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PEDS FINAL C 2020 Questions and Answers


1. A nurse is teaching a parent of a child with hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching? • “I will have my child rest.” • “I will compress the site.” • “I will apply heat.” • “I will elevate the affected part.” 2. A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? • Body weight • Skin integrity • Blood pressure • Respiratory rate 3. Which of the following children should the nurse identify as a potential action of abuse? • A child who has frequent visitors • A child who uses the call light frequently • A child who has a BMI indicating obesity • A child whose parents answer questions for the child 4. A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? • “My child will take the enzymes to improve her metabolism.” • “My child will take the enzymes 2 hours before meals.” • “My child will take the enzymes following meals.” • “My child will take the enzymes to help digest the fat in foods.” 5. A nurse is assessing a 3 month old. Which of the following findings should he report to the provider? • Unable to pick up an object with his fingers • Unable to sit without support • Unable to raise head when in prone position • Unable to bring an object to mouth 6. A nurse is admitting a 6 month old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has confirmed the fluid imbalance? • 2 mL/kg/hr. • 0.5 mL/kg/hr. • 7.5 mL/kg/hr. • 15 mL/kg/hr. 7. A nurse is planning care for an infant who has spina bifida and is to undergo surgical ? Which of the following interventions should the nurse include in the plan of care? • Maintain the infant in the supine position • Provide a latex free environment • Limit visitors to immediate family members • Initiate contact precautions 8. A nurse is caring for a child who has just died. The parents ask to be left alone so that they ? The nurse should: • Discourage this because it will only prolong their grief • Grant their request • Kindly explain that they need to say good bye to their child now and leave • Assess why they feel that this is necessary 9. A nurse is educating new parents on risk factors for sudden infant death syndrome (SIDS). Which of the following statements by a parent would indicate a need for additional teaching? • “I will give my baby a pacifier during naps and at bedtime.” • “Our baby will sleep in my bed because I am breastfeeding.” • “My baby will be placed on her back when sleeping.” • “We will remove blankets and toys from the crib.” 10. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client would indicate to the nurse a need for further teaching? • “I only need to catheterize myself twice every day.” • “I only use a suppository every night to have a bowel movement.” • “I do wheelchair exercises while watching TV.” • “I carry a water bottle with me because I drink a lot of water.” 11. A parent tells a nurse that her toddler drink a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk for which of the following disorders? • Rickets • Iron deficiency anemia • Obesity • Diabetes mellitus 12. A toddler weighs 77 pounds. What is the appropriate maintenance IV fluid rate? • 75 mL/hr. • 45 mL/hr. • 33 mL/hr. • 52 mL/hr. 13. A nurse is caring for a toddler admitted to a pediatric unit. Which of the following statements should the nurse use when preparing to check the child’s vital signs? • “Can you stand still while I feel how warm you are?” • “I am going to take your blood pressure now.” • “I am going to listen to your heart.” • “Can I listen to your lungs?” 14. A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child? • Rye • Wheat • Barley • Rice 15. A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child’s vital signs? • “I am going to take you blood pressure now.” • “Can you stand very still while I feel how warm you are?” • “I am going to listen to your heart.” • “Can I listen to your lungs?” 16. A nurse is panning care for a 5 month old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? • Keep the infant NPO for 6 hr. prior the procedure • Place the infant in an infant seat for 2 hr. following the procedure • Hold the infant’s chin to his chest and knees to his abdomen during the procedure • Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min. prior to the procedure 17. A nurse is assessing a toddler who has acute nephrotic syndrome. Which of the following findings should the nurse report to the provider? • Yellow nasal drainage • Poor appetite • Irritability • Facial edema 18. A parent calls a clinic and reports to a nurse that his 2 old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? • “Try switching to a different formula.” • “Bring your baby in to the clinic today.” • “Give your infant an oral rehydration solution.” • “Burp your baby more frequently during feedings.” 