --------- Correct Answer - -------- -- Having the adolescent repeat memorized facts about the painful event is an example of the non-pharmacological pain management strategy of thought-stopping. Thoughts such as "the pain will be gone soon" or "I'll be home by this time tomorrow" can help the child control the pain. After listing the facts, the nurse should then have the adolescent condense and memorize the facts to repeat them whenever pain occurs. A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following ndings should the nurse identify as the priority? --------- Correct Answer --------- -- When using the urgent vs nonurgent approach to client care, the nurse should identify that the priority nding is a capillary rell of 5 seconds. A capillary rell above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock. A nurse is reinforcing teaching with the guardian of a child who has severe iron- deciency anemia and a new prescription for ferrous sulfate oral suspension. Which of the following statements by the guardian indicates an understanding of the instructions?

• -------- Correct Answer ----------- The nurse should inform the guardian that the child's hemoglobin and hematocrit levels should be monitored routinely for several weeks to

determine the effectiveness of treatment. The nurse should also inform the guardian that treatment can take up to 3 months to be effective. A nurse is reinforcing postoperative teaching with the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? --------- Correct Answer ----------- To prevent infection, the parent should be able to verbalize and demonstrate proper folding of the diaper to protect the surgical incision from contamination. A nurse is reinforcing teaching with the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include? --------- Correct Answer - ---------- The child should walk the bike through intersections and crosswalks to decrease the risk of injury. A nurse is teaching an adolescent client who has juvenile rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching? --------- Correct Answer ----------- The nurse should encourage this adolescent who has idiopathic arthritis to attend school. The adolescent should attend school, even on days when she experiences joint pain or stiffness. A nurse is collecting data from a child who is postoperative. Which of the following ndings should the nurse identify as an indication that naloxone should be administered? --------- Correct Answer ----------- The nurse should monitor the child's respiratory status postoperatively and plan to administer naloxone if respiratory depression is present. Naloxone is an opioid antagonist used to reverse the effects of opioids administered perioperatively. A nurse is reinforcing teaching with an adolescent about managing asthma and using a peak expiratory ow meter. Which of the following statements by the client demonstrates an understanding of the teaching? --------- Correct Answer -----------. This statement by the adolescent indicates an understanding of the teaching. A peak ow rate in the green zone indicates the current treatment has been effective; therefore, the adolescent should continue with their current medication regimen. A nurse in a provider's ofce is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups? --------- Correct Answer ----------- Toddlers demonstrate parallel play A nurse is planning to reinforce education with the parents of a school-aged child who has attentiondecit/hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? --------- Correct Answer ----------- A. Visual organizational charts are helpful for children with ADHD due to their high level of distractibility A nurse in an urgent care clinic is collecting data from a preschooler who has indications of child maltreatment. The nurse should identify that which of the following

ndings is a manifestation of physical abuse? --------- Correct Answer ----------- Bruises at various stages of healing are a manifestation of physical abuse A nurse is caring for an adolescent who has sickle cell anemia and is experiencing a vaso-oclusive crisis. Which of the following manifestations should the nurse expect? : --- ------ Correct Answer ----------- A. Clients in a vaso-oclusive crisis typically experience increased pain. The pain can be generalized or localized and might be stationary or migratory in areas such as the joints and abdomen. A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse take to help decrease the child's risk of experiencing a vaso-occlusive crisis? --------- Correct Answer ----------- Adequate hydration is an effective strategy for preventing sickle cell crises. Maintaining adequate hydration can reduce the risk of sickle cell formation A nurse is assisting with evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following ndings should indicate to the nurse that the surgery was successful? --------- Correct Answer ----------- An infant who has a biliary obstruction will have clay-colored stools because the ow of bilirubin into the intestinal tract is blocked. If the surgery is successful, the infant's stools will change to yellow and then brown in color A nurse is preparing to administer a vaccine to a 4- year-old child. Which of the following statements should the nurse include in the preparation for this procedure?. --- ------ Correct Answer ----------- The nurse should provide age-appropriate explanations to assist with reducing anxiety for children who are undergoing procedures. A nurse is assisting with evaluating an adolescent client who was treated for syphilis. Which of the following ndings indicates the treatment was effective? --------- Correct Answer -----------. A sudden episode of hypotension, fever, tachycardia, and muscle aches is known as a Jarisch-Herxheimer reaction, which is caused by the sudden destruction of spirochetes after therapy. A nurse is collecting data from a school-aged child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following ndings should the nurse investigate further as an indication of child --------- Correct Answer ----------- The nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this further and report the ndings to the provide A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group? --------- Correct Answer -----------. The nurse should recommend pushing a toy lawn mower as a play activity for a toddler. Toddlers are developmentally ready for pushpull toys, and they enjoy play activities that allow imitation of adults.

A nurse is collecting data from a 6-month-old infant. The guardian reports that the infant does not appear interested in the bright-colored mobile hanging above the crib. Which of the following techniques should the nurse use to check the infant's visual acuity? ------ --- Correct Answer ----------- The nurse should check the infant's ability to see by positioning the infant upright, holding a brightly colored toy or object in front of the infant's face, and moving it from side to side. The nurse should observe the infant for the ability to xate on the toy and track its movement. The nurse can also perform this data-collection technique using a human face as a visual target A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of acute lymphoblastic leukemia (ALL). Which of the following statements from the child indicates an understanding of the teaching? --------- Correct Answer ----------- Most children who have ALL and receive chemotherapy are expected to survive, with up to 95% achieving remission. A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?. --------- Correct Answer ----------- The nurse needs to apply continuous pressure for at least 10 minutes to help stop the child's bleeding. A nurse is reinforcing teaching with a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? --------- Correct Answer ----------- Adolescents might spend time using a computer, but parents should know what they are doing and who they are communicating with and limit the time. The American Academy of Pediatrics guidelines recommend 2 hours of screen time daily. A nurse is collecting data from an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority?. --------- Correct Answer -----------. When using the airway, breathing, and circulation (ABC) approach to client care, the nurse should identify that checking the adolescent's oxygen saturation level is the priority. By monitoring the adolescent's oxygen saturation level and respiratory status, the nurse can identify if the client has developed opioid-induced respiratory depressio A school nurse is checking the lunch tray of a school-aged child who has a new diagnosis of celiac disease. Which of the following foods should the nurse instruct the child to remove from the tray? --------- Correct Answer ----------- The school nurse should identify that wheat bread should be eliminated from the child's diet because it contains gluten. Therefore, the nurse should remove it or instruct the child to remove the roll from the tray. Foods containing rye and barley should also be eliminated from the child's diet. Consuming these foods can exacerbate the manifestations of celiac disease, including diarrhea, steatorrhea, abdominal distention, and abdominal pain. A nurse is reinforcing teaching with the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? ---------