19. A nurse is panning home care for a 9 year old child who is discharged following an acute asthma attack. Which of the following growth and developmental stages according to Erikson should the nurse consider in the planning? • Identity versus role confusion • Initiative versus guilt • Industry versus inferiority • Autonomy versus shame and doubt 20. A nurse is caring for a child who has been physically abused by a family member. Which of the following is an appropriate statement for the nurse to say to the child? • “I promise I won’t tell anyone about this.” • “Your family is bad for doing this to you.” • “Let’s discuss what happened together with your family.” • “It is not your fault that this happened.” 21. A nurse is assessing an infant with Trisomy 21 (Down’s syndrome). Which of the following are common characteristics? (Select all that apply) • Muscular hypertonicity • Large ears • Protruding tongue • Hyperflexibility • Transverse palmar ceases 22. A nurse in an emergency department is assessing a 3 year old child who has a high fever, severe dyspnea, and is drooling. Which of the following interventions is the nurse’s priority? • Prepare for nasotracheal intubation • Obtain blood culture specimens • Insert an IV catheter • Administer an antipyretic 23. A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first? • Ask the client to blow his nose • Suction the nostril • Notify the physician • Test the drainage for glucose 24. A nurse at the pediatric hotline receives a call from a mother who plans to administer aspirin (St. Joseph Children’s) to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response? • “Give her acetaminophen, not aspirin.” • “Give her no more than three baby aspirin every four hours.” • “Follow directions on the aspirin bottle for her age and weight.” • “You’ll have to call your physician.” 25. A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask? • “Have you given your child aspirin in the past 2 weeks?” • “Has your child had any injuries recently?” • “Has your son had a sore throat recently?” • “Was your son born with this cardiac defect?” 26. A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client’s neurovascular status? • Measure the circumference of the thigh • Monitor the client’s calf for edema • Palpate the femoral pulse • Instruct the client to wiggle his toes 27. A nurse is caring for a client diagnosed with glomerulonephritis who has recurrent hypertension and edema. Analyzing the client’s lab results in relationship to his disease process, the nurse would expect to find an increase in which values? • RBC • Creatinine clearance • Specific gravity • BUN 28. A nurse is promoting meningococcal conjugate vaccine (Menactra) at a health fair. Which of the following individuals are candidates for the vaccination? • An 18 year old youth who lives in a college • A 65 year old person who volunteers at an elementary school • A 78 year old person who lives in an assisted living home • A 7 year old child who attends daycare before and after school 29. A client who is postpartum asks the nurse at a pediatric clinic what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply) • Turn on the radio • Swaddle the newborn in a receiving blanket • Allow the newborn to continue crying • Carry the newborn • Take the newborn for a ride in the car 30. A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler? • Participates in imaginary play • Builds a collection of cards • Controls impulsive feelings • Expresses need for privacy 31. A nurse is providing education to a school age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching? • “Use the peak expiratory flow meter once per week.” • “You should stop playing basketball, but you can swim instead.” • “Take cromolyn sodium at the first sign of breathing difficulty.” • “Avoid triggers that cause an attack.” 32. A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after initial diagnosis and treatment. The nurse should recognize that the parent understands the child’s nutritional needs when she states which of the following? • “I will limit my child’s fluid intake.” • “I will make certain that pancreatic enzymes are taken with all of my child’s snacks and meals.” • “I will prepare low-fat meals for my child.” • “I will restrict the amount of salt in my child’s food.” 33. A nurse is assessing an infant following a motor vehicle crash. Which of the following findings should the nurse monitor to identify increased intracranial pressure? • Depressed fontanels • Brisk pupillary reaction to light • Tachycardia • Increased sleeping 34. A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply) • Place the client in a side lying position • Assess the client’s airway patency • Restrain the client • Place a tongue depressor in the client’s mouth • Remove objects from the client’s bed 35. A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? (Select all that apply) • Apnea • Cyanosis • Coughing • Sunken abdomen • Frothy saliva 36. A nurse at a pediatrician’s office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? • Provide a high carbohydrate meal • Do nothing because the ferrous sulfate will induce vomiting • Contact the poison control center • Give the child syrup of ipecac 37. A nurse is assessing an 11 month old infant. Which of the following manifestations is associated with a CNS infection? • Jaundice • Bulging fontanel • Negative Brudzinski sign • Oliguria 38. A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make? • “Normal bone growth can be affected.” • “The blood supply to the bone is disrupted.” • “Bone marrow can be lost through the fracture.” • “The younger the child the longer the healing process will take.” 39. A nurse is reviewing data for four children. Which of the following children should the nurse assess first? • A 4 year old child who has asthma and a PCO2 of 37 mm Hg • A 7 year old child who has diabetes insipidus and a urine specific gravity of 1.000 • A 10 year old child who has sickle cell anemia who reports severe chest pain • A 1 year old toddler who has roseola and temperature of 38° C 40. A nurse is caring for an adolescent client who has pelvic inflammatory disease secondary to a sexually transmitted disease (STD) and will need intravenous antibiotic therapy. The child tells the nurse, “My parents think I am a virgin. I don’t think I can tell them I have an STD.” The appropriate response by the nurse is which of the following? • “If you want me to, I can tell your parents for you.” • “Your parents will have to know why you are being admitted.” • “Give your parents a chance, they’ll understand.” • “You seem frightened to tell your parents.” 41. A nurse is preparing to administer oral medication to a 3 month old infant. Which of the following actions should the nurse take to ensure successful administration? • Place infant supine in crib • Position syringe to the side of the tongue • Measure elixir using a medicine cup • Mix medication with formula 42. A nurse is completing a history and physical on a 3 year old child who is admitted for a surgical repair of Tetralogy of Fallot (TOF). Which of the following manifestations of the condition should the nurse expect? (Select all that apply) • Decreased PO • Obesity • Cyanosis • Systolic Murmur • Energetic 43. A nurse is caring for a 2 year old child who is hospitalized and throws a tantrum when his parent leaves. Which of the following toys should the nurse provide to alleviate the child’s stress? • Picture book about hospitals • Stuffed animals • Set of building blocks • Toy hammer and pounding board 44. A nurse is planning care for a 6 year old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client’s plan of care? • Implement seizure precautions • Admit the client to a private room • Measure head circumference every shift • Place the client in a semi-Fowler’s position 45. A nurse is caring for a hospitalized 4 year old child who is on airborne precautions. Which of the following activities is appropriate for the nurse to implement this child? • Putting a puzzle together • Watching a video game in the playroom • Constructing a model airplane • Pulling a wagon with toys in the hallway 46. A nurse is caring for a 10 month old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant’s growth and development? • Change the infant’s diaper as soon as soiling occurs • Tie colorful latex balloons to the side of the crib • Provide a small electronic toy • Allow the infant to stand in the crib 47. A nurse is discussing the effects of chemical agents on infants. Which of the following identifies the rationale for an infant’s increased absorption through the skin? • Infants have a larger body surface area relative to weight • Infants have an immature nervous system • Infants have a slower metabolic rate than adults • Infants are obligatory nose breathers 48. A nurse is caring for a 7 year old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instructions? • “I will encourage her to drink half a cup of water or sugar free fluids every 30 minutes.” • “I will continue to check her blood sugar two times every day.” • “I will notify the doctor if her temperature is not controlled with acetaminophen.” • “I will report a change in her breathing or any sign of confusion.” 49. A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint of the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint? • Remove the weights for a few minutes each hour • Apply lotion to the skin under the edges of the splint • Reposition the client to keep him from staying in the same position in bed • Apply a foot plate to the bed 50. A nurse is caring for a client who has a new short leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider? • Inability to flex the toes of the casted foot • Dependent edema distal to the cast • Ecchymosis of the distal foot • Moderate level of pain 51. The nurse is caring for a 6 month old with suspected meningitis. Which clinical manifestations should the nurse prepare to assess if meningitis is confirmed? (Select all that apply) • Photophobia • Fever • Edema • Irritability • Bulging anterior fontanel 52. A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions? • Place the infant in an upright position • Place the infant in a prone position • Place the infant on his right side • Place the infant on his left side 53. A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits? • Shows no reactions to the painful stimuli • Extends the body part toward the stimuli • Pushes the painful stimulus away • Flexes the upper and extends the lower extremities 54. A nurse is reviewing the laboratory results of an adolescent who has chronic glomerulonephritis. Which of the following findings should the nurse expect? • Serum phosphorous 4.0 mg/dL • Absence of proteinuria • Serum potassium 3.0 mEq/L • BUN 50 mg/dL 55. A nurse is teaching a parent of a 2 year old child about safe food choices. Which of the following foods should the nurse recommend? • Grapes • Celery • Bananas • Raw carrots 56. A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? • “I want to learn how to use my child’s feeding tube as soon as possible.” • “I’m glad that my child’s ostomy is only temporary.” • “I want to learn how to empty my child’s urinary catheter bag.” • “I’m glad my child will have normal bowel movements now.” 57. A nurse is caring for a child who has autism. Which of the following are expected behavioral findings. (Select all that apply) • Delayed language development • Enjoys socializing • Spins a toy repetitively • Attentive • Avoids eye contact 58. A nurse is planning care for a 10 month old infant who is 8 hr. postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant’s plan of care? • Apply and release elbow restraints periodically • Suction the mouth with an oral suction tube • Keep the infant supine • Feed the infant with a spoon for 48 hr. 59. The nurse is doing a routine assessment on a 14 month old infant and notes that the anterior fontanel is closed. This should be interpreted as: • A normal finding • An abnormal finding- indicates need for developmental assessment • A questionable finding- infant should be rechecked in 1 month • An abnormal finding- indicates need for immediate referral to practitioner 60. A nurse is providing teaching to a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? • “My morning blood glucose should be between 90 and 130.” • “I should not take my regular insulin when I am sick.” • “I should eat a snack half an hour before playing soccer.” • “I can store unopened bottles of insulin in the freezer.” 61. A nurse is preparing to administer a vaccine to a 4 year old child. Which of the following vaccines should the nurse administer? • Varicella (VAR) • Haemophilus influenza type b (Hib) • Meningococcal (MCV4) • Hepatitis B (Hep B) 62. A nurse is preparing to apply a cast to a preschooler’s arm. Which of the following should the nurse do? • Wrap the arm of the child’s doll or toy prior to the procedure • Place a heated fan at bedside to facilitate drying • Tell the child, “This will make your arm feel better.” • Support casted arm with a firm grasp 63. A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to see first? • An infant with gastroenteritis who has three stools during the prior shift • A school age child with diabetes who requires blood glucose monitoring • An infant with pertussis receiving oxygen via nasal cannula • A toddler with dehydration whose IV was decreased to a rate of 42 mL/hr. 64. An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to: • Encourage parents to room in • Encourage contact with children the same age • Provide privacy • Explain procedures and routines 65. A nurse is assessing a 6 month old infant at a well-child visit. Which of the following findings should the nurse expect? • Uses thumb and index fingers in a pincer grasp • Closed posterior fontanel • Lateral incisors • Sitting steadily without support 66. A nurse is caring for a school age child who sustained a closed head injury. Which of the following findings is an early indicator of increased intracranial pressure? • Irritability • Bradycardia and hypertension • Glasgow Coma Scale of 14 • Pupils 4 mm and reactive 67. A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following interventions should the nurse plan to take? • Administer albuterol prior to CPT • Perform vibration during the client’s inspirations • Perform CPT immediately after the child eats • Percuss each lung segment for 15 min. 68. A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take? • Monitor oxygen saturation • Obtain a throat culture • Use a tongue depressor to observe the epiglottitis • Initiate airborne precautions 69. A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take? • Initiate airborne precautions • Keep thermometer in the toddler’s room • Allow the toddler to play in the common room • Place the toddler in a room that has negative air pressure 70. The parents of a toddler asks a nurse at a well-child visit how the child’s frequent temper tantrums can best be handled. Which of the following the nurse suggest to the parent? • Tell the child that temper tantrums are no acceptable • Restrain the child physically • ? temper tantrums • ? child by offering to play a game 71. A parent tells the nurse that she doesn’t want her infant immunized because of the discomfort associated with injections. The nurse should explain that: • This is not a good reason for refusing immunizations • Infants do not feel pain as adults do • This cannot be prevented • A topical anesthetic, eutectic mixture of local anesthetic (EMLA), can be applied before injections are given 72. A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development. Place Erikson’s stages of psychosocial development in order from birth through age 18 yrs. • Trust vs. mistrust (1) • Autonomy vs. shame and doubt (2) • Initiative vs. guilt (3) • Industry vs. inferiority (4) • Identity vs. role confusion (5) 73. A nurse is assessing the psychosocial development of a toddler. The nurse should recognize that this stage is characterized by which of the following? • Negative behaviors characterized by the need for autonomy • Demonstrations of sexual activity • Imaginary playmates • Erikson’s stage of initiative versus guilt 74. A nurse is caring for a school age child with acute glomerulonephritis who has peripheral edema and is producing 35 mL of urine per hour. The child should be placed on which of the following diets? • Low-sodium, fluid restricted • Low-carbohydrate, low-protein diet • Low-protein, low-potassium diet • Regular diet, no added salt 75. A nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate and cannot be aroused. The most appropriate management of this child is for the nurse to: • Discontinue morphine until the child is fully awake • Discontinue IV infusion • Administer naloxone (Narcan) • Stimulate child by calling name, shaking gently, and asking to breathe deeply 76. A nurse is teaching a school age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following actions should the nurse include? • “Limit fluid intake during meal time.” • “Withhold insulin dose if feeling nauseous.” • “Notify the provider if blood glucose levels are over 350 milligrams/deciliter.” • “Test the urine for ketones.” 77. A nurse is caring for a 3 year old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that the dehydration therapy has been effective? • Respiratory rate 24/min • Heart rate 130/min • Urine specific gravity 1.015 • Capillary refill greater than 3 seconds 78. A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings? • Hypertrophic pyloric stenosis • Intussusception • Inguinal hernia • Tracheoesophageal fistula 79. A nurse receives a call from a parent of a child who has von Williebrand disease and has having a nosebleed. Which of the following instructions should the nurse give to the parent? • “Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes.” • “Place your child in a supine position with a pillow under her back.” • “Apply ice at the base of the nose for 5 min. and then check for bleeding.” • “Place your child in a sitting position with her head tilted back.” 80. A nurse is caring for a child that is experiencing a seizure. Which of the following would be the most appropriate action for the nurse to do? • Restrain the child’s arms • Position the child laterally • Use a padded tongue blade • Attempt to stop the seizure 81. A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first? • Place the child on droplet precautions • Assist with obtaining an x-ray of the child’s neck • Initiate IV antibiotics • Administer 0.9% sodium chloride IV solution 82. A nurse is caring for a 6 month old who is postoperative following a myringotomy. Which of the following is an appropriate method to assess the infant’s pain level? • Analog pain scale • FLACC pain scale • ER pain scale • Faces pain scale 83. A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool age child. Which of the following actions should the nurse plan to take? (Select all that apply) • Apply to intact skin • Cleanse the skin prior to procedure • Apply the medication 30 minutes to an hour before the procedure begins • Use a visual pain scale to evaluate effectiveness of the treatment • Spread the cream over the lateral surface of both forearms 84. A nurse is obtaining an infant’s vital signs. The heart rate is 180/min. and the temperature is 40° C (104° F). The father asks the nurse, “Why is my baby’s heart beating so fast?” Which of the following is an appropriate response by the nurse? • “Your baby’s heart is beating fast in an attempt to cool down the body.” • “This is within the expected range for your baby.” • “The fever is causing an increase in your baby’s heart rate.” • “As your baby begins to fall asleep, the heart rate will decrease.” 85. A female teen volunteer is assigned to the pediatric unit for the day and reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? • Reading a book to a 4 year old client who has AIDS • Refilling the ice pitchers for clients on the unit for the charge nurse • Helping a 7 year old who has celiac disease make out the next day’s menu • Playing a computer game with a 15 year old male client in skeletal traction 86. A nurse is caring for a child who has hemophilia and reports an increase in bruising. Which of the following lab values should the nurse recognize as contributing to this manifestation? • WBC 8,000 mm3 • Hemoglobin 13.0 g/dL • Platelets 110,000 mm3 • RBC 4.6 million/mm3 87. A nurse is providing care for an infant following a surgical repair of a cleft lip. Which of the following actions should the nurse take to minimize the infant’s crying? • Offer the infant a pacifier • Position the infant on the abdomen • Place the infant in a playpen at the nurses’ station • Rock the infant with a favorite blanket 88. A 6 month old infant has had surgery to correct intussusception. The surgeon has prescribed clear liquids by mouth. The nurse correctly administers which of the following? • Sterile water • Full-strength orange juice • Oral electrolyte solution • Half-strength infant formula 89. A nurse is assessing an infant who has possible cerebral palsy. Which of the following manifestations of cerebral palsy should the nurse expect to find? • Smiles when mother appears at three months • Sits with pillow props at eight months • Tracks an object in surroundings with eyes • Uses pincher grasp to pick up a toy 90. A nurse is speaking with the mother of a 6 year old child. Which of the following statements by the mother should concern the nurse? • “My child has recently lost both front top teeth.” • “Sometimes my child acts bossy with his friends.” • “My child often cheats when we play board games.” • “The teacher says my child has to squint to see the board.” 91. A nurse is assessing a preschooler for a routine wellness checkup. Which of the following should indicate a need for further evaluation? • The child is crying and states, “I do not want a shot.” • Respiratory rate is 25/min. • The child is sitting on the exam table pretending to be in a boat surrounded by sharks • Blood pressure is 122/80 mm Hg 92. A nurse is providing teaching to the parents of a 1 week old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching? • “The pulse oximetry might not be accurate during times of excessive movement.” • “We will rotate the probe of the pulse oximeter every 24 hours.” • “The probe of the pulse oximeter can be applied to a finger or a toe.” • “We will notify the doctor if the pulse oximeter consistently reads 100% 93. A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? • Tetralogy of Fallot • Coarctation of the aorta • Tricuspid atresia • Patent ductis arteriosus 94. A nurse is completing discharge teaching to a parent of a child with a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires clarification of the teaching? • “The onset of low blood glucose usually occurs rapidly.” • “Sweating can occur with hypoglycemia.” • “My son may be very thirsty or have fruity breath when hypoglycemic.” • “My son may complain of feeling shaky when he has a low blood glucose level.” 95. A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler. Which of the following statements by the parents indicates an understanding of the teaching? • “The quality of food I provide him is more important than the quantity.” • “Because he is such a picky eater, I will give him one of my vitamins each day.” • “I should expect him to have an increased appetite.” • “His average daily intake should be about 3,000 calories.” 96. A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? • Prone • Semi-Fowler’s • On the unoperated side • Trendelenburg 97. A nurse is caring for a 5 year old child who has had 300 mL of urine output over the past 12 hr. period. The child weighs 48 lb. Which of the following actions should the nurse take? • Provide oral rehydration fluids • Notify the MD • Keep monitoring • Perform a bladder scan at the bedside 98. A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These findings are associated with which of the following diagnoses? • Influenza • Bronchiolitis • Epiglottitis • Croup 99. A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse’s priority? • Respiratory rate 20/min. • Blood pressure 92/50 mm Hg • Heart rate 72/min. • Abdominal pain rated 4 on a scale of 0 to 10

